Do the Math

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Being a woman of a certain age, I dutifully went in for a “routine” colonoscopy a few weeks ago. My doctor came to see me before the procedure. She spent about 5 minutes reviewing the procedure and asked me to sign the consent form. I was in the procedure room for about 10 minutes and then we were done.

A few days ago, I got the bill. The hospital charged $2,252.00 for her time and was paid $1,126.11. This is only the charge for the physician. The other costs were billed at $2,721.39. I was in the hospital for about an hour and the charge was $5,010.56. They were paid $3,074.85.

I am glad I had a competent physician who did not perforate my bowel and I respect the technical expertise required to safely perform this procedure. But it got me to wondering about the reimbursement for the work I do.

This is how it compares.

If I spend 15 or 30 minutes with a patient on a routine cursory visit, my agency is paid $58.14. If we were to book our psychiatrists with a patient every 15 minutes, we could charge $232.56/hour but this does not account for the phone calls between visits or the discussion with other colleagues or family members. Recently, I have been trying to have longer network meetings. These often last an hour and some of them last longer. The most my agency can bill is $115.88 and this is regardless of how many clinicians are in the room. And in contrast to my gastroenterologist, there are no extra charges for any of our other staff who work to help our clinic run smoothly – the receptionist, the staff in our records department, the nurse who might be available to handle calls at other times of the day, the IT department, the people who send out these bills.

Now I realize that many who visit the MIA website, think psychiatrists are worth a lot less than $58.14. But there are others who complain that psychiatrists do not spend enough time with their patients.

So if you are a hospital or an outpatient clinic, what are you likely to offer? Routine colonoscopies on healthy people where you schedule people every 10 minutes and charge $5,000 a person or 15 minute psychiatry appointments where you can charge $232.56 per hour or extended 1-2 hour network meetings where ambiguous and complicated problems are discussed with multiple clinicians for a total charge of $115.88?

This is a fact of modern medicine – at least as practiced in the U.S. – that has to be addressed if we want to talk about reform. Procedures are highly valued, clinical relationships are not. This is not an argument for a medical centric system. It is one of the reasons I have argued for marginalizing medicine.  I would add that I have no complaint about my salary but my wonderful colleagues who work by my side are not paid well at all.  They leave their jobs and this leads to a fracturing of our most valuable commodity – the relationships we strive to build.   And I am a big supporter of hiring people with lived experience but they also need to be paid a living wage and, as you may have read elsewhere on this site this week, they are as vulnerable as any of us who work in less technical ways. This is a part of the story that is hard to ignore.

While I am glad I am polyp-free for now, I have to say that doing things to healthy people is pretty good business in medicine these days.

Do the math.

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

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32 COMMENTS

  1. I think its key to bring up the issue of money and its generally what I think of as the achilles heal of psychiatry. Hospitals are shuttering hospital beds at an astounding rate for just the reason you have outlined. They can make far more money doing medical procedures than for managing complex emotional problems through psychiatric consultations and temporary housing, aka psych units.

    In Portland this last week, all the main hospitals went on “divert” because they were overloaded with people coming to the hospital for a mental health crisis and looking for a bed. For those that don’t know, going on divert means having so many patients in the ER that there is not enough room for them and they have to be diverted to other hospitals if possible. For many mental health patients, this also means “boarding”, staying for days in a small room waiting for a bed.

    Going on “divert” is extraordinarily expensive for hospitals and they try to avoid it like the plague. Even though my hospital was losing quite a bit of money in their psychiatric units, they chose to keep them open because it was still more cost effective than often going on divert.

    This has led Portland to creating a new hospital that will be devoted to psych admissions (sometime in late 2016.) The new Unity hospital will replace most all the hospital beds in the city. In many ways it is likely that they will try to turnstile patients out the door as quickly as possible because it is simply too expensive to manage emotional crisis using a medical model.

    I think this is the number one argument to make with people who don’t care about mental health, issues with medications, coercion, etc. Creating non-medical alternatives is….cheaper.

