Undersupply of Psychiatrists; the Economics

[SomeDoc]

Firstly, the current undersupply of psychiatrists is a major public-health concern. There is a projected increase of 15-20% demand for mental health services up to 2020, and not enough of us to provide those services.

That being said, I'm all for market supply-demand dynamics in favor of favorable compensation and bargaining power of psychiatrists, however reading this in the 2011 Merritt Hawkins Physician Recruitment Incentives gave me pause for concern:

The 2011 Review confirms the continued steep increase in demand for psychiatrists, a specialty where supply is increasingly unable to keep up with demand. Seventy percent of psychiatrists are 50 years old or older and many are at or near retirement age.

The worst case scenario is that supply does not keep up appropriately with demand and we end up having an increase in midlevel encroachment through legislative changes simply because of public necessity. This has already happened in some areas of the country, and while I am not in favor of this, patients at the very least gain some access to care, as opposed to no access at all.

Supply-demand dynamics is a fine balance, and part of this is dependent of a variety of independent variables, such as the population demographics, the current prevailing economic status, etc; but I shudder to think of the possibility of having our field encounter the disaster we see happening in fields like anesthesiology, with CRNA's. On the other hand, take for example what has happend on the other end of the spectrum with pathology- an oversupply of pathologists from the 1990's onward has progressively eroded bargaining power of individual pathologists, placing favor to mega-labs like labcorp, etc, who can dictate the terms of employment.

It is safe to assume that the need for mental health services will only continue to increase as our population ages and grows, and as compensation dynamics change (we have already achieved parity from a legislative perspective, projected increased access to care through the Affordable Care Act). A thoughtful and prudent increase in supply is bound to be healthy for the profession and the nation.

Thoughts?

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[digitlnoize]

Yep. The shortage is terrible. I actually think it's much, much worse than is being projected. I'm not sure the shortage projections are considering the average age of psychiatrists, or the fact that most work well less than 40h/wk.

When you add to this the fact that many psychiatrists don't take insurance, we have a huge access problem too.

Is there a solution? I'm not sure. Even if everyone wanted to go into psych, there aren't THAT many spots going unfilled. We could certainly fill more of those spots with US grads, but most of the spots ARE being filled. Plus, I am of the opinion that a huge shortage is a great thing for us, financially, although it's a terrible thing for the patients.

My wife is a dental hygienist, and there was a huge predicted shortage of those ~10 years ago too, so there's been this drastic expansion of hygiene schools across the country, and now, many grads are having a tough time finding jobs. We don't want to do the same thing to ourselves.

I think that in the end, we will wind up with good psychiatric care being only for the rich and upper middle class. Access for the poor will become terrible. In my state, salaries for the state psychiatrists actually aren't terrible, but I'm not sure that's the case everywhere or that it will continue.

The new federal laws won't change much for us.

 

[jettavr6]

One would expect our compensation to increase greatly due to supply and demand. But the system isn't built (fixed) that way. If compensation goes up drastically for example, on a 90807 cpt code, then you might see some family practitioners allotting time in their schedules to do this. Cash charging psychiatrists will probably continue to do well in niche markets. Not many patients can afford to pay cash out of pocket for their care.

 

[michaelrack]

Definition of 'Demand'

An economic principle that describes a consumer’s desire and willingness to pay a price for a specific good or service. Holding all other factors constant, the price of a good or service increases as its demand increases and vice versa.

Read more: http://www.investopedia.com/terms/d/demand.asp#ixzz20QEHv0kM


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The NEED for psychiatrists is much higher than the DEMAND

I believe NEED will increase, DEMAND will slowly decrease (insurance reimbursement will decline under obamacare)

 

[billypilgrim37]

The NEED for psychiatrists is much higher than the DEMAND

I believe NEED will increase, DEMAND will slowly decrease (insurance reimbursement will decline under obamacare)

Precisely. We aren't on the same side of many policy issues, but this is correct. The only argument against it might be that primary care specialties (possibly including psychiatry) may be mostly ignored for cost controls while lower hanging, more expensive fruit are initially targeted. Maybe.

