As a solo-practice psychiatrist, I am more connected to the cost/value equation of my services than the typical system-employed physician. I’ve also written in prior posts about my concerns with modern psychiatry. I have worked in a variety of settings over the course of my career, and I realize that coming to an understanding of something as complicated as another person’s subjective life experience is a very difficult endeavor. At the very least, such an understanding takes time. It also takes a willingness to maintain the constant recognition that my perception may be wrong, and may be the result of my own bias. Finally, it takes a certain amount of intelligence. Over time, certain patterns of thought become apparent and easier to recognize– but these patterns are extremely complex, and trying to provide insight into such patterns, without causing a person to take offense, requires intelligence, patience, and tact.
I have come to the realization (a somewhat surprising realization, frankly) that psychiatry works, when practiced properly. I’ve come to realize that the ten-minute med check is worse than worthless, as a ten-minute glimpse of a person’s day is more likely to lead to the prescribing of a harmful medication than a helpful one.
On the other hand, if one has the time to sit and share small talk, then review the important issues occuring in a person’s life, and then discuss the problematic symptoms that the patient is experiencing…. then ask questions that provide context for the symptoms, and perhaps make a small suggestion or two in order to provide outside insight into the cause of the symptoms…then present the different medications sometimes used for the person’s symptoms, after first discussing whether the person would prefer medication over working on the problem through more ‘mindful’ approaches… then discuss the different side effects possible with each medication, and the likelihood that the medication chosen would be helpful…
If one does all of these things, psychiatry can actualy lead to profound improvement in a person’s symptoms.
I thought about this situation recently, after paying over $500– my deductible– to repair my car, after hitting a deer. The cost had to be paid, and I found the money and paid it. I’m not a ‘rich doctor’ for reasons that I’ve discussed elsewhere, so the expense was significant– but I need a car, and it had to be paid. Likewise, I had to come up with $3000 to repair my septic tank this spring, since the alternative– having disgusting liquid bubble out of my lawn– was not an option. I had to pay my speeding ticket– I’m trying to slow down now, by the way– and I had to pay for my own health problems.
If I need surgery, the cost will likely run in the tens of thousands of dollars. Heck, having a couple warts removed ten years ago cost $400, and the doc was in the room for about 5 minutes. My auto repair bill, paid graciously by my insurer, amounted to $11,000.
Then there is the cost of psychiatric care. For reasons I alluded to in the first paragraph, I have rejected the insurer’s model of psychiatric care– the 4-6 patient-per-hour, 10-minute med check. I spend 90 minutes on the first appointment– often more. And follow–up appointments last at minimum 30 minutes, and for more complicated cases, 60 minutes. Because I see only a third as many patients, I do not accept the dramatic discounted fee offered by insurers, and patients are required to pay something.
For patients with a deductible, their cost is essentially the same as for an in-network doctor. For others, insurers pay some portion of my fee, and for some, insurers pay nothing, leaving the burden of the full cost of an appointment– $199– on the patient. For that $199, the patient receives 30 minutes of my attention, based on an education that cost me over $100,000 (not counting college), and 16 years of my life to complete– not counting grad school.
I see people who are truly suffering; people with significant anxiety, depression, addictions, phobias– problems that cause much greater disability than would a torn ACL. So here (finally) is my question. Why is it that people will roll their eyes and pay their $2000 deductible for the torn ACL, as their insurer pays $20,000 more, yet refuse to spend anything to treat their depression? Given the effect of social anxiety on a career, why will people pay $3000 for a septic tank, yet consider $400 unreasonable if spent to improve their ability to interact with others?
We all know the importance and value of a close relationship with a friend or spouse; we all fear being alone at the end of our lives. So why do we consider a $1000 plasma TV a ‘steal’, yet consider the same amount, if spent to solidify a marriage, a huge expense?
There is so much good that psychiatry can do. But I am not impressed by the value of fast diagnoses, and rapid-fire medications. On the other hand, a limited series of visits, to treat targeted symptoms, is one of the most cost-effective areas in medicine. I often think to myself, ‘I can FIX this person’s problem– but not in 30 minutes!’ I’ll be frustrated that a person does not consider treating their psychiatric symptoms as valuable as purchasing a new car, or a larger house. Gosh– my entire cost of treatment– enough for plenty of visits– can be covered by ONE monthly mortgage payment. And while the mortgage bills keep coming, the benefits of treating one’s symptoms can become a gift that keeps giving, month after month and year after year.
Please help me out by answering the poll below– I’ll try to discuss the results on my radio show in a few weeks. Thank you for helping me understand an issue that’s had me a bit frustrated!