    The problem is that there once one has gone down the road of taking meds for long periods of time, there is no way to avoid working with the medical model- meaning someone who has gone off their meds, or is experiencing instability with their psych drugs, has to see a doctor in order to adjust them, or restart them and taper down if possible. Essentially, those in crisis are forced to use the excessively expensive medical model of crisis because of their need for medication assistance. Its a snake eating its tail.

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  2. Although I am not a proponent of the medical model and feel that many non-medical approaches work best when it comes to mental health concerns, I am struck by the difference in payment to a psychiatrist vs the payment to a medical doctor in another field of medicine. Psychiatry and alternative mental health services seem to be devalued across the board. Interestingly, psychiatric medications are right up there in cost with other meds. and are industry leaders in terms of profit for Big Pharma…I have to wonder if this whole thing is rigged…our culture creates mental dis “ease” and then we support big profits for those who provide a quick fix and a way to muffle our suffering…

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    • “The whole thing is rigged,” yes. But the issue is the cost of medical care in the US in general is absurdly high.

      My daughter had a sprained ankle, we didn’t take as much as an aspirin from the doctor, we picked up an ankle brace and crutches at the Walgreens. We got an x-ray only. We were in the clinic for about 1/2 hour, max. It cost us over $2500. The x-ray, itself, cost $35.

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    • “I am struck by the difference in payment to a psychiatrist vs the payment to a medical doctor in another field of medicine”

      A colonoscopy is a surgical procedure. It’s not the same as something like a “check-up”, in which case both psychiatrists and general practitioners make about the same amount of money, but for some reason all the houses and cars of all the psychiatrists I’ve ever hunted down were nicer than either of my family docs.

      What Sandy is leaving out, or just not going into detail enough, is that an ENTIRE TEAM of professionals was involved in her one hour visit, including an anesthesiologist. Very expensive equipment was also used, including state-of-the-art video and monitoring systems. Whether anything was found or not, a biopsy was still likely performed to check for signs or a history of colitis. You really can not compare surgery to psychiatric evaluations and drug treatments. When was the last time a psychiatrists had to use a $600,000 piece of equipment to do a psychiatric evaluation?

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    • “Psychiatry and alternative mental health services seem to be devalued across the board. Interestingly, psychiatric medications are right up there in cost with other meds. and are industry leaders in terms of profit for Big Pharma…”
      Perfect system: big money for drugs and low wages for people who distribute them so that they are more easily corruptible.

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      • This is one of the strange contradictions. Some of the psychiatric facilities in the University Hospitals in Ireland have got ceilings that leak on to patients beds; yet the University Psychiatric departments that run them have got millions to spend on dead end genetic research.

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  3. It cheered me up recently to see a recommendation to stop the routine yearly exam of people with no health problems. When you need urgent care, it may be either a long wait (so much for urgent) or you might have to go to the emergency room to pay over five-hundred dollars to have an infected hangnail lanced, because doctors are spending so much time on healthy people. YMMV according to your HMO.

    Specialists are making a mint on people they don’t need to see in the first place, and another pile of money on false positives.

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  4. Re: “… She spent about 5 minutes reviewing the procedure and asked me to sign the consent form.”

    Therein lies the difference between psychiatry and other forms of conventional medicine. What amazes me are the stories I’ve read about people who were billed for psychiatric treatment they never agreed to !!!

    As far as the rising (astronomical cost) of health care in general… this is going to get worse before (if) it gets better. The “Affordable Health Care Act”, aka “Obamacare” is forcing people to buy catastrophic coverage at outrageous rates. Pick from one of 6 or 8 private insurance companies, all of which are being paid off for their cooperation (as are the drug makers) for a “Bronze” plan with a $6,000 deductible, “subsidized” by the feds…. At least until tax time, at which tim H&R Block is seeing approximately 80% of filers will owe money back to the IRS.

    And you gotta love how the infrastructure for Obamacare (buildings, computers, additional IRS agents, etc) cost $800 billion (almost a trillion) dollars. Not to worry, it was syphoned from Medicare – elderly and disabled folks, the ones who need it the most. It is a tax, and a scam!

