Guest Blogger Jesse: Philosophy Follows Funding

The “Chapter that Wasn’t Written” in Shrink Rap should have been on the changes in psychiatry due to insurers. Recent posts have underlined the effect of pharmaceutical companies and the ways in which they have distorted data and biased the attempts to have an evidence-based practice. While these comments have a lot of validity, I think the  influence of Big Pharma on the field has been exaggerated. There is another culprit which has had a more pernicious and less easy to combat effect on psychiatry.

When insurance companies started to severely limit psychotherapy and reduced reimbursements drastically, the entire field of psychiatry changed. They made practicing purely a med management model much more profitable than talking to patients. Worse, they created an atmosphere in which a doctor who saw his patients frequently was considered to be doing something unnecessary. Just a short time ago there was no need in Maryland to explain to one of the “reviewers of medical necessity” even twice-a-week psychotherapy. Such treatment rapidly became impossible to get approved.

The training programs changed to reflect the economic reality. Psychiatric residents once had extensive training in psychotherapy. Many residents were in psychoanalysis. No more. Becoming expert on how the mind, as opposed to the brain, works has been abandoned to psychologists and social workers. As always, Philosophy Follows Funding.

Guest Blogger Jesse: When Patients Don't Pay

Dinah asked that I “blog on what you do when patients don't pay.” I’ll try to put that question in a larger context. If a patient is seeing a physician for treatment of a mole, or of a fever, the treatment of those illnesses has no relation nor is affected by when or how the doctor is paid (other, of course, that the doctor might refuse to treat the patient). In psychodynamic therapy, where the therapist is helping the patient with relationships, anxieties, attitudes, and conflicts, everything that occurs is potentially helpful if it is understood. Observing and thinking about actions and feelings is a part of the treatment, as important a tool to the therapist as a stethoscope to a cardiologist.


Money is something loaded with meaning to most people. What does it mean that the patient forgets to pay? Does it mean “if you really cared about me you would not charge me”? Is it a reflection of anger for something that occurred in the last session? Is it a displacement of feelings from something else (“my boss didn’t give me the raise I expected”)? Is it completely inadvertent (Freud famously said “Sometimes a cigar is only a cigar”)?


There are so many possibilities, and the psychodynamic therapist wants to understand them. How the patient relates to the therapist is some part of how he relates to others. The patient hopefully starts to watch his own actions and attitudes, and also tries to understand them. A nonjudgmental stance helps the patient do this.


The therapist himself needs to be comfortable dealing with the subject of money. Sometimes beginning physicians fluctuate between feeling they are too inexperienced to be paid and feeling that they deserve anything they ask. We physicians might even (unfortunately) take on the attitudes of the insurance companies themselves (“Identification with the Aggressor”).


There are times when the treatment needs to be discontinued, or the patient referred for other care. Clearly, if the therapist has allowed a patient to go a long time without paying, without good reason thoughtfully discussed, both doctor and patient have unwittingly colluded in avoiding very important issues.


Many therapists believe it is important for the patient to pay something, regardless of his economic state. It is part of the patient’s self-esteem. It indicates a professional relationship, one in which the patient essentially is employing the therapist (physician, lawyer, accountant, et al) and in which the therapist has professional obligations to the patient. It is therefore part of the professional boundaries.


There is a curative aspect to the attitude I’m describing. To the extent that the patient can increase his ability to examine his own actions and feelings in a nonjudgmental manner he gains control over areas of life which may have been becoming increasingly difficult for him.


What have others experienced in this regard, and how do you think of these issues?

Talk Doesn't Come Cheap

Gardiner Harris has an article in today's New York Times called "Talk Doesn't Pay So Psychiatrists Turn to Drug Therapy." The article is a twist on an old Shrink Rap topic--Why your Shrink Doesn't Take Your Insurance. Only in this article, the shrink does take your insurance, he just doesn't talk to you.

With his life and second marriage falling apart, the man said he needed help. But the psychiatrist, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.”

Ah, Dr. Levin sees 40 patients a day. And the doc is 68 years old. This guy is amazing, there is no way I could see 40 patients a day for even one day. He's worried about his retirement, but I wouldn't make it to retirement at that pace. Should we take a bet on whether Dr. Levin has a blog?

