Putting the Care Back into Healthcare
It’s a sad reflection of our mental healthcare system when most, if not all, of the calls I get, are from patients who have become exasperated by it. The commonest anecdotes include: 1) They never really explained my diagnosis or medication to me, 2) I only spent a few minutes with the doctor, and 3) I’ve been given so many different diagnoses, I don’t know what is going on.
What does this tell us? I think the system is broken. It was supposed to have the patient’s best interests at heart, show compassion and responsiveness to their needs, and above all, develop a meaningful and solid connection with the patient. Now, it appears as if it is preoccupied with everything else except those basics. Having worked in different states, across the pond in the UK, and “in the system” here myself for the last twenty years, I can now see where our new referrals are coming from, especially when they relate to the above anecdotes.
Many patients have also described feeling slotted into digital boxes with a rubber-stamped diagnosis and billing code. Managed care was created a few decades ago by the big healthcare corporations, but is now used practically everywhere. It wouldn’t matter if the behavioral health care system was not entirely geared around insurance-based practices and all for the sole purpose of payment. Yes, you guessed it—it’s the dollar that drives it all.
So why would I write about this you might ask? Because, as a psychiatrist, I have seen, firsthand, this systemic obsession spill into virtually everything many clinicians do nowadays and how that ultimately impacts patients. This way of doing things typically applies to the insurance-based system that was designed to control healthcare costs. As out-of-network providers, Insight does not subscribe to that model, and I really believe we are all the better for it. I can say this with confidence because our own patients regularly tell us how much better it is and why.
So, what went wrong? In my opinion, core ethical principles of care and compassion took a complete backseat to the gamesmanship of how the system pays hospitals and practices and what piece of the financial pie was paid by whom. This means that providers are forced to pile in patients almost like a drive-thru fast-food restaurant or an airline overbooking seats just to stay afloat financially. Without getting bogged down into a dense discussion of all the intricacies and nuances of controlling healthcare costs, let me just bring the discussion back to the basics.
That way of practicing clinical care is just plain wrong. We should never view patients as commodities or units on a production line. But that’s unfortunately how insurance-based care has turned out. The unintended and dangerous consequences for mental health care, in particular, are as follows:
- Mistaken diagnoses: I can attest to seeing this one all too often. While I recognize that some diagnoses can be difficult to spot early on and that they evolve over time (like Bipolar Disorder or Schizophrenia), I have seen the disastrous consequences of clinicians overlooking the most common anxiety disorders, mistaking them for say ADHD—all because a patient told them that they couldn’t concentrate. If only a few more questions had been asked to get a better context, they would not have been started on stimulants that inevitably make anxiety worse and what’s more, sets the patient up for both physical and psychological dependence on controlled substances. But that requires time to think through with a detailed history taking. Insurance-based practices emphasize quantity over quality of care and rush diagnosis and treatment,
- Piecemeal Prescribing: I’ve spoken to this previously, but it is relevant here too. In medical school, physicians are taught principles of prescribing via the scientific discipline of pharmacology. Nowadays, and from my experience of nearly two decades, the use of such principles appears to be rapidly eroding.
When patients come to see clinicians, they volunteer symptoms that bother them. That’s understandable and such symptoms do need to be addressed. However, with the speed and brevity of most psychiatric medication appointments (15 minutes), I have seen the consequences firsthand: prescribing sleeping pills or addictive benzodiazepines like Xanax® or Klonopin® when insomnia is the tip of the iceberg of depressive/mood disorders. Or patients getting repeat prescriptions of benzodiazepines for years when an SSRI (like Prozac or Zoloft) was the recommended long-term treatment. Then we see the combining of sedative medications when neither one alone has reached its therapeutic dose.
The above kind of prescribing goes against what has been tried and trusted principles taught in residency and medical school. Michael Jackson’s death was related to just such prescribing. If your psychiatrist is seeing 20-30 patients a day, such shortcuts in prescribing are inevitable and becoming more widespread.
- Patient dissatisfaction and disillusionment with the medical profession: By the time they have come to see me, many patients will have already experienced the above gamut of experiences. I find myself having to reassure them that this time will be different and that we will get to the bottom of their problems. It’s not hard to understand their initial jadedness: our profession has been more often part of the problem than the solution over all these years. So, to quote Mahatma Gandhi, I try to “be the change I want to see in this world.”
Hence, I find myself working hard to emphasize first principles, such as patient autonomy and basic education about diagnoses, how medications work, and what to expect from therapy and medications combined. For this reason, my own appointments are typically longer than the industry standard often lasting two hours for an intake.
Yes, there is hope.
It helps that the overarching ethos at Insight into Action Therapy resonates with my own deeply held values about service and compassion as genuine cornerstones of clinical practice and that this practice is also not hamstrung by the bureaucratic paperwork demands that otherwise would be on it if this were a typical insurance-based practice. I realize that this arrangement does not cater to all patient needs, but I have also been pleasantly surprised when I find patients deliberately foregoing their designated insurance-based choice of provider in order to seek out and then continue their care with us. In so doing, I have enjoyed long-lasting connections with patients who have frequently voiced their satisfaction with feeling properly cared for. I am similarly relieved that our ability to provide superbills with relevant billing and diagnosis codes allows many of our patients to seek reimbursement for out-of-network services at this practice.
So, as an epilogue, I would like to say that, in spite of the system, there are still many caring and competent healthcare providers willing to go the extra mile for their patients. I just hope this provides you with inspiration to find one. I also look forward to hearing from you if I can help meet your particular mental healthcare needs.