    Yeah, if you want to see things really become unaffordable, let the feds get involved. If you don’t like my political views, blast away. I’ll just read. Tired of asking to take political debate to the Forums where they belong, only to be charged with being a “censor.” No further comment.

    Duane

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    • Duane, if Medicaid and Medicaire were killed tomorrow that would be the end of psychiatry as we know it. In fact Medicaid/cair has inflated healthcare costs artificially.

      The solution? More government controls.

      What concerns me about more tax dollars going into the medical system and more government control invested is that it will wind up making unethical medical practices more powerful too. A.K.A. Pharma-psychiatry. Just ask one of our Canadian friends how this is working out for them.

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  5. For my routine colonoscopy in January which was performed in the doctor’s private clinic, I was billed the equivalent of 680 USD. There was a separate bill for the laboratory work, which was a good dealer cheaper. My son’s psychiatrist, who practices as a psychoanalyst, charges the equivalent of 200 USD per hour. (She sees him for the full 55 minutes.) The difference is that I don’t live in the United States. Doctors here aren’t particularly well paid, and in the city where I live there is huge competition for psychiatrists/psychoanalyts. It’s often referred to as an “El Dorado” for psychiatry because I understand it’s got the highest concentration of them of the world. The only way to make more money is to see more patients, and there are only so many hours in the day.

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  6. So much I would like to say but …. going to cackle at my own jokes here.

    One thing I will say Dr Steingard is that I am going to leave a copy of this article at my next psychiatrist appointment, and a $5 tip.

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  7. Hi Sandy-Thanks for the post. We’re back to the discussion of the ridiculous way in which medicine is practiced in America. I do remember a lecture given by Otis Brawley, who is the medical director for the American Cancer Society, at Georgia State. He talked about occult blood as being a pretty good screening tool for colon cancer. (Relatively cheap.) I guess there is something to be said for colonoscopy and cutting polyps before they undergo epithelial/mesenchymal transitions, but as with breast cancer tumors, my guess is that in the future we’ll know how to predict which ones are “too worry about” and which are innocuous.

    I’m currently reading Steven Brill’s America’s Bitter Pill. The first half discusses all the factions that were lined up at the trough when forging the Affordable Health Care Act. The American public was not represented. When I see my doctor, who is a nice guy, I feel like a commodity. Given that the costs of health care are rising faster than even the military budget, can this be sustained?

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  8. Well, as somebody whose neuroleptic drug induced brain damage from childhood has cursed him to a life of disability on SSI, if I put my monthly income into a dollar-an-hour number based on “working” FORTY hours a week, it’d barely be 4 dollars an hour. Considering that psychiatric drug prescribing is based on trial and error and that polypharmacy is based on absolutely no scientific evidence at all, it’s hard for me to take any argument seriously that asserts a psychiatrist should even be paid at all. If society does indeed decide one day that the brain damaging drugs should stay (it has certainly only been allowed because the public was duped into thinking they were “medicine”) then they might as well be OTC because there’s no real expertise to be had in prescribing them. The money you referred to is obscene as far as I’m concerned considering the harm they leave in their wake, obscene regardless of what other more scrupulous medical specialties make.

    And remember; psychiatry is the ONLY branch of medicine where the vast majority of its patients are low-income and in poverty. It’s the ONLY medical specialty that is being paid to drug people up and then toss them back to the streets. Psychiatry is the only reason we have homeless or otherwise poverty stricken people who can honestly say that the U.S. tax payers have spent hundreds of thousands, if not millions of dollars on them in their life time, yet they are still in poverty because it all went into the pockets of professionals… professionals who themselves might as well be on welfare.

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  9. Eek – I recently found out that Act Up campaigned for universal health care in the USA.

    It seems some kind of similar campaign is needed here.

    A funding system that puts delivering Treatment instead of building relationships is never one that is going to put what we know is useful above the prescrbing of drugs.

