Under fee-for-service arrangements, clinics are organized around what generates the maximal income. Whether for-profit or not-for-profit, making money is the primary concern. Clearly the pressures on "for-profits" are greater since someone (stockholders, corporate officers, owners) wants an income stream. Not-for-profits are more likely to be content with any side to the black of expenses.
In fee-for-service arrangements, payors (government or insurance companies) decide what's allowable and not allowable. For example, U.S. government Medicare regulations prohibit billing for group psychotherapy if anyone moves in the room or if music is used. I asked the compliance officer at the community mental health center what would happen if participants switched chairs after the group began. "Could we still bill?" In complete seriousness, she told me that she'd have to look into that question and get back to me. Apparently the U.S. government is not happy about singing and dancing, the key elements of all indigenous ceremony. Also excluded are music therapy, art therapy, dance therapy, and drama therapy. I wonder how they decided that these methods were so inferior to "talking heads" as to prohibit the entire group session from any payment if these tools are used. A literature certainly exists to document their use and usefulness within the Veteran Administration's health care system, so, apparently, only veterans in approved V.A. facilities may sing and dance.
My working conditions were bad enough before clinic restructuring, even in a relatively enlightened environment. I was given half an hour per patient which also included charting time, phone calls, and any non-contact (with the patient) services that needed to be provided. I also had to be available to consult to the therapists as needed. While barely doable, this far exceeded the 15 minutes per patient I was given when I worked in community mental health in Pennsylvania. Because the most money can be made on my writing prescriptions, this is what I am expected to do. Talking to people is done by therapists, who have master's degrees and can be paid less than me. Government and insurance companies have decided that drugs are more valuable than talk. Studies consistently show psychotherapy equal to medication by 16 weeks, though not necessarily by six weeks. However, some of the talk that occurs with the therapists in the community mental health center consists of half-hour check-ins once monthly, clearly not enough time for someone to change his or her brain.
I was able to negotiate doing two late groups so long as the income from the groups met or exceeded what would have resulted from my seeing individual patients. Just before clinic restructuring, I was able to negotiate an hour appointment with clients during the lunch hour so that I could actually be helpful. I have two people now whom I see for an hour weekly, though not all weeks since sometimes other meetings are required that interfere.
Clinic restructuring was supposed to improve care for patients in New York. Let's look at what really happened. Under our old system, the clinic would bill for visits with nurses. People who were stable often saw the nurse either alternating with the psychiatrist for the patient's quarterly visit or seeing the nurse more often and the psychiatrist once yearly. (This occurred because the family doctors in the community refused to manage patients with mental illnesses, for they could have taken over writing the prescriptions and saved the health care systems large amounts of money.) Suddenly, no one could bill for nurse visits. What New York's Office of Mental Health had failed to realize was that the nurses were the stable pillars in the patients' lives. Doctors came and went, but nurses keep their jobs for a long time and have become the continuity for the system. They stay and really get to know the clients, who are usually much more bonded to the nurses than the doctors.
My predecessor was well known by the patients for his very brief visits (and all his notes read the same). The nurses, however, really appeared to care about the patients and spent time with them. An informal friendliness existed between nurses and patients that wasn't observable in the more formal and stiff transactions between doctors and patients. Clinic restructuring eliminated that! I assume educational level was supposed to trump relationship.
Now I am expected to see a patient every twenty minutes, still responding to the therapists when needed, and still managing any crises that occur. This is nevertheless, five minutes better than what I encountered in Pennsylvania. This was to make up for not being able to bill for nurses' visits (and therefore not being able to let the nurses see patients). So far, because of the large number of "no shows", I've been able to end the day more or less on time, but in a more stressful, less thoughtful way than before. Gone are the letters to the primary care physicians I used to dictate. No time for that. Gone is the time to check medication interactions for everyone. Now I can only check for the potentially glaring problems. Gone is the time to review other medical conditions and prescriptions from other physicians except for the few. I was muddling through until I learned this week that not only must I do the impossible (assess a new patient and prescribe a medication in 20 minutes), but the trains must run on time. No patient was ever to wait more than 15 minutes.
