Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Thursday, October 23, 2014

Let's Talk about the ACA

I got a lot of responses to my recent post, Reinvention. I have to say, I was really touched by the concern people expressed, and I appreciate the suggestions for augmenting my soon-to-be-depleted income. I want to assure everyone that I am not on the verge of starvation.

One of the commenters focused on the Affordable Care Act (ACA), or Obamacare, and remarked, correctly, that not all the problems with healthcare can be blamed on the ACA. There was also a question of whether or not any of the NY exchanges covers out of network providers, because apparently, there's at least one that does in Massachusetts. Well, I checked, and there is no out of network coverage in the NY Exchange, except for immediate, emergent care.

Back in January, The Carlat Report published an article entitled, An Ethical Perspective on the Affordable Care Act, which I wrote. The contract I signed with them indicates that once 6 months has passed since the publication, I'm allowed to publish or use it myself, and since it's been that long, I thought I'd includea version of it here:

An Ethical Perspective on the Affordable Care Act

The Patient Protection and Affordable Care Act (PPACA), commonly referred to as the “ACA” or “Obamacare”, was signed into law on March 23, 2010. It’s mission: to secure health care for all US citizens, irrespective of age, gender, race, medical history, or socioeconomic status. This article will present a brief review of the ACA, and then discuss its ethical considerations, especially as they pertain to psychiatry.

First, An Ethics Refresher:

There are generally considered to be four principles of medical ethics:
Autonomy, which implies respect for a patient’s ability to make decisions for himself or herself; Justice, which allows for equal treatment of all, including fair allocation of scarce resources; Beneficence, or acting for the good of the patient; and Non-Maleficence which is the principle of primum non nocere, first, do no harm.

Ideally, any interaction with or treatment of a patient obeys all four principles, but in reality this is often not possible. For instance, the tension between autonomy and beneficence comes into question when determining patient capacity.

Provisions of the ACA are set to take effect by 2020, and generally fall into two categories: increasing access to healthcare (by mandating insurance coverage), and improving the quality and efficiency of health care delivery. Table 1 lists all the provisions scheduled through 2015, divided roughly into these two categories.

For the most part, potential ethical dilemmas for psychiatrists will occur in the quality and efficiency improvement category. Particular areas of concern are new innovations to improve quality and bring down costs, integrated health systems, linking payments to quality outcomes, payment bundling, and paying physicians based on value rather than outcome.

The Collaborative Care Model:

The Collaborative Care Model, developed by Wayne Katon, M.D., and Jürgen Unützer, M.D., at The University of Washington, is a type of integrated health system. Its implementation highlights many of the ethical pitfalls of the ACA, particularly as they pertain to psychiatrists.  In this model, primary care clinic patients are screened for psychiatric illness using simple rating scales. If the screen is positive, they are referred to a care manager, usually a MSW or other behavioral health provider, who oversees their psychiatric care. The care manager is, in turn, supervised by a psychiatrist, who reviews cases at regular intervals, but does not see the patients, except under unusual circumstances. Patient progress is measured by rating scales, until clinical goals are achieved. And providers are reimbursed based on clinical outcomes. (Link)

There have been some reports of success with this model. A study by Katon, et. al examined 214 participants with poorly controlled diabetes, coronary heart disease, or both and coexisting depression, randomized to usual care or collaborative care management by a medically supervised nurse. The intervention combined support for self-care using motivational and encouraging coaching, with pharmacotherapy, either citalopram or buproprion. At 12 months, patients in the intervention group had significantly greater overall improvement compared to controls. There was a significant difference in scores on the SCL-20 depression scale alone, but non-significant differences in the other individual outcome measures (HgbA1C, LDL, systolic BP).

The collaborative care model raises numerous ethical questions. It provides access to psychiatric care to many more patients than could be seen individually by psychiatrists, particularly in remote rural areas, thus allowing for the just distribution of scarce resources. At the same time, beneficence, and even non-maleficence, need to be considered, because care is being provided by people with limited training-in the Katon study, nurses attended a 2 day training course on depression management and behavioral strategies. And in a 2006 meta-analysis of collaborative care for depression, Gilbody, et. al found that, “...effect size was directly related to ...the professional background and method of supervision of case managers.”