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  10. One complicated part of this is that because the funding is part of health insurance, it bolsters medical iterations of the problem.While I anticipated JefferyC’s response, agencies like mine are forced into a certain medicalization that does not make sense. For instance, physicians needs to sign off on treatment plans to indicated that they are “medically necessary”. This time adds up and is not directly reimbursed. We would otherwise not get paid for the services our therapists (and others) offer. While JeffreyC points out that there were others in the room with the gastoenterologist (just a nurse) and that there is a fee to use the procedure room, there was an additional considerable charge for this. If there had been a biopsy, that would have been an extra charge. If an anesthesiologist had been present, she would have also submitted a bill. There is nothing comparable for us and, yes, there are others involved in the work we do. Sometimes, I find that the most important work I do is to just be available to people – on the phone, sometimes by e-mail, with family (if permission is granted).
    I do take some pride in the fact that I can see people regardless of their ability to pay but in contrast to what JeffreyC has noted, there is a decent business among people who do not use insurance and pay psychiatrists directly for their service. Those psychiatrists are always full, charge way more than $58 for a consultation, have waiting lists, and make a decent income.
    I knew that there would be many who would find $58 too much for any psychiatrists. Some of you find the profession so useless that nothing is “worth it”. But anyone who is involved in reform can’t ignore payment – regardless of who in the end gets paid – and that is what I was trying to highlight here.

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    • “But anyone who is involved in reform can’t ignore payment – regardless of who in the end gets paid – and that is what I was trying to highlight here.”

      Well here in lies the problem with that. The reason you would be paid is to supposedly help people who are deemed “mentally ill”, a majority of which live in poverty and would be helped a whole lot more if the money that went to pay professionals were used to help them get out of poverty instead. Maybe after all your would-be patients are educated, trained and employed then you could be allowed to sort through what’s left to try to find any “real” “mental illness”, but to think that we pay professionals even 50 dollars an hour, to “help” one person whose life would be made so much better if you just gave them the 50 dollars, is obscene as far as I’m concerned.

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        • As an adult on SSI I had once spent 14 days in a psych unit, one of two times as an adult that I’ve been sucked back into that system. But this was the first and only time I actually got to see the bill, as for some reason they sent it to me. Although medicaid would eventually cover it, it was around 20,000 dollars. At the time, I was already crushed by the fact that SSI — which was around 650 a month back then — was (and still is) absolutely nowhere near enough to live off of. I would never get to be a free, dignified, independent adult citizen, as I would either have to go to the group home or bum off my parents. Could you imagine in this situation, realizing that these professionals received 20,000 from the same government/tax payers that give you next to nothing, just to keep an eye on you while waiting for some drugs to kick in? I realized that if I wanted to, I could become a career mental patient, spend months in the psych units, cost the tax payers many millions of dollars over time… and still be doomed on the outside to receive barely enough money to be a bum and live off a fast food value menu.

          It’s not a matter of whether I or other so called “mentally ill” people are being “paid enough” or not. That’s not my point at all. I honestly don’t think that I or others should be receiving tax dollars at all, but rather a fair and just restitution system should be put in place instead. The problem is that psychiatry is making money off of what are essentially societies lepers of our time. It is a matter of exploitation. The mental health professionals shouldn’t be allowed to make a single penny until the people they are purporting to help at least have the social and economic foundation to live a decent life. Otherwise, what’s the point? Paying professionals. That’s it. It’s a welfare system for doctors and healthcare workers.

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    • I think a lot of problems could be headed off at the pass if the Surgeon General declared problems of mental functioning and being emotionally overwhelmed conditions worthy of treatment without a medical diagnosis being necessary.

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  11. hi sandy

    the problem is just that procedures are more highly valued than relationships it is that procedures fraudently are rated at higher RVUs for time than they should be. So a standard screening colonoscopy which takes all of 10 minutes is billed on the assumption it takes 75 minutes! The problem for psychiatry is we are essentially paid on how much time we actually spend with the patient (not to mention that psychotherapy is valued as less than E&M). So we are talking about here is that you get $115.88 for an hour or so of network meetings – this would be like being able to do 6 of these in an hour and getting paid the same which would be $695.28.