 

[F0nzie]

Definition of 'Demand'

An economic principle that describes a consumer’s desire and willingness to pay a price for a specific good or service. Holding all other factors constant, the price of a good or service increases as its demand increases and vice versa.

Read more: http://www.investopedia.com/terms/d/demand.asp#ixzz20QEHv0kM


------------------------------------------

The NEED for psychiatrists is much higher than the DEMAND

I believe NEED will increase, DEMAND will slowly decrease (insurance reimbursement will decline under obamacare)

Brilliantly concise post distinguishing need vs. demand. On a macroeconomic scale these terms are not synonymous in a 3rd party payer system. Legislation is key. Niche markets like cash are far more complex.

 

[whopper]

From what I understand some insurance companies even dropped compensation rates since government healthcare was passed. In my area, most of the psychiatrists dropped Anthem, everyone citing that Anthem lowered reimbursement.

Now I'm not sure if this really happened because right when they allegedly dropped the price, that's when I started accepting Anthem patients, and man, did I fill up very quickly, though Anthem didn't pay much.

 

[vistaril]

Firstly, the current undersupply of psychiatrists is a major public-health concern. There is a projected increase of 15-20% demand for mental health services up to 2020, and not enough of us to provide those services.

That being said, I'm all for market supply-demand dynamics in favor of favorable compensation and bargaining power of psychiatrists, however reading this in the 2011 Merritt Hawkins Physician Recruitment Incentives gave me pause for concern:

The 2011 Review confirms the continued steep increase in demand for psychiatrists, a specialty where supply is increasingly unable to keep up with demand. Seventy percent of psychiatrists are 50 years old or older and many are at or near retirement age.

The worst case scenario is that supply does not keep up appropriately with demand and we end up having an increase in midlevel encroachment through legislative changes simply because of public necessity. This has already happened in some areas of the country, and while I am not in favor of this, patients at the very least gain some access to care, as opposed to no access at all.

Supply-demand dynamics is a fine balance, and part of this is dependent of a variety of independent variables, such as the population demographics, the current prevailing economic status, etc; but I shudder to think of the possibility of having our field encounter the disaster we see happening in fields like anesthesiology, with CRNA's. On the other hand, take for example what has happend on the other end of the spectrum with pathology- an oversupply of pathologists from the 1990's onward has progressively eroded bargaining power of individual pathologists, placing favor to mega-labs like labcorp, etc, who can dictate the terms of employment.

It is safe to assume that the need for mental health services will only continue to increase as our population ages and grows, and as compensation dynamics change (we have already achieved parity from a legislative perspective, projected increased access to care through the Affordable Care Act). A thoughtful and prudent increase in supply is bound to be healthy for the profession and the nation.

Thoughts?

sure....psychiatry is always going to be, along with general pediatrics and outpt general int med, one of the lowest paying specialties.....

trying to look at it in simple supply-demand terms is faulty. the "demand" for psych is flexible....meaning that most pcps can look at the texas algorithm or starD or whatever to treat their pt who didnt respond initially to an ssri. there isn't any reason they cant(they are literate Im assuming).....so if supply/demand gets too out of whack, that will correct that way.....

on the inpt side, there are other factors at work that make typical supply demand curves worthless....

 

[whopper]

the "demand" for psych is flexible....meaning that most pcps can look at the texas algorithm or starD or whatever to treat their pt who didnt respond initially to an ssri. there isn't any reason they cant(they are literate Im assuming).....so if supply/demand gets too out of whack, that will correct that way.....

I wouldn't say that given the lack of knowledge PCPs have showed with SSRIs but besides this PCPs already are the highest block of prescribers of psychotropics. PCPs as a whole prescribe more psychotropics than we do. They're already doing what you mentioned and we still have the psychiatrist-shortage problem.

Vistaril, question, what program are you in?

 

[strangeglove]

PCPs may be perfectly capable of prescribing even the most complex medication regimens. There are only so many psychiatric drugs and none of them are any more complicated than Coumadin, for example. It's really the behavioral part of psychiatry, e.g. dealing with patients who are suicidal, violent, angry, devaluing, substance abusing, psychotic, etc. that they can't do so well. Sadly, many psychiatrists who call themselves "psychopharmacologists" are the same.

