Is Psychiatry really “just medication management”?

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bpop

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Hi guys.

I’m a pre-med student very interested in Psychiatry. I’ve seen therapists and Psychiatrists in my life for personal reasons, and I only saw the Psychiatrist for my medications.

Are there other places Psychiatrists work than just offices? What are some other things Psychiatrists do than just medication management? I’m sorry for the dumb post, I just want to know what else they do besides diagnose and prescribe prescriptions.

Thank you!
 
bpop said:
Hi guys.

I’m a pre-med student very interested in Psychiatry. I’ve seen therapists and Psychiatrists in my life for personal reasons, and I only saw the Psychiatrist for my medications.

Are there other places Psychiatrists work than just offices? What are some other things Psychiatrists do than just medication management? I’m sorry for the dumb post, I just want to know what else they do besides diagnose and prescribe prescriptions.

Thank you!
Click to expand...

@splik , @whopper , @nitemagi

I feel like you guys would have some great answers for this.
 
I’m in 100% private practice. I integrate psychotherapy and medication, to some degree with every patient. In an average week, I have about 30, 1-hour sessions with a traditional therapy focus (relationships, self, stress) and 10, 1/2-hour sessions with a symptom/medication focus. Also, 10% of my week includes forensic evaluations, mostly competency to stand trial, at local prisons/jails.


Sent from my iPhone using SDN
 
It's definitely possible to integrate psychotherapy in a private practice. The more important thing though, even in "med management" cases therapy techniques are priceless. The treatment is also happening in the face to face encounter, not just with the meds.
 
bpop said:
Hi guys.

I’m a pre-med student very interested in Psychiatry. I’ve seen therapists and Psychiatrists in my life for personal reasons, and I only saw the Psychiatrist for my medications.

Are there other places Psychiatrists work than just offices? What are some other things Psychiatrists do than just medication management? I’m sorry for the dumb post, I just want to know what else they do besides diagnose and prescribe prescriptions.

Thank you!
Click to expand...

There should be some good relevant info for you here.

Choosing a Career in Psychiatry
 
The whole “is psychiatry just Med management?” question gets so old.

Why aren’t Medstudents making threads asking

“Is infectious disease just Med management?”

“Is endocrinology just Med management?”

“Is neurology just Med management?”

“Is rheumatology just Med management?”

It seems like the fact that we are trained both in meds and also non-medication treatment (psychotherapy) but on average do more meds than therapy, somehow strangely gets held against psychiatry compared to other specialties where meds really are the only available treatment.
 
Armadillos said:
The whole “is psychiatry just Med management?” question gets so old.

Why aren’t Medstudents making threads asking

“Is infectious disease just Med management?”

“Is endocrinology just Med management?”

“Is neurology just Med management?”

“Is rheumatology just Med management?”
Click to expand...
because no other specialty uses the term "med management" a term I personally despise because it makes us sound like we're pharmacists. psychiatrists made their own bed by using this ridiculous term and supporting the 15 minute "med check". For the op, I do not even prescribe medications.
 
RomanticScience said:
I’m in 100% private practice. I integrate psychotherapy and medication, to some degree with every patient. In an average week, I have about 30, 1-hour sessions with a traditional therapy focus (relationships, self, stress) and 10, 1/2-hour sessions with a symptom/medication focus. Also, 10% of my week includes forensic evaluations, mostly competency to stand trial, at local prisons/jails.


Sent from my iPhone using SDN
Click to expand...

How are you getting away with 1 hour sessions? Insurance does not cover this. most jobs require you to do primarily med management.

I personally do supportive therapy in my med management sessions but there is no time for me to do traditional therapy (CBT, Psychodynamic psychotherapy)
 
splik said:
because no other specialty uses the term "med management" a term I personally despise because it makes us sound like we're pharmacists. psychiatrists made their own bed by using this ridiculous term and supporting the 15 minute "med check". For the op, I do not even prescribe medications.
Click to expand...

Would you just call them “follow up appointments”? Have any thoughts on better terminology or ways of conceptualizing what psychiatrists do for patients with chronic illness on meds?
 
ryerica22 said:
How are you getting away with 1 hour sessions? Insurance does not cover this.
Click to expand...


whatever gave you this idea?! what do you think psychiatrists who take insurance and have psychotherapy based practices do? it's not "getting away" with anything, it is about providing an appropriate level of care for patients.

