Opinion On Illinois Becoming 3rd State

[clusterF]

While I think this all about politics and lobbying, PAs and NPs should be higher on the totem pole than psychologists regarding prescribing midlevels. Clinical psychology has VERY limited value to add when it comes to prescribing.

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[smalltownpsych]

While I think this all about politics and lobbying, PAs and NPs should be higher on the totem pole than psychologists regarding prescribing midlevels. Clinical psychology has VERY limited value to add when it comes to prescribing.

This opinion is based on....? Have you ever worked with a psychologist or an independently practicing PMHNP or patients with mental health issues? Do you know research that supports this contention?

 

[TexasPhysician]

Posting this in a thread talking about the IL requirements is at best disingenuous and at worst purposefully misleading.

Here are the educational requirements./QUOTE]

To compare - that curriculum puts someone pretty close to an MS3 level education by my calculations. Psychiatric illnesses result from many medical illnesses or masquerade as one. Being able to identify them, understand appropriate lab work, understand psychopharm, etc. is why psychiatry is an 8 year program (medical school + residency).

Illinois is basically saying this can be HIGHLY condensed safely with a limited formulary. My opinion - a disservice and unsafe.

Could psychiatrist training be condensed? Sure. This much? Not in my opinion.

 

[clusterF]

This opinion is based on....? Have you ever worked with a psychologist or an independently practicing PMHNP or patients with mental health issues? Do you know research that supports this contention?

The training I have as a psychiatrist.
Working with many psychologists and answering their questions regarding medications/physiology etc.
Training psychologists and having an understanding of the training that they get.

Also working with PAs and NPs although I do not train them, they just know more. Actually RNs and many LVNs (who work in psychiatry), especially after years of training, have a better grasp of medications than psychologists.
I don't want to disparage psychologists across the board. They do many things well. Medications not so much. Its like asking a psychiatrist to do brain surgery just because we are MDs. It doesn't work that way and a 14 month course which is a poor equivalent of 3rd year of medical school is not going to fix that.

 

[Therapist4Chnge]

Illinois is basically saying this can be HIGHLY condensed safely with a limited formulary. My opinion - a disservice and unsafe.

How is this training different than NP or PA training? If anything…it is *more* restrictive than NP training and requires *more* than PA training.

 

[smalltownpsych]

The training I have as a psychiatrist.
Working with many psychologists and answering their questions regarding medications/physiology etc.
Training psychologists and having an understanding of the training that they get.

Also working with PAs and NPs although I do not train them, they just know more. Actually RNs and many LVNs (who work in psychiatry), especially after years of training, have a better grasp of medications than psychologists.
I don't want to disparage psychologists across the board. They do many things well. Medications not so much. Its like asking a psychiatrist to do brain surgery just because we are MDs. It doesn't work that way and a 14 month course which is a poor equivalent of 3rd year of medical school is not going to fix that.

I agree with much of what you said. We don't know medications or physiology that well. We focus on assessment, research, and psychotherapy. Isn't that what the additional training that is required to be a RxP would be expected to remedy? My greatest fear is not that I wouldn't be able to develop competency in this area (if RxP was to come to my state), but that I would end up doing what our PMHNP does currently. Which is 15 minute med checks for a lot of people who could benefit from other forms of treatment but won't avail themselves of it. It's getting to the point where I dread seeing referrals from her because of the approximately 80% no-show rate.

 

[MacDonaldTriad]

We already have armies of primary care doctors writing psych meds poorly. They may be a little better at recognizing organic causes than a psychologist, but a psychologist might have some advantage in diagnosis and symptom tracking.

New referral: “I hope you can help me, I’ve failed almost every antidepressant there is, here is my list.”

You: “OK, Prozac 40mg for ten days doesn’t count, Effexor 37.5 mg for 6 months doesn’t count, Elavil 50 mg for 2 years doesn’t count. Looks like we are starting over.”

 

[smalltownpsych]

We already have armies of primary care doctors writing psych meds poorly. They may be a little better at recognizing organic causes than a psychologist, but a psychologist might have some advantage in diagnosis and symptom tracking.

New referral: “I hope you can help me, I’ve failed almost every antidepressant there is, here is my list.”

You: “OK, Prozac 40mg for ten days doesn’t count, Effexor 37.5 mg for 6 months doesn’t count, Elavil 50 mg for 2 years doesn’t count. Looks like we are starting over.”

