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.

Sunday, April 28, 2013

And The Winner Is...

The results of my completely non-scientific and woefully under-sampled survey are in. Thanks to everyone who filled it out, and for those of you who didn't, I haven't lost faith in you for next time, whenever that turns out to be.

Drumroll, please (percentages rounded):

1. Which change in the new DSM-5 (as opposed to the old DSM-5) do you think will do the most harm?

Binge Eating-11%
Disruptive Mood Regulation Disorder-11%
Removal of Multi-Axial System-11%

2. Which change in DSM-5 do you think will do the most good?

Chapter Rearrangement-33%
Gender Dysphoria-22%
Removal of Multi-Axial System-11%

3. Do you plan to buy the DSM-5 when it's released?


4. Do you think DSM-5 will change the way you practice?

Yes, in a bad way-11%
Yes, in a good way-0%

Since I didn't ask people to explain their reasoning in the survey, I don't know why they feel the way they feel. However, I'm going to empathically place myself in the minds of those who voted for the winners, and try to write about why I, as them, would have chosen as I did, and also about what the literature shows. FYI, not all of the results agreed with my own opinion, but I think the occasional exercise in empathy is a good thing.

I'll cover Bereavement and Chapter Rearrangement in another post, but I just want to comment on the last two results. Think about it. Most people do not plan to buy the new DSM, and no one thinks it's publication, nay, existence, is a good thing.

Um, APA, you worked on this for years, with all the attendent Sturm und Drang, and no one thinks it'll do any good. What gives?

Another CPT Resource

Here's a link to a CPT "Coach":


It walks you through a checklist that allows you to determine the code for each session. I played around with it a bit, and I personally found it cumbersome and more time-consuming than just writing my note after familiarizing myself with the guidelines.

But some people might find it useful, so check it out.

Monday, April 22, 2013

Skype-chiatry Link

Thanks to Dinah, from Shrink Rap, for her comment on Tele Me More. The podcast includes an interesting discussion of the more technical aspects of Skype-chiatry (In the future, will people practice Skypoanalysis?). Check it out, episode #49.

Sunday, April 21, 2013

Tele Me More

I want to pick up where I left off with the telepsychiatry post by looking at evidence in the literature.

One study, The Effectiveness of Telemental Health Applications: A Review  
Canadian Journal of Psychiatry | Nov 2008, reviewed 72 papers. There was evidence of success with "Telemental health" (TMH) in the areas of child psychiatry, depression, dementia, schizophrenia, suicide prevention, posttraumatic stress, panic disorders, substance abuse, eating disorders, and smoking prevention. Evidence of success for general TMH programs and in the management of obsessive–compulsive disorder were less convincing.

Another study, Outcomes of 98,609 U.S. Department of Veterans Affairs Patients Enrolled in Telemental Health Services, 2006–2010, Psychiatric Services, 2012, compared number of inpatient psychiatric admissions and days of psychiatric hospitalization among patients who participated in remote clinical videoconferencing during an average period of six months before and after their enrollment in the TMH services. Psychiatric admissions of TMH patients decreased by an average of 24.2%, and days of hospitalization decreased by an average of 26.6%.

Yet another study of 494 subjects, Is Telepsychiatry Equivalent to Face-to-Face Psychiatry? Results From a Randomized Controlled Equivalence Trial, Psychiatric Services, June 2007, compared interactive videoconferencing with face to face treatment in psychiatric consultation with brief follow-up (monthly, up to 4 months), and found equivalent improvements in function in both groups, with similar levels of satisfaction with service. And TMH cost 10% less than face-to-face treatment.

A study of 297 individuals, published in The Lancet in 2009, Therapist-delivered internet psychotherapy for depression in primary care: a randomised controlled trial, found that 38% of patients treated with online CBT recovered from depression (BDI<10), vs. only 24% of patients treated as usual by their GP. Since this study was done in the UK, I'm not sure what the usual function of a GP is there, and whether some do psychotherapy.

The China American Psychoanalytic Alliance (CAPA) has offered Skype or Oovoo training in psychoanalysis and psychotherapy to clinicians in China since 2006. It also offers low fee Skype psychoanalysis and Psychotherapy. There seems to be a lot of satisfaction with the program, with waiting lists for treatment, but there is no data that directly compares the results with face-to-face treatment.

So what do we know?

  • TMH seems to be helpful in treating some conditions, such as depression and PTSD.
  • In veterans, TMH has decreased admissions and length of stay by roughly 25%. 98,000 veterans-you can't ignore that number.
  • TMH was equivalent to face-to-face treatment for consultation with brief follow-up, and cost less.
  • Online CBT looked better than treatment by a GP in the UK.
  • Many Chinese who otherwise wouldn't have access to psychotherapy or psychoanalysis are eager to have TMH treatment.
Based on this information I'd like to see a more formal study of face-to-face vs. Skype treatment for  a more general population, and for, say, psychodynamic psychotherapy, before drawing any conclusions. But I certainly wouldn't dismiss the idea of TMH entirely. 

Please note, my DSM-V survey will close on the 28th, so if you haven't responded yet, you still have time. Just click HERE.

Tuesday, April 16, 2013

Why Would I Do That?

Is it just me, or do other people get requests from insurance companies to accept less money for services?

It usually starts with a fax, with some indication of urgency, like, "Time Sensitive Material, Please Respond Immediately!" The first time this happened, I thought, "Oh, my patient needs some form filled out so she can be reimbursed, I better take care of it." I don't accept any insurance, but I do give my patients bills they can submit on their own, and if they need some form or other filled out, I'll do so.