So the article has a whimsical, oh-but-for-the-good-old-days tone. In-and-out psychiatry based on prescribing medications for psychiatric disorders is bad, but the article doesn't say why. In the vignettes, the patients get better and they like the psychiatrist. Maybe medications work and psychotherapy was over-emphasized in the days of old? The patients don't complain of being short-changed, and if Dr. Levin can get 40 patients a day better for ---your guess is as good as mine, but let's say-- $60 a pop and they only have to come every one to three months, and there's a shortage of psychiatrists, then what's the problem? Why in the world would anyone pay to have regular psychotherapy sessions with the likes of someone like me?

After my post last week about The Patient Who Didn't Like the Doc. On Line , I'm a bit skeptical about on-line reviews. Still, I Googled the psychiatrist in the story, and the on-line reviews are not as uniformly positive as those given by the patients who spoke to Mr. Harris. Some were scathing, and they complained about how little time he spends with them. In all fairness, others were glowing.

The article makes psychiatrists sound like money-hungry, unfeeling, uncaring, sociopaths. Either they're charging $600 a session (...oh, can I have that job?) or the financial aspect is so important that they're completely compromising their values for the sake of a buck. This doctor believes that patients get the best care when they receive psychotherapy, and the rendition Mr. Harris gives is that it's understandable that he's compromised his values to maintain a certain income. I don't buy it and I don't think it portrays psychiatrists accurately or favorably. If the doctor felt that it was the high ground to give treatment to 40 patients a day who otherwise couldn't get care, then this portrayal wouldn't be so bad. And that may be the case---I don't know him and I don't know Mr. Harris and I do know that an occasional reporter has been known to slant a story. I found it odd that there were no other options here aside from 4 patients/hour, 10 hours/day, not to mention the 20 emergency phone calls a day that he manages in the midst of all the chaos. Why hasn't this doctor left the insurance networks and gone to a fee-for-service model with a low volume practice if psychotherapy is what he enjoys and what he feels is best? Or why doesn't he devote an hour or two a day to psychotherapy? Okay, I shouldn't rag on the poor doc, I only know him through a newspaper portrayal, but I don't think this article showed psychiatry at its finest hour. And yes, I know there are psychiatrists out there who have very high volume practices.

The Guilty Doctor

Times are tight and we're all looking to save money, be it our own or someone else's. Many will say that when it comes to the skyrocketing costs of health care, doctors are responsible for part of the problem. We order too many tests, either to cover ourselves in the event of a malpractice suit, or because patients pressure us, or because we genuinely believe that the tests are necessary for patient care, but in many circumstances, a cheaper option is available. We order medications that are expensive when cheaper medications are available. And psychiatrists offer care-- like psychotherapy-- that could be done by clinicians who are cheaper to educate and willing to work for less money.

Here are some voices on decreasing cost: From KevinMD's post on when patients (in this case the patient is a doctor), pay cash. More on the same story directly from Jay Parkinson, here is Today I Was a Patient. The most absolutely cool thing I learned from Dr. Parkinson this morning is about a website I had never heard of before called ZocDoc which lets people schedule on-line appointments with new physicians (including shrinks!)--like OpenTable for Docs...I asked for more info about this, but such a website fits Roy's vision of dying and going straight to heaven. And MovieDoc has strong opinions on allocating resources: we shrinks should not be letting patients ramble on about their romantic lives, why one psychiatrist can treat 1,000 patients if they stop that psychotherapy nonsense! ClinkShrink, too, has had a lot to say about allocation of services, but I'll stop now before the blog explodes.

I buy it, too. Docs should feel an obligation to care about cost-containment. In recent times, this translates very simply into the fact that I feel guilty no matter what I do. I sit with a patient and I consider trying a cheaper option for medications before I try a more expensive one. But then I think: isn't my obligation to do my very best by this patient? Why shouldn't my patients get the latest-greatest available medication when other patients do? And what's the cut-off for how much it's worth for....relief from voices, a better mood, a good night's sleep? How do we even begin to put dollar signs on such things?

I'll give you a scenario. A patient comes to me already on an anti-psychotic medication. He says it helps, but it's unclear why it was ever started. At some point, he stops taking it, and it becomes much more clear why he ever needed it: he becomes flagrantly psychotic and completely unable to function. I restart the medication, using the one he was on, which happens to be fairly cheap as the second generation anti-psychotics go. So all good: the med works, I know he tolerates it, and it's the cheapest of the choices, by a lot. Oh, until he gains 20 pounds. Now what? There's Abilify which is, oh, many times more expensive, but is less associated with weight gain...should I try that? I hesitate because of the cost, and then I think perhaps I should try one of the older medicines, of the Haldol generation-- much, much cheaper, but many patients hate it. As a field, we seem to agree that these first-generation anti-psychotics are not the way to start; the atypicals are the usual first-line treatment. Maybe this patient won't have side effects, maybe he'll be fine, I could "try." But isn't that making my patient into a guinea pig? If it were me, would I want to try a medication with many known side effects, when other medications are available? Nope. So I go back and forth between what is best for my patient and what makes sense for society. I share some of my thoughts with the patient, whose private health insurance pays for them, and he clearly wants what's best for him, not what saves society money.