I am thinking that Prozac takes two to three weeks to reach a therapeutic level in the bloodstream (not sure about serotonin level in the brain), and that the second two are sub-therapeutic dosages? If that is correct, then am I ready to write scripts?
I also work with patients who have been to counseling and it didn't help. When I ask them about it, I find out that they were getting a non-therapeutic dose of psychotherapy, too!

 

[Therapist4Chnge]

You: “OK, Prozac 40mg for ten days doesn’t count, Effexor 37.5 mg for 6 months doesn’t count, Elavil 50 mg for 2 years doesn’t count. Looks like we are starting over.”

I see the problem….the prescriber should have just written for Xanax, Adderall, and Oxy; those all seem to get positive results on self-report from the pts.

 

[vistaril]

I don't think that was the point. PCP's don't have the time to develop a thorough psych diagnosis with patients and safely monitor them. The PCP's I know are incredibly busy. If psychologists would really team up with PCP's by providing a thorough diagnosis and monitor all psych patients within the PCP clinic, PCP's would be more on board with prescribing meds. From a safety standpoint, this is much more ideal.

yes and there is no way to get paid for it, so that's out. Would you like to work with another professional and share the same pie with them? of course not

 

[greenlion]

Posting this in a thread talking about the IL requirements is at best disingenuous and at worst purposefully misleading.

Here are the educational requirements. Additional requirements about ongoing collaboration, limited formulary etc. can be found farther along in the bill.

-------------------------------------------------
(225 ILCS 15/4.2 new)
Sec. 4.2. Prescribing psychologist license.
(a) A psychologist may apply to the Department for a

prescribing psychologist license. The application shall be made on a form approved by the Department, include the payment of any required fees, and be accompanied by evidence satisfactory to the Department that the applicant:

(1) holds a current license to practice clinical psychology in Illinois;

(2) has successfully completed the following minimum educational and training requirements either during the doctoral program required for licensure under this Section or in an accredited undergraduate or master level program prior to or subsequent to the doctoral program required under this Section:

(A) specific minimum undergraduate biomedical prerequisite coursework, including, but not limited to: Medical Terminology (class or proficiency); Chemistry or Biochemistry with lab (2 semesters); Human Physiology (one semester); Human Anatomy (one semester); Anatomy and Physiology; Microbiology with lab (one semester); and General Biology for science majors or Cell and Molecular Biology (one semester);

(B) a minimum of 60 credit hours of didactic coursework, including, but not limited to:
1 Pharmacology; Clinical Psychopharmacology; Clinical
2 Anatomy and Integrated Science; Patient Evaluation;
3 Advanced Physical Assessment; Research Methods;
4 Advanced Pathophysiology; Diagnostic Methods; Problem
5 Based Learning; and Clinical and Procedural Skills;
6 and
7 (C) a full-time practicum of 14 months supervised
8 clinical training of at least 36 credit hours,
9 including a research project; during the clinical
10 rotation phase, students complete rotations in
11 Emergency Medicine, Family Medicine, Geriatrics,
12 Internal Medicine, Obstetrics and Gynecology,
13 Pediatrics, Psychiatrics, Surgery, and one elective of
14 the students' choice; program approval standards
15 addressing faculty qualifications, regular competency
16 evaluation and length of clinical rotations, and
17 instructional settings, including hospitals, hospital
18 outpatient clinics, community mental health clinics,
19 and correctional facilities, in accordance with those
20 of the Accreditation Review Commission on Education
21 for the Physician Assistant shall be set by Department
22 by rule;
23 (3) has completed a National Certifying Exam, as
24 determined by rule; and
25 (4) meets all other requirements for obtaining a
26 prescribing psychologist license, as determined by rule.
-------------------------------------------------

Your "rolling eyes" emoticon doesn't make sense considering your post. According to your posting it's only 96 credit hours (after the so-called "biomedical preqs" which themselves fall far short of pre-medical preqs). And we haven't even touched upon the actual rigor of the credit hours (i.e. what kind of 'pharmacology' are they studying without any organic chemistry or biochemistry requirements?) For that matter what can they possibly glean from medical rotations in IM, EM, Surg, Peds, OBGYN etc without medical knowledge? Most of it seems like posturing.

