Obamacare's effects on Psychiatry

[DOC PENGUIN]

I've yet to meet a doc from Canada who complains nearly as much as docs here say they will complain if we emulate Canada's system. I actually met several at the conference I just got back from. They appeared to be well-fed, well-dressed, had some money to eat nice food at a conference, and also didn't have to deal with a lot of hassles that we need to deal with on an almost daily basis. None of them wanted to trade systems.

That's a totally unscientific sampling, but I'd actually welcome going to more of a Canadian single-payer type system. I don't like Obamacare because I don't think it goes far enough or solves the fundamental problem.

I guess this is where we disagree. You will always have doctors on either side say their system is better or worse than ours. Even though there is relatively successful implementation of Single payer healthcare in other countries, the grass is not greener. America's high healthcare costs stem from 1. 3rd Party Payer, 2. Medicare, Medicaid.
Pay out of pocket healthcare has gone down, too. In Canada a physician is able to work privately (more and more are, but still very small) but in the UK, you are a government employee if you choose to be in the NHS. I think We can implement a more market driven, privatized system with very little regulation. That is not to say there are no stable rules. My point is, Americans like me love seeing whether the grass is greener on the other side. IN healthcare, we are all raised to believe only a big few can service. I think a market driven approach with lots of CHANGES in how it is conducted is the best possible way we can have healthcare. As for me, i vouch for a Savings program in place of Medicare and medicaid as a start. Repeal the ACA as well. And start regionalizing Government services. THis is my very stupid opinion, but notice how i am trying to smartly make my case4 rather than calling everybody here stupid.

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[Therapist4Chnge]

I am so glad that i am not in this thread. i might die.

...because of a death panel?

 

[DOC PENGUIN]

I think the good old days of medicine are making a comeback! And who cares about obamacare (DUMB NAME) I'm doing cash only private practice and the gov't can go eff off!

PRIVATE PRACTICE AND LESS GOVERNMENT REGULATIONS FTW!

RAND PAUL 2016 baby!

Oh by the way, have you heard about their awesome charity program in Kentucky?

 

[DOC PENGUIN]

...because of a death panel?

No, Most doctors are left of center and i think Libertarianism is dying in the american system. If anything, the psych forum has been very nice to us who want to implement a privatized system.

 

[DOC PENGUIN]

You've been in the South too long if you're going to equate slavery with professional licensure being tied to accepting public insurances. That would get you cut in some of the neighborhoods near me!

IU was wondered why the state governments had to license me twhen i just went through 4 years of school. Nevermind, WHY CANT THE AAAC,LCME or the DAMN AMA license?!

 

[BS81]

IU was wondered why the state governments had to license me twhen i just went through 4 years of school. Nevermind, WHY CANT THE AAAC,LCME or the DAMN AMA license?!

Because they have no legal authority. The thing that keeps people from practicing medicine without a license is that it is illegal due to state laws. A state can arrest you for practicing medicine without a license, the AMA, AAMC can't do anything.

 

[DOC PENGUIN]

Because they have no legal authority. The thing that keeps people from practicing medicine without a license is that it is illegal due to state laws. A state can arrest you for practicing medicine without a license, the AMA, AAMC can't do anything.

Well, Its just a complaint. I agree calling yourself a doctor without a license should be banned, but that takes a toll on the law, bureaucracy and a sort of freedom to be a healer. I do think the AMA should act as a the main licenser of what makes a good physician. Just like how the LCME defines a good med school.

 

[Therapist4Chnge]

No, Most doctors are left of center and i think Libertarianism is dying in the american system. If anything, the psych forum has been very nice to us who want to implement a privatized system.

It amazes me that anyone in healthcare can be anything left of Moderate.

 

[splik]

No, Most doctors are left of center and i think Libertarianism is dying in the american system. If anything, the psych forum has been very nice to us who want to implement a privatized system.

Are you kidding? most doctors are right wing. the specialties that are the most full of democrats are FM, peds, and psychiatry. but physicians in general are for obvious reasons more on the conservative end of the political spectrum. anesthesiologists are probably the most ring wing.

