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Articles    H2'ed 4/16/10

Psychology and Health Care Reform

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Insurance companies could use this same logic with mental health care. If they limit access, they would, in effect, be saying, "you have unlimited coverage", but, given sufficiently few credentialed providers, you could only be seen every 6 to 8 weeks, unless your provider controlled access so as to see you weekly, which few do. This is because having more patients who come less often provides more economic security than having less patients who come more often. In the latter scenario, one patient dropping out of treatment or completing treatment has a much larger impact upon cash flow than the first scenario.

Dr. Johnson was most concerned that psychologists would forget or neglect to do psychotherapy just as psychiatrists have largely done. He informed me that what excited psychologists these days was (1) health psychology, or the opportunity to work alongside physicians in primary care offices with medical patients, and (2) gaining the opportunity to prescribe medications. He was concerned that the one hour long psychotherapy visit would be shortshrifted in their rush to work alongside physicians or to function like physicians. Being a physician, I am familiar with both of these areas. I believe that we psychiatrists have largely created thee voids that psychologists are now rushing to fill in our failure to train and interest primary care doctors in mental health. The insuance companies have helped this along by refusing to pay primary care doctors for extra counseling time which is required to attend to mental health needs in primary care, even if it is only 5, 10, or 15 minutes extra time. The exception to this is Canada, where physicians are reimbursed, but at a lesser rate than for medical care. These same companies will reimburse psychologists working in primary care practices To the insurance companies, this looks like two unrelated and separate visits on the same day (to two different providers), which is apparently more acceptable than one longer visit for the same purposes to one provider. This is despite studies having confirmed the superior effectiveness of one person spending more time with patients and providing more services than dividing this up between two or more providers, all of whom spend less time. Apparently, the better we know someone (through spending more time with them), the more effective we can be. This is because of the crucial of relationship in health care, a factor which insurance companies underestimate.

I was able to reassure Dr. Johnson that some psychiatrists still do psychotherapy and those who do often take institutes for four years after completing their psychiatric training. These institutes can be psychoanalytic, behavioral, narrative, gestalt, or more, but are relatively common among psychiatrists who practice psychotherapy. They are done part-time during evenings and weekends while psychiatrists practice during their days.

I have seen psychologists doing 10 to 15 minute counseling sessions in primary care offices. While helpful, I agree with Dr. Johnson that these visits are not a substitute for psychotherapy.

What concerns me more is psychologists prescribing medications. I used to feel neural to slightly positive about this, until a friend took over the coordination of one of the training programs to teach psychologists how to do this. My friend was initially enthusiastic about her new job and jumped into it with both feet. She soon resurfaced at the shallow end of the pool, bruised, and looking for new work.

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Lewis Mehl-Madrona graduated from Stanford University School of Medicine and completed residencies in family medicine and in psychiatry at the University of Vermont. He is the author of Coyote Medicine, Coyote Healing, Coyote Wisdom, and (more...)
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