 

[Therapist4Chnge]

Sure it does. NP & PA have similar training hours. I still have yet to see data that any more training is needed.

 

[greenlion]

Sure it does. NP & PA have similar training hours. I still have yet to see data that any more training is needed.

They don't. Psych NP education is closer to medicine from the getgo and is much more credit hours. Ultimately requiring a minimum of a nursing master's with many PMHNP programs requiring nursing doctorates now. (vs. your 96 credits hours wouldn't even be close to enough for a bachelor's-couple that with how easy those 96 credit hours sound with no difficult prereqs) Their clinical hours likewise are more at 600. (Not to mention the fact that they're more likely to know what's going on during their hours.)

And once again- Psych NPs are midlevels!! And NPs are NOT allowed to practice independently in Illinois. Nor should they (depending on what kind of minimum healthcare standard we want in the US).

The funny/scary thing is that Illinois is supposed to have the highest education/training among the 3 states that let psychologists prescribe. NM/LA should at least match IL- only the most self-interested psychologist would argue that.

 

[whopper]

Is there a list of the "limited formulary"? If the list is limited enough I could potentially think the Illinois law is acceptable for me.

The most recent time this happened on the forum-Oregon, I didn't back it because 1-there was no limited formulary and 2-while the Oregon law required an MD/DO to supervise, it didn't set clear guidelines as to who had the final say. If there was a disagreement (and one would be inevitable) it didn't specify what that meant. Could the psychologist then still prescribe but with a documented disapproval from the physician? Does that mean their prescription is null and void? The law didn't answer those questions.

And the requirements for training (IIRC) were worse than the Illinois law.

So you could've had a psychologist, possibly without physician approval, prescribing a very toxic medication such as Clozapine or lithium in the Oregon law and with patchwork training.

If the limited formulary were, for example, only SSRIs, and modern antidepressants such as Wellbutrin, no antipsychotics, no mood stabilizers, no benzos, no Zolpidem, I could consider backing it.

Still, this begs the question, why don't PCPs, psychiatrists, and psychologists on a primary level just team-up?

 

[heyjack70]

I just received an email saying that our tele-psychiatrists for children 12 and under is going to be up and running and to start referring kids there. Right now we have an PMHNP for 13 and up and soon to be tele-doc for the kids. This is the solution for the community. The medical doctors would rather have me do the job than the mid-levels because they recognize my expertise in diagnosing and treating mental illness. The primary care docs don't want to deal with psychiatric care. If we had enough psychiatrists, it wouldn't be a problem. From what I hear, the shortage is not just in rural areas like my own, so what is the solution, if not psychologists?

***edit*** FYI just wanted to add that I used to be more anti-RxP, but the needs of my patients and the community are pushing me in the other direction.

Pay more and they will get the psychiatrist. All of this complaining about vacant jobs in underserved areas and I have yet to hear about a psychiatrist salary going up in any real way. I hear plenty of unfilled jobs in rural areas at $210-240K, and they complain about not attracting a psychiatrist. The salary never goes up. When supply is low and demand is high you pay more.

 

[F0nzie]

Pay more and they will get the psychiatrist. All of this complaining about vacant jobs in underserved areas and I have yet to hear about a psychiatrist salary going up in any real way. I hear plenty of unfilled jobs in rural areas at $210-240K, and they complain about not attracting a psychiatrist. The salary never goes up. When supply is low and demand is high you pay more.

The roadblock to higher pay is medicare/medicaid reimbursements and subsidies from state funding. Also, as specialty we are weak at generating revenue and we have a high no-show rate. If you schedule 12 patients per day and 6 do not show you are not keeping the ship afloat. If you applied a community model for a private practice you will be lucky to clear a resident's salary. So think of that extra 150k as free money.

 

[whopper]

When supply is low and demand is high you pay more.

Easier said than done. Our pay is usually at the mercy of insurance companies and the government that are barring market forces from doing the capitalism correction that should've happened years ago.

 

[TexasPhysician]

Easier said than done. Our pay is usually at the mercy of insurance companies and the government that are barring market forces from doing the capitalism correction that should've happened years ago.

Then a billing code for rural areas could be put in place. There are many possible solutions, but the government is horrible at best with medical care.

 

[clusterF]

The funny thing is that some psychologists have a hissy fit when anyone talks about how mfts and lcsws, who often have more actual therapy training, should be equally licensed and paid to do therapy.

