FM managing psych cases

[Horners]

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Hey all,

So I’m on my FM rotation and I noticed something strange today.

We had 2 patients today that came in with primarily psychiatric issues (complicated anxiety and depression. Multiple drug failures, hx of drug abuse blah blah)

When I asked the doc why they don’t refer out, they said “because we don’t have a psychiatrist in the area who takes insurance... and even if they find one it takes 6 months to see them”

Also, she made this comment about that the reason psychiatrists don’t take insurance is bc insurance will pay 50% when it’s a psych issue but they’ll pay 80% when it’s a medical issue.


My questions are:

1) are the patients really getting the best care here? Or can an FM guy really manage everything up till schizo/BPD and it’s a ok

2) insurance pays 50% when they know it’s a psych problem vs like a UTI??? (Find that to be kinda crazy)


Sent from my iPhone using SDN mobile

 

[PikminOC]

Man sues doctor, pharmacist after alleged misdiagnosis, overdose leads to severe skin condition

 

[splik]

My questions are:

1) are the patients really getting the best care here? Or can an FM guy really manage everything up till schizo/BPD and it’s a ok

2) insurance pays 50% when they know it’s a psych problem vs like a UTI??? (Find that to be kinda crazy)

1. not everyone needs to see a specialist or gets better care from doing so. there are some fantastic family physicians who can do a pretty good job managing psychiatric disorders. many are not good. a good proportion want nothing to do with psych patients. It is also true that many patients who would benefit from a psychiatrist do not get to see one because of the distribution of psychiatrists skews to urban metropolitan areas near the coasts, and that a lot of psychiatrists dont want to treat people with mental illness.
2. CPT codes pay different amounts depending on the specialty. its more complicated for psych because mental health benefits are carved out as distinct from medical benefits and thus some insurances may not cover mental health at all and it is true that reimbursement for "behavioral health" is often poorer than for something else. all this depends on the specific insurance plan and geographic area etc.

 

[Crayola227]

1. not everyone needs to see a specialist or gets better care from doing so. there are some fantastic family physicians who can do a pretty good job managing psychiatric disorders. many are not good. a good proportion want nothing to do with psych patients. It is also true that many patients who would benefit from a psychiatrist do not get to see one because of the distribution of psychiatrists skews to urban metropolitan areas near the coasts, and that a lot of psychiatrists dont want to treat people with mental illness.
2. CPT codes pay different amounts depending on the specialty. its more complicated for psych because mental health benefits are carved out as distinct from medical benefits and thus some insurances may not cover mental health at all and it is true that reimbursement for "behavioral health" is often poorer than for something else. all this depends on the specific insurance plan and geographic area etc.

I'm confused, a lot of psychiatrists don't want to treat mental illness? What do they do instead? I mean, I know there are non-clinical things out there for anyone, but this puzzles me.

 

[clausewitz2]

I'm confused, a lot of psychiatrists don't want to treat mental illness? What do they do instead? I mean, I know there are non-clinical things out there for anyone, but this puzzles me.

Treat problems of living, i.e., the high-functioning garden-variety depr-anxious client who constitutes the majority of bourgie people who visit a therapist or psychiatrist. As opposed to someone who's been hospitalized five times in the past three years and carries an SMI type diagnosis.

Although maybe splik means something entirely different, shouldn't speak for him.

 

[Crayola227]

Treat problems of living, i.e., the high-functioning garden-variety depr-anxious client who constitutes the majority of bourgie people who visit a therapist or psychiatrist. As opposed to someone who's been hospitalized five times in the past three years and carries an SMI type diagnosis.

Although maybe splik means something entirely different, shouldn't speak for him.

that all makes a lot of sense now

 

[PikminOC]

1. not everyone needs to see a specialist or gets better care from doing so. there are some fantastic family physicians who can do a pretty good job managing psychiatric disorders. many are not good. a good proportion want nothing to do with psych patients. It is also true that many patients who would benefit from a psychiatrist do not get to see one because of the distribution of psychiatrists skews to urban metropolitan areas near the coasts, and that a lot of psychiatrists dont want to treat people with mental illness.
2. CPT codes pay different amounts depending on the specialty. its more complicated for psych because mental health benefits are carved out as distinct from medical benefits and thus some insurances may not cover mental health at all and it is true that reimbursement for "behavioral health" is often poorer than for something else. all this depends on the specific insurance plan and geographic area etc.

But when there is a complication and it goes to court like the case I posted, the fm will be cited for not referring to the specialist

 

[lyla]

Treat problems of living, i.e., the high-functioning garden-variety depr-anxious client who constitutes the majority of bourgie people who visit a therapist or psychiatrist. As opposed to someone who's been hospitalized five times in the past three years and carries an SMI type diagnosis.
.

I still have a hard time wrapping my head around this. For me ... I almost always have preferred working with SMI/safety net/community MH than the "worried well."

 

[DisorderedDoc417]

Man sues doctor, pharmacist after alleged misdiagnosis, overdose leads to severe skin condition

That practitioner has no idea about lamictal. Although I am constantly paranoid about this happening in my patients who decide 400 of lamictal is no longer for them and they abruptly stop it!!!

 

[futuredo32]

2. CPT codes pay different amounts depending on the specialty. its more complicated for psych because mental health benefits are carved out as distinct from medical benefits and thus some insurances may not cover mental health at all and it is true that reimbursement for "behavioral health" is often poorer than for something else. all this depends on the specific insurance plan and geographic area etc.

