3 Things I Would Tell Every Psychiatrist Today

Each year in May the American Psychiatric Association convenes the world’s largest psychiatric conference. Routinely attended by over a quarter of all psychiatrists practicing in the US, the mass of specialist physicians will help themselves to a veritable feast of CME activities and courses spanning the gamut of science and emerging trends in mental health. World famous keynote speakers will reflect on the state of behavioral health services in the US and abroad, and attendees will leave the event loaded with scientific tidbits empowered to improve their practices. There are three messages that may escape their attention, however. Three elephants in the room that are simply too big to ignore. Three challenging truths that the profession must face, or be relegated to the sidelines as the world of behavioral health shifts and shivers over the next decade.

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Of all medical specialties, psychiatrists are among the least likely to accept public or private insurance. In fact, according to a 2014 study, almost half of all psychiatrists practicing don’t accept any form of insurance – a problem magnified on the coasts.¹ The authors point to a 17% decline in acceptance rates between 2005 and 2010. Rates of health insurance coverage are reaching nearly 90% across the country, in part because of the Affordable Care Act. Also supporting coverage for greater numbers is stronger enforcement of the federal parity laws that require equal reimbursement of mental health and substance abuse services. These trends are nothing but positive, particularly as the latter reflects a cultural shift away from the stigma surrounding mental illness. Taken together, though, the result is an unprecedented crunch on the existing mental health system. Consider, too, that more than half of all practicing psychiatrists are within 10 years of retirement and yet there is no significant movement on the horizon in the creation of GME slots. This perfect storm will challenge the psychiatric workforce to deliver the evidence-based care it will be teaching at the APA Annual Meeting.

To be sure, the refusal to take insurance is a growing trend across specialties (see the AAFP’s statement on direct primary care), and so psychiatry is not alone. But psychiatry has some of the lowest overhead of all medical specialties, and with this could come more flexibility, and greater capacity for cash-only practices. Cash-only practices, on the whole, are more likely to take fewer-and less complex-patients, arguably persons with less disability. The more the profession is seen as not willing or able to reach out to populations most in need, the less relevant it will become-especially to lawmakers considering bills for psychologist prescribing or loosening oversight requirements for mid-level practitioners. The profession must renew its commitment to the underserved, the disabled, or those unable to pay cash for services, or be content with others encroaching on its professional turf who are willing to treat and manage complexity.

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Payers and the public alike are shifting in their expectations of medical professionals, and value-based purchasing is growing in its appeal. To maximize the value equation (outcome/unit cost), psychiatric practitioners must demonstrate outcomes to keep up with costs. The field of behavioral health has been slow to incorporate validated measurement-based outcomes, often because they are seen as antithetical to the practice of psychiatry despite their documented benefit.² Although the profession espouses quality improvement and self-assessment, the Assembly of the APA has far from embraced performance in practice modules as an essential part of Maintenance of Certification. While admittedly riddled with complexities and perceived as meaningless, what other solutions are out there?

Ironically, the field of psychiatry has some of the most advanced health services models that fit neatly into value-based purchasing for the healthcare system of the next decade. Referred to as Collaborative Care, these models allow for a team to be held accountable for outcomes in populations suffering with depression. With new CPT payment codes on the horizon for Collaborative Care models, will the profession embrace them adequately?  Much remains to be seen, but the lofty ideal of pay-for-performance is not likely to fade over the coming years. Clinicians and professions who can back up their worth with outcomes and numbers will ride the tide of healthcare reform more successfully.

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3. Psychiatrists must relinquish some aspects of clinical diagnostic and therapeutic control in favor of team-based collaborations.

Translation: clinicians must learn to trust the basic capacity of non-psychiatric colleagues to diagnose and initiate treatment plans for relatively uncomplicated mental illnesses. Presently, over half of all psychotropic medications are prescribed by clinicians without formal psychiatric training, a number likely to increase with increasing demand for services. If psychiatrists generally continue to espouse that they are the only capable mental health diagnosticians by reinforcing notions that only they can perform a comprehensive psychiatric history and physical prior to initiation of a treatment plan, they will severely limit access to any behavioral health assessments or treatments-a situation that may create a perception of non-collaboration and guild-serving advocacy placed above the needs of populations seeking care.

In fact, because it involves multiple perspectives and diverse therapeutic skills, team-based care can allow for richer understanding of a patient, creative engagements, and more nuanced intensification of treatment. The whole is truly greater than the sum of the parts.  To operate in a team, psychiatrists must value and respect the input from team members, something physicians in general are taught to be inherently skeptical of.

For many clinicians, attending the APA Annual Meeting will be a transformative experience. The field of mental health is at a tipping point globally. In Atlanta in a few days, the largest concentration of psychiatrists in the world will congregate and talk.

What would you like to say?  How would you like them to transform? Weigh in:  

#APAAM16     ...     #whatiwouldsay     ...     @erikvanderlip

References:

1. Bishop TF, Press MJ, Keyhani S, Pincus HA. Acceptance of insurance by psychiatrists and the implications for access to mental health care. JAMA Psychiatry. 2014;71:176-181. doi:10.1001/jamapsychiatry.2013.2862.

2. Guo T, Xiang Y-T, Xiao L, et al. Measurement-based care versus standard care for major depression; a randomized controlled trial with blind raters. Am J Psychiatry. 2015;172:1004-1013. doi:10.1176/appi.ajp.2015.14050652.