 

[erg923]

The funny thing is that some psychologists have a hissy fit when anyone talks about how mfts and lcsws, who often have more actual therapy training, should be equally licensed and paid to do therapy.

???

 

[vistaril]

Easier said than done. Our pay is usually at the mercy of insurance companies and the government that are barring market forces from doing the capitalism correction that should've happened years ago.

whoa....there is nothing that would prevent a 'capitalism correction' if that's what should have happened. If our services were so important then policyholders(and by extension the companies they work for) would demand changes and force competition.

I guarantee, for example, that if the procedure fee paid by insurance companies for a screening colonoscopy was 25 dollars then GIs wouldn't take that.....and patients would be pissed. And There would be great incentive for insurance companies to up the reimbursement to bring GIs back in their umbrella.....the market correction would a bit of time, but it would almost certainly happen

 

[vistaril]

The roadblock to higher pay is medicare/medicaid reimbursements and subsidies from state funding. Also, as specialty we are weak at generating revenue

what? I read all the time in here by several residents that psychiatrists make tons of money for reasonable hours....

 

[vistaril]

The roadblock to higher pay is medicare/medicaid reimbursements and subsidies from state funding. Also, as specialty we are weak at generating revenue and we have a high no-show rate. If you schedule 12 patients per day and 6 do not show you are not keeping the ship afloat.

if you're scheduling just 12 patients per day and not doing some sort of very high priced cash pay boutique practice(or working at the VA), then you would make less money than a toll booth worker.

 

[Leo Aquarius]

If you applied a community model for a private practice you will be lucky to clear a resident's salary. So think of that extra 150k as free money.

@vistaril. You forgot the last part. Let me quote it again since you missed it. "If you applied a community model for a private practice you will be lucky to clear a resident's salary." Don't apply community models to PP.

For the Gazillionth time, when you run your own practice at a modest $200 per hour (where I am that's cheap, $300 is the norm) that fills after a year of proper marketing efforts, you're making tons of money. Tons in our neck of the woods means $300,000, maybe $400,000. That's plenty for my liking. Maybe your expectations are vastly different.

 

[vistaril]

@vistaril. You forgot the last part. Let me quote it again since you missed it. "If you applied a community model for a private practice you will be lucky to clear a resident's salary." Don't apply community models to PP.

For the Gazillionth time, when you run your own practice at a modest $200 per hour that fills after a year of proper marketing efforts, you're making tons of money. Tons in our neck of the woods means $300,000, maybe $400,000. That's plenty for my liking. Maybe your expectation is vastly different.

and for the gazillionth time, the majority of BE/BC psychiatrists in the US don't practice this way.

And as something of an aside, if you're so committed to practicing this way(high dollar outpt cash pay), I don't even know what the heck the point this part of your residency is. Or honestly the last 6 years of your training/education in total. Except for maybe addiction outpts in a boutique cash practice....

 

[Leo Aquarius]

I read somewhere that over 70% of psychiatrists work in the outpatient setting. $200 an hour, which really means per month, is well worth keeping one's mental health going. People spend $5 a day on starbucks, yet they balk at $200 a month to keep their depression under control.

 

[Leo Aquarius]

and for the gazillionth time, the majority of BE/BC psychiatrists in the US don't practice this way.

And as something of an aside, if you're so committed to practicing this way(high dollar outpt cash pay), I don't even know what the heck the point this part of your residency is. Or honestly the last 6 years of your training/education in total. Except for maybe addiction outpts in a boutique cash practice....

Welcome to the sunny state of California.

 

[vistaril]

Welcome to the sunny state of California.

California is a huge state....the majority of BE/BC psychiarists in California don't practice this way either. I certainly get tons of job listings advertising in California(probably not the spots you want to live/work). I'm sure there are pockets of certain cities in California where this is more common.

 

[Leo Aquarius]

We can agree that jobs of all kinds are out there. For those who are ambitious, you can do extremely well. For those who want the easy job where everything is done and laid out for you, your income will reflect that cushion. There's something for everyone. We can also agree that plenty of jobs sit waiting for us. A luxury many other specialties wish for.

You're receiving jobs from head hunters. You and I both know those are bottom of the barrel. I get them too. 40 hrs a week. $120 per hour. A cog in someone else's PP wheel usually.