 

[sunlioness]

I agree with Splik. I'm a definite minority where I work and the physician parking lot was full of Romney stickers. There were a few scattered Obama stickers. Mine was the only car sporting one for Jill Stein. The day after the election I was sitting in the physician lounge and got to overhear conversations where people by and large agreed that the result of the election guaranteed this country was headed straight for Hell. And this in a state that went for Obama overall.

I think trusting the free market to regulate anything is naive though we likely wouldn't need to worry about healthcare because we'd all be dead from environmental pollution.

America's high healthcare costs stem from 1. 3rd Party Payer, 2. Medicare, Medicaid.

According to the presentation I saw this week at APM (from a very pro-Obamacare guy) the #1 healthcare cost in the USA is hospitals and #2 is physicians. The real interesting thing though was the graph he had about healthcare spending related to some measure of a country's economy. I forget what the measure was, but essentially the graph showed that healthcare spending went up the more wealthy a country was. But they were all more or less on the line on the graph. Except for the USA. We were so far above the line, it was crazy. It would be nice to at least get back on the line. I'm not sure exactly how ACA does that, as this guy seemed to think it would, but I agree that it would be a good thing.

 

[splik]

Quite apart from the fact that there isn't and never will be a free market in healthcare, there is a compelling moral argument against having a freemarket in healthcare which is that whilst a tiny minority would benefit, many more would be worse off, and healthcare of the nation overall would decline. There is a reason why the US has such a poor track record in healthcare compared to every other developed country, and many developing countries, and is the worst overall in terms of expenditure vs outcomes on various indices. The other problem is that neoliberal economics is based on the notion that individuals are rational decision makers. That simply isn't the case when it comes to health, where the decisions are so emotive, the information so complex, and the stakes so high, that what the patient wants, and what the physician knows is right are often at odds. This is especially the case in psychiatry, where patients may be unwilling participants in this supposed free market.

As I've said elsewhere, I always find it amusing how often those that harp on about how great it would be for their to be a free market in healthcare are the most opposed to NPs and other mid level providers. In a truly free market, anyone would be able to provide health services, free from government interference in the form of licensure, and the market forces would act to remove poorly performing practitioners. But the most ardent advocates (including the father of American Neoliberalism Milton Friedman) stated that medical licensure was the protectionistic act of the a guilded profession, determined to keep physician earnings high, quality low, and eliminate competition. This, he believed was an affront to liberty. Until licensure as a requirement to be a healthcare provider is removed, there can never be a truly free market in healthcare. But then who wants the government protecting the public, when it government the public needs protecting from, right?

 

[digitlnoize]

I practice "common-sense libertarianism". State licensure is a necessary evil. But it should not require that I sacrifice my right to opt out of being a govt employee if I so choose.

I am also not opposed to government assistance in healthcare, especially for those who truly need it. I am opposed to that being the ONLY option.

You can keep your Obamacare...but it cannot be compulsory. I am no one's slave.

 

[toothless rufus]

I agree with Splik. I'm a definite minority where I work and the physician parking lot was full of Romney stickers. There were a few scattered Obama stickers. Mine was the only car sporting one for Jill Stein. The day after the election I was sitting in the physician lounge and got to overhear conversations where people by and large agreed that the result of the election guaranteed this country was headed straight for Hell. And this in a state that went for Obama overall.

I think trusting the free market to regulate anything is naive though we likely wouldn't need to worry about healthcare because we'd all be dead from environmental pollution.



According to the presentation I saw this week at APM (from a very pro-Obamacare guy) the #1 healthcare cost in the USA is hospitals and #2 is physicians. The real interesting thing though was the graph he had about healthcare spending related to some measure of a country's economy. I forget what the measure was, but essentially the graph showed that healthcare spending went up the more wealthy a country was. But they were all more or less on the line on the graph. Except for the USA. We were so far above the line, it was crazy. It would be nice to at least get back on the line. I'm not sure exactly how ACA does that, as this guy seemed to think it would, but I agree that it would be a good thing.

Even were this true, or we were the primary reason...then oh well, too bad, they'll just have to accept that we are expensive, worth it, and deal with it. The training is long and arduous, the personal sacrifices not insubstantial, and the responsibilities and skill sets required are high. (Oh and salaries should match inflation)

We are worth every single penny, and its a cost that should be gladly borne without the temerity to ever pay us less than what we are worth, lest we decide that its no longer worth it. Then have fun with that.

