This week I had lunch with Dr. Martin Johnson, a Honolulu psychologist in private practice, who educated me to more ramifications of the new U.S. health care reform bill for mentalhealth care. As of July 1, 2010, he told me, insurance companies must cover mental health diagnoses on par with their coverage for medical diagnoses. Thus, if no cap exists for the number of covered visits for diabetes, no cap can exist for the number of visits a person can have for major depression or for schizophrenia, so long as the insurance company provides any mental ill coverage at all.
Immediately I asked, "won't all the companies just drop their mental health coverage?"
"No," Dr. Johnson answered, because the largest consumer of insurance plans are the large companies and they care that their employees have coverage for substance abuse treatment and for mental health, since these are the main reasons for losing good employees. Untreated employees do not return to work and must be replaced. Replacing employees is a complany's biggest expense." Dr. Johnson had earned an M.B.A. degree prior to becoming a psychologist and was well informed about the business view of mental health coverage. "Employers are not going to buy insurance products that lack mental health and substance abuse coverage. To be competitive, insurers must cover these services."
Though this made sense, it reminded me of an item in a newsletter to which I subscribe, Silicon India." This newsletter reported to its largely Indian audience that U.S. companies had decided that employees were readily replaceable and were therefore disposable commodities. This fit my impression of business in the U.S. better than Dr. Johnson's statement that recruitment and retention are a company's biggest costs. "But who will they credential to provide the coverage?" I asked.
"That's the question," agreed Dr. Johnson. "Clearly psychiatrists and licensed psychologists will be covered, but what about the many other mental health care providers?" He didn't know. These include marriage and family therapists (who paradoxically, mostly see individuals), licensed clinical social workers, certified counselors, certified drug and alcohol counselors, school psychologists, educational psychologists, and more. Whether insurance companies will reimburse any or all of these providers remains to be seen.
Despite this very good news, insurance companies have other tricks to reduce coverage. They can limit the number of credentialed providers. If they credential only a small number of providers in a given speciality or field, then access is limited. Only providers approved by the insurance companies are eligible to bill them. If this number is kept low, access is reduced, and utilization decreased. I observed this in action in the 1980s when I worked for an HMO in California. One of my duties was to provide acupuncture in the Pain Clinic. The HMO widely advertised how progressive they were to provide acupuncture. However, given that only two physicians provided acupuncture and only a part of their time, access was limited. Patients waited six months and could only be seen every six to eight weeks. This is rarely enough for most acupuncture protocols to be effective, especially for more serious and chronic pain syndromes. I challenged our policy, suggesting that we limit access so that people who began acupuncture could be seen once or twice per week until they finished a course of treatment that would be sufficiently intense as to have a chance of being effective. My suggestion was vetoed. The point was advertising coverage, not providing effective treatment programs. Upper management did not even believe that acupuncture worked. The intent was more about marketing than efficacy.
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.
She had incorrectly thought that psychologists would be excited to learn psychopharmacology (and basic science) in the way it is taught now in U.S. medical schools. Was she ever wrong!
Medical schools have come to the realization that learning basic science in isolation from clinical work is basically time wasted. Retention of the information is poor. While medical students are legendary for their memorization skills, most of the material is forgotten after the exam. This was my experience and that of my colleagues. The basic science we remembered came later, when we were treating patients and read about the basic science aspects of their disease. We remembered the information because it was relevent to a real person whom we know. We had long forgotten our basic science classes. Thus, some years ago, beginning with the University of New Mexico (Harvard rapidly followed and took most of the credit), courses in the separate disciplines were largely eliminated. Instead, medical students work together in small groups with a mentor. They spend 4 to 6 weeks perorgan system focusing upon several common diseases with real patients to interview and examine. They interact with relevant faculty as they explore all aspects of all illness, including the underlying changes that occur in cells, its biochemistry, genetics, physiology, epidemiology, and more. At the same time, students learn how to treat the illness. Having real patients packs the information into a narrative, the best means of memory storage. Doing their own research, presenting their findings to their mentor and fellow students, and answering questions like those that will be posed to them in practice are exciting ways to achieve competence in a field in which there is always too much to know and what is known is continually changing. My friend was scheduled to teach a class on the body anatomy, physiology, endocrinology, etc. (they get only one 2 unit course on everything below the brainstem). She proudly showed me her plan. She had started with the lungs. She divided her six students into two teams. One team had a COPD (chronic obstructive pulmonary disease) patient, while the other had an asthma patient. Their final job was to pick medications for these patients that would have the least interactions with the underlying illness and the medications used to treat it. Their task was to choose a drug for (a) depression, (b) anxiety, (c) mania, (d) psychosis, and (e) sleeplessness. They were to speculate on CAM (complementary and alternative medicine) therapies that the patients might also be using and to discuss other non-medical therapies that might be helpful. In the process, they were to wander around the hospital (they all worked at the same hospital) and meet their counterparts who interacted with such patients. They were to visit the pulmonary function lab and watch the technicians assess lung function, finding out how these two diseases were differentiated. They were to go to the pathology lab and watch a lung being autopsied and examined under the microscope in a frozen section. They were to talk to pulmonologists and respiratory therapists and learn as much as they could about how these diseases affected the normal structure and function of the lung (which required them to learn something about its normal structure and function). During class, each group would take turns presenting to her and to the other students what they had learned and the conclusions they had made. She would correct any errors and comment on their choices of medications and conclusions. She was also available all week as a consultant in case they got stuck in any aspect of their discovery. My friend wanted the psychologists to see how physicians learn and in the process, to learn how to think more like physicians (see the book, How Doctors Think). She had admonished the students to avoid spending more than six hours for each student during the week on this task since it was only a two credit course. She thought they could get carried away with the excitement of learning in this manner and of discovering the body and its mysteries.
The students showed my friend! Unanimously,all six went to the Chair of her Department and demanded that she be replaced as the teacher of their course. She showed me the letter they wrote in which they accused her of wasting their time, both in class, and outside of class. They accused her of didactic negligence. They demanded powerpoint presentations and a class of basic scienc e without any clinical correlation. They asserted that her assignments were ridiculous. Her Chair did replace her as a their teacher, giving the class to a retired pediatrician who agreed to present didactic powerpoints of basic science. My friend resigned in humiliation.
Later she told me that the pediatrician had told her that mostly the students slept through his lectures and that he was teaching on a high school level about what is a fat, what is a protein, what is a carbohydrate, etc. He had no confidence that these students could ever treat a patient or ever should. He had concluded that they were overworked in the daytime and had conspired to find a way to do the least work possible in "night school", for which their employer was footing the bill and requiring them to go. By demanding a mid-term and a final, they could agree to set the curve at a level in which they were all essentially equal. Making presentations would have required them to actually work and learn.
My friend's replacement teacher agreed with her that he would, of course, give them all "A"s, regardless, because it was too much of a hassle not to do so. The students had won.