I suppose the question presumes that I know what's best for him. And clearly, I don't. One of my big concerns is that he had this awful recurrence of a terrible illness, and each time, it takes weeks to get better,time lost from his life. There is no guarantee that Abilify, with a more favorable side effect profile, will be equally efficacious, or that Haldol, cheaper if you will, will also work. There is the risk of relapse with any medication change and this is why some patients tolerate medications that cause weight gain or diabetes.

And then there is the "at what cost?" for that particular symptom. A patient wants a medication for sleep-- trazodone and benedryl don't work, ClinkShrink flips when anyone prescribes Seroquel for sleep ($3/pill for 25 mg per drugstore.com), benzodiezepines are contraindicated, and then there's Rozerem at $5/pill. Is a good night's sleep worth $5 night? Of whose money? And what if the patient is on generic Ambien ($1/pill or less) but wants to take Ambien CR ($4/pill) because it helps him sleep longer? And how do you feel about Provigil, which comes in at $20 a pill for the 200mg dose? Stepwise therapy, you say--- where a patient must try cheaper medications before he is allowed access to the more expensive ones? And who determines efficacy? And how do we deal with the hassles of pre-authorization? Maybe we should decide that certain medicines are so expensive that they shouldn't be offered to anyone?

Unemployment Is Not Good For Your Mental Health

From the NYTimes, "Poll Reveals Trauma of Joblessness in US" by MICHAEL LUO and MEGAN THEE-BRENAN

The article notes:

With unemployment driving foreclosures nationwide, a quarter of those polled said they had either lost their home or been threatened with foreclosure or eviction for not paying their mortgage or rent. About a quarter, like Ms. Newton, have received food stamps. More than half said they had cut back on both luxuries and necessities in their spending. Seven in 10 rated their family’s financial situation as fairly bad or very bad.

But the impact on their lives was not limited to the difficulty in paying bills. Almost half said unemployment had led to more conflicts or arguments with family members and friends; 55 percent have suffered from insomnia.

“Everything gets touched,” said Colleen Klemm, 51, of North Lake, Wis., who lost her job as a manager at a landscaping company last November. “All your relationships are touched by it. You’re never your normal happy-go-lucky person. Your countenance, your self-esteem goes. You think, ‘I’m not employable.’ ”

A quarter of those who experienced anxiety or depression said they had gone to see a mental health professional. Women were significantly more likely than men to acknowledge emotional issues.

Getting Help When Money is Tight and When It's Not

Moving on from the Hummus debate...

Today's NYTimes has an article called Getting Mental Health Care When Money is Tight.
Leslie Alderman writes:

According to a recent survey by the federal Substance Abuse and Mental Health Services Administration (Samhsa, pronounced SAM-suh) , the leading reason that people with mental health issues don’t seek treatment is cost. They fear the fees.

The article goes on to list websites, support groups, self-help ideas (yes, exercise was in there!), pastoral counselors and an assortment of options for people who want help but are uncomfortable with the cost. The author even suggests:

If you have a good relationship with your primary care physician, you could see him or her. Your doctor may be able to refer you to a local mental health center for therapy, and maybe consider medication to help you out of your immediate funk. Doctors may also know of psychologists who see patients on a sliding fee scale.

Hmmm, sounds like psychiatrists aren't a very generous crew-- there's no mention of the idea that one of those might discount their fees.

In Maryland, there have traditionally been a few options:
1) Community Mental Health Centers have treated uninsured, indigent patients, specifically those with major mental illnesses. These patients are deemed "gray zone" and have been cared for in the clinics....not sure that continues with all the governmental budget cuts. Often these patients end up being eligible for Medicaid, and sometimes SSDI (Social Security Disability) and eventually Medicare.
2) Homeless patients (and homeless is defined pretty loosely, and not limited to 'street' people--) can be seen at Health Care for the Homeless-- they're sliding fee scale allows for
very low fees.
3) The Pro Bono Counseling Project coordinates care for those with limited resources through a network of volunteers in the community. The list includes therapist of every ilk-- but I will say the social worker volunteers greatly outnumbers the psychiatrists.
4) Teaching programs (and this was an option in the NYTimes article) offer treatments of all types--- including psychoanalytic training programs where discounted analysis is available.