What happened to mental health parity???

 

[hallowmann]

1. not everyone needs to see a specialist or gets better care from doing so. there are some fantastic family physicians who can do a pretty good job managing psychiatric disorders. many are not good. a good proportion want nothing to do with psych patients. It is also true that many patients who would benefit from a psychiatrist do not get to see one because of the distribution of psychiatrists skews to urban metropolitan areas near the coasts, and that a lot of psychiatrists dont want to treat people with mental illness.
2. CPT codes pay different amounts depending on the specialty. its more complicated for psych because mental health benefits are carved out as distinct from medical benefits and thus some insurances may not cover mental health at all and it is true that reimbursement for "behavioral health" is often poorer than for something else. all this depends on the specific insurance plan and geographic area etc.

Best explanation here.

I've rotated through quite a few places where the best someone can get in terms of behavioral health treatment is an FM doc and maybe a 3 mos booked out social worker. It sucks for patients. Almost every place I rotated at in medical school with the exception of the tertiary medical center had psychiatrist shortages with a minimum wait of 6 mos, and that's if they accepted your insurance/their services were covered.

 

[clausewitz2]

I still have a hard time wrapping my head around this. For me ... I almost always have preferred working with SMI/safety net/community MH than the "worried well."

I mean, I feel similarly because it's vastly less boring. I think a lot of people avoid it because a) it's harder and more intensive of thought/time if done well b) it's often hard to do it well due to structural factors in your agency/clinic you have no power over c) very little scope for a private practice in most places. Add that people working in community MH tend to fall into one of three types a) new graduates in their first job who will get chewed up and spat out (or move on when they have enough supervision hours for full licensure), b) dyed-in-the-wool, mission-driven true believers and c) time-servers or people who couldn't hack it elsewhere. If the mixture leans heavily towards the third type, it is somewhat demoralizing if you actually do care very much.

 

[OldPsychDoc]

What happened to mental health parity???

Always ways around it...especially when prevailing sentiment in government is to favor insurance companies, not patients.

 

[futuredo32]

Always ways around it...especially when prevailing sentiment in government is to favor insurance companies, not patients.

Which totally sucks.

 

[Jules A]

When I asked the doc why they don’t refer out, they said “because we don’t have a psychiatrist in the area who takes insurance... and even if they find one it takes 6 months to see them”

I hear this often and think its a load of crap as an excuse not to initiate a needed psych referral. Ideally they would refer out immediately and do their best in the meantime to stabilize the patients you describe who are likely to be more than those who only need a little whiff of Zoloft, which of course they are unlikely to get from a PCP anyway. In my area it seems they only prescribe whatever psych med samples they have on hand.

 

[Candidate2017]

I still have a hard time wrapping my head around this. For me ... I almost always have preferred working with SMI/safety net/community MH than the "worried well."

Not everyone enjoys working with low insight, low compliance populations. Someone should do a RCT of random blow dart LAIs combined with3 hots and a cot. I wouldn't be surprised if outcomes and efficacy were better than psychiatric care.

Therapy is also more enjoyable and useful for higher functioning populations. Much more rewarding to help a capable individual fulfill their high potential.

 

[VA Hopeful Dr]

I hear this often and think its a load of crap as an excuse not to initiate a needed psych referral. Ideally they would refer out immediately and do their best in the meantime to stabilize the patients you describe who are likely to be more than those who only need a little whiff of Zoloft, which of course they are unlikely to get from a PCP anyway. In my area it seems they only prescribe whatever psych med samples they have on hand.

I'm constantly amazed at the number of PCPs who won't do basic psych. I've gotten new patients before who came to me after their last FP wouldn't continue their pre-existing Wellbutrin. Its one thing to not want to mess with stuff like lithium or geodon. But SSRIs and other first line agents for anxiety and depression should easily be within a PCP's ability.

 

[clausewitz2]

I'm constantly amazed at the number of PCPs who won't do basic psych. I've gotten new patients before who came to me after their last FP wouldn't continue their pre-existing Wellbutrin. Its one thing to not want to mess with stuff like lithium or geodon. But SSRIs and other first line agents for anxiety and depression should easily be within a PCP's ability.

Seems sort of scandalous that a PCP wouldn't be comfortable with Wellbutrin, given the whole smoking cessation indication...

 

[clausewitz2]

Not everyone enjoys working with low insight, low compliance populations. Someone should do a RCT of random blow dart LAIs combined with3 hots and a cot. I wouldn't be surprised if outcomes and efficacy were better than psychiatric care.

Therapy is also more enjoyable and useful for higher functioning populations. Much more rewarding to help a capable individual fulfill their high potential.

The insight and adherence tend to increase significantly when symptom eradication is not the chief objective. There is a distinct role for therapy with these patients, but it certainly is going to be quite different from helping high-functioning neurotics. For what it's worth, some of the personality disorders can be pretty crippling as well, and there therapy is the only game in town.

You and I have different ideas of what is rewarding, but y'know, that's okay, despite this being the Internet.

 

[DisorderedDoc417]

Not everyone enjoys working with low insight, low compliance populations. Someone should do a RCT of random blow dart LAIs combined with3 hots and a cot. I wouldn't be surprised if outcomes and efficacy were better than psychiatric care.

Therapy is also more enjoyable and useful for higher functioning populations. Much more rewarding to help a capable individual fulfill their high potential.

Almost in tears laughing.