by Bridget M. Kuehn MSJJAMA, June 19, 2013 309[23]:2425-2426.
JAMA: What is collaborative care?Dr. Katon: It involves a care manager, who is a nurse or other collaborative care professional, who sees the patients and provides enhanced education and tracks their outcomes. The care manager uses a case registry to monitor all the patients being treated for mental illness in the practice. If a practice physician starts a patient on an antidepressant, the care manager monitors the patient’s response. The care manager’s job is to make sure patients don’t fall through the cracks. The care manager receives weekly supervision from a psychiatrist, who, based on the patient’s experience with the medication and initial clinical response, may recommend medication changes. The care manager communicates the psychiatrist’s recommendation to the primary physician.
JAMA: What kind of training do clinicians need to implement this model?Dr. Katon: It’s a new role for psychiatrists because they are not directly seeing the patients. Most psychiatrists are used to working directly with the patient vs being responsible for a population of patients. It’s a team approach.They must learn the concepts of measuring care outcomes and utilizing stepped-care approaches where increases in intensity of care are driven by outcomes. The American Psychiatric Association offered a course in collaborative care at its annual meeting. The Academy of Psychosomatic Medicine also has training in this model of care.
When I read the criticisms of psychiatrists in the comments on this and other blogs, the psychiatrists being raled about were unfamiliar to me. They are people who see patients for brief sessions and prescribe medications based on symptoms. At first, I thought the critics were exaggerating, but that’s not right. They are seeing psychiatrists shaped by the APA/DSM-III/Academic/PHARMA/Managed-Care view of psychiatry. Psychiatrists willing to sign on to their panels. And their complaints ["bio-bio-bio"] are perfectly legitimate. It’s the psychiatry third party payers have been willing to pay for ["medication management"]. If referred for any kind of therapy, it would be to other mental health types who have agreed to be on "the plan." That split arose with the arrival of Managed Care. The Carriers paid psychiatrists well to do "medication management" only and opened up insurance reimbursement to non physicians because they charged less and would agree to the kind of control the carriers were interested in. So the psychiatrist/therapist split became the standard for the last twenty plus years.
Certainly by the time I went into practice [late 1980s], that writing was on the wall. I thought about returning to Internal Medicine, but that’s not where my heart was. So I opened my office and worked hard for twenty years. I decided that insurance wasn’t any of my business, so I gave out bills with a DSM Code and a CPT code and left the rest to my patients, refusing requests to call for approval or join anything. I was blessed with a decent reputation from my academic years and a wife who, like me. came from a modest background and aspired to nothing more than that. So I worked long hours, adjusted fees for people that I thought I could help and couldn’t afford treatment, and was way busier than I needed to be.
I refer to those years as being in a cocoon or cloistered, because I didn’t know how much things were changing. But at the time, it didn’t feel that way. My close associates were doing the same thing and it just felt like my life. The point here is that the psychiatrists being criticized made a lot more money than I ever did, and they did what they were being paid to do. They are now what people see in their minds when they say "psychiatrist." There was a flowering of psychologists, social workers, etc. in private practice being paid by the Managed Care people to do time limited therapy/counseling and glad for the work. Since I wasn’t on any plans or panels, I never saw people whose carriers controlled things so tightly. My patients who used insurance did their own dealings with their carriers.
My intuition is that that this system is going to come to something of an end. This Integrative Care business sounds like a move to reduce or eliminate the involvement of both the psychiatrists and the therapists. Notice that the only mention of therapy is, "May offer brief psychotherapy" for the "care managers" [two versions…]. So essentially "covered" mental health care means medication from primary care followed along using tests like the PHQ-9.
Managed Care has no interest in covering mental illness and never has – cutting reimbursement wherever possible. Having essentially created the psychiatrist everyone complains about as the standard, they are now moving to cut even that, as above. The psychiatrists are going to be reimbursed for reviewing charts with a care manager and that’s it. I expect they’d like to get non-physician mental health types to be "care managers." Why the APA would be actually promoting such nonsense is beyond me. The Academic/Pharmaceutical complex seems to be morphing into the Academic/Managed Care complex quickly.