In addition, types of treatment may be limited to medication, and follow-up to screening questionnaires, often conducted via telephone. 

What are the ethical implications of overseeing care for many patients who will never be interviewed in person? As a psychiatrist, would you be comfortable signing off on such care?
There is the question of putting an additional burden on primary care providers.
And there is the broader question of wasting resources by not utilizing the psychiatrist’s hard-earned skills. Which psychiatrists will find this work appealing, and will the model influence which medical students chose to pursue careers in psychiatry?

What about other models? The Family Medicine Department at The University of Iowa Health Center has been running a grant-funded project called, Collaborative Medicine and Behavioral Health (CoMeBeh), in which Family Medicine residents spend one day a week onsite at the Adult Psychiatry clinic practicing general medicine, icluding routine care such as Pap smears and vaccinations. Thus far, responses from patients, as well as residents, have been extremely positive. 
This model provides better quality psychiatric care than the Katon Model. But it also targets a much smaller population, specifically, those patients who are seen regularly in a psychiatry clinic, rather than those seen in a primary care clinic. And unlike the Katon model, it doesn’t encourage psychiatric care for those patients who might need such care, but who might be unwilling to seek it out on their own. (Link)

Value vs. Volume:

There are several innovations of the ACA which are intended to encourage not only better quality care, but better quality care at equal or lesser cost. In other words, greater value. 

The motivation for this idea seems clear. It acknowledges that a high volume of patients does not allow for much individual time or attention, so it attempts to incentivize physicians to provide better quality care for each patient.
Given that a goal of the ACA is to ensure coverage for all, it is paradoxical to expect doctors to spend more time with and provide better care for each patient, and to simultaneously reduce cost, when there are more patients to be cared for. But even assuming it is possible to get more for less, how does one go about implementing these innovations? How is value measured? And what ethical quagmires does one encounter in the process? 


The Physician Quality Reporting System (PQRS) was designed by the Centers for Medicare and Medicaid Services (CMS) as a way to improve the quality of care of Medicare beneficiaries by tracking practice patterns and providing incentive payments. It was implemented on a voluntary basis in 2007, for Medicare Part B Fee For Service (FFS) beneficiaries. But beginning in 2015, there will be payment adjustments for Medicare providers who do not satisfactorily report data. 

The PQRS is ponderous. Providers can report via one of five methods, some of which require a vendor. Beginning in 2014, providers are required to report at least 9 measures within at least 3 domains (e.g. Patient Safety, Person and Caregiver-Centered Experience and Outcomes, Communication and Care Coordination, Effective Clinical Care, Community/Population Health, Efficiency and Cost Reduction), at a certain frequency. 

One example of a measure pertinent to psychiatry is PQRS #9, Anti-depressant Medication Management: 

Percentage of patients 18 years of age and older who were diagnosed with major depression, and who remained on antidepressant medication treatment. Two rates are reported
Effective Acute Phase Treatment: Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks) 
Effective Continuation Phase Treatment: Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months) 

Clearly, this "measure of quality" has nothing to do with how well the patient is doing, and everything to do with coming up with something that can be easily measured-how long the patient has been taking medication. What if the patient is responding poorly, or taking an ineffective dose, or should be tapered off meds? Is that an example of "ineffective treatment"?

Similarly, “value-based purchasing holds providers of health care accountable for both cost and quality of care... [It involves]: measuring and reporting comparative performance; paying providers differentially based on performance; and designing health benefit strategies and incentives to encourage individuals to select high value services and providers and better manage their own health and health care.”
But how is performance determined, and will the patient's role be considered in this determination? Patients sometimes make poor choices. Should the physician’s income be adversely affected by those choices? Will doctors “cherry-pick” patients they think will be “good”? And is the patient’s autonomy diminished if the doctor is held responsible for his or her decisions?