 

[DOC PENGUIN]

Are you kidding? most doctors are right wing. the specialties that are the most full of democrats are FM, peds, and psychiatry. but physicians in general are for obvious reasons more on the conservative end of the political spectrum. anesthesiologists are probably the most ring wing.

Really Anesthesiologists? How? I thought most of them were Pot smokers.

 

[DOC PENGUIN]

I agree with Splik. I'm a definite minority where I work and the physician parking lot was full of Romney stickers. There were a few scattered Obama stickers. Mine was the only car sporting one for Jill Stein. The day after the election I was sitting in the physician lounge and got to overhear conversations where people by and large agreed that the result of the election guaranteed this country was headed straight for Hell. And this in a state that went for Obama overall.

I think trusting the free market to regulate anything is naive though we likely wouldn't need to worry about healthcare because we'd all be dead from environmental pollution.



According to the presentation I saw this week at APM (from a very pro-Obamacare guy) the #1 healthcare cost in the USA is hospitals and #2 is physicians. The real interesting thing though was the graph he had about healthcare spending related to some measure of a country's economy. I forget what the measure was, but essentially the graph showed that healthcare spending went up the more wealthy a country was. But they were all more or less on the line on the graph. Except for the USA. We were so far above the line, it was crazy. It would be nice to at least get back on the line. I'm not sure exactly how ACA does that, as this guy seemed to think it would, but I agree that it would be a good thing.

Okay, My statistics were from the CATO institute and my opinions are totally stupid, but give me some credit for addressing the 3rd party payer model that we have in this country today. It is basically not negotiating prices with your physician and then asking someone else to pay it. It became popular after ww2 because of numerous tax incentives made in 1946. Before then, we paid the same way we pay for other items. I think we should adopt a singaporean and/or Swiss system. My preference for the latter. However, America does not need a system, if we want to reduce costs, we can start by doing fundamental changes in our business model. Lets start doing more cash practices, more catastrophic insurance, more state responsibility and less federal responsibility for medicare. Privatize and Cut healthcare items. It will not takes months but Decades. But i think by 2050, we can have a good market system with nessecary and minimal government oversight. BTW, i thought jill stein was very well spoken and intelligent during the debates. Even though i was a Ron Paul Supporter.

 

[DOC PENGUIN]

Even were this true, or we were the primary reason...then oh well, too bad, they'll just have to accept that we are expensive, worth it, and deal with it. The training is long and arduous, the personal sacrifices not insubstantial, and the responsibilities and skill sets required are high. (Oh and salaries should match inflation)

We are worth every single penny, and its a cost that should be gladly borne without the temerity to ever pay us less than what we are worth, lest we decide that its no longer worth it. Then have fun with that.

Just remember that you, as a psychiatrist, will be up with lots of stiff competition. You better hone your skills and win.

 

[DOC PENGUIN]

Quite apart from the fact that there isn't and never will be a free market in healthcare, there is a compelling moral argument against having a freemarket in healthcare which is that whilst a tiny minority would benefit, many more would be worse off, and healthcare of the nation overall would decline. There is a reason why the US has such a poor track record in healthcare compared to every other developed country, and many developing countries, and is the worst overall in terms of expenditure vs outcomes on various indices. The other problem is that neoliberal economics is based on the notion that individuals are rational decision makers. That simply isn't the case when it comes to health, where the decisions are so emotive, the information so complex, and the stakes so high, that what the patient wants, and what the physician knows is right are often at odds. This is especially the case in psychiatry, where patients may be unwilling participants in this supposed free market.

As I've said elsewhere, I always find it amusing how often those that harp on about how great it would be for their to be a free market in healthcare are the most opposed to NPs and other mid level providers. In a truly free market, anyone would be able to provide health services, free from government interference in the form of licensure, and the market forces would act to remove poorly performing practitioners. But the most ardent advocates (including the father of American Neoliberalism Milton Friedman) stated that medical licensure was the protectionistic act of the a guilded profession, determined to keep physician earnings high, quality low, and eliminate competition. This, he believed was an affront to liberty. Until licensure as a requirement to be a healthcare provider is removed, there can never be a truly free market in healthcare. But then who wants the government protecting the public, when it government the public needs protecting from, right?

