As a solo practitioner I can make comments here. The issue really is time. Mental status exams are the only tool I have to make a diagnosis and start a treatment plan. There are no tests that I can do that tell me it’s depression or schizophrenia. A large portion of this exam is based on history which is difficult to illicit particularly if someone is having a hard time thinking and recalling information. These evaluations take about an hour of time. Then I have to consent for the medications, which takes more time. Follow up exams take at least 20 minutes to assess if everything I started is working or if there is something else that I need to focus on that was missed. A primary care doctor can look at labs, make a diagnosis and finish with a patient in 10 minutes. My husband, a physician has told me that when he walks into the hospital to see a patient, he picks up the chart, looks at labs, makes a diagnosis, develops the treatment plan and by the time he walks into the patient’s room can say “hello” to the patient, state what’s wrong, what he is going to do and leave; all within about 7 minutes. It takes him 5 minutes to complete the chart paperwork. This would be impossible in a psychiatry practice.
Insurance companies particularly government insurance DOES NOT PAY enough for me to run a business and cover my ass for malpractice. If I don’t spend enough time, due diligence; I run the risk of a malpractice law suit, a law suit where the insurance (Medicaid) only paid about $40 for that visit.
In my office I have a biller that submits claims to my patient’s insurance. The insurance company then sends what it would pay me to the patient instead. Most of my patients find this acceptable. Medicare and Medicaid makes this kind of reimbursement to the patient virtually impossible.
A real solution here could be to use physician extenders particularly in the outpatient setting. There is the available psychiatrist who has several physician assistants or nurse practitioners presenting cases and after discussion with the psychiatrist goes back to the patient to implement treatment plans. This is the model we use in residency training programs. Patients not responding to treatment would be seen by the psychiatrist. Psychiatrists for this oversight are paid hourly and physician extenders are paid based on their level of training which is less and more cost effective. Patients who want to see the psychiatrist would have to pay accordingly. This would serve the greatest number for the least cost and could raise the baseline of mental health care in this country. The time efficiency would also decrease wait time for continued treatment appointments. The under served could greatly benefit as well.
I agree there is a mental health crisis. We should begin by talking to psychiatrists first.