The new criticism is that psychiatrists will be doing their "bio-bio-bio" thing without even seeing the patients at all. As you can surmise from the quotes above, about the only thing psychiatrists who agree to do this Integrative Care can do is talk about medications with a care manager with a list of medicated patients and a fist-full of test results. The end of this story is that decent mental health care isn’t going to be "covered" at all. In truth, it hasn’t been "covered" for a very long time. I’m glad I saw where all of this was headed such a long time ago and didn’t even think about entering that arena. That’s why so many of us aren’t in the AMA, or the APA, or on any of the Managed Care panels.
Not going to be pursuing recertification when due in 4 years, that is for sure.
How do APA members continue membership with this now being crafted?
You want to see real zombie hoards, go to the APA conference and just watch the participants walk around the halls and sit in lectures.
Sheesh, covert suicide bombers without explosives….
sorry the above comment was not labeled correctly, my bad
Joel Hassman
“Managed Care has no interest in covering mental illness and never has – cutting reimbursement wherever possible. Having essentially created the psychiatrist everyone complains about as the standard, they are now moving to cut even that, as above.”
This is the definition of health care reform for psychiatry.
If the numbers of health problems and their costs being caused by psyche drugs were accounted for, then perhaps insurers would think again about paying for them as routinely as they do.
“This is the definition of health care reform for psychiatry.”
I would say that “This is the definition of health care reform for all of mental health.”
My guess is that the fate of the therapist class [psychologists, social workers, counselors, etc] will be no better. The only “mental health professional” in the insurance universe left in this scheme will be the “care manager” whose responsibilities include:
While some may think this an alarmist view, just imagine what you might have thought 5 years ago if I had said that psychiatrists would be consulting on medication management without seeing the patients or the doctors prescribing to those patients.
In essence, Dr. Katon proposes that the way to deal with affordable healthcare reform is to pare healthcare down.
Of course it is. The only way to make health care equal is to make it horrible for everyone. Leapers of faith leave that part out.
Psychiatry is going to be like Dentistry in terms of the pay mix. Even the best dental insurance polices cover, at most, about 1K in costs a year. The rest is out of pocket. So if you want your teeth and gums fixed, you pay through the nose. (For some reason I find that last line funny). 🙂 For Psychiatry, those with money to spend will find good care in terms of medication and therapy; for those who don’t have ample disposable income, well they are basically screwed. Smile!
Sorry, Wiley. The thinking now is only ever in the short-term. In banking, in government, in agriculture, in education, in healthcare…
I could go on, but I think you’ll understand. I agree it shouldn’t be this way, yet I see no one holding any position of power interested in changing it. and in fact it works against their own self-interest.
My guess is that the fate of the therapist class [psychologists, social workers, counselors, etc] will be no better.
I agree. Yet my guess is, in the beginning of this we’re going to see a golden age for them. They have to give the serfs time to adapt to the new dynamic and what they and the few psychiatrists scattered amongst them will provide for this wonderful and exciting, new cost-efficient “care plan” is a sense of legitimacy. It is all about the lie, of course.
You know what is sad, most of those who comment here are either not in the real trenches of what is true psychiatry of late, or, are just itching to be bitching what mental health care should be, but are just in total and complete denial of what patients should be realistically expecting of responsible and sound mental health care. Yeah, I am just one grunt in the field, but, after 20 plus years doing this work, I can say with some accuracy and acceptability, everyone is freakin’ clueless what is realistic to expect!
Oh, and as a shout out to Dr O’Brien, the real term here is “Leper”, not “leapers”. Things are just sloughin’ off as the lack of efficacy in mental health continues to degrade. People can accuse me of just being beyond cynical and jaded, or, perhaps see that a caring and committed psychiatrist is beyond burnt out, but just spontaneously combusted!