I really don't like the use of the word, Neoliberalism. And yes, Friedman has a certain point. It is protectionist. I think that it is good that the federal government is not licensing doctors. However, i think the AMA, AAAC, LCME and other organizations are much more appropriate to license physicians. The individual boards already do board certification. While you may find quack healers, i bet you some money that sensible people (78% of the populations) will ask for credentials.

 

[notdeadyet]

However, i think the AMA, AAAC, LCME and other organizations are much more appropriate to license physicians.

That would be akin to having Boeing mange the FAA or Nissan run the DMV.

While you may find quack healers, i bet you some money that sensible people (78% of the populations) will ask for credentials.

You'd lose that bet. I've seen dozens of doctors through my life and never asked one for credentials (except for a surgeon). And any DO will tell you that a small minority of patients ever ask about their degree despite many/most patients have no idea what a DO is.

The coast majority of most patients don't ask credentials because they are confident in the quality control for physicians. No one would want to lose that.

 

[toothless rufus]

Just remember that you, as a psychiatrist, will be up with lots of stiff competition. You better hone your skills and win.

I'm sorry, but I don't follow. Competition from whom? Other psychiatrists? There's kind of a shortage... Or how this comment arises from my original post.

 

[DOC PENGUIN]

I'm sorry, but I don't follow. Competition from whom? Other psychiatrists? There's kind of a shortage... Or how this comment arises from my original post.

Psychologists, Psych NPs, Psychotherapists, Unlicensed, Phds, PsyD, and Clinical psychologists are competition for those with lesserneeds at least in the psychotherapy route.

 

[DOC PENGUIN]

That would be akin to having Boeing mange the FAA or Nissan run the DMV.


You'd lose that bet. I've seen dozens of doctors through my life and never asked one for credentials (except for a surgeon). And any DO will tell you that a small minority of patients ever ask about their degree despite many/most patients have no idea what a DO is.

The coast majority of most patients don't ask credentials because they are confident in the quality control for physicians. No one would want to lose that.

Well, air travel used to be regulated by the CAB. They imposed stringent congtrols on air travel at the time and back then only the rich could pay. Pan American Airlines then put a 500 buck Coach seat to attract more people. This worked. By the 1980s, air travel was common and cheap.

For Doctors, i am not saying there should be NO regulation. I think that sensible regulation is good. I think the government should let people buy insurance across state lines. I also think innovative companies like Big J in new Mexico and Medlion in California are much better than the regular HMO or PPO. IMO, Credentials ought to be certified by people who know them best. Whether that is the government or the academy is stupid banter that i will lose at. I think the AMA or the AAMC or the LCME is much better than the state governments is because they are usually more adept at doing it. They usually know when to be innovative or conservative. They already have high standards for physicians in the country. The LCME already accredits schools, the AAMC brings together national standards and the AMA makes sure everyone who practice medicine practices it well. I don't understand why they can't start licensing?

 

[toothless rufus]

Psychologists, Psych NPs, Psychotherapists, Unlicensed, Phds, PsyD, and Clinical psychologists are competition for those with lesserneeds at least in the psychotherapy route.

Eh. Not interested in psychotherapy, at this at this point. Although for those who are great.

However I am concerned about the psychologist prescriptive privileges thing. Most recently up for vote in Illinois. Cannot fathom how anyone thinks anything less than medical school (or PA NP grudgingly) is necessary and required to do this.

 

[vistaril]

Eh. Not interested in psychotherapy, at this at this point. Although for those who are great.
.

then from nps/pas who work for 75k.......do you think the zoloft or wellbutrin you prescribe after a basic "I'm feeling down" intake works a lot better than theirs?

And unless you are an extreme candyman, do you actually think private cash pay patients are going to be banging down your door to have *you* prescribe them their lamictal for their mood swings?

If all you are interested in is an outpt private practice med mgt clinic, honestly, what do you think you bring to the table that a solid psych np doesnt? they use most of the same evidence based treatment protocols....to the extent they do exist at least.

 

[diagonal]

then from nps/pas who work for 75k.......do you think the zoloft or wellbutrin you prescribe after a basic "I'm feeling down" intake works a lot better than theirs?

And unless you are an extreme candyman, do you actually think private cash pay patients are going to be banging down your door to have *you* prescribe them their lamictal for their mood swings?