I only see a few patients (I have a highly specialized practice) and my initial consultations are 90mins-2hrs. You code is a 99205 + 99354 + 99355 and justify the reason for prolonged services. medicare in my area pays $505 for this two hour visit, and private insurances substantially more.

for therapy visits it is 99213/99214 + 90836 (or possibly 90838 depending on the insurance and kind of therapy). in my area medicare pays $254 for a 99214+90838 1 hour visit
 
ryerica22 said:
How are you getting away with 1 hour sessions? Insurance does not cover this. most jobs require you to do primarily med management.

I personally do supportive therapy in my med management sessions but there is no time for me to do traditional therapy (CBT, Psychodynamic psychotherapy)
Click to expand...

WTH?

This combo is the standard of care/evidence-based treatment for some of the most commonly treated psychiatric conditions. Business models or preferred CPT codes doesn't equate to what is clinically appropriate. The most ironic part of your claims is that INSURANCE COMPANIES KNOW THIS actually pay you for such services. Where do you work?
 
Old&InTheWay said:
Would you just call them “follow up appointments”? Have any thoughts on better terminology or ways of conceptualizing what psychiatrists do for patients with chronic illness on meds?
Click to expand...

Why does it have to be mysterious? As far as terminology, “follow up” seems fine and works for other specialties.

As for conceptulization, I would just say we are practicing medicine.
 
splik said:
whatever gave you this idea?! what do you think psychiatrists who take insurance and have psychotherapy based practices do? it's not "getting away" with anything, it is about providing an appropriate level of care for patients.

I only see a few patients (I have a highly specialized practice) and my initial consultations are 90mins-2hrs. You code is a 99205 + 99354 + 99355 and justify the reason for prolonged services. medicare in my area pays $505 for this two hour visit, and private insurances substantially more.

for therapy visits it is 99213/99214 + 90836 (or possibly 90838 depending on the insurance and kind of therapy). in my area medicare pays $254 for a 99214+90838 1 hour visit
Click to expand...
Oh man... Those are amazing compared to 90837 reimbursement rates

Sent from my SM-G950U using SDN mobile
 
No. I would argue that the most successful psychiatrists make the most bank doing things other than general high repetition routine “medication management”. That in particular has a fixed low value. Managing medication also has very different levels of complexity. For example, sub-specialists (i.e. child, addiction) etc the complexity involved in deal with a fairly complex regimen easily be comparable or exceed any typical cognitive sub specialist (i.e. neurology/rheumatology, etc). This type of services are mainly cash only and market rates exceed insurance reimbursement by quite a bit. People are not stupid. Patients and family know that the value in having a quality child psychiatrist correctly manage a problem adolescent’s med regimen is potentially HUGE in terms of long term career and academic functioning, if not literally life or death. I literally have people on Medicaid emptying their savings to pay me FULL CASH to get their meds right.

There are also psychiatrists who focus their practice on psychotherapy or combined treatment. This, believe it or not, is in high demand. As you can imagine, if you have a good insurance plan, it’s easier to deal with one person who does both meds and therapy than having split treatment. So these people end up filling first and make MORE money than your typical employed med mill psychiatrist. Secondarily, typically a psychiatrist is much better as a “point person” for case management in a private practice setting. This type of service also IMO has enormous value.

The *average* EMPLOYED psychiatry job may be mostly a bunch of 99213 visits, but the variance there is huge. I think a typical US grad can get into a fairly engaging career pathway in this field. Remember, about 40-50% of psychiatrists who are actively practicing don’t take ANY insurance—they are not employed.
 
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Armadillos said:
The whole “is psychiatry just Med management?” question gets so old.

Why aren’t Medstudents making threads asking

“Is infectious disease just Med management?”

“Is endocrinology just Med management?”

“Is neurology just Med management?”

“Is rheumatology just Med management?”

It seems like the fact that we are trained both in meds and also non-medication treatment (psychotherapy) but on average do more meds than therapy, somehow strangely gets held against psychiatry compared to other specialties where meds really are the only available treatment.
Click to expand...

Neurologists routinely do "cool" procedures such as eeg and emg, while only a minority of psychiatrists do procedures such as ECT. All of those specialties listed perform (or at least interpret)interesting diagnostic tests ... for example endocrine procedures to identify AND localize hyperadenalism
 
splik said:
whatever gave you this idea?! what do you think psychiatrists who take insurance and have psychotherapy based practices do? it's not "getting away" with anything, it is about providing an appropriate level of care for patients.

I only see a few patients (I have a highly specialized practice) and my initial consultations are 90mins-2hrs. You code is a 99205 + 99354 + 99355 and justify the reason for prolonged services. medicare in my area pays $505 for this two hour visit, and private insurances substantially more.

for therapy visits it is 99213/99214 + 90836 (or possibly 90838 depending on the insurance and kind of therapy). in my area medicare pays $254 for a 99214+90838 1 hour visit
Click to expand...
Thanks, I did not know about the 99355 code. I will look it up. Prolonged Evaluation and Management (EM) Services
 
ryerica22 said:
How are you getting away with 1 hour sessions? Insurance does not cover this. most jobs require you to do primarily med management.

