This is one of those threads where it's just not worth engaging, and I don't know why I am.
The problem herein lies in the bold:
Some psychiatrist see the "typical behavior and pharm recs" as something they can rattle off in three minutes and just move on. Good geriatric psychiatrists and good nursing home psychiatrists (of which there is obvious overlap) can spend a LOT of meaningful time in psychoeducation with family and caregivers, practical problem solving, and skillful medication management (because not everyone does great on whisps of risperdal or seroquel). Then there becomes the issue of helping the family make decisions about disposition and level of support. This stuff makes a lot of sense and can save money. Patients with dementia who have support and a thoughtful physician (probably geriatrician or geri psychiatrist either can work in different situations) can stay at lower levels of supervision for longer (generally preference of patients AND families) and when they do require an increase in levels of care, the transitions can be smoothed such that they avoid things like acute hospitalizations that are very expensive that come from bad planning or waiting too long.
Experiences may vary, but I know a lot of very good geriatric psychiatrists who do a lot of good for their patients. It's not sexy. Most of this work SHOULDN'T require a psychiatrist or even an MD, but part of our role is integration and coordination and team leading, and most of this work simply doesn't get done, and it falls to us as apparently the only folks often paying attention about what's important. It's not just stamping risperldal 0.25mg QHS scripts.
If you restrict the role of a psychiatrist, then the psychiatrist might not be very useful. But there are things you can ACTUALLY do. And some folks actually do it. Those folks do NOT include me. I find none of this work appealing at all, and have no interest in being involved with it. If Vistaril doesn't find it appealing either, that's totally fine. It's not necessarily the most rewarding work depending on your personal preferences. Given how expensive acute care is, there are cost savings to be had. If psychiatrists were paid for how much money we could save the system, that would often be a better marker of our financial value.
We have a combined internal medicine/psychiatry geriatric center (not like combined specialties--just both are present in the same place) and they have the sort of therapists and case managers, etc., that make these kinds of things really work well with physicians who are the team leaders and make important treatment planning decisions.
I don't neccessarily disagree with a lot of this, although I do think the role of an 'expert' gerpsych or geriatrician for med mgt recs is probably overrated. There aren't ten million different complicated drugs out there....generally if the standard drugs or dose don't produce any benefit, the 'expert' is going to do the same thing anyone else would do- try something further down the line.
Would agree that psycoeducation for the family and caregiver is a skill, but everything boils down to getting this into a billable code....speaking towards the outpt world(since as you mentioned the goal is to keep these pts out of expensive hospitalizations)you can bundle care for partial day programs and stuff, but someone(be it their internist, geriatrician, fm, geri psychiatrist, etc) is still seeing the pt for med mgt and still billing(likely medicare) for it.....and the reality is that there is only so much you can do to work within that system.
At this combined center(im assuming outpt?) where demented geri psych patients are seen, my guess is that the structure works in the following way:
-internist is billing medicare for his office visit
-psychiatrist/geri psych billing medicare for his office visit
-the other people(lcsws, PT/OT if that is applicable, whatever) are either billing individually(more likely) or billing as part of bundled care(less likely, but possible depending on level of care) or the center is just effectively eating that salaried position(not likely but who knows)
Now there may be some institutional funding to help out with this or a block grant from somewhere, which is nice and complimentary, but if the pt is medicare the individual providers are still billing the same way(assuming they are seeing the pt)
What medicare sees when they are paying out claims for that patient isn't likely to be any different than if the pt were to see one of your buddies in private practice(maybe he goes to the nursing home and sees pts) and then is transported to her internist across town for her outpt appt. It's better in the sense that it is more convenient for the patient and the providers can communicate with each other more easily and records are probably more accessible of course.