If all you are interested in is an outpt private practice med mgt clinic, honestly, what do you think you bring to the table that a solid psych np doesnt? they use most of the same evidence based treatment protocols....to the extent they do exist at least.

Sounds like you got yourself into a career that is facing a large light at the end of a tunnel. Strange choice.

 

[vistaril]

Sounds like you got yourself into a career that is facing a large light at the end of a tunnel. Strange choice.

I dont look at it quite like that, but we are fooling ourselves if we dont think there isnt going to be increased pressure from midlevels over time, especially in certain settings(ie outpatient med mgt, which is the most common setting). And honestly, it doesn't not make sense. Doing an intake and then making *medication* recs for most mood disorders, especially unipolar, just isnt brain surgery.

The VA over the last 5 years has begun to increasingly hire psych NPs in that role. Community mental health centers as well. That will have more of an effect on demand/salaries over time as that increases.

 

[toothless rufus]

I dont look at it quite like that, but we are fooling ourselves if we dont think there isnt going to be increased pressure from midlevels over time, especially in certain settings(ie outpatient med mgt, which is the most common setting). And honestly, it doesn't not make sense. Doing an intake and then making *medication* recs for most mood disorders, especially unipolar, just isnt brain surgery.

The VA over the last 5 years has begun to increasingly hire psych NPs in that role. Community mental health centers as well. That will have more of an effect on demand/salaries over time as that increases.

Well then I guess we are screwed. Time to change specialties.

 

[diagonal]

I dont look at it quite like that, but we are fooling ourselves if we dont think there isnt going to be increased pressure from midlevels over time, especially in certain settings(ie outpatient med mgt, which is the most common setting). And honestly, it doesn't not make sense. Doing an intake and then making *medication* recs for most mood disorders, especially unipolar, just isnt brain surgery.

The VA over the last 5 years has begun to increasingly hire psych NPs in that role. Community mental health centers as well. That will have more of an effect on demand/salaries over time as that increases.

My theory is that people with resources will always demand physician treatment. As far as salaries, well, don't work at the VA. Work for yourself.

 

[vistaril]

My theory is that people with resources will always demand physician treatment. As far as salaries, well, don't work at the VA. Work for yourself.

but as nps and pas assume more clinical work at vas, cmhcs, and other places that increases supply of psychiatrists in other venues.

As for 'people with resources', the vast majority of adult psychiatry care given in this country(and billed) is for the following groups and not self pay :

-the insured/managed care/whatever
-medicare/medicaid
-the indigent not on medicare/medicaid(obviously only in some settings)

And no, the insured don't always get to 'demand' physician treatment. Insurers can stagger plans in such a way to encourage PA/NP use.

 

[vistaril]

Well then I guess we are screwed. Time to change specialties.

big area between what I said and you said. I just think that psychiatrists(especially those that don't do therapy or offer any unique services) are going to struggle in some areas to justify their use.....I think there are a lot of factors contributing to this, not just ACA stuff.

On a practical level....think about your outpts you aren't doing therapy with. The non-smi outpts. What are you doing for them that a psych nurse practioner couldn't?

 

[diagonal]

but as nps and pas assume more clinical work at vas, cmhcs, and other places that increases supply of psychiatrists in other venues.

As for 'people with resources', the vast majority of adult psychiatry care given in this country(and billed) is for the following groups and not self pay :

-the insured/managed care/whatever
-medicare/medicaid
-the indigent not on medicare/medicaid(obviously only in some settings)

And no, the insured don't always get to 'demand' physician treatment. Insurers can stagger plans in such a way to encourage PA/NP use.

Doing so would just increase demand for cash only psychiatry. There are too few psychiatrists, a problem which is only going to grow larger. And let us not ignore the fact that many psychiatrists can't speak English properly, which allows those that can even greater pull in the cash only market.

 

[diagonal]

big area between what I said and you said. I just think that psychiatrists(especially those that don't do therapy or offer any unique services) are going to struggle in some areas to justify their use.....I think there are a lot of factors contributing to this, not just ACA stuff.

On a practical level....think about your outpts you aren't doing therapy with. The non-smi outpts. What are you doing for them that a psych nurse practioner couldn't?

I do agree that therapy is a way to create demand for your services. It's how I intend to support going off the insurance grid.