I personally do supportive therapy in my med management sessions but there is no time for me to do traditional therapy (CBT, Psychodynamic psychotherapy)
Click to expand...

The insurance products in my market reimburse the 90838 code. The demand in my area allows me to accept just these and cash. Not many do, so I hear or just reimburse it the same as 90836 (38-52 min therapy).


Sent from my iPhone using SDN
 
bpop said:
Hi guys.

I’m a pre-med student very interested in Psychiatry. I’ve seen therapists and Psychiatrists in my life for personal reasons, and I only saw the Psychiatrist for my medications.

Are there other places Psychiatrists work than just offices? What are some other things Psychiatrists do than just medication management? I’m sorry for the dumb post, I just want to know what else they do besides diagnose and prescribe prescriptions.

Thank you!
Click to expand...

I'm sure others have answered your question, but wanted to give my two cents for whatever it's worth. You will be trained to do both but most of us lean towards what we're better at, and thats usually psychopharm (medication). Going through medical school you're taught pharmacology way more than psychotherapy so graduating makes you a bit bias. In residency, some programs will be heavier on medication versus others will be a bit more intense towards therapy. Most of us though lean towards medication management though -- but realize that when you do a patient interview/encounter, you're subconsciously doing a bit of psychotherapy too. It all goes hand in hand.
 
sluox said:
No. I would argue that the most successful psychiatrists make the most bank doing things other than general high repetition routine “medication management”. That in particular has a fixed low value. Managing medication also has very different levels of complexity. For example, sub-specialists (i.e. child, addiction) etc the complexity involved in deal with a fairly complex regimen easily be comparable or exceed any typical cognitive sub specialist (i.e. neurology/rheumatology, etc). This type of services are mainly cash only and market rates exceed insurance reimbursement by quite a bit. People are not stupid. Patients and family know that the value in having a quality child psychiatrist correctly manage a problem adolescent’s med regimen is potentially HUGE in terms of long term career and academic functioning, if not literally life or death. I literally have people on Medicaid emptying their savings to pay me FULL CASH to get their meds right.

There are also psychiatrists who focus their practice on psychotherapy or combined treatment. This, believe it or not, is in high demand. As you can imagine, if you have a good insurance plan, it’s easier to deal with one person who does both meds and therapy than having split treatment. So these people end up filling first and make MORE money than your typical employed med mill psychiatrist. Secondarily, typically a psychiatrist is much better as a “point person” for case management in a private practice setting. This type of service also IMO has enormous value.

The *average* EMPLOYED psychiatry job may be mostly a bunch of 99213 visits, but the variance there is huge. I think a typical US grad can get into a fairly engaging career pathway in this field. Remember, about 40-50% of psychiatrists who are actively practicing don’t take ANY insurance—they are not employed.
Click to expand...

High volume Med management in suburbia dealing with anxiety depression can do 5 med management visits per hour at about 100 a pop, that’s 500/hr, you are saying you can beat this doin cash only or anything else? This is not including income from hiring therapists, tms, etc
 
Merely said:
High volume Med management in suburbia dealing with anxiety depression can do 5 med management visits per hour at about 100 a pop, that’s 500/hr, you are saying you can beat this doin cash only or anything else? This is not including income from hiring therapists, tms, etc
Click to expand...
My psychiatrist charges 99215 for every appointment and gets about $50. That's for half hour.
 
birchswing said:
My psychiatrist charges 99215 for every appointment and gets about $50. That's for half hour.
Click to expand...

This doesn’t sound right. That’s really low, maybe Medicaid rates for 99215. In addition, 99215 in 30 minutes would be for only the most complex patients - about to be hospitalized, on Clozapine, etc.
 