Do you know of other resources? By all means, write in!

So my other thought was this. I think health insurance is a good thing, and actually, I hope some reasonable level of health care should be accessible to all, but given that it's not, have we become complacent in a way that's not helpful? The article starts out talking about a person with what may be a major depression and the person is afraid that the cost of treatment will add to the stress:

IMAGINE this situation. You fall into a deep malaise. Friends say you need help, but you don’t have insurance (or the insurance you do have has very limited mental health benefits), and you worry that extra bills will only add to your malaise. So you do nothing.

The article goes on to describe discount means of getting care, and you know I think these are all reasonable options. But we all know there are people who worry about money with a variety of thresholds-- one could worry that extra bills will add to the stress even if there's money in the bank. And no where does the article suggest that if there is some means of paying for care, that the cost of NOT getting treatment may well exceed the cost of getting care. Maybe the person above has a depressive episode-- maybe he'll go for an evaluation, a few weekly visits, then a year's worth of monthly visits, and get meds from Walmart or free doc samples. Let's pretend he responds well to the first medication, that he gets a lot out of a few therapy sessions, and ...hmm....maybe $600 later he feels a lot better. Let's say he doesn't spend that money and he's miserable. Let's say he loses his job, he loses opportunities...he lives life less fully.

I've watched people who pay $20K year for their child's kindergarten not be willing to go outside their HMO to get appropriate medical care for the same child.

I liked Alderman's article, she offers good suggestions. I guess I just wished that she'd made the suggestion that, if possible, psychiatric treatment might be worth paying for. I know I'm going to get comments from people who really do stretch to pay for their treatment. I'd love to hear from the folks who have a few resources but still elect not to get treatment they might like to have.

Sliding Fees

A lot of psychiatrists and other mental health professionals tell me they slide their fees, giving reduced rates to patients who can't otherwise afford to come. I want to ask: How do docs decide to do this? At clinics, scales are based on income (perhaps by family size), and just income, with a pre-set structure. But in private practice, this isn't usually the case (I don't think), and I wondered what other people do. In general, I've hesitated to slide my fees very much and this gets hard. Some of the patients I see live life without many luxuries-- rented homes, used cars, rare vacations. Sometimes it's a choice-- they choose not to work (when they could), and sometimes they are struggling quite hard to make ends meet, and yet they don't utter a word of concern about my fees. If anyone brings it up, it's me. Other times, patients are very verbal about their financial issues, how much they plan and calculate exactly what they can afford, and are very concerned about my fees and exactly what they can or can't afford. What's hard is that some of these same people are "strapped" because their life styles include many luxuries--boats, luxury cars, nice trips, a fine bottle of wine here or there, expensive tuitions, and maybe unexpected expenses. They come less then they should, or would like, because my fee is high. Maybe they've bitten off more then they should have (especially in the current economy) and are going through bankruptcy proceedings, or are simply worried about what the future might bring. Being tight on funds and the perception of what one can afford is based on many things, and so I'm putting this out not to get my own answers, but to ask how other people deal with this? Years ago I had a friend who was seeing a patient at a greatly reduced fee, only to discover that he lived in a much nicer house then she could afford-- it put some tension into the therapeutic relationship, I'm sure.

The High Price of Sanity: What Antipsychotics Cost

When I was in medical school, there were these medications that were used to treat hallucinations and delusions (what we psychiatrists call "psychosis") and sometimes extreme agitation. They were the neuroleptics, and they worked: medicines like thorazine, and haldol, and mellaril, and navane. Oh, and like prolixin, too. They worked, but they came with a horrible stigma and lousy side effects. Some people tolerated them with no problems, some people even preferred how they felt when they were on them, but a lot of people found them to be pretty awful. Some made patients very tired -- this is why they are also referred to as major tranquilizers. Others were less sedating, but they made people very stiff: a side effect called Parkinsonism because they chemically gave people a temporary state similar to Parkinsons' Disease. You can sometimes look at someone and know they are on medication, and this is never good. And sometimes they caused a permanent, irreversible movement disorder called Tardive Dyskinesia. Okay, so people really don't like taking these medications, and sometimes they can be fine-tuned with other medications to halt the side effects, but they come with a price.