But insurance companies are sneaky, and I'm glad I read the form carefully. What it said was, "You billed the patient for X dollars. We want you to agree to be paid half that, and if you sign your name, that's the most you can ever be reimbursed. And by the way, we also expect you to hand over your firstborn child."

So when I get these, I ignore them. Then the insurance company usually follows up with a few more faxes, and finally, a phone call, asking me to call them back regarding a claim. Again, they make it sound ominous.

What is going on here? Do they really think I'm going to accept half my usual fee? What incentive are they offering? I'm no expert, but I'm guessing that in any genuine negotiation, each party has to have something to offer the other. But it's just, "You accept less money, and in exchange, we give you absolutely nothing." I don't understand how they think they can convince me. Maybe it's just the wild hubris of very deep pockets who believe the future of healthcare is ONLY through them.

Has anyone else had this experience? I'd love to hear what people think the rationale is behind it.

Oh, and if you would be so kind as to take my VERY BRIEF and HIGHLY USEFUL survey, I'd be most grateful.

Sunday, April 14, 2013

Dr. Tele-Love, or, How I learned to Stop Worrying and Love Skype

In the process of learning all about the new CPT coding, I also learned that phone and Skype sessions are not covered by insurance. The reasoning seems to be that they are considered substandard care. And apparently you can't cut a deal with your patient in which he will pay you for a phone or Skype session, regardless of his coverage, because a patient cannot legally agree to substandard care. Well, I guess you CAN make that agreement with your patient, but if he ever decides to sue you, you're buggered.

Furthermore, the point was made by the lawyer who gave the talk I attended that if you call your doctor to ask about something, say, at night, you don't get a bill for it. So, by extension, you can't bill for a full session that takes place on the phone.

True. Only lawyers can bill for phone exchanges. By the minute.

Personally, I don't like phone sessions. Maybe because I don't like talking on the phone, in general. I find it difficult to lose that sense you get of a patient who's in the room with you, not to mention the facial expressions and other visual cues (admittedly, these are lacking in analysis, as well).

That said, sometimes, it's necessary. A patient who needs to move suddenly, but hasn't transitioned to another psychiatrist yet. Or maybe doesn't want to. A patient who's laid up at home because of illness. Or maybe because of maternity or paternity leave. A patient who has to fly to a distant city due to a family emergency or a death.

It seems to me there are a lot of good reasons to rely on phone or Skype sessions, especially when the patient would suffer without any session at all. Are we, as psychiatrists, really supposed to spend 45 minutes on the phone with a patient, making the same comments and interpretations we would make in person, working just as hard as we would in person, and then not charge for the session?

This is a topic for another time, but why do people think it's immoral, or somehow distasteful, for doctors to want to make a living? Are we really supposed to work for free?

So what's the deal, here? Why is tele-medicine considered substandard? Is it just an excuse to limit coverage, or is it based on some factual data?

As it turns out, prison systems routinely use tele-psychiatry. I hope it isn't the case that prisoners are getting substandard care.

And you can use telepsychiatry in some states, but not others. Additionally, the use of telepsychiatry varies based on type of insurance.

For instance, medicaid covers telepsychiatry in NY.

Private insurance varies by insurer. My guess is, if there's any excuse not to cover, they won't cover.

Medicare covers telepsychiatry with some provisos. First, the consumer must be located in a "non-metropolitan statistical area", which may or may not be the same thing as a Health Professional Shortage Areas (HPSA) .

From what I can tell the consumer also has to have the session in a qualified facility, which I guess means that he or she needs to show up at a clinic or hospital, and have a qualified staff person with him or her. During the actual session? I can't figure that out.

The clinician, on the other hand, can be anywhere, even at home, but has to be licensed in the appropriate state. I assume that's the state where the patient is located.

Now, back to that "substandard care" business. If it's good enough for prisoners and people in rural, underserved areas, it should be good enough for anyone. Alternatively, it's not really good enough for anyone, but it's the best anyone can do under certain circumstances.

The next question is, "What does the literature say about how telepsychiatry compares to in-person treatment?"

Stay tuned.

Sunday, April 7, 2013

DSM-5: Take My Survey, Please

Yup, it'll be here soon. I was hesitant to write about it, and I can barely call it by its name. Maybe if I don't say it, it'll disappear.
What convinced me to write about it was the dumb, completely irrelevant fact that it's going to be published on my birthday. And you can preorder it on Amazon for only $133.22.

Here's a list of some of the changes:

1. Asperger's subsumed under the heading of Autism Spectrum Disorder.
2. Inclusion of Binge Eating Disorder.
3. Bereavement exception removed from the diagnosis of depression.
4. Gender Identity disorder changes its name to, "Gender Dysphoria".
5. Addition of Disruptive Mood Regulation Disorder for children who display “persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year.”
6. Inclusion of Hoarding and addition of Excoriation as individual diagnoses.
7. Substance Abuse and substance Dependence combined under the heading, "Substance Use Disorder."
8. Dissolution of the Multiaxial System. Axes I, II, and III are now combined, with separate notations for psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V).
9. Chapters restructured based on disorders’ apparent relatedness to one another. These changes will align DSM-5 with the World Health Organization’s (WHO) International Classification of Diseases, eleventh edition (ICD-11).

I've been wondering about why I'm so wary of this new manual. Maybe because it's the "bible" of psychiatry, and reimbursement will be based on it, despite the sometimes nebulous scientific underpinnings of some of its content. Or maybe because it has the potential to pathologize normal elements of the human condition, such as grief following a loss, or temper tantrums during childhood.

And I wonder which of the changes will do the most harm. And which the most good.

What do you think? Please take the following 4 question survey. I'll post the results, and write in detail about whichever changes are the best and worst, in your opinion.