Future of Psychiatry Practice

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system1c

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Does anybody have an opinion on the future of psychiatry? First with the congressional voting on medicare reimbursements and with the front runner of the Democrats proposing to focus more on mental health issues? Do you think this will be a benefit to this specialty, or will this be more a benefit(or responsibility) for the Primary Care or Family Physician. With the addition of telepsychiatry, is this medicines little secret that this specialty may see more applicants in residencies in the future?

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Does anybody have an opinion on the future of psychiatry? First with the congressional voting on medicare reimbursements and with the front runner of the Democrats proposing to focus more on mental health issues? Do you think this will be a benefit to this specialty, or will this be more a benefit(or responsibility) for the Primary Care or Family Physician. With the addition of telepsychiatry, is this medicines little secret that this specialty may see more applicants in residencies in the future?
We'll all be finding out together.
 
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Two possible avenues currently being discussed are an integrative care model and a neuropsychiatric care model. The integrative care model somewhat assumes that the current scope of psychiatric practice is failing to meet the mental health needs and will requite partnering with other primary care physicians in a primary care setting (Link).

The neuropsychiatric model refers to increased integration of neuroscience and neurology into psychiatric residency programs. Psychiatry and neurology courses in medical school are currently taught as entirely separate entities while they essentially lie at opposite ends of the spectrum in the same organ. There are currently five combined neuropsychiatry residency programs and the idea behing ACGME's release of the "Milestones for psychiatric training" is to integrate more and more neurology into psychiatry residencies to one day have more neuropsychiatrists who are able to teach the next generation of mental heath providers (Link).
 
Does anybody have an opinion on the future of psychiatry? First with the congressional voting on medicare reimbursements and with the front runner of the Democrats proposing to focus more on mental health issues? Do you think this will be a benefit to this specialty, or will this be more a benefit(or responsibility) for the Primary Care or Family Physician. With the addition of telepsychiatry, is this medicines little secret that this specialty may see more applicants in residencies in the future?
I'm thinking that we will just see a greater emphasis on access to medications as that is the solution that is easiest to sell. The future looks like this and in some ways it is already here. Ensure that the primary care providers (mostly mid-levels) have patients complete a 9-item depression screen. If positive, write script for anti-depressant. If it is a kid with problems in school, ADHD screen and stimulant. Mental health needs have been addressed. We're done here. Nothing to see. Move along.
Hmm. I sound a bit cynical. I probably shouldn't post at the end of the week. :grumpy:
 
Cynical, maybe, but if you are right, no one will be getting much better. We will still have plenty of referrals. Check list psychiatry seldom works very well and this is good and bad depending upon your view of it.
 
Two possible avenues currently being discussed are an integrative care model and a neuropsychiatric care model. The integrative care model somewhat assumes that the current scope of psychiatric practice is failing to meet the mental health needs and will requite partnering with other primary care physicians in a primary care setting (Link).

The neuropsychiatric model refers to increased integration of neuroscience and neurology into psychiatric residency programs. Psychiatry and neurology courses in medical school are currently taught as entirely separate entities while they essentially lie at opposite ends of the spectrum in the same organ. There are currently five combined neuropsychiatry residency programs and the idea behing ACGME's release of the "Milestones for psychiatric training" is to integrate more and more neurology into psychiatry residencies to one day have more neuropsychiatrists who are able to teach the next generation of mental heath providers (Link).

Good luck getting anyone outside of academia and maybe Kaiser to agree to this kind of red tape ridden nightmare, especially in child.

What we're really headed towards, IMO, is a two tier system, where private practice is almost universally cash and for the upper middle class and above and poorer people meaning middle class and below have to deal with academic and state mental health systems.

Proof? Look at what insurance companies are doing across the country. Dropping psych reimbursements now that we have mental parity so that psychiatrists will leave their network. Abandoning coverage of cheap psych meds like Atarax. They want out of mental health as much as we do. Our patients are high utilizers of health care dollars and they'll save money (in the short term) if we leave the system. Over half of us already have (more in child) and it's only growing.
 
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I wonder how to bill for spending time with prior auths?