Oh, and to Arby, watch out for the reactive talons of some you challenge at these blogs. And stay away from pistol butts!
Mickey – broaden the horizon on this issues and post some of your links on right here:
http://www.cmeinstitute.com/psychs-talk/?url=sanchez1.asp
I plan to do the same thing at some point this weekend between tweaking PowerPoints. Clearly the effort to recruit more people to sell this model is broad. In the hospitals the dynamic is different because as a physician it is literally forced on you.
I wonder if it would help if it were easier for people to become pdocs? I don’t mean lowering standards. Maybe if there was a way to make it more affordable and more training programs, it would be a bit cheaper and more accessible to hire psychiatrists. It sounds like insurance companies consider psychiatrists to be too expensive to employ for more than just as a consultants.
Though, I feel like I’m seeing this model for other specialists. I’ve been noticing that when I get referred to a specialist (neurology, dermatology, whatever), I often see an NP or PA. I don’t even see the specialist. It seems like they are just working in a consulting position. I thought this was weird, because I feel like that defeats the point of getting referred to a specialist. I would think doctors would wan to, at the very least, conduct their own evaluations.
The managed care approach is market sensitive. The war cry in the 1990s was: “There are too many ‘expensive’ specialists and we are going to put them out of business either by buying them out or controlling access through primary care gatekeepers.” The public protested against that model and MCOs started to market “no referrals to specialists needed”. They also started to put more and more of the “expensive” specialists on their staff and take a cut of their fees off the top. Now that they control significant numbers of the specialists, the next step is to manage them by telling them what to do in terms of productivity and how to practice.
Hopefully the movement to avoid employment by this cartel and opt out of their networks will lead a pendulum swing back to personal care.
I currently work in an area where there is very heavy managed care penetration and I can still see specialists and can count on seeing a physician who will spend an adequate amount of time with me and have a reasonable conversation with me about my problems.
The whole problem of managed care was inevitable when insurance effectively became prepayment of services.
During WW2, FDR put into effect wage controls. So employers boosted benefits, including “hospitalization”. This is what health insurance actually used to be called. It was true insurance, a protection against disasters. Not maloccurances that would predictably happen.
But then Congress never good rid of the tax exempt status of employer health, and it made sense to increase benefits instead of wages. By the 1970s health insurance covered nearly everything including routine care.
if your homeowners insurance covered termites, gutter repair, remodeling, redecorating and remodeling, you premiums would increase twenty fold in a hurry.
I was in my 20s and had a catastrophic policy when I finished residency. It was cheap, I loved it I never used it, but I had peace of mind and I think it cost me something like 1200 a year.
For thirty years I’ve been hearing nonsense about health care being a right and therefore we have to have universal insurance, as if health care and health insurance are the same thing. Somehow sensible moderate and affordable policies like having universal catastrophic emergency care while letting people pay out of pocket for routine care or eliminating the employer deduction for health insurance were never seriously entertained. Because that doesn’t advance the goals of the Fabian socialists.
Of course mangled care had to happen, because we simply couldn’t continue with health care on demand paid for by third parties. There was no disincentive to overtreatment.
Where APA screwed up from the beginning was making every problem in life a mental illness. Had they stayed with the Feighner/St. Louis diagnoses (excluding homosexuality), we would have been taken seriously by mangled care executives. But you can’t expect them to take us seriously when psychiatry claims that Mood Disorder NOS is a disease “just like” neuroblastoma. It’s not just insurance companies that can’t abide that, but the public nor anyone with common sense won’t either.
So now we have committed suicide by painting ourselves in a corner. The extinction of the specialty is a fait accompli, especially with this collaborative/fascist care model. (No that is not an overstatement, look up the definition of fascism, it doesn’t necessarily mean Nazis. The next step is overseas outsourcing, then replacement by a computer.
But we are collectively not innocent victims. Organized psychiatry actively participated in the suicide of a profession. What the APA is doing now is absurd, but asking insurance to pay most of routine psychotherapy or routine office visits for every one of life’s wisdom problems was unreasonable as well.