Accountable Care Organizations (ACO’s) are groups of doctors, hospitals, and other providers who have agreed to work together to improve care and reduce costs. ACO’s that successfully demonstrate quality care and reduced costs “share in the savings” they create for Medicare. In addition, selected ACO’s can participate in the advance payment model , which provides upfront and monthly payments that can be invested in the ACO infrastructure. 

Ethical considerations for all the value measurement provisions include who is being served by these measures of value, and whether they truly measure value, or simply take up time and energy better spent with patients.

The Bundled Payments for Care Initiative involves paying a lump sum, rather than individually, for an “episode of care”. For example, if a patient is admitted for a course of ECT, rather than separately reimbursing the hospital, anesthesiologist, and psychiatrist who performs the ECT, all three will be reimbursed in one lump sum, presumably to be divided in a mutually agreed upon way. The intention seems to be to encourage collaboration between providers, and limiting of costs and overhead. But the effect may be limiting who is willing to participate, and "turfing" of work.

Coverage vs. Care:

Leaving aside questions about quality and efficiency, the ACA’s goal of health coverage for all presents its own ethical dilemma.  An expectation of medical care goes along with insurance coverage, but there is a discrepancy between the number of patients seeking treatment that will be paid for by their insurance, and the number of practitioners who will accept their insurance. In this respect, psychiatrists in private practice are in an unusual position. A study by Bishop et. al, published in JAMA Psychiatry Online on December 11, 2013, notes that psychiatrists are significantly less likely than physicians in other specialties to accept private noncapitated insurance (55.3% v. 88.7%, respectively, p<.001), Medicare (54.8% v. 86.1%, p<.001), and Medicaid (43.1% v. 73.0%, p<.001). 

The reasons for the discrepancy are unclear. One possibility suggested by the article is that while reimbursement rates for office-based psychiatric treatment are similar to those for office-based medical evaluation/management, psychiatrists don’t see as many patients per day as physicians from other specialties, resulting in less income for those who accept insurance. 
Another possibility is the fact that there are more psychiatrists than doctors from other specialties in solo practice (60.1% v. 33.1%), and solo practices require less infrastructure than larger practices, so there is less motivation to hire staff to interact with insurance companies, which is necessary to dispute claims and ensure reimbursement.
The article also cites a 14% decline in the number of graduates of psychiatry training programs between 2000 and 2008, and an aging workforce, as reasons the demand for psychiatrists exceeds the supply, and allows psychiatrists to not accept insurance. 

This is an ethical conundrum. Do we, as physicians, have a moral obligation to accept insurance, even if we lose income as a result? Or to provide care for patients who are unable to pay our full fees? Should we donate some percentage of our services, free of charge, to those who could not otherwise afford care? Or is it more ethical to treat patients who are free of the session limits and formulary restrictions that come with insurance coverage, even at greater financial cost to the patient? 

In regard to the doctor’s need to make a living, Freud writes, “It seems to me more respectable and ethically less objectionable to acknowledge one's actual claims and needs rather than...to act the part of the disinterested philanthropist—a position which one is not, in fact, able to fill, with the result that one is secretly aggrieved, or complains aloud, at the lack of consideration and the desire for exploitation evinced by ones patients.” (On Beginning the Treatment (Further Recommendations on the Technique of Psycho-Analysis I). The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913): The Case of Schreber, Papers on Technique and Other Works, Pp. 131-132

The ACA has taken on the challenge of guaranteeing affordable and quality health care for all Americans. This is a noble undertaking, with vast challenges, and unpredictable ramifications, including ethical dilemmas for doctors. What are the moral implications of refusing to accept insurance? Does that harm or help our patients? Is it possible to provide better care at lesser expense, and will we or our patients suffer as a consequence? How do we know what constitutes better care, and are measures of care helpful, or simply time-consuming? Is it more ethical to provide full care for the few, or limited care for the many? Perhaps we can view these dilemmas as opportunities to re-examine our values, and the reasons we chose to become doctors in the first place.

Monday, October 20, 2014

NY Times: Why Doctors Need Stories

I just want to link to an article by Peter Kramer, published today in the NY Times:

Why Doctors Need Stories

It's about the role of the case vignette, and how it shouldn't be discounted in the face of evidence based medicine. It also reflects my personal opinion about the significant limits of CBT, despite all its hype.