    No one is going to argue that procedures are costlier for all sorts of reasons. But what people don’t realize is how the value of a medical visit or procedure is determined. Relative Value Units (RVUs) are the units of cost each is determined (as you know) and broken down into work, practice expense and professional liability. Obviously the practice expense and professional liability is much greater for a screening colonoscopy than psychotherapy or a 99213 15 minute visit but the work RVU is significantly higher too. The RVUs for medical visits and procedures is set by a group of the AMA and this group is made largely out of subspecialists which is why dermatologists, cardiologists, Gastroenterologists etc make such vast sums of money. It is not just because they do procedures (which would be hard to argue with except that clearly the cost of these procedures is grossly overrated) but they get paid on the assumption said procedures takes 6-7 times as long as they do and the higher the volume you do the more you can earn. In psychiatry you can’t really do that. So not only are primary care specialties undervalued, specialists are vastly overpaid in what is tantamount to fraud on the part of the AMA.

    Congress has tried and failed to claw back setting physician remuneration from the AMA. The fact is patients are being screwed and it is a lot dirtier that the actual mechanics of procedures costing more, but not adjusting the work RVU to take into account that a colonoscopy no longer takes 75 minutes and hasnt for many many years.

    I would of course argue that getting into this discussion of what is valued misses the point. Which is that fee for service just doesn’t work. It costs too much, incentivizes unnecessary visits, investigations and care and leads to many people being vastly overpaid. And ultimately everyone ends up paying more with little evidence this is good for our health.

    v

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    • There’s a lot of ‘you scratch my back, I’ll scratch yours’ in that arrangement. Too bad caregivers can’t raise their pay, we’re underpaid and considered to be “unskilled” when being a caregiver requires a lot of skills, including thinking very carefully about the patient and negotiating.

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      • I think there are huge complex arguments here.

        I agree payment for services does not work.

        What is needed is payment for services that are needed rather than for what is provided. That implies some kind of central planning.

        A great book on UK healthcare is NHS PLC by Alyson Pollock in which she makes the case for planning for need and how privitised services with markets cannot provide this. http://www.amazon.co.uk/NHS-Plc-Privatisation-Health-Care/dp/1844675394

        Obviously psyhchiatry is drug obsessed nonsense that on the whole ignores the causes of mental distress but market based deliverly makes it hard to provide the alternative, the making of trusting relationships where the person and thier situation is understood, clarified and the person and thier network helped to address these problems.

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  12. One reason that alternatives to mainstream medicine (as well as alternatives to ‘mainstream lifestyle,’ in general) has been growing in the USA is because of all the players involved in mainstream medicine, that has nothing to do with healing, but all about business. That’s ‘the system’–whether public or private.

    Alternative healing–at least the way I practice it–is based on ease and directness, pure focus on the issues of the client. These tangential issues of payment protocol and insurance can often detract from the focus on the client’s issues and healing.

    When looking at ‘reforming’ the system, it is impossible to stop at one area of the medical system because there are so many connected institutions, including largely the government. The way the system is set up is already so stacked against the client and their health in every respect, which is why I don’t see any way around radical change, to where the client is not at the whim of multiple profiteers when they require or ask for support with their health and well-being.

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  13. There was an article in the local newspaper about how wide the variation is in the prices charged to people from hospital to hospital and clinic to clinic for the exact same procedure and in many cases, depending on what the procedure is, the variation is unbelievable. So, what’s wrong with that picture???? There doesn’t seem to be any one set price for any one procedure and there is no oversight agency for any of it. So, hospitals and clinics simply charge what they think they can get away with and most of the time, they get away with it! Something is very badly wrong with medicine in the United States today and there doesn’t seem to be much if any regulation at all going on.

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    • It’s not just psychiatry that needs to be looked at and regulated more uniformly than is taking place right now. All of medicine needs to be severely overhauled. I’m old enough to remember when doctors brought their black bags and made house visits. Those days are long, long gone.

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