This was the last straw of exasperation for me. In our money-driven but also customer service oriented model, we had lost track of how some tasks and patients simply take longer to manage than others. Just this last week I had managed to diagnose two cases where profound hypothyroidism turned out to be the cause of much of two women's psychiatric distress. This was because I listened to the women's stories which took actually 45 minutes to tell, coupled with writing prescriptions, charting, and ordering laboratory tests. Both these women had been coming to the clinic for two years and no one had had the time to think about the thyroid gland. If we treat people like widgets on an assembly line, then they will get assembly line care.
I caught up and ended the morning on time, but, heaven forbid, not without some people waiting longer than 15 minutes. Front desk staff had been frantically paging me every three minutes while I tried to focus on the story I was hearing. In this case, it was lucky that I listened for a long time as it was only at the end of the story that one of the women told me that she bruised easily and the bruises were large the final clue to her diagnosis.
So I got in trouble. Earlier, I had made a suggestion to management that we could tell patients that there might be wait times and to think of their appointment time as representative of a range rather than a precise moment. This was consistent with the somewhat random arrival times of many of our patients who would oversleep, come in the afternoon for a morning appointment, or the morning for an afternoon appointment, or be a day early or a day late. I always worked them into my schedule, assuming that this was as close to their expected arrival time that they could achieve. My proposal was summarily rejected. The other doctors managed to be on time. What was wrong with me?
They're right. I'm the anomaly. I come from a culture which would never interrupt someone in the middle of a story. We recognize that people need narrative closure. They need to tell the story they came to the doctor to tell.
My manager accused me of thinking I was the only one in the clinic and I was ignoring the potential contributions of the therapists who could give emotional support and listen to the people's stories. My arguments sounded lame. Who cares about narrative closure? Why should I need rapport or to establish a relationship with someone just to prescribe medicine. None of the other doctors did. What was wrong with me? No one cared about what I was proud to consider good diagnostic work. The level of one woman's thyroid stimulating hormone was 88. The other's was 134. Normal levels are 0.4 to 4. We'd been missing this for some time. Apparently running the trains on time was more important than keeping them from breaking down.
I realized that I will never be a psychiatrist at heart. I remain a family physician interested in people and their minds and relationships and families. In family medicine, we knew we often ran late and had too little time, but we tried harder than psychiatry does, I suspect, to let people tell the story they came to tell. We can't hear more than one story per visit, but at least we can work to help people achieve narrative closure on that one story. Hopefully, the people we see will feel cared about. That apparently is not necessary in psychiatry.
Now, back to my initial point. If I were given a budget and a panel of patients for which to care, I could do a much better job than I'm doing now. I'd do more groups (though clinic restructuring has made three people in a two hour group equal in payment to one person for an individual 15 minute medication visit). Groups eliminate much duplication of effort and allow sufficient time to do therapeutic work. With groups, I can see 12 people over 12 hours, while, even in Pennsylvania, it would be only 8 for two hours of individual appointments, and six in New York. I'd challenge the physician only does medication assumption. I'd create better, more helpful teams with the therapists (now we talk to the therapists as a group for 20 minutes every other week). Maybe one of us would focus on family and community aspects while the other would do more work with the individual. Or maybe we would target different symptoms with our interventions. In our center we never do appointments with more than one person at a time. We certainly don't go out into the community. I'd change that and we'd meet the patients where they live. We'd make contact with their pastors, teachers, and other important people in their lives. We'd become part of the community instead of hiding in isolation between the goals of privacy and objectivity.
I think this is the general practice-mental health model that my friend and colleague, Dr. Venetia Young, champions in the United Kingdom. We'd connect instead of isolate. This is also what my patients need to do. We don't now model for them how to do that in the least. I could and would do so much more for patients outside of a "fee-for-service" system and so would most of my colleagues.