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Sign in now[...] think I’ve made the point I wanted to make, but if you have time, please stop by my own web site and answer a poll that asks about attitudes toward paying for psychiatric care. Your answer would [...]
Thanks for a very insightful post. I could not have expressed my feelings better. Please keep caring.
Dear Dr. Junig,
This is the 1st article/post that I’ve read in about 1.5 years on this subject that fits my feelings and experiences with emotions, counselling and psychiatry to the T. I discovered your website from this post on PsychCentral, and will happily continue following the rest of your post on both sites. I would love to get in touch with you some day to share perspectives. Please keep sharing, if I lived in the States I would love to have you as my Psychiatrist. Good luck on your practice, model and please continue furthering the field in a positive direction!
Cheers,
Jacek Mokrzec
Before I started on Medicaid, I had no insurance and could not afford it. $199 was just not possible, no matter how much I stretched things (psychiatric care IS important; however, so is rent, food, etc). Medicaid now covers everything; though, do to the issues with it (declining reimbursement) it was difficult to find a good psychiatrist who would take it. I am fortunate that I did. He operates under a similar philosophy as yourself concerning “med checks”, as well.
I believe that your services are worth what you charge and I have all the respect for the years and effort you put into it; the general public is incredibly unfair when they talk about physician salaries. I just can’t pay it.
First off, I love this post. I’ve been really drawn to becoming a psychiatrist as I feel I have the compassion, and potential in patience, and intellect to help people through their times. But naturally the question does arise as to how to charge your worth and still make your services enticing enough for the community to see your value and pay it.
But i’ve heard many private practice psychiatrists mostly operate on a “cash only” basis so thats reassuring. Though, I equally love the challenge of business/marketing, and with the technology in years to come, I’m sure i’ll be able to run a practice that fulfills my financial hopes, but also abides to the philosophy of this post and serves a great deal of of the community by making it more cost effective for them.
Anyway, great post, will come back to read more!
Chris
Thank you, Chris! I really enjoy my practice– more and more as time goes on, as I get to know my patients better and better. I do worry, of course, about the future of healthcare– and in particular about government involvement. Yes, healthcare is ‘sick’, but I’m afraid of the ‘one solution fits all’ approach of Washington. I hope that I’m able to ‘opt out’ of whatever mess is created– at least until the kinks are worked out!
The salary issue is difficult to discuss without getting people angry… but I realized the other day that if you look at the reimbursement of physicians by the state or Federal government– Medicaid or Medicare– that physicians are paid less than teachers on an hourly basis. In fact, it isn’t even close, if you take into account fringe benefits. Yes, the government assumes that doctors will make up the difference by what they charge other patients– those not covered by Medicare or Medicaid. But as more people are on public assistance, and as the state and feds scramble to find doctors to treat people covered by those programs, they should at some point recognize the fact. I come from a family of teachers– my mother, sister, brother, sister in law, and others– so I’m not trying to pick a fight– but rather, only to point out the way things are. I’m using numbers from the State of WI web sites, showing a total average compensation for teachers ranging from $70,000 to over $100,000 dollars per year, depending on the district, and dividing by the number of school days times an 8-hr day. Both professions involve continuing education and working after hours– so I consider that part of the equation to be moot. One profession requires 4 years of college; the other requires 4 years college, 4 years med school, and 4 years residency.
I teach medical students in Milwaukee each week, and know that many will face debt well over $100,000 upon graduating. I see the pressure they face to enter the fields that guarantee a high income– like orthopedics, radiology, or ENT surgery– and worry about the future of psychiatry.
[...] management can be done well, the “med check” is often critiqued as an assembly-line approach that treats collections of symptoms, not people. The assembly-line metaphor highlights [...]
Dear Doctor, the reason *I* don’t see a psychiatrist is because of government reporting and privacy issues. How can we talk freely and really get to the bottom of anxiety, rage, etc. when the dear doctor must report what he/she subjectively evaluates a patient as having or being. Suppose the patient is distraught, angry, depressed and they are DIAGNOSED with PTSD. (or any number of things, PTSD being common) Well, that little item can ruin somebodies life. Not that their life is great to begin with or they wouldn’t be in a shrink’s office, but it could get much MUCH worse. No privacy equals no trust and no doctor visit. Too risky. See how simple that is?
Understood. That, frankly, is one reason I value being independent, and not belonging to insurance panels…. With the big ‘systems’ these days, you never know who has access to what. Anything said in my office stays in my office. I don’t use outside dictation services ; I don’t use outside medical record services; and I talk to the patient before any records are released for any purpose at all.
I DO have to protect patients who threaten themselves with imminent harm, and I DO have a legal obligation to warn another person who is facing imminent harm from my patient. Otherwise— it is just between us.