Also, anyone else getting annoyed with pharmacists at ins companies mailing crap saying that stable populations aren't allowed to be continued on a medication because of that ****ing BEERS list?
 
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I wonder how to bill for spending time with prior auths?

Also, anyone else getting annoyed with pharmacists at ins companies mailing crap saying that stable populations aren't allowed to be continued on a medication because of that ****ing BEERS list?
Almost EVERY med is on that list!
 
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Does anybody have an opinion on the future of psychiatry? First with the congressional voting on medicare reimbursements and with the front runner of the Democrats proposing to focus more on mental health issues? Do you think this will be a benefit to this specialty, or will this be more a benefit(or responsibility) for the Primary Care or Family Physician. With the addition of telepsychiatry, is this medicines little secret that this specialty may see more applicants in residencies in the future?

Primary care has so much to cover already....
 
Proof? Look at what insurance companies are doing across the country. Dropping psych reimbursements now that we have mental parity so that psychiatrists will leave their network. Abandoning coverage of cheap psych meds like Atarax. They want out of mental health as much as we do. Our patients are high utilizers of health care dollars and they'll save money (in the short term) if we leave the system. Over half of us already have (more in child) and it's only growing.

How are they allowed to drop the reimbursements if there is parity? Obviously I do not understand anything about parity.
 
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The future of psychiatry question has been posted on this board in 2004, 2006, 2007, and 2010.

So far so good.
The sky is falling... And it likely always will be...


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My own feeling is that psychiatry has tilted too far toward medicalization to the extent that it feels more medicalized than other specialties even. And acccess to psychiatric care has become for the few: some are instead imprisoned or simply go without care.

The suffering of the human mind is such a different condition than all other medical problems and is so pervasive in modern society that I think psychiatry should be more integrated toward the whole of a person and access to care should be more pervasive at varying gradients throughout our cities. There shouldn't be only this threshold between nothing and 911. There should be walk-in clinics. If we're to stick with community service boards, they need huge reform or funding--honestly I can't tell if they're underfunded or just dysfunctional. They should be as open as a library and for everyone. In my experience you need a lawyer to get help from one, and how does that affect the indigent? It seems that they actively don't want to help people.

I think both the scope of and access to psychiatry need to be broader. You have to step back and look at the picture of treating the mind (or if you aren't cringing, even the soul). I think healers can have a place next to priests when they are earnest and committed. When I said that psychiatry has become more medicalized than other specialties, this is what I was referring to. I was so anxious at my last dentist appointment that my dentist gave me a massage—it helped and because he's really good at what he does (besides actually dentistry) I got my filling done when I probably would have otherwise just left. I've met some psychiatrists where all you'd have to do to give them a fright is say, "Hello."
 
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bad things tend to happen when psychiatrists give their patients massages
Lol, yes, I could see that crossing a line. This dentist is so wonderful. I wish I could sing his praises high enough. I have very bad anxiety and Tourette's and all at once when I was 20 all my teeth got cavities. I saw so many dentists who would try to work on me and give up or would just outright refuse. I am a bit of a moving target. I got a lot of bad dental work done over the years and the filings kept falling out. This dentist tried sedation with me three different times and it didn't help, but he has been so, so patient. It's his demeanor that is what makes the difference. While it sound cliche at most place, going there is like visiting a family. That dental practice is the happiest group of people. I'm now pretty good at siting through cleanings and fillings, and even root canals and crowns. My mouth is up to date.

