Recently I was contacted by a reporter who wanted to speak to me about why it’s so difficult for patients to find a psychiatrist. She’d found me by Googling “Why psychiatrists don’t take insurance” and already had read an article I’d written with that title. That day, it had snowed hard enough that most of my patients had canceled; the grocery store had closed; and I had plenty of time to chat with a reporter. The other thing I noted – perhaps because other psychiatrists had unexpected free time because of the snow – was that Maryland Psychiatric Society’s listserv was getting a lot of posts. The posts focused on issues to do with maintenance of certification (MOC) or with the fact that every physician in the state was now going to be required to have a CME credit on opioid prescribing for licensure renewal, and there would be a requirement for physicians to take a course on substance abuse to renew their CDS registration. The hope is that these courses will reduce deaths caused by narcotic overdose, and the courses would be required for all physicians without regard to whether they are relevant to their practice.
The reporter and I started with a discussion of why so many psychiatrists have chosen not to accept health insurance (myself included). She then told me about an insured man who had been diagnosed with schizophrenia and substance abuse who was unable to get an appointment with a psychiatrist. She asked me an interesting question: “Don’t psychiatrists want the challenge of treating the difficult cases?” The patient in question never did find a psychiatrist in time and he ended up committing a murder then dying by suicide – an awful tragedy that highlights access to care problems.
In addition to a private practice, I have worked in community mental health centers, and I discussed how that setting is often better suited for patients with serious psychiatric illnesses. More services are offered, and having a variety of mental health professionals in the same facility promotes better coordination of care between psychiatrists, therapists, and case managers, as well as with family, residential care providers, and day programs. The problem is that demand for treatment at outpatient clinics is high, and sometimes the waits for an initial appointment are long, or clinics even may stop accepting new patients at times when they get overloaded.
We talked about the logistics and trade-offs of working in a clinic vs. a private practice, and the reasons why working full time in a high-volume clinic might lead physicians to want a change after a few years. And then the reporter asked me another interesting question – with such long waits, why don’t the clinics hire more doctors? I explained that there was a shortage of psychiatrists and began to talk with her about demands on physician time that take time away from patient care. With the e-mails flying about MOC and new course requirements, it was a place to start, but the snow was still falling, and she heard a lot about the factors that drain physician time and money, both limiting how many patients a psychiatrist can see and driving up the cost of care.
By the time I got off the phone, I decided to tally all of the things that we are required to do to see patients. I was able to get some quick help on the listserv, from friends, and on Twitter.
Every time an agency or insurance company sets up a requirement for a physician, there is a small diversion of time. There is no limit on how many different requirements can be set or whether they need to be relevant to the physician’s work. While I realize there is little sympathy for physicians who, for the most part, are still blessed to earn a good living while doing meaningful work, these diversions add hours to a doctor’s day and cause them to burn out more quickly. So the insurance company that demands that a physician devote 20 minutes to get authorization to prescribe a medication that costs pennies a pill is actually harming society. And no one oversees the big picture.
That said, here was the list we came up with of factors that drain time and money in a clinical practice. Please note that some of these items – for example, uncompensated time returning calls to patients or keeping clinical records – are just part of being a doctor; they’re not something that should be eliminated. Similarly, issues related to having a space to work are part of having a business. I wanted the list to be complete to illustrate the demands on a psychiatrist, not to suggest that none of these things are important. Obviously, some doctors are faster or slower at certain tasks, and people vary greatly in how much time they devote to clinical practice vs. teaching, research, or writing articles for Clinical Psychiatry News. I obtained information in a very quick and casual manner; none of this should be construed as scientific.