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The following is a reader take by Matthew Mintz.



Despite being mentioned on ABC News, and the medical blogosphere, the recent study in the Archives of General Psychiatry that shows psychiatrists are less likely to use “couch” therapy hasn’t garnered the attention it deserves.

The study found that for patients who saw psychiatrists, the percentage of visits involving psychotherapy (where the physicians talk to you) decreased from 44.4 percent in 1996-1997 to 28.9 percent in 2004-2005. This is despite that fact that psychotherapy has been found to be effective for many mental health disorders. The authors and commentators note that the way in which psychotherapy is reimbursed (“reimbursement for one 45- to 50-minute outpatient psychotherapy session is 40.9% less than reimbursement for three 15-minute medication management visits”), but the findings go far beyond that and are a good indication of the future of primary care.

What is not clearly stated in the study is that in 1996-97, about 55 percent of patients who paid out of pocket received psychotherapy compared to about 40 percent who paid with insurance. In 2004-05, the percentage slightly increased for patients paying out of pocket (59 percent), but dropped by almost half (23 percent) for patients using insurance. The reality is that over the past decade, the way in which psychiatry is practiced and delivered has dramatically changed based on reimbursement structures. We now have two types of care delivery for mental health services.

In general, there are two types of psychiatrists whose practices are remarkably different: those that accept insurance and those that do not. For those that do not take insurance, psychiatrists prescribe medication, administer psychotherapy, or do both. Those psychiatrists not taking insurance generally manage medication only, using other health care professionals (psychologists, licensed psychiatric social workers, etc.) to administer counseling and other forms of “talk therapy.”

For many insurances, mental health is a carved out benefit. In other words, instead of getting a referral from your primary care physician to a specialist who accepts your insurance, patients needing mental health care must call the central number of the company their insurance contracts with, and speak to an intake person, who is usually a nurse or social worker. This person will then authorize therapy and direct the patient to a covered provider. Sometimes they determine whether or not a psychiatrist is really needed or whether a non-physician provider can do the job. Alternatively, some mental health benefits direct all patients to a psychiatrist initially, whose main job is to manage medication and direct patients in need of counseling to non-physician providers.

This description is by no means intended to discredit psychologists or psychiatric social workers, who provide excellent and effective care. In fact, I am not even arguing that this is a bad system. With limited health care dollars, maybe it makes sense for MDs to focus on medication, and non-MD professionals to deliver cognitive services. The point is that the low reimbursement for cognitive services from both government and private payers has dramatically changed the way mental health care is delivered in the US, transforming it into a two tiered system. More importantly, the same is likely to happen to primary care, where much of the work of the primary care physician is non-procedural.

The rise of concierge care is only the beginning. Unless there are substantive changes to the way cognitive services are reimbursed, specifically for primary care, general health care will similarly develop into a two-tiered system for those patients who pay for primary care with health insurance and those that pay out of pocket. Having a primary care physician that knows you as an individual, calls you back on the phone to answer questions, fits you in to an appointment when you are sick and takes the time to talk to you in an unrushed visit will only be available to those that can pay for these visits out of pocket.

Those paying for primary care with insurance should expect (in the not too distant future) limited access, routine care delivered by PA’s and NP’s, and rushed visits with the MD, whose primary focus will be medication management and directing you to non-physician providers for counseling and discussing your various health concerns. Health care reform that does not address the central issue of low reimbursement for cognitive service and high reimbursement for procedures and diagnostic studies will only encourage this shift.

In fact, this trend has already started.

Matthew Mintz is an internal medicine physician and blogs at Dr. Mintz’ Blog.