That comment about the massage came up during the question of medicalization. The other dentists I saw were probably very good technically but were not good at dealing with me. I guess I was saying that in fields that you would conventionally think of as less "soft" than psychiatry, there is sometimes more non-clinically proven healing in some form or another--whether it's a dentist giving a massage or my PCP who writes a picture of a man going on a walk and sunshine on a prescription pad. I actually feel like psychiatry, at least in my experience, is more medicalized than some other specialties. When you think of a subject matter like the human mind (or soul), it seems like the direction of psychiatry has gone toward nuts and bolts and away from humanism. I'm not exactly sure what a more whole person approach to psychiatry would look like, but the 15 minute med checks are not it. At least for me, I am told in very direct terms to save anything that isn't nuts and bolts for my therapist. I guess everyone should do what they're best at, but in my imagination of the future of psychiatry (an optimistic view) I saw perhaps a swing back to something more ambiguous and individualized with the patient. I was telling my psychologist the other day how it seems like people go to school to learn all these things about the people they'll treat rather than learning about them from meeting them—rather than deducing something about a person or people in general from interacting with them. That's something I didn't write about in my first post because it seemed too ambitious and also intangible. But I was thinking about a model in which the entire practice of clinical psychiatry could be viewed as one large trial from which to learn more about mental suffering. I started wondering whether my psychologist had learned anything about mental suffering or human behavior from me, rather than the other way around. It seems like medicine works that way sometimes, maybe more so in the past? I'm not an expert on Freud, but I believe he deduced a lot of what he concluded based on each patient being a sort of case study. It seems to me that there is still much to be learned about why people do the things they do and why they suffer the way they do--so much so that it seems people like me are always referencing someone as far back as Freud.
 
Lol, yes, I could see that crossing a line. This dentist is so wonderful. I wish I could sing his praises high enough. I have very bad anxiety and Tourette's and all at once when I was 20 all my teeth got cavities. I saw so many dentists who would try to work on me and give up or would just outright refuse. I am a bit of a moving target. I got a lot of bad dental work done over the years and the filings kept falling out. This dentist tried sedation with me three different times and it didn't help, but he has been so, so patient. It's his demeanor that is what makes the difference. While it sound cliche at most place, going there is like visiting a family. That dental practice is the happiest group of people. I'm now pretty good at siting through cleanings and fillings, and even root canals and crowns. My mouth is up to date.

That comment about the massage came up during the question of medicalization. The other dentists I saw were probably very good technically but were not good at dealing with me. I guess I was saying that in fields that you would conventionally think of as less "soft" than psychiatry, there is sometimes more non-clinically proven healing in some form or another--whether it's a dentist giving a massage or my PCP who writes a picture of a man going on a walk and sunshine on a prescription pad. I actually feel like psychiatry, at least in my experience, is more medicalized than some other specialties. When you think of a subject matter like the human mind (or soul), it seems like the direction of psychiatry has gone toward nuts and bolts and away from humanism. I'm not exactly sure what a more whole person approach to psychiatry would look like, but the 15 minute med checks are not it. At least for me, I am told in very direct terms to save anything that isn't nuts and bolts for my therapist. I guess everyone should do what they're best at, but in my imagination of the future of psychiatry (an optimistic view) I saw perhaps a swing back to something more ambiguous and individualized with the patient. I was telling my psychologist the other day how it seems like people go to school to learn all these things about the people they'll treat rather than learning about them from meeting them—rather than deducing something about a person or people in general from interacting with them. That's something I didn't write about in my first post because it seemed too ambitious and also intangible. But I was thinking about a model in which the entire practice of clinical psychiatry could be viewed as one large trial from which to learn more about mental suffering. I started wondering whether my psychologist had learned anything about mental suffering or human behavior from me, rather than the other way around. It seems like medicine works that way sometimes, maybe more so in the past? I'm not an expert on Freud, but I believe he deduced a lot of what he concluded based on each patient being a sort of case study. It seems to me that there is still much to be learned about why people do the things they do and why they suffer the way they do--so much so that it seems people like me are always referencing someone as far back as Freud.
I learn from my patients every day. Psychology is moving in the same direction unfortunately with many having a belief that techniques are what matters. To me the essence of what we do is that we understand the psychological and biological underpinnings of emotions, thoughts, and behaviors and then try to apply that knowledge to help bring more understanding to our patients. We also gain a lot of our understanding of human experience from our patients and then this knowledge can help other patients. Ultimately though, each person is the room with me is an individual who has a unique experience. That means that at every moment with a patient we really don't know what will work or won't, what to say or not to say, what to prescribe or not to prescribe, and whether a patient is ready to talk about the trauma or will be retraumatized by it. The master clinicians can work within that framework and tolerate the uncertainty of this profession, the rest reassure themselves by clinging to formulas, techniques, medications, and statistics and eventually resort to blaming patients for the failures in treatments. It takes years of clinical experience to develop even a basic competency and decades to begin to develop a sense of mastery of this work and few people really get that. So many clinicians dispense advice and call that psychotherapy. Clueless.
 