TexasPhysician said:
This doesn’t sound right. That’s really low, maybe Medicaid rates for 99215. In addition, 99215 in 30 minutes would be for only the most complex patients - about to be hospitalized, on Clozapine, etc.
Click to expand...
Yeah, she bills me 99215 every single time. But we almost never make med changes. Like at the last appointment she told me to try a probiotic. That was a 99215. We talk about her family, etc., and she writes me refills. Right now I have "Cadillac" insurance (my dad's last year of employment so he went all out on the best plan which I'm still under) and I have Medicaid as secondary. I can see what my insurance pays (Medicaid pays whatever the primary doesn't). The most recent time was $59.95 for a 99215 (she requested $250 and that's what they paid), but that's up from what it used to be. My other practitioners bill 99213s and get reimbursed much more, like sometimes 150-200. I've been told that the reason we have so few psychiatrists in my area are the low reimbursement rates. One person explained to me how it related to us having one of the largest military populations in the country in this region, but I can't remember how that related to private insurance reimbursements. I've always assumed she bills 99215 because she only gets a tiny bit more than if she billed a lower service. I can't imagine she does it with all her patients as it would draw suspicion. I know that I am unusual in that I get a half hour. I'm not familiar with clozapine, but I'm not on anything exotic (which isn't to say not deleterious). She's never drawn labs (except genetic testing).

I just looked up the private pay place near me (which is not taking patients). Initial 1.5 hour evaluation is $220. 15 minute follow-up is $60. And half hour follow-up is $120. So, that's higher than what she's making, but it's still pretty low compared to rates I've seen for larger cities. I think I'm kind of in a psychiatry desert.
 
birchswing said:
Yeah, she bills me 99215 every single time. But we almost never make med changes. Like at the last appointment she told me to try a probiotic. That was a 99215. We talk about her family, etc., and she writes me refills. The most recent time was $59.95 for a 99215 (she requested $250 and that's what they paid), but that's up from what it used to be. My other practitioners bill 99213s and get reimbursed much more. I've always assumed she bills 99215 because she only gets a tiny bit more than if she billed a lower service. I can't imagine she does it with all her patients as it would draw suspicion. I know that I am unusual in that I get a half hour. I'm not familiar with clozapine, but I'm not on anything exotic
Click to expand...

What you describe is a mistake or fraud.
 
birchswing said:
Initial 1.5 hour evaluation is $220. 15 minute follow-up is $60. And half hour follow-up is $120. So, that's higher than what she's making, but it's still pretty low compared to rates I've seen for larger cities. I think I'm kind of in a psychiatry desert.
Click to expand...

If initial evaluations are actually 1.5 hours, $220 is a ridiculously low rate. The follow up rate would be ok in a situation with minimal overhead.
 
michaelrack said:
If initial evaluations are actually 1.5 hours, $220 is a ridiculously low rate. The follow up rate would be ok in a situation with minimal overhead.
Click to expand...

Maybe it’s supposed to be 320 instead of 220....

It doesn’t even make sense given the follow up rates. Follow ups are working out to 240/hr while the intake is 147/hr.
 
I read it wrong. It looks like it's one to one and a half hours for $220, meaning the time may vary:

Screen Shot 2019-01-01 at 8.28.24 PM.png
 
birchswing said:
I read it wrong. It looks like it's one to one and a half hours for $220, meaning the time may vary:

View attachment 246294
Click to expand...

Those are very low rates. In comparison, my masters-level counseling interns charge more than that for counseling. PhD counseling in my area is over 2x that.
 
TexasPhysician said:
Those are very low rates. In comparison, my masters-level counseling interns charge more than that for counseling. PhD counseling in my area is over 2x that.
Click to expand...
Yes, I've been told that's why we attract so few, and those we attract are sort of . . . weird.

Edit: Also, people don't tend to stay long. I've been asked before why I stay with an unconventional psychiatrist. It's in large part because she's stayed in the area.

We're by no means a poor area. Nor is it particularly rural. I've been told it has something to do with military reimbursement rates setting the trend for the area, but not sure about that.
 
Last edited:
splik said:
whatever gave you this idea?! what do you think psychiatrists who take insurance and have psychotherapy based practices do? it's not "getting away" with anything, it is about providing an appropriate level of care for patients.

I only see a few patients (I have a highly specialized practice) and my initial consultations are 90mins-2hrs. You code is a 99205 + 99354 + 99355 and justify the reason for prolonged services. medicare in my area pays $505 for this two hour visit, and private insurances substantially more.

for therapy visits it is 99213/99214 + 90836 (or possibly 90838 depending on the insurance and kind of therapy). in my area medicare pays $254 for a 99214+90838 1 hour visit
Click to expand...
WOW. Medicare or any insurance doesn't pay nearly this much in Michigan. I am definitely working in the wrong state.
 
RomanticScience said:
I’m in 100% private practice. I integrate psychotherapy and medication, to some degree with every patient. In an average week, I have about 30, 1-hour sessions with a traditional therapy focus (relationships, self, stress) and 10, 1/2-hour sessions with a symptom/medication focus. Also, 10% of my week includes forensic evaluations, mostly competency to stand trial, at local prisons/jails.