The psychoanalysts may have the last laugh after all. Because a boutique cash only practice will likely thrive for the elite that can afford it as insurance based care becomes increasingly worthless to patients.
Joel Hassman, what would a patient realistically expect of a psychiatrist?
Arby, I think quality of care by psychiatrists is an issue at any price, due to the corrupted “evidence base” for the drugs. However, quality of care by a non-psychiatrist prescribing psychiatric drugs is undeniably worse.
Full disclosure: When I was working for a medical association, the big issue was incursion by allied health professionals on specialist turf. The key to winning the legislative battle: Emphasis on patient safety.
This is so freaking obvious to me. But, in psychiatry’s case, it means recognizing patient injury, which the profession stalwartly refuses to do (except a few outliers like David Healy and cepuk.org).
It’s not too often you see an entire profession commit suicide in the most hyper-intellectual way possible. But maybe this is a form of socioeconomic Darwinism. If psychiatrists cannot organize to save their own specialty, perhaps going down the drain is its appropriate destiny.
This oncoming train wreck is fascinating. If I weren’t a consumer advocate calling for a pox on all houses in terms of psychiatric drug prescription, I would be horrified.
Altostrata,
I am not sure what you mean. Did you think I was implying that a psychiatrist at a different price point would make a difference or that there are no quality of care issues with their current practices?
Sorry, Arby. I must have been responding to Tom.
@ James
Insightful points, especially about what insurance should really be for. The purpose of insurance is to protect people against rare disasters, not routine events. The concept of insurance doesn’t make any sense when applied to routine health visits. So we have the current madness.
Worse, the incentives for reimbursement all seen to reward upcoding and doing unnecessary tests. Now even office visits with a PCP can cost hundreds of dollars.
Thank you. As far as upcoding, you’d never be able to get away with that if the patient were paying out of his own pocket. Look at vet bills vs. doctor bills.
I always wondered what it would be like to live in a world where going to the doctor was affordable and didn’t require insurance. My Dad is old enough to remember when doctors came to your house. And that wasn’t for rich people. He came from a poor family and the doc still came to their house.
Of course he also says they couldn’t do much for you back then. In the good ol’ days you just died. They didn’t have all these modern medicines and technology to keep people going for years and years. So that right there will raise the cost of healthcare.
I remember asking Grandpa how his dad died. He said he just got really old, went to his room, stopped eating, and he died. Grandma said that’s how it was to her memory too when she was growing up. Old people just got weak, stopped eating, and then they died at home with their family. No one used a nursing home or had tons of life support on hand. Though I don’t know what’s a better way to die. The cheap way (at home), or with a bunch of trained professionals on hand to make you as comfy as possible. No clue.
I dunno about vets. I’ve seen some charging as much as doctors. I know a couple people who have already purchased health insurance for their dogs cuz of the cost. I asked a lady who worked for an expensive vet about it, and she says it’s really expensive to maintain a vet practice when you have all the latest technology and whatnot.
On collaborative care.
I consider myself to have been practicing collaborative care for the past 20 years. But the model is very different than what I perceive as the APA’s.
I noticed that most of the patients in a primary care practice have medical conditions that are in part or in whole caused by stress, anxiety, or depression. This would include those with headaches, functional bowel disorder, auto-immune conditions, and chronic pain. Then there are patients who need to undergo treatment that is painful and anxiety or depression inducing, e.g. cancer patients. So those are the patients I have focused on treating.
I work with those patients and find my medical knowledge invaluable in guiding my choice of treatments, both pharmacologic and non-pharmacologic. I teach them mindfulness, imagery, and self-hypnosis and will make them audio recordings to take home for practice. I have to alter the techniques according to the pathophysiology of their medical condition and how stress, anxiety and depression are involved with that. I spend 30-50 minutes per session and often use electrophysiolgic monitoring, particularly heart rate variability, to make sure a technique is having the desired effect on their autonomic nervous system before sending them out with instructions to practice it.