Two possible avenues currently being discussed are an integrative care model and a neuropsychiatric care model. The integrative care model somewhat assumes that the current scope of psychiatric practice is failing to meet the mental health needs and will requite partnering with other primary care physicians in a primary care setting (Link).

The neuropsychiatric model refers to increased integration of neuroscience and neurology into psychiatric residency programs. Psychiatry and neurology courses in medical school are currently taught as entirely separate entities while they essentially lie at opposite ends of the spectrum in the same organ. There are currently five combined neuropsychiatry residency programs and the idea behing ACGME's release of the "Milestones for psychiatric training" is to integrate more and more neurology into psychiatry residencies to one day have more neuropsychiatrists who are able to teach the next generation of mental heath providers (Link).
God, I would love it if they mixed neuroscience and neurology into psychiatry. Let us deal with the fun stuff of neurology.
 
The neuropsychiatric model refers to increased integration of neuroscience and neurology into psychiatric residency programs. Psychiatry and neurology courses in medical school are currently taught as entirely separate entities while they essentially lie at opposite ends of the spectrum in the same organ. There are currently five combined neuropsychiatry residency programs and the idea behing ACGME's release of the "Milestones for psychiatric training" is to integrate more and more neurology into psychiatry residencies to one day have more neuropsychiatrists who are able to teach the next generation of mental heath providers (Link).

One concern I have about some of this thinking is that there is an assumption (in some cases) that combining neurology and psychiatry will somehow inject more neuroscience into psychiatry. This makes basically no sense. The underlying science of psychiatric disorders constitutes a branch of neuroscience, and although it may be something which receives relatively little focus in psychiatry residency, it doesn't receive any focus in neurology residency. Understanding a great deal about strokes, epilepsy, parkinson, etc. and their clinical management will not better equip psychiatrists to integrate emerging neuro-scientific findings about schizophrenia, PTSD, bipolar etc. into our practice, which is really what the goal should be. If anything, having to learn the clinical management of an additional set of disorders which systems have been effective in segregating across the globe will reduce the amount of time available for this type learning. Luckily there are more well-considered attempts at tackling this task: http://www.nncionline.org/about-nnci/
 
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The Psychiatry Board Certification is by the American Board of Psychiatry and Neurology. One third is neurology knowledge.
My understanding was that the reason why some people do a neuropsychiatry fellowship is because they don't get to see as many borderline patients or get trained for it. Is that incorrect? I thought the boards being a 1/3 neurology is just to be able to show you know the differences like say you got a patient with Wilson's Disease.
 
My understanding was that the reason why some people do a neuropsychiatry fellowship is because they don't get to see as many borderline patients or get trained for it. Is that incorrect? I thought the boards being a 1/3 neurology is just to be able to show you know the differences like say you got a patient with Wilson's Disease.

In my practice, I see a overlap with psychiatry and neurology. I think it's important to understand the nuances of both fields. You have to know when to refer and why. One of my patients had PD.
 
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The future of psychiatry question has been posted on this board in 2004, 2006, 2007, and 2010.

So far so good.
I saw that. Blame my lack of imagination to change the title up, but I was trigger happy to start a thread soo.....
 
Proof? Look at what insurance companies are doing across the country. Dropping psych reimbursements now that we have mental parity so that psychiatrists will leave their network. Abandoning coverage of cheap psych meds like Atarax. They want out of mental health as much as we do. Our patients are high utilizers of health care dollars and they'll save money (in the short term) if we leave the system. Over half of us already have (more in child) and it's only growing.

I guess thats one of the things I'm talking about, will there be a political push to force for insurance to pay for mental health with all the national news that high profile suicides have been making? I mean what are insurance companies supposed to cover minimally? What insurance company will cover DBS treatments I wonder?
 
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How are they allowed to drop the reimbursements if there is parity? Obviously I do not understand anything about parity.

From what I understand, their argument is that since we have lower overhead costs than other specialties that it works out to paying us the same as the others. At least that's the argument I was told Anthem used when my state's psych association tried to sue them.
 
