Today: 65th Birthday While in Psychotherapy
Tomorrow: Will Psychiatrists do Psychotherapy?
The Happy 65th Birthday Conversation
I remember the first time I had the “Happy 65th birthday” conversation with a patient. He was a very successful businessman and financial investor whom I had first seen in my New York practice about 15 years previously at the time he was having some personal and business crises. He was in twice week psychotherapy with me for about three years. When he was 62 his wife died and he came in for a few sessions during this difficult time but handled his grieving as well as could be expected. He came back to see me two years later related to conflicts within himself and with his children about a decision whether or not to get married to a women with whom he had a relationship for about 6 months. I saw him once per week and as I expected, he was working well in therapy.
Your Fee is Reduced
I knew his 65th birthday was coming up and when he came in and announced it was his birthday I replied, “Happy Birthday and your present from me will be that your fee will be reduced 150% to about $100/session”. I elaborated that this was the Medicare fee for 45-50 minute psychotherapy sessions. He laughed and said, “Of course not, I am more than glad to pay your full fee and you know that I have no trouble affording it.” He was quite surprised when I told him that would be against the law and that I was mandated to charge him the Medicare fee. He offered to pay the difference and thought it was grossly unfair to me for him to pay me a reduced fee. I told him that I had no choice and that the only way that I would be able to see him was to charge him only the Medicare allowable fee. Obviously, this became a topic in the therapy with him but that is not the point that I am discussing here.
Impact on the Psychiatrist of Treating Patients on Medicare
Over subsequent years as many of my patients aged, I had similar conversations with them. I had previously treated a relatively small number of patients on Medicare and was comfortable in accepting the reduced fees. While the fee for psychotherapy was much lower than my customary fee, the Medicare fee for psycho-pharmacology was only slightly below my usual fee and the time of these visits were 20-30 minutes per session. When I would see patients who had private insurance, most of their policies allowed them to see a doctor “out of network” which usually meant that the patient was allowed to make up the difference in payment of what their policy allowed for treatment and that of my usual fee. I also had a major academic position so overall the Medicare portion of my income was relatively small.
While I could theoretically limit the number of patients that I would see on Medicare, I was not comfortable in choosing individual patients to treat using that criterion. Once I would agree to see a patient, as I stated above, I would be obligated to charge them only the Medicare fee. So as I always did, I continued to accept Medicare patients as they came to me if I felt I could help them.
However, as the years progressed I was increasingly involved with other professional activities mainly research, special projects as well as eventually becoming the Speaker of the Assembly of the American Psychiatric Association. This meant that I had less time for private practice and therefore seeing patients on Medicare would have a more significant impact on my income. There happened to be a brief period where I was not treating any patients on Medicare. Since it would not impact any of my current patients, at that point, I made a decision to do something that I thought I would never do. It was something that I understood an increasing number of psychiatrists and other doctors in New York, Washington D.C. Texas and I am sure other locations were doing.
The Opting Out Solution
I opted out of Medicare! This is a legal process where a doctor files papers with Medicare which states that he or she is no longer part of the Medicare program and can no longer submit bills to Medicare nor could any of his or patients submit your psychiatric bills to Medicare for reimbursement. In fact, patients had to sign a statement that they understood that neither they nor their heirs could be reimbursed for any bills that you had given them for treatment. I, of course could see any patient of Medicare age but they could only pay me out of pocket or be reimbursed through insurance that they might have other than Medicare. This worked satisfactorily for me as I had a limited private practice, which I also continued when I recently relocated to Southern California. I will always tell patients when they first call me for a consultation that I am no longer part of the Medicare program and the implications of this. Some find this O.K. and will see me while others will not.
I don’t believe that my particular decision to opt out or the decision of other psychiatrists to do likewise seriously impacted the availability of care in the two communities in New York and California where I practiced. As far as I could see, there still are sufficient psychiatrists accepting Medicare. Perhaps some were not offering psychotherapy to such patients but were there to do psycho-pharmacology, which is essential care for many conditions. Also, in these areas there are many psychologists and social workers who are trained in psychotherapy, many of whom have a fee schedule less than the prevailing psychiatric fees for psychotherapy. They often work in conjunction with a psychiatrist who prescribes medication. Such dual therapy, in my experience, usually works quite well. However, in some situations it is much more ideal that a psychiatrist should do the psychotherapy and prescribe the medication to an individual patient. If psychiatrists continue to opt out in these communities or in communities where there are limited psychiatrists, this could become a major problem.
Implications of New Changes in Our Healthcare System
We are on the verge of major changes in our healthcare system. Certainly I hope and expect that the coverage of mental illness will be on parity with other medical conditions. This should include inpatient treatment and outpatient follow-up care for serious mental illness, which includes substance abuse. It should also include psychiatric care for all designated mental conditions. It is possible that there will be limitations put on the number of sessions allowed for psychotherapy and on the fee schedules that are set up for this form of treatment. Ideally the fee schedule should be fair and equivalent to other medical care, based on the time that the psychiatrist spends administering psychotherapy for patients who need it. These are very complicated issues. While psychotherapy has been shown to be effective with evidence-based research, there may not be the same degree of established research as to the efficacy compared to some other medical conditions. This could lead to limitations or no reimbursement for psychotherapy of certain conditions. If the emerging system limits or discourages psychiatrists from doing psychotherapy, this will be a great loss in providing mental health care in this country. The growth of psychotherapy has a history as coming from psychiatrists, along with our colleagues in the mental health field So many of the great therapists and teachers have been outstanding dedicated psychiatrists. If psychiatrists are forced to do less psychotherapy, there will be a diminution in training programs and psychotherapy research, which could be a great loss to the quality of care being delivered in this country.
I fervently hope that we make major changes in our healthcare system. I personally believe that there should be a public option even though I recognize the possible dilemma as I indicated above, that could occur for psychiatrists who wish to utilize their psychotherapy skills along with their other psychiatric treatment modalities. The best way to work this out is to continue to put a searchlight on all aspects of this issue. I hope that this piece will stimulate discussion that will allow us to continue to move forward and solve these problems.
Your comments are welcome.