 

[vistaril]

Doing so would just increase demand for cash only psychiatry. There are too few psychiatrists, a problem which is only going to grow larger. And let us not ignore the fact that many psychiatrists can't speak English properly, which allows those that can even greater pull in the cash only market.

cash only psychiatrys demand doesn't have that super high of a ceiling just because people only have so much money. You actually think there is a substantial number of middle class patients with insurance now who are going to demand they have a psychiatrist refill/adjust their wellbutrin and ssri vs a midlevel(or pcp...some will drift back there) and PAY HUNDREDS OUT OF POCKET to do so?

if you're doing cash only, you're likely going to have to do a good bit of therapy. And a lot of psychiatrists quite frankly don't want to do so(or dont know how to do so with a cash paying population that expects a lot)

 

[vistaril]

I do agree that therapy is a way to create demand for your services. It's how I intend to support going off the insurance grid.

well if you can get people to pay a lot of money for you to talk to them, more power to you......I dont know the % of adult psychiatrists who do exclusively cash pay therapy and make >250k/year net, but it is almost certainly very very small.

 

[toothless rufus]

Doing so would just increase demand for cash only psychiatry. There are too few psychiatrists, a problem which is only going to grow larger. And let us not ignore the fact that many psychiatrists can't speak English properly, which allows those that can even greater pull in the cash only market.

But we are physicians and therefore better trained. Personally, I would not want to go to a midlevel for anything. The midlevel thing was not ever a good idea. What were they thinking?! Exclusive rights for physicians to practice medicine sounds about right, if it's going to cause us grief. Sorry.

 

[diagonal]

well if you can get people to pay a lot of money for you to talk to them, more power to you......I dont know the % of adult psychiatrists who do exclusively cash pay therapy and make >250k/year net, but it is almost certainly very very small.

Most doctors aren't very savvy.

 

[toothless rufus]

big area between what I said and you said. I just think that psychiatrists(especially those that don't do therapy or offer any unique services) are going to struggle in some areas to justify their use.....I think there are a lot of factors contributing to this, not just ACA stuff.

On a practical level....think about your outpts you aren't doing therapy with. The non-smi outpts. What are you doing for them that a psych nurse practioner couldn't?

If the existence of midlevels drives down our compensation, then yeah, that's a bad thing, no?

 

[vistaril]

If the existence of midlevels drives down our compensation, then yeah, that's a bad thing, no?

is it a bad thing for me from a personal financial perspective? Yeah....I guess. So are a lot of things I dont have control over, some of which I agree with and some I don't.


but really, back to the original question- how does our better training(and I grant it is better) provide that much extra value in your typical mild depressive d/o outpt? I know the approach most np's take from a pharm perspective for those cases(or GAD cases or whatever), and it's pretty much the same as the one most veteran psychiatrists take....the zoloft you prescribe in med checks doesnt work any better than theirs.

 

[Leo Aquarius]

I know the approach most np's take from a pharm perspective for those cases(or GAD cases or whatever), and it's pretty much the same as the one most veteran psychiatrists take....the zoloft you prescribe in med checks doesnt work any better than theirs.

Are you suggesting NPs are just as capable of managing psychotropic medications as psychiatrists, or even as you say veteran psychiatrists? You've got to be kidding me. The pill itself doesn't change no matter who prescribes it. Obviously. So if I as a psychiatrist prescribe Coreg, I must be just as useful as a cardiologist because hey, the Coreg I prescribe "doesn't work any better than theirs."

I hire a cardiologist because he has much more experience with who should get CHF medications, at what doses, under what conditions, what side effects to look for, side effects to anticipate, what to do to prevent unwanted side effects, how to treat those side effects if they appear, how to improve the dosage, etc etc etc. I would hire a psychiatrist for these reasons over anyone else (NPs, etc) if I need psychotropics.

 

[vistaril]

Are you suggesting NPs are just as capable of managing psychotropic medications as psychiatrists, or even as you say veteran psychiatrists? You've got to be kidding me. The pill itself doesn't change no matter who prescribes it. Obviously. So if I as a psychiatrist prescribe Coreg, I must be just as useful as a cardiologist because hey, the Coreg I prescribe "doesn't work any better than theirs."