By the way, visit any PP psychiatrist office in CA and tell me how many charge less than $200 per hour. If you're not in the middle of Bishop, then you won't find many.

 

[vistaril]

I read somewhere that over 70% of psychiatrists work in the outpatient setting. $200 an hour, which really means per month, is well worth keeping one's mental health going. People spend $5 a day on starbucks, yet they balk at $200 a month to keep their depression under control.

the 70% number seems low......but even so, take the 70%, then multiply it by the % of psychiatrists who are cash only, and you'll get a percentage that is pretty low....

As for the $200......that would be true, but how in the hell can they be confident of 'keeping their depression under control'(vs placebo or some control) by 1 appt per month with their psych? If that's true, that's the best damn psychiatrist in the history of the world.

 

[vistaril]

We can agree that jobs of all kinds are out there. For those who are ambitious, you can do extremely well. For those who want the easy job where everything is done and laid out for you, your income will reflect that cushion. There's something for everyone. We can also agree that plenty of jobs sit waiting for us. A luxury many other specialties wish for.

By the way, visit any PP psychiatrist office in CA and tell me how many charge less than $200 per hour. If you're not in the middle of Bishop, then you won't find many.

there are lots of pp psychiatrists in California who don't charge by the hour period and practice outpt psychiatry like a lot of others in the country(coded visits reimbusrsed by copays and insurances)

 

[Leo Aquarius]

there are lots of pp psychiatrists in California who don't charge by the hour period and practice outpt psychiatry like a lot of others in the country(coded visits reimbusrsed by copays and insurances)

Yes, and when you bill for therapy and medication management for the session you can bring in around $200 per hour WITH insurance. My point is, whether you take insurance or not you're still sitting pretty.

 

[Leo Aquarius]

the 70% number seems low......but even so, take the 70%, then multiply it by the % of psychiatrists who are cash only, and you'll get a percentage that is pretty low....

As for the $200......that would be true, but how in the hell can they be confident of 'keeping their depression under control'(vs placebo or some control) by 1 appt per month with their psych? If that's true, that's the best damn psychiatrist in the history of the world.

So you are supporting my point that psych patients need close care, and they are willing to pay well for that care.

 

[whopper]

whoa....there is nothing that would prevent a 'capitalism correction' if that's what should have happened. If our services were so important then policyholders(and by extension the companies they work for) would demand changes and force competition.

No. The problem being is that employees don't want to tell their employers they are mentally ill. Ever hear of the stigma of mental illness. Further, let's assume that person did tell their employer. Aside that the employer could then try to fire the person just for being mentally ill (and this does happen), employers won't take up a war to demand that insurance companies raise the pay of psychiatrists because it's not like that employer will then have an army of mentally ill employees.

But let's talk about a more open problem such as obesity where it is obvious to the employer what is going on with their employee.

You think a grocery store manager is going to take on an insurance company, demanding that there be more PCPs and dieticians with the current obesity then diabetes, MI, HTN, HLD, epidemic because he sees some of his employees overweight?

 

[heyjack70]

Easier said than done. Our pay is usually at the mercy of insurance companies and the government that are barring market forces from doing the capitalism correction that should've happened years ago.

The city/county could pick up the slack in salary and reap the benefit of less crime, more employment, etc...if they cared about people with mental illness.

 

[smalltownpsych]

The funny thing is that some psychologists have a hissy fit when anyone talks about how mfts and lcsws, who often have more actual therapy training, should be equally licensed and paid to do therapy.

That is a completely inaccurate statement. I have worked with many newly licensed master's level providers in several states and have yet to see one that comes even close to the level of experience that a psychologist would have upon attaining licensure. They generally have at least half of the supervised hours prior to licensure because we usually get about 3 years of half-time clinical experience during our doctoral training and one year of full-time and intensive training during internship (so long as it is accredited, but that is another issue). After that we get our degree and have an equivalent amount of post-degree hours to obtain which is typically all that the masters level people focus on when making the argument that they have more training. I won't even go into the quality of the training other than to say, I think we beat them hands down there as well. To me this is roughly equivalent to saying that a NP or PA is better trained than an MD.

 

[vistaril]

So you are supporting my point that psych patients need close care, and they are willing to pay well for that care.