Sent from my iPhone using SDN
Click to expand...
Are you boarded in forensics?
 
As others say above -- it's not. This is a generational issue. The earlier generations of psychiatrists practiced a lot of therapy. Then in the 90s basically therapy training fell out of favor in psychiatry training. And the pendulum is swinging back towards therapy. But in the community is a generation (20 years) of trained psychiatrists who only trained in medications. So you can do (and learn to do) much much more than meds.
 
splik said:
in michigan (outside detroit) medicare pays $430 for a 2 hour visit and $218.85 for a 99214+90838 60 minute visit with E&M and psychotherapy
Click to expand...
According to my biller, Medicare wont pay for more than a 45 minute visit initial eval or therapy. She wont even send a 60 min evaluation because she said it will be rejected. She's pretty much "THE" biller for private practice psychiatrists in the area I practice.
 
futuredo32 said:
According to my biller, Medicare wont pay for more than a 45 minute visit initial eval or therapy. She wont even send a 60 min evaluation because she said it will be rejected. She's pretty much "THE" biller for private practice psychiatrists in the area I practice.
Click to expand...
I would be curious about a second opinion from a biller that specializes in therapists rather than psychiatrists.
 
Merely said:
High volume Med management in suburbia dealing with anxiety depression can do 5 med management visits per hour at about 100 a pop, that’s 500/hr, you are saying you can beat this doin cash only or anything else? This is not including income from hiring therapists, tms, etc
Click to expand...

Do people really do 5 med mgmt visits an hour??? That just sounds crazy to me.

And yes, you can beat this with cash only with only therapy.
 
Mad Jack said:
*glances at genetic and neuropsychological testing* yeah we don't have testing
Click to expand...

Lol.. I think he meant tests that actually change management. Who orders genetic tests routinely in psychiatric practice ?
 
There are some practices now where it's standard on intake for every patient.

I've had it done three times from the same psychiatrist (three different companies, each "better" than the last). It makes my psychiatrist happy so I do it even knowing it's a waste of somebody's money (not sure who is paying). A small sample of saliva is not much to placate her, and I've never had to pay a dime. Has never changed management at all. I'm assuming she gets to bill for a procedure and that's why she does it, but not positive if there are other kickbacks. Sometimes she just gets really excited about new things. I have seen several psychiatric practices where there is a "Genesight" logo on the web-site so it's definitely a thing now. I don't think my psychiatrist is representative of psychiatrists, though. Her payments received according to CMS open payments were above the national average by $30,000 last year for her profession. And I know for a fact every patient she sees has had at least one genetic test because it's part of seeing her. So there is probably a small percentage of psychiatrists doing the bulk of the testing.

Having said all that, a psychiatrist could order useful tests like CT scans, sleep studies, thyroid evaluations, and from what I've heard ECT can be helpful in otherwise refractory cases.
 
liquidshadow22 said:
Lol.. I think he meant tests that actually change management. Who orders genetic tests routinely in psychiatric practice ?
Click to expand...
It changes management pretty routinely around here, as it is standard in many practices and covered by most insurance. Neuropsychiatric testing is great for catching malingerers, for instance, and good genetic tests can save months of sorting through meds to find the right combo. Proper diagnosis is also key to proper treatment, so utilizing testing scales that can properly sort, for instance, your MDD patients from your bipolar II patients is critical, as bipolar patients that are misdiagnosed as MDD typically receive antidepressants which the research shows just aren't all that effective for their cases, and the average time for proper diagnosis is 10 years for a misdiagnosed patient in this particular circumstance.
 
michaelrack said:
Psychiatrists can order tests performed and interpreted by others (neuropsychological testing etc).... endocrinologists perform and interpret the test themselves
Click to expand...
Genetic testing requires interpretation to use properly. If you're just going by color codes and not reading and understanding the individual genes involved you're doing your patients a disservice.
 
There is also the aspect of monitoring your patients for metabolic side effects and searching for medical causes of psychosis. It isn't up to medicine to find out whether my patient has psychosis secondary to lupus, syphilis, or thyroid issues, for instance.
 
Pharmacogenetic testing is the diagnostic approach of the future and I fear it always will be. Regardless at present the evidence is very, very shaky for actual clinical utility. As a hail Mary whatevs but I don't think it conveys all that much in information-theoretic terms wrt med choice nor should it meaningfully impact your priors.

While scales can be very helpful in making sure you assess things systematically, they cannot substitute for a clinical interview done by someone who knows what they're doing when it comes to bipolar II. Probably the most efficacious procedure in those cases is making a phone call to someone close to the patient.
 
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