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.

Wednesday, January 22, 2014


I have one of those free subscriptions to magazines from some credit card points, and I don't even remember if I actually ordered a year of Real Simple, or if it was substituted for something else I ordered. I don't look at it much, but I got the February 2014 issue in the mail today, and as I was flipping through to "Roasted Salmon/Barley/Smoked Paprika/Fennel/Swiss Chard/Chickpeas/Basil/Scallions, which I will never have the time or energy to prepare, I noticed an article entitled, The Patient Will See You Now. It's about deciding whether or not to break up with your doctor. It includes some common sense recommendations-voice your concerns, ask what you can do to be seen on time, and so on. In the sidebar, it lists "5 Common Signs That You Need A Change".

1. You're doctor doesn't tailor recommendations to your life.
2. He's always running late.
3. She rushes you.
4. The office is disorganized.
5. She's arrogant.

And since Real Simple is a pretty mainstream publication, tailored more towards women, admittedly, I'm working on the assumption that it reflects what people want from their doctors-they want to be listened to, they want their doctor to spend enough time with them so they feel understood, they want their individual concerns addressed, they want a thorough exam which they seem to equate with time (in my experience, more related to the doctor's skill, but what do I know), and they want to be treated with respect.

None of this is unreasonable. Except.

The lead article in this month's Carlat Report, An Ethical Perspective on the Affordable Care Act, is about some of the ethical conundrums that will arise, if they haven't already, due to the vastly increased number of insured, as well as the other provisions of the ACA. I know a little something about this article because I wrote it. And I'm going on the record now to state that it was extremely difficult to write, mainly because the more I researched the topic, the more discouraged I got about the whole mess.

Allow me to quote:

Several innovations of the ACA are intended to incentivize doctors not only to provide better quality care, but better quality care at equal or lesser cost—in other words, greater value. However, since a goal of the ACA is universal access to health care, this means that doctors are expected to spend more time with more patients, while providing better care for each patient at a reduced cost.

(Note: I'm not allowed to post or otherwise publish the full article for, I think, six months, but I'm pretty sure one small quote is okay. So.)

See the problem? The ACA is convinced that its provisions will allow people to get better care from and spend more time with their doctors, but these same provisions make it impossible to do so. The American public is in for a serious disappointment.

Also today, I received the January 17, 2014 edition of Psychiatric News, and there, on page 4, is an article entitled, DB Helps Develop Tool Kit to Help Physicians Thrive in ACOs. The tool kit was released by the Toward Accountable Care Consortium of North Carolina, to help doctors organize into ACOs, where doctors and hospitals agree to work together to provide "better value" care, meaning higher quality at less cost, and "share in the savings" they generate. These can involve a collaborative care model, in which patients in a primary care setting are screened by their PCPs for psychiatric problems, and then referred to a care manager, often an MSW, who follows up. Psychiatrists supervise the care, but never see the patients. The quality of care in an ACO needs to be measured, to determine if it is both "quality" and cost efficient. This is done by the soon-to-be-not-officially-mandatory-but-you'll-be-penalized-financially-if-you-don't-do-it PQRS, for example, which involves a mind-boggling process, and "measures" that are just time-consuming and meaningless checkboxes.

Allow me to quote:

“This is the wave of the future,” [Bridges] said. “We are leaving fee for service for some kind of new payment system that rewards value, and I believe we are really on the cusp of a remarkable change in the way psychiatrists are going to be working.”

This is the ACA's definition of spending more time with patients and providing better care. And here we doctors are, trying simultaneously to satisfy the people who read Real Simple, and the provisions of the ACA.

After much consideration, I've come to the conclusion that the solution to all of this is obvious.

I need to stop reading.