By the time I was a resident, the new generation of antipsychotics had come along. Risperdal, Zyprexa, Geodon, Abilify, Seroquel, Invega, the list marches on. These medications also worked and people didn't mind taking them (...okay, some people didn't mind taking them). They are also used for mood stabilization, to calm agitated states, for mania, as augmentation for depression, and sometimes for sleep. They aren't addictive, they aren't as stigmatized, and the immediate side effects aren't so troublesome. It's much easier to get patients to consider taking them and my experience is that in the short run, they help a lot of people feel better and function better. The down side has been that in some people they cause weight gain, diabetes, and hypercholesterolemia/hyperlipidemia. We don't seem to know who will have these problems (clearly, not every one does) and sometimes people are so sick without them that we're stuck fixing one disease while contributing to, or causing, another, and that needs treatment, too. And did I mention that these medications cost a fortune. If that's not enough, we have to order regular blood tests to monitor for the problems they cause, and patients may need more and expensive medications to treat the conditions the medicines cause.

So how much does it cost to stay sane? The state of Maryland, apparently, spends $80 million a year for atypical antipsychotics (these newer medications) for patients with Medicaid, and I suppose for uninsured patients in the hospital. This doesn't count the patients who self-pay, or have private insurance, or who get samples from their doctor, or who have Medicare. So the cost of keeping my state sane is pretty high. So far, only one of these medications, risperidone, is available in a generic.

Okay, so I price-shopped. I called some pharmacies, and here's the price for 30 pills. Remember, some people take higher doses-- I priced middle-range doses-- and some patients take several pills a day:

DRUG	Walgreens	CVS	Sam’s Club	Independent
Risperidone (Risperdal brand), 3mg	$339	$385	$292	$295
Risperidone (generic), 3mg	$170	$203	$150	$  46
Quetiapine (Seroquel brand), 25mg	$  85	$103	$  82	$  97
Quetiapine (Seroquel brand), 200mg	$265	$324	$262	$262
Haloperidol (Haldol brand), 5mg	$  10	$  11	$    4	$  28
Aripiprazole (Abilify brand), 10 mg	$449	$542	$440	$450

Hmmm, so there's a $3/pill differential for Abilify, depending on where you get it?
Oh, and I wondered about the generic risperidone--- $203 at CVS and $46.50 at a local independent pharmacy? I asked the pharmacist to check it twice, and then I called a second mom & pop pharmacy, and their price was just under $40. If you pay cash, it's worth shopping around. Are these the prices your insurance company pays? I doubt it-- they negotiate deals and have formularies. I asked how much the state pays for the medications for a patient with Medicaid, and none of the pharmacists I asked could tell me...one said it was top secret. Okay.

One note on Haldol, the older generation medication-- I'm not sure if the $28 price was for generic or name brand, the others were all for the generic.

Does the Failing Economy Lead to Psychiatric Disorder?

In yesterday's New York Times, Pam Belluck writes "Recession Anxiety Seeps into Everyday Life." She talks about people who've needed psychiatric care, including medications, because of the poor economy. Some are people who are not actually having financial problems, but are very symptomatic, nonetheless.

So what have I seen? I work in two different outpatient settings, but I can summarize what I've seen pretty easily.

---In the private practice setting, every patient has at least mentioned the troubled economy and concerns about money, if not in passing, then as a cause of significant worry and personal concern. Some people have decided to come less often. Referrals are down. No one new has presented with their only complaint being anxiety because of money worries, but in the realm of things causing stress, it's pretty much on everyone's list. Many people are worried about losing their health insurance.

--In clinic settings, many of the patients I see receive disability or some other source of fixed income. Money is always a stress, there's simply not enough of it. Or, they live in a setting where their needs are met, their money is managed with no room for luxuries or savings, and it's not something they mention to me. There are no jobs to be lost, no cars to be repossessed, no luxury vacations to be longed for. Here, few mention the economy or money worries in a way that relates to economic changes: they have no credit, mortgages, or portfolios, and paying the bills is the same struggle it's always been.

Anyone else notice anything interesting?

Just A Little More Time

Okay, so I'm going to post a scenario and I want your opinion. There's no 'right' answer, I don't think, or you'll tell me if there is. I'm particularly interested in opinions from other mental health professionals, so please note in your comments if you're one of those, but as always, I'm interested in feedback from all our readers.