I guess thats one of the things I'm talking about, will there be a political push to force for insurance to pay for mental health with all the national news that high profile suicides have been making? I mean what are insurance companies supposed to cover minimally? What insurance company will cover DBS treatments I wonder?

There already has been. Mental health parity laws were part of the ACA. Insurance companies now DO provide more mental health coverage. The problem is that they dropped the rates for those codes, and now WE (at least more and more of us every day) don't accept the insurance...which is a different problem.

Since the government can't force us to take any insurance (that would be akin to slavery), we are free to not take insurance and charge cash, in our free society, at least.
 
From what I understand, their argument is that since we have lower overhead costs than other specialties that it works out to paying us the same as the others. At least that's the argument I was told Anthem used when my state's psych association tried to sue them.

So did the psych association win? I'm guessing no.
 
nope it was dismissed: http://www.gpo.gov/fdsys/pkg/USCOURTS-ctd-3_13-cv-00494/pdf/USCOURTS-ctd-3_13-cv-00494-0.pdf

This lawsuit was filed in 2013 however so before the ACA came into force re: mental health parity. however the suit was dismissed as the court ruled that the APA and CPA did not have standing to file a suit on the first place under ERISA to place claim's on behalf of patients. Even psychiatrists do not have standing to do so.

That's not my state. ;) But same result even after ACA essentially.
 
State governments could do this as a condition of medical licensure in that state.

In theory. I'd move, even if it meant leaving the country, before I'd live in a place where the government forced me to work for them. I don't think it'd hold up to constitutional challenge either. But yes, they could try it. Mass. tried it not that long ago, and was met with huge opposition, even in their liberal state, so I don't see this happening in most states, but it's possible. Any state that tries it will be met with a physician exodus, however.

We have to remember that we have the power here. They need us. We don't have to do what they say, as long as we do it as a unit.

This is rather naive. The current plan seems to be to get rid of OON. Most cash patients hope to be able recoup something from their insurance. If OON no longer exists, patients wont be able to claim any of the cost of treatment back. This will force more people to accept insurance because fewer patients will be willing to pay out of pocket.

Depends how bad the shortage is and if ANYONE takes insurance. We're living under such a severe shortage that the extreme demand will mostly protect us until that is corrected, which probably won't be in our careers as they're not increasing the volume of psychiatrists being trained.

Obviously this is somewhat location dependent, and getting fully rid of OON might force people to move to the "right area", but there's PLENTY of good, in-demand, areas where people may not want to pay cash but have the means and don't have a choice.

Now, the ethics on this is another matter.

Oddly, it's not the reimbursement of the insurance that makes me not want to take it. Medicare pays ~$75 for a 99213 in my area, which would give you $225 per hour at 3 per hour, which isn't bad, especially when mixed with some level 4's. It's the overhead and the onerousness of it. If we went single-payor and eliminated the mess, and kept reasonable rates, I'd consider it, as it would open the way for a high volume, low-overhead practice. Under the current system? No way.
 
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Digitnize, why do you think under single payer the paperwork would be less onerous?Or that the fees would still be reasonable?
 
Digitnize, why do you think under single payer the paperwork would be less onerous?Or that the fees would still be reasonable?

Haha, good question. I'm not sure that I do, but I think it'd be easier to fax/bill/headache with 1 place, with 1 set of rules, than with 100 different insurers, each with their own rules.

I think the pay would be average. They couldn't drop it too low without risking every doctor abandoning the system, which would be political suicide. The elderly are a huge voting bloc, and if all their doctors walk away, Congress will hear about it. This will keep rates, as it does for Medicare, reasonable. Compared to Anthem, in my state, which slashed psychiatrists' rates to about 70% of medicare.

As I said above though, I believe we're headed towards the life of Dentistry and Optometry, forced out of the "medical" system and into our own field. Patients with money can pay for our services, or purchase their own, ****ty, mental health insurance that doesn't cover nearly enough (look at dental insurance). Patients without money will just be screwed and continue to over-burden the state mental health systems and university programs.
 
As I said above though, I believe we're headed towards the life of Dentistry and Optometry, forced out of the "medical" system and into our own field.

For real? I hope not!
 
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