 

[snarfer]

PCPs may be perfectly capable of prescribing even the most complex medication regimens. There are only so many psychiatric drugs and none of them are any more complicated than Coumadin, for example. It's really the behavioral part of psychiatry, e.g. dealing with patients who are suicidal, violent, angry, devaluing, substance abusing, psychotic, etc. that they can't do so well. Sadly, many psychiatrists who call themselves "psychopharmacologists" are the same.

What about Clozaril? I dislike the term 'psychopharmacologists' as well. Nothing is wrong with the term psychiatrist. I haven't had much experience with Coumadin since internship but I didn't think it was too complex. Reading and adjusting those ventilator machines on the ICU I did not like.

 

[freaker]

PCPs may be perfectly capable of prescribing even the most complex medication regimens. There are only so many psychiatric drugs and none of them are any more complicated than Coumadin, for example. It's really the behavioral part of psychiatry, e.g. dealing with patients who are suicidal, violent, angry, devaluing, substance abusing, psychotic, etc. that they can't do so well. Sadly, many psychiatrists who call themselves "psychopharmacologists" are the same.

I think at times we under-sell ourselves in psychiatry--or for that matter, in any non-surgical specialty. You say that PCPs can handle the most complex medical psychiatric regimens, but that would also require quite a bit of investment in time and energy--in the office and outside the office doing quite a bit of reading and review and experimentation. You learn in part in psychiatry through constant application, and PCPs are not commonly having to deal with complex psychiatric patients.

When I speak to PCPs, I find they often aren't as secure even with the medications as I thought they would be, and at times when I get a patient who wants to return to their PCP to manage their medications following a consultation, I get a request by the PCP for a bit more than a consult and to go ahead and to manage a moderately treatment resistant depression.

I'm reminded everytime that I go through Kaufman that while I may retain and use a bit more neuro than most other physicians, I'm definitely not even close to being a neurologist. You get used to rotating in your own sphere, get used to it, and forget what you don't know until it shows up in your office.

I will say I have a lot of respect for PCPs. It must be maddening to have to see as many patients as they do and to be in charge of so many systems at once.

 

[sunlioness]

I agree with Freaker. PCPs certainly have my respect for the wide array of things the may be called upon to deal with on any given day.

I've met some PCPs who've been very competent and confortable managing mental illness. Others who weren't comfortable prescribing 20mg of citalopram. And some who were scarily overconfident. I thinks it's like anything else, really.

 

[whopper]

From personal experience, I'd say PCPs are fine as a whole for mild depression and anxiety so long as they don't use benzos to treat it, or if a PCP continues a successful medication regimen. Other than that, I've noticed that as a group the person will be better going to a psychiatrist.

A way to extend the psychiatrist is to have them work at a primary care practice with the PCP so once the patient is stabilized, that patient can just be continued with the PCP, but if they worsen, they can readily go back to the psychiatrist.

 

[snarfer]

I have the utmost respect for PMDs. But I've seen a few putting patients on Xanax 2mg TID, Paxil, adderall for 'anxiety and depression" and only refer them to psychiatry when pts ask for Xanax 4mg TID or more than 60mg of Adderall. I recently asked a very nice PMD if she would consider stopping prescribing this rather odd regimen of Y meds to one particular patient with bipolar d/o who refuses accepting any Y meds from psychiatry. Pts denies having any mental health issues but only willing to see me for therapy. PMD replied "no, i don't think this would be good. she's very nice (and wealthy). " Well, a month later the pt fired this PMD anyway b/c this doc isn't board certified. But at least pt is willing to let me start her on a mood stabilzer.

 

[whopper]

IMHO the PCPs (and psychiatrists) giving out benzos and stimulants indiscriminately is due to laziness, not lack of knowledge. Virtually every medstudent graduates knowing these are substances of abuse and that benzos aren't good treatment long-term in most cases.