I hire a cardiologist because he has much more experience with who should get CHF medications, at what doses, under what conditions, what side effects to look for, side effects to anticipate, what to do to prevent unwanted side effects, how to treat those side effects if they appear, how to improve the dosage, etc etc etc. I would hire a psychiatrist for these reasons over anyone else (NPs, etc) if I need psychotropics.

lol....look at all this nonsense. I'll switch out 'who should get CHF meds' with 'who should get antidepressants' to show you how ridiculous your example is......

1) who should get antidepressants?

People who say they are depressed.......that's the way it works. The % of people who go to an outpt psychiatrist endorsing depressed mood(or whatever you want to say...sadness, melancholy,etc) who initially gets an antidepressant is 98%+.......same as for midlevels.

2) at what dose?

ummm....typically the starting dose. You do know how to find that somewhere right? Surely you've even done it yourself at some point....

3) Under what conditions?

Huh...what does this even mean? Daily is typically the most frequent scenario......

4) side effects to anticipate?

Hate to burst your bubble, but even many of the lpns in our clinic know the main side effects of most antidepressants.

5) how to treat those side effects if they appear?

Data is mixed....but as a general rule of thumb it is always go back to benefit of the drug vs discomfort/risk of side effect and opt for the greater of the two. Or reduce dose. Or change med. Again, thats something most of the lpns in our clinic know....hardly the domain of the mighty psychiatrist.

6) how to improve the dosage?

My guess would to change it to a better dose. That one is below the lpns in our clinic

CHF is far more complex than an initial outpt depression eval. Far far more complex.

 

[BS81]

Really, anything that any PCP feels they can comfortably treat a Psych NP will treat just fine as well. Mild/Moderate depression falls under that category... I really don't see the argument there, just follow STAR-D algorithm and there you go. There are also Cardiology NPs that treat bread and butter CHF, it's really not that difficult either.

I'm interested in your recent change of heart Vistaril. You were looking at a job doing 6 med checks per hour and now you seem to be leaning against that. What would be your advice to make yourself have added value over an NP? How are you gonna make your 250k?

 

[digitlnoize]

Are you suggesting NPs are just as capable of managing psychotropic medications as psychiatrists, or even as you say veteran psychiatrists? You've got to be kidding me. The pill itself doesn't change no matter who prescribes it. Obviously. So if I as a psychiatrist prescribe Coreg, I must be just as useful as a cardiologist because hey, the Coreg I prescribe "doesn't work any better than theirs."

I hire a cardiologist because he has much more experience with who should get CHF medications, at what doses, under what conditions, what side effects to look for, side effects to anticipate, what to do to prevent unwanted side effects, how to treat those side effects if they appear, how to improve the dosage, etc etc etc. I would hire a psychiatrist for these reasons over anyone else (NPs, etc) if I need psychotropics.

Exactly. So far this week, I've seen the following PCP regimens from real live doctors:

Pt 1: CC: Terrible, uncontrolled anxiety, panic attacks in the setting of end stage COPD.
PCP MD Tx: Effexor + Wellbutrin + Abilify + Clonazepam + Trazodone. QTC = 570. Oh, I forgot...Ultram too.

Pt 2: CC: Panic Attacks, anxiety, depression.
PCP MD Tx: Paxil + Clonazepam + Opiates + known alcoholism -> Pt overdosed in SA.

Pt 3: CC: Anxiety (this was a curbside from a FM clinic)
PCP MD Tx: 1st line: Effexor. 2nd line: Wellbutrin. 3rd line: Xanax. 4th line: More Xanax.
Me: "Have you tried them on an SSRI?"
PCP: "Yeah. Wellbutrin. The only thing that works for them is Xanax. I'm just going to give them more of that."

Yeah, I bet the NP's are just as good as the non-psych MD's...

 

[Fastball32]

Psychiatry and Plastic Surgery have been the two fields that can thrive on cash practices.
I think the affordable healthcare plan may impact psychiatric cash practices, however in the long run I think it would become more like the European system.
Right now, FDA approvals are sponsored by university professors with drug company ties and with Obamacare, ultimately literature from the Cochrane report and others will have a greater impact and be more beneficial to society as a whole

 

[MissAmanda]

anyone know of any good. thorough, thoughtful books/resources of how the recent policy changes will affect physicians' practices?