A patient and doctor have a long-standing relationship, they always meet for a 50 minute session, and if often goes closer to 60 minutes. Perhaps a few times they've even gone longer. It's been years, and now the sessions are scheduled erratically, so it's not a given that things can be finished up 'same time next week.' On this particular session, the patient brings up something towards the end that unexpectedly takes a long time-- maybe she wants the doc to write a new script (maybe it's even Xanax ! and the doc is uncomfortable). Some disagreement follows, and the session goes until a quarter after the hour. The doctor never formally states there will be a charge for the session that has run over and there has never been a charge for an over-time session before, though this session may be longer than any other. Is the doc justified in sending out a bill for the extra time? And if so, by how much? An extra quarter of a session, or an extra 50% given that the session technically ran 75 minutes and not 50 minutes. Does it matter if it was the last patient of the day and there's not an all-day back up for everyone else because of the extra time? Let's say it was the patient's final session and so please don't answer with "examine it in the next session" or "send a bill and see what the patient says." And don't worry about the Xanax, new script, whatever issue, it doesn't really matter Why the session ran over, the scenario is about the time and the unexpected charge.

I often run my 50 minute sessions closer to an hour, and sometime I run a few minutes over that. There have been a handful of sessions that have run quite a bit over, and it's never occurred to me to charge for something that wasn't agreed upon in advance, but I'm not saying it isn't the right thing to do-- boundaries, income, time-is-money and the doc has bills to pay, too.

Just wanted your thoughts.

The Patient Who Wouldn't Pay

I posted the latest poll on the sidebar and I thought there would be hands-down winner, that everyone would agree, the hardest thing to talk about in therapy is MONEY. Payment. Fees.

Maybe it's just from the therapist's side, but I HATE TALKING ABOUT MONEY. I really hate it. How much do I hate it? A lot.

On the phone before I meet someone, I'm very clear about a bunch of money things-- I hate this, it turns me off, but people have the right to know what they're getting into and if it isn't clear there are a lot of misunderstandings. So I don't participate with insurance companies, the patient needs to pay up front and then submit the bill so the insurance company will reimburse him directly. He needs to call the insurance company before he even comes in-- it's called "preauthorization" and if you don't jump through this hoop, some companies will refuse to reimburse at all. Many companies have a separate managed care component for mental health and ask for a treatment plan. The patient needs to find out how many visits he has before a treatment plan needs to be submitted (it may be 1, it may be 8, it may be 11, it may be never) and he has to to tell me Where to send the treatment plan to. Then he has to count the appointments so I know when the next treatment plan is due (--oh, actually I have a system for doing this, but it doesn't hurt to have a back up reminder). I tell the patient the cost of the evaluation and the cost of a regular 50 minute session. I tell them to expect to pay at the time of the visit-- that's the most comfortable way I've found to say it. A lot of people say "no thanks, I'll find someone in my network," and that's fine. I say a few other things too, like how to find my office and what to expect, and that it's fine to bring someone if that will be helpful, and definitely bring your medications.

I hate talking about money (did I mention that?). What I don't do is ask for payment during the session, it feels tacky. Most people write a check at the end---they were told this is the policy on the phone. If they don't, I send a bill at the end of the month, with all the other bills. The majority of people mail or bring a check, and it's just not a problem. Here and there, someone just doesn't pay. I hate asking. Eventually, I ask. Usually I don't, and eventually the patient pays, but I've been stiffed by a few people.

There was once a woman who'd seen me for years, payed at every session, and then had an unexpected financial crisis and now was really struggling. I didn't ask her to pay for the full session, instead, I nagged her to submit to her insurance company and at least pay the portion they would pay. Should I mention that the reason for her unexpected crisis was that she outspent her excessive standard of living? I've had this happen a few times, and I tell people to catch up at they rate that they can. In the case of people who have had true crises (lost jobs with few assets any way), I will slide their fee. But I'm not so comfortable doing that when the patient drives a late model luxury car or owns a vacation home. I'm sympathetic to their sudden financial plight, but I need to make a living, too. My hardest is the patient who struggles and struggles just to make a living, sleeps on the couches of friends, every purchase is a hardship, and I would say "forget it," I'll see you for free, but for that little drug habit--- if you can swing upwards of $50/week on your habit, another $50 for your cigarettes, a few bottles of wine, then maybe it's good to make a minimal payment on your shrink bill to that shrink who calls around to get you free samples.

Do you want to hear about the surgeon who came twice and never paid the bill? Or the patient who moans about every dime of the bill and the struggles to get reimbursed, but spends in a way most people wouldn't dream of spending on luxury trips, 5-star restaurants, homes so big the utility bills are bigger than his medical bills? Or the few patients I've seen who simply didn't pay at all--even after being asked, uncomfortably, repeatedly, just said "next time," or "I'll send a check" or "I did send a check." The odd thing is these aren't people who are talking about their financial hardships, they're people who are talking about their vacations and boats. The reality is they make a profit by not paying, because they get reimbursed by their insurance companies (often these same patients will ask to have the statements regenerated two or three times), but they never pass along the fee. This is called fraud, I believe.