I submitted this comment:

As a psychiatrist and psychoanalyst, I applaud Dr. Kramer's embrace of "the story". But I don't think case vignettes need to be limited to the role of adjunct to evidence based medicine. Case vignettes actually do supply statistical evidence. A research group from the University of Ghent, in Belgium, specializes in Meta-Synthesis (as opposed to meta-analysis), in which they mine the data generated by a large collection of single case vignettes. You can check out their website: singlecasearchive.com, where you can search for different parameters within papers that have already been published.

You may recall my mention of this topic in a post from last January, The Rest of the Meeting. Feel free to recommend my comment (under the name, Physician NYC-not sure how that happened) from 2:14pm on Sunday the 19th.

Saturday, October 18, 2014


Hello. Sorry for the prolonged absence. I've been pretty busy with a number of things. I've started studying for Boards in earnest. It's unpleasant, and I don't feel like I'm getting anything useful out of the experience, but it does take up time.

I've also been dealing with family stuff of the happy variety. I do feel like I'm getting something useful out of that, but it does take up time.

My husband and I are both self-employed, so we get our medical insurance from Freelancer's Union. I'm not sure if that exists everywhere, but we have it here, in NYC, and it's a great idea because you don't have to buy individual coverage at skyscraper prices if you don't work for some company. We've had it for several years and the coverage has been decent, if not stupendous.

But in keeping with all the plans under Obamacare, starting in January, Freelancer's is no longer going to offer any plans with out of network coverage. And this is a big deal. Not so much because I won't have out of network coverage, myself, although that's important. But because some of my patients are also insured through Freelancer's, and will be losing their out of network coverage. And I don't accept any kind of insurance. I'm guessing that in the not-too-distant future, employer-sponsored plans with out of network benefits will also go the way of the dodo. Why should companies pay for that, right?

Not all my patients pay my full fee. But those who do can often afford it only because they have reasonable reimbursement. And even those who don't pay my full fee use their insurance to help cover whatever I'm charging them.

So what's gonna happen in January? I'll either have to charge less per session, or my patient's will have to see me less frequently, or not at all. I'm anticipating a significant drop in my income. So significant, in fact, that if I don't find a way to make up the difference, in a couple years, I won't be able to afford to run my practice.

This is not an exaggeration. NYC real estate prices are ridiculous. As a reference point, the cheapest studio apartments in Manhattan rent for about $1250 a month-and those aren't even professional offices, and they're in a neighborhood where it's not worth having an office if you want patients. Add to that all the other costs of running a practice, plus food, clothing, shelter, and family expenses, and I'm toast.

My practice is not atypical for NYC. Most psychiatrists in private practice, the ones I know and whose work I respect, anyway, don't take insurance. And these days, it's not just psychiatrists who are completely out of network-other MD's have stopped, too. And I happen to know that my full fee is way on the low side for NYC.

It seems like it's time to reinvent myself. Do I refuse to see patients who can't pay me in full? Do I increase my full fee so those patients who still have out of network coverage can help compensate for those who don't? Do I figure out a way to market myself to that portion of the population who can afford my fee? Do I start accepting Groupons? Do I go concierge style? Do I accept whatever patients can pay me, and take a second job as a barista? Do I play the lottery on a regular basis? Do I develop a clever psych app? Do I monetize my blog? Do I find some other way to offset my losses? Gambling? Home pornography? Airbnb?

You may have noticed that I didn't include accepting insurance as one of my options. I don't consider it a viable option. If I were to sell out that way, I'd be bogged down in all kinds of extra scutwork, the insurance companies would do everything in their power to avoid paying me (United still owes me a couple thousand from back when I accepted medicare), and even when they did pay me, it wouldn't be enough to allow me to maintain my practice.

Or maybe I close my practice completely and find a new profession, after pouring a good percentage of my life, and enough money to feed a small third world country for a year, into medical school, residency, and analytic training.