 

[jmadden]

A team of financial advisers spoke to residents at our program and revealed that the avg salary of psychiatrists have steadily increased over the past 5 years, and will continue to do so because of the shortage. This is probably no surprise to us, but I'm sure thankful for it. Many other specialties can't say the same thing.

Its based on the age demographic of psychiatrists, much older then other specialties. More will retire or work PT exacerbating shortages. EM is the opposite demographic, young

 

[jmadden]

I agree with Splik. I'm a definite minority where I work and the physician parking lot was full of Romney stickers. There were a few scattered Obama stickers. Mine was the only car sporting one for Jill Stein. The day after the election I was sitting in the physician lounge and got to overhear conversations where people by and large agreed that the result of the election guaranteed this country was headed straight for Hell. And this in a state that went for Obama overall.

I think trusting the free market to regulate anything is naive though we likely wouldn't need to worry about healthcare because we'd all be dead from environmental pollution.



According to the presentation I saw this week at APM (from a very pro-Obamacare guy) the #1 healthcare cost in the USA is hospitals and #2 is physicians. The real interesting thing though was the graph he had about healthcare spending related to some measure of a country's economy. I forget what the measure was, but essentially the graph showed that healthcare spending went up the more wealthy a country was. But they were all more or less on the line on the graph. Except for the USA. We were so far above the line, it was crazy. It would be nice to at least get back on the line. I'm not sure exactly how ACA does that, as this guy seemed to think it would, but I agree that it would be a good thing.

Well #2 is a straight lie 6% tops of the 2.8 trill annual healthcare expenditure is physicians. Ask him for his stats and post, they always juke them. Like physicians gross services billing as a hospital employee is counted as their income when insurance reimburses only a % of whats billed and as employees of the hospital they collect only a % which is included in their salary, some is just required for base income and above some level they may get a bonus or raise. Its still the 200k income they make in the end. 600k physicians approximately not including residents and fellows. Do the math yourselves based on physician salaries. We could all work for free and it wouldnt make a dent in this healthcare shakedown

 

[jmadden]

Well #2 is a straight lie 6% tops of the 2.8 trill annual healthcare expenditure is physicians. Ask him for his stats and post, they always juke them. Like physicians gross services billing as a hospital employee is counted as their income when insurance reimburses only a % of whats billed and as employees of the hospital they collect only a % which is included in their salary, some is just required for base income and above some level they may get a bonus or raise. Its still the 200k income they make in the end. 600k physicians approximately not including residents and fellows. Do the math yourselves based on physician salaries. We could all work for free and it wouldnt make a dent in this healthcare shakedown

Find out the guys schedule and hand out fliers before hand exposing his deliberate manipulation. Dont underestimate the propaganda machine against physicians even from other physicians

 

[MissAmanda]

I've seen some articles mention physicians would be pushed to cash-only practices. I am wondering would cash-only practices be legal under obamacare? Would physicians be required to take insurance?

 

[freaker]

No, Most doctors are left of center and i think Libertarianism is dying in the american system. If anything, the psych forum has been very nice to us who want to implement a privatized system.

Incorrect, though perhaps in your local practice region. An independent physician recuriting firm ran a survey of physicians, who supported Romney by 20% over Obama.

I have a feeling that as our nation continues to sink deeper in debt (and it will), we will end up moving more and more to a privatized, pay-for-service system.

 

[freaker]

I've seen some articles mention physicians would be pushed to cash-only practices. I am wondering would cash-only practices be legal under obamacare? Would physicians be required to take insurance?

I have no doubt that the tyrants in Washington will take every liberty to regulate and squash any entrepreneurial soul out there who dares to offer something better or with more features for a price. It's only "fair' and "equal," you know. Unless, of course, you're serving them, at which point it will be perfectly acceptable.

My guess is that more physicians will move to a cash-only system, at which Washington will deal with the (Washington-created) shortage of physicians by mandating that all must take health insurance.

But yes, right now, cash-only is permissable.

 

[michaelrack]

That would be akin to having Boeing mange the FAA or Nissan run the DMV.

.

There are numerous examples of professional/industry groups governing a profession/industry, often in partnership with the government.

This is especially common in finance- the Fed is a private organization with some gov oversight, working with government agencies such as the FDIC to oversee banks (among its other functions). Another example is the FASB (private) working with the SEC (gov).