Uncomfortably, I've been left to say on a few occasions, "Why don't you catch up and then call to schedule the next appointment." I hate talking about money.

I'm sorry, I sound bitter and this is an issue with so very few people. Most people, if they fall behind, they say something and I'm happy to have them catch up at their own pace, and they do. Nothing specific set me off tonight, I just was surprised that more people have trouble talking about sex than money. Maybe I'm feeling a little Grinchy. You can guess which I'd rather talk about.

Why Shrinks Don't Take Your Insurance

Many psychiatrists in private practice don't take insurance, or don't 'accept assignment.' They require the to patient pay them and then the patient can submit to his health insurance company and reimbursement is made directly to the patient. This often means that the patient, having gone Out-Of-Network, has a higher co-pay &/or a higher deductible, and the hassle of paperwork. Generally, if a patient sees an In-Network psychiatrist, they make a copay and the hassle of getting the rest of the money falls on the doctor.

This means that access to psychiatric care is limited to those who have the money to pay up front, the wherewithal to stick their statements into an envelope and send them to the insurance company-- after they've called a separate managed care company, gotten pre-authorization, had Dr. Shrink submit a treatment plan, yada yada yada, as Mr. Seinfeld would say-- and the willingness to take on the financial risk that the insurance company might find some reason not to reimburse. By not accepting assignment, the doctor has greater control about little things like getting paid, but the patient supply becomes limited in a way that restricts access to care. Patients who want the financial and logistical benefit of remaining in their network are often surprised to find that it's difficult to find an in-network psychiatrist (even though the insurance company has this large list of providers) or that those psychiatrists aren't taking patients, or that they see patients for brief med checks but not for psychotherapy, or that it's hard to find a psychiatrist who feels warm and fuzzy enough. From the patient's point of view, it's not fair. There's a reason for this: it's not fair.

So why don't all shrinks accept assignment, why aren't they lining up to be members of insurance networks who would funnel lots of patients their way?

Let me tell the story from the psychiatrist's point of view. If a psychiatrist doesn't accept assignment, s/he sets his own fee-- generally what the market will bear-- perhaps decides when and if and for whom to slide or even forgo his fee, and he gets paid by the patient. This one is easy.

If the psychiatrist accepts assignment, he agrees to practice according to the terms of the insurance company. He sees the patient and collects the copay. Maybe it's a flat $30 co-pay. Maybe it's 80% for the first 5 visits and 70% for the next 5 visits and 60% for all the visits after that oh but the patient is only covered for 25 visits a year and the psychiatrist has agreed not to balance-bill as part of the deal. I don't know what happens if the patient needs a 26th appointment, I believe the doc eats the fee or simply doesn't offer the extra sessions. At any rate, the doctor now needs to figure out how much the patient has to pay and it's his responsibility to collect this. Oh, but it's not 80%/70%/60% of HIS fee that the insurance company will pay, it's 80% of what the insurance company has decided is Usual & Customary. And if they decide that Usual & Customary Rate (UCR) is $10/session or $25/session or $50/session less than anyone in town charges, then that's what they pay on. And while it might be a piece of cake to calculate if the the UCR was say $100/session and the patient paid $20 and the insurance company paid $80, well it's a pain in the neck if the UCR is $97.84/ session and you have to keep count of the sessions and figure out the percentages. Should I mention that different insurance policies by the same company can have different payment rates so someone has to call for each patient, verify the insurance, find out the terms, co-pays, deductibles, and this involves sitting on hold and dealing with assorted prompting menus. And if the insurance company finds a reason Not to pay, the doc is stuck--he can't bill the patient, he's just out the money. For a psychiatrist who does psychotherapy and sees maybe 8 patients/day at an insurance company discounted fee, well, it can be a big deal to have the insurance issues. And if the patient has two insurance policies and they each have different terms and they each decide not to pay because the other is the primary insurer-- oy! So not only is the psychiatrist taking his chances on getting paid, but he now has to have a secretary, an overhead expense his I-don't-accept-assignment compatriot may or may not want or need. And he now has to have an office big enough to accommodate secretarial space. I'll also tell you that while the secretary is paid an hourly fee, his ability to get paid is only as good as her motivation to follow through on dealing with the insurance companies, refiling denied claims, clarifying primary versus secondary insurance and getting the amount of the co-pays correct.