When I was getting ready to leave my inpatient job and open my practice, I spoke to a friend/colleague who had started her practice two years earlier. She told me that she had written herself a script, which she memorized, of how to tell patients what her fee was. She did this because after accepting $5 per session fees in the clinic, as a resident, she thought it would be hard to keep a straight face when she quoted her fee as $250 a session (this was maybe a dozen years ago).

I'm finally getting to the point where I feel like I deserve my fee. Like I have the knowledge, skill, expertise, and experience to warrant what I charge. I've noticed feeling that way lately. It's been a nice change. And now it's not going to matter.

I can't honestly say I'm surprised by any of this. It's just an extension of what I wrote about in Coverage vs. Care:

1. Everyone has health coverage.
2. Doctors will stop accepting that coverage because they can't afford to practice with those reimbursement rates.
3. Patients will stop going to the doctors who don't accept their coverage.
4. Doctors who don't accept coverage will lose all their patients.
5. Doctors who don't accept coverage will be forced to start accepting insurance or close their practices.
6. Goto 2.

Tuesday, September 30, 2014

New App-Pager

I saw an ad on the subway today for a new app called, "Pager". You download the app, input your info, and then you can report any symptoms you might be having, and get a doctor to make a house call within 2 hours.

That's right! The new innovation in medicine is house calls.

The app was designed by the same people who brought you Uber, the taxi summoning app. Which makes sense. In case you're interested, and I must say I'm intensely interested in this, here's a Wall Street Journal article about Pager from back in May.

But today was the first ad I'd seen for it, and I ride the subway every day.

I did the instant chat thing with Michelle from Pager when I checked out the site, because I was curious about a few things. Here are the screen shots:

Okay, so it's not foolproof, but they do have some way of addressing safety concerns.

I asked about safety because I remember my doctor making house calls when I was a kid, but this was someone with whom my family and I had a long-established relationship. Not a stranger.

I asked about Gyn just to be challenging. And I asked about Psych to see what they would say, and if I could potentially work there one day. Not that that's my current plan, but I do think this is a much more promising venue than telemedicine. These are real medical visits, with real physical exams. Wounds can be sutured, school physicals dealt with, flu shots given, labs ordered and followed up, prescriptions written.

I was thinking about this in comparison with Urgent Care centers, and for reasons I  can't really justify, I prefer this system. I somehow have the sense that if I walk into an urgent care center, I'll end up dealing with someone who has less training and knowledge than I do, and I'll be frustrated and walk out. I'm not sure why a doctor working for Pager would be any different, except that, at least according to the WSJ article, doctors do this to supplement their incomes, and to avoid the frustration of working at insurance based clinics. Somehow that seems more reasonable, or at least more in line with my approach. But I'd be interested to hear other people's thoughts.

Pager is $50 for a call or text that does not require in-person follow up, $199 for a weekday house call, and $299 for a weekend/evening house call. I believe it's only available in Manhattan, currently. I'm also not sure what the time limit is for a house call. Pager will provide you with appropriate bills to submit to insurance.

The site seemed reasonably responsible in weeding out emergencies, which was reassuring. It also seemed really suitable for someone visiting NYC and staying in a hotel.

Is this the future of medicine? Surely not the future of Psychiatry-house calls are kinda off limits for the way I practice. But Pager has an option for telemedicine, so maybe it could be tele-psychiatry, with an option for in-person follow-up if necessary. Sounds confusing, but better than run-of-the-mill distance psychiatry.

I did download the app. It required my name (false), email, cell number, and photograph, which it claims to need. It requires a credit card to set up an appointment, but not for plain old registration. I entered my office location, but I couldn't figure out how to access a list of local doctors without entering my current symptoms. Maybe I'll try that out.

Wednesday, September 24, 2014

Happy New Year

For those who celebrate the Jewish New Year, have a good and a sweet year. For those who don't celebrate the Jewish New year, also have a good and a sweet year.

Shannah Tovah!

Monday, September 22, 2014

Prozac "News"

This article was in the NYTimes.