Not really.....my point was that seeing a psychiatrist once a month for an hour session doesn't neccessarily provide much punch in the way over 'making sure depression is handled' vs other possible controls(having fm prescribe meds, going to a run them in run them out psych who takes their insurance, etc)......

iow, of course people would be willing to pay 200 dollars per month to beat what they percieve as their depression or anxiety or whatever. Duh. And I'd pay 200 dollars per month to be taller or better looking or more intelligent or whatever, but what's the evidence that it will do so vs any other control that doesn't cost 200 dollars?

 

[vistaril]

No. The problem being is that employees don't want to tell their employers they are mentally ill. Ever hear of the stigma of mental illness. Further, let's assume that person did tell their employer. Aside that the employer could then try to fire the person just for being mentally ill (and this does happen), employers won't take up a war to demand that insurance companies raise the pay of psychiatrists because it's not like that employer will then have an army of mentally ill employees.

But let's talk about a more open problem such as obesity where it is obvious to the employer what is going on with their employee.

You think a grocery store manager is going to take on an insurance company, demanding that there be more PCPs and dieticians with the current obesity then diabetes, MI, HTN, HLD, epidemic because he sees some of his employees overweight?

All these things you talk about do go to the true market value of our services.....your statements above possibly do go to explaining why the true market value of our services is what it is. IOW, we're not reimbursed a lot because the powers that be/matter don't really value what we do and our leverage is not very strong. Factors like those are obviously core principles of a free market system, so no 'correction' is warranted.

 

[vistaril]

Yes, and when you bill for therapy and medication management for the session you can bring in around $200 per hour WITH insurance. My point is, whether you take insurance or not you're still sitting pretty.

depends on the area, how you're coding, how many patients an hour you are seeing, no show rate, etc.....lots of factors....

but do this same hypothetical exercise(as many have done in here before for psych) for a volume based IM outpt practice(or god forbid an optho practice or something) and you truly get some eye popping numbers......

the numbers very rarely work out the same way they do for insurance based practices in reality as they do in a powerpoint ideal. If that was the case then I could easily do the same sort of calculations for a volume based IM practice and get take homes of 1.2-1.4 million per physician....but that doesn't typically happen.

 

[Therapist4Chnge]

Very valid points @vistaril, as the business of healthcare is not simple multiplication (# pts x $ rate = salary). I've presented on related topics and the business side of things is only getting more complicated because of Obamacare. I think psychiatry is still in a very good position because of the supply/demand issues…but anyone reliant on insurance reimbursements will be disappointed in the coming years.

 

[whopper]

The city/county could pick up the slack in salary and reap the benefit of less crime, more employment, etc...if they cared about people with mental illness.

Completely agree.

Another factor is that states are pushed--by insurance companies to discharge ASAP, yet they want to keep the pay of psychiatrists lower, in effect reducing the needed number of psychiatrists in the community to take up those that are discharged.

If insurance companies based our pay on market forces, not their desire to penny pinch, it would dramatically help the problem and many more medical students would likely go into psychiatry upon hearing of an average salary about 50K higher than it is now, in turn this would decrease the need to allow psychologist prescribers while likely decreasing the number of patients needing to go back to the hospital due to relapse.

 

[smalltownpsych]

Completely agree.

Another factor is that states are pushed--by insurance companies to discharge ASAP, yet they want to keep the pay of psychiatrists lower, in effect reducing the needed number of psychiatrists in the community to take up those that are discharged.

If insurance companies based our pay on market forces, not their desire to penny pinch, it would dramatically help the problem and many more medical students would likely go into psychiatry upon hearing of an average salary about 50K higher than it is now, in turn this would decrease the need to allow psychologist prescribers while likely decreasing the number of patients needing to go back to the hospital due to relapse.

Maybe we could convince them to pay us a bit more too and we wouldn't be so eager to take a piece of your pie! The truth is that our interventions, which includes both psychotherapy and medication are cost effective and we have research to support it and some insurance companies see that as well. We just need to ensure that we don't allow them to degrade compensation by degrading qualifications of providers.

 

[vistaril]

Completely agree.

Another factor is that states are pushed--by insurance companies to discharge ASAP, yet they want to keep the pay of psychiatrists lower, in effect reducing the needed number of psychiatrists in the community to take up those that are discharged.

If insurance companies based our pay on market forces, not their desire to penny pinch,QUOTE]

but their desire to penny pinch'(and also more importantly their ABILITY to do so without repurcussions) is the dominant market force at play here.