So how and why does any psychiatrist accept insurance? Basically, the insurance companies pay okay for short appointments with a psychiatrist. While there are time standards for coding psychotherapy appointments (25 minutes, 45-50 minutes), nearly everyone charges more per hour for a 25 minute appointment than for a 50 minute appointment, even many of the out-of-network docs. So a psychiatrist who sees two patients in an hour makes more than a psychiatrist who sees one patient in an hour, and often the insurance companies-- perhaps eager to encourage their policy holders to seek psychotherapy with a cheaper provider-- will pay a reasonable amount for a shorter session-- perhaps they make this worth doing. And "Med Management" 90862 for those of you who like CPT codes-- has no time restrictions on it. If a psychiatrist can squeeze four or five patients into an hour, he can do okay by the insurance companies.

Okay, I googled it and this is what I found: for Medicare, based on 2004 rates, irrespective of geography (so I guess a national average as each state has a different fee), the allowable fee for a 45-50 min psychotherapy session with medication management is $103.80. Half an hour is allowed at $71.31, and a 90862 med management with no time stipulation goes for $51.15 (here is my source)-- if you can see a patient in 10 minutes, you're doing as well as some lawyers. I'm not sure I'd call it psychiatry, and I'm not sure how long I'd survive or how much better the patients would get, but hey.

The Co$t of Being Depressed

Okay, I've truly lost it. I've just spent the last half hour on the phone calling a couple of pharmacies to find out the cost of antidepressants, all for Shrink Rap. You see, as a doctor, I've never learned what this stuff costs. I know vaguely that the older stuff is cheap, and the latest greatest is expensive, sometimes really expensive. I actually started my research yesterday. I thought I'd compare the prices at a local independent boutique pharmacist in a ritzy neighborhood where home delivery is offered, to a chain, to Walmart or Sams Club with the assumption that Walmart would be the cheapest--though really, I'm not sure of this. My quest was limited, however. By the time I really sat down to do this, it was so late I was limited to 24-hour pharmacies, so no Walmart in the comparison.

With my gratitude to the pharmacists who humored me, here's what I found.

The local independent pharmacy informed me that "our system doesn't allow us to look it up without a prescription." Huh? I asked again several times, they couldn't tell me what a medication cost. Okay....

CVS-- a large chain store-- I got a pleasant sales person on the phone.
Similarly at Walgreens. Pharmacists are generally nice people, I've found.
So all prices are for 30 pills, I aimed at the usual antidepressant doses. A little bit of confusion around Elavil (amitryptiline), one of the older tricyclic antidepressants which I just about never use, but it's cheap. I asked about a 100mg dose and CVS told me it came as 75 mg while Walgreens said they had it as 100mg. I only asked for a few prices at Walgreens, mostly to see if there was variation (there was). Zoloft, Lexapro, and Trazodone are scored pills, so if you take half the listed dose, this will last you two months. Many people, however, are on 200 mg of zoloft, and since the largest pill is the 100mg tablet, double the price for high doses. These are the cash prices, in US dollars, and I called pharmacies in Maryland. I tried to set this up as a table spreadsheet, but blogger ate that format.

Paxil, 20 mg...................... 125.99
generic Paxil 20 mg............ 48.95
generic Prozac, 20 mg ........19.19 .............29.99 (Walgreens)
Zoloft, 100 mg ....................140.99
generic Zoloft, 100mg ......... 45.19
Celexa, 40mg .......................122.99
generic Celexa, 40mg............ 33.69
Cymbalta, 60mg .................. 149.99........... 142.99 (Walgreens)
Nortryptiltine, generic, 75mg.. 31.69
Lexapro, 20 mg ..................... 106.99......... 105.99( Walgreens)
Elavil, 75mg ............................53.59
generic Elavil, 75mg................ 10.99,,,,,,,,,,, 12.39 (walgreens)
Trazodone, 150mg ,,,,,,,,,,,,,,,,,,, 23.19
Wellbutrin XL, 300mg............ 215.99
generic Wellbutrin XL, 300mg... 149.99....... 139.99 (Walgreens)

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[from Roy]
Don't forget about Walmart's $4 list. You can buy 30 pills of any of these for $4, whether you have insurance or not. In the hospital, we frequently choose meds for uninsured pts based on this list (eg, Prozac 20 mg = $4/mo. Elavil, Paxil, Trazodone and Doxepin are other choices for antidepressants.)