It includes a retro report video which describes, in essence, Prozac's celebrity. The video leaves me kind of unsatisfied. It alludes to the unproven suspicion that Prozac increases suicidality, but drops the subject. It focuses more on the marketing of Prozac: "PRO" as in professional. "AC" as in action. And "Z" that sounds powerful, or techy, according to the article. They have quick videos of Elizabeth Wurtzel (author of Prozac Nation, also see this ghastly piece by her in yesterday's Times), and Peter Kramer (author of Listening to Prozac-check out the "before and after" of him with brown hair and with grey hair, and of the computers he uses). And it references the controversy of what Prozac is treating-is it "cosmetic"?, what is illness?, etc. All in 9 minutes.

I guess I expect a media video to be more interested in the controversies. There's a lot that could be said about the suppression of data. And the marketing guy they interviewed is satisfyingly slimy, so I can't really complain. Basically, it's a small capsule.

Tuesday, September 16, 2014

Learning New Things

I hope people are familiar with the Khan Academy. It's a wonderful resource created by Sal Khan, an MIT graduate who went on to work in business. While he was working, he started making little You Tube videos on the side, to teach math to his cousins. Then he realized that people who weren't his cousins were also interested in his videos. He thought about charging for his educational efforts, but then he remembered MIT's Open CourseWare.
There are a lot of online learning sites these days, including MIT/Harvard's EdX, Coursera, Codecademy, and Udacity, but Open CourseWare started it all. MIT decided to make all of its course materials, including syllabi, homework assignments, and lecture videos, available online, to the public, for free.

The Khan academy teaches a huge range of topics, from statistics to art history, from kindergarten level math to immunology. Recently, they even started offering test prep for standardized tests like the SAT, to level the playing field with students whose parents can afford private tutoring, and they have a college admissions section for some guidance.

I get periodic emails from them, and I recently received a link to this video, entitled, You Can Learn Anything:

For those who didn't bother to watch it, the video claims that no one is born smart, that learning requires struggle for everyone, and that this is a good thing. And ultimately, with enough effort, anyone can learn anything.

I applaud the notion that learning requires struggle. It casts frustration in a new light, and reminds people to persevere. But I don't believe that anyone can learn anything.

I studied math as an undergraduate, and for a miserable year in graduate school. And one of the few bits I've retained from all the math I learned and subsequently forgot is that math is HARD. Medical school was a lot of work, and what I do now requires intense effort and a certain kind of smarts. But nothing I've encountered comes close to the shear reasoning ability required for math.

Math beats everyone. Mathematicians, people who have chosen math for their professional lives, rarely produce new research past age 30.

One notable exception was the Hungarian mathematician, Paul Erdos (pronounced AIR DISH).

Paul Erdos

He produced new material pretty much until his death in 1996 at age 83. Erdos never married or had any romantic relationship that anyone was aware of, gave away all his money in contests he devised for young mathematicians, lived with his mother until her death, and subsequently by hopping from the home of one mathematician to the next ("Another roof, another proof"), and used amphetamines most of his life so he could spend 19 hour days working on math ("Plenty of time for rest in the grave").

To give you a little more flavor, he once wrote a letter to a fellow mathematician that went something like this:

Dear So and So,
Today I am in Australia. Tomorrow I leave for Hungary. 
Let k be the smallest integer such that...

Sure, Erdos never stopped learning. Math. But at what price? It's not clear that he was able to learn much of anything else. Certainly normal social interactions eluded him.

It's great that the Khan Academy has taken it upon itself to encourage people to learn. Learning is awesome! But I think there's a danger in encouraging the idea that anyone can learn anything, that the most difficult concepts are accessible to anyone with determination, regardless of innate talent or intellect. Because that isn't true. I will never be a Hall of Fame quarterback, or an Olympic sprinter, or even a mathematician like Erdos. And that's okay.

It all reminds me of a short story by Vonnegut, Harrison Bergeron (it was copyrighted in 1961, so I feel okay linking to it because it's been more than 50 years). The story takes place in 2081, when everyone is completely equal. Anyone who is exceptional in any way, be it dance, intellect, music, whatever, is subject to the Handicapper General, who plants noisemaking devices in people's heads to distract them from original thoughts, and attaches weights to anyone of physical prowess. All so no one will feel "less" then anyone else.