This work is fascinating and rewarding. I follow the literature in a wide variety of specialties. The medical doctors find what I do extremely useful as I am seeing their more difficult patients, often ones who have significant addiction or behavioral issues, and helping them improve. Because I focus on helping people improve their function rather than their feelings the treatment is phasic, patients come in more frequently when they are learning skills, and less frequently or not at all while they are practicing those skills. I rarely have to fill out a treatment plan and have more work than I know what to do with.
Also this work is very hard for non-physician therapists to do as few of them have taken the time or had the interest to acquire the medical knowledge that is needed. I can also work with patients who are seeing a therapist for therapy to treat anxiety or mood disorders because the techniques I teach them help them modulate their emotions more effectively and increase their distress tolerance, thus helping them make faster progress in therapy.
So I love collaborative care the way I practice it. It has everything to do with understanding as much about the mind and body as possible and working closely and intensively with patients. To my mind nothing like the APA version.
My understanding is that one of the fastest growing practice models in general medicine is the cash or retainer. Combined with a high deductable policy and the per month may be lower than a currently available policy that is in effect a pre-pay all inclusive medical plan.
Dentist and vets have had to sell their practices on need and provide their customers with a positive experience. This is very different from the current cattle call nature of general medicine.
In the above situations people are willing to pay to see a physician and that physician tries to provide the most positive experience possible.
It is also important to note that in Europe almost every country includes cash only and private insurance medical practices and hospitals. We seem to be the ones insisting on a one policy for all, and all receiving the same care model.
I argued with some very prominent doctors that insurance was not medical care. Today we find fewer people have insurance as the net ACA numbers are negative and those with insurance have to drive hours for a hospital or have no listed physicians in their area.
We need to return to a simpler practice model where there is direct contact between patient and doctor.
Steve Lucas
Dr. Arpaia,
What you are doing and what the APA is proposing are worlds apart.
What would have happened to any of us during our consultation liaison rotation way back when if we’d have done a case presentation without actually seeing the patient? We’d be lambasted and thrown out of residency and justifiably so.
We thought all psychiatrists had these standards. But certain leaders in academia are willing to concede those standards because of their religion, namely radical Fabian collectivism. It is obvious that Lieberman and most of the authors from the APA publications are radical egalitarians and Ezekiel Emanuel clones. They care more about supporting ACA and the theories behind it than and if patient care suffers, well that’s an egg that had to be broken for the greater good. And when it all comes crashing down, they won’t be there to pick up the pieces and they won’t be affected it. They are hypocrites, just like Charlie Chaplin, who also loved collectivism, but wanted “artists” to be excluded from its negative consequences like high taxation.
This isn’t all on Obama even though ACA is a disaster. Medicare is and was unsustainable and Bush threw gasoline on the fire by adding Part D. He also had an MD as senate majority leader for several years and chose not to do anything about this problem such as the moderate and sensible reforms I suggested in an earlier post. I despise both parties, and they both earned it.
Bottom line is nothing in medicine is going to get cheaper and better until the patient has to pay for most of routine care it or the country simply becomes insolvent, which is inevitable with 100 trillion in unfunded obligations.
Let me clarify..they are egalitarian during cocktail chat but they are not going to share with the proletariat any of that conflict of interest honoraria from big pharma. I mean, sharing the benefits of capitalism is nice in theory but when they visit Napa, it would just be wrong to miss out on a gourmet meal at the French Laundry.
Gee, Dr. O’Brien, however you got “radical egalitarianism” out of the ACA, I’m not going to be sorry that enough people aren’t dying for lack of affordable health care to make you feel noble enough.
Who made health care unaffordable? If you say greedy doctors and hospitals and insurance, you fail econ 101. People have always been greedy…that’s not the independent variable. Look at the graph of health care inflation…what year did it take off? What major piece of federal legislation passed that year? Coincidence?
If you think “radical Fabian collectivism,” “radical egalitarians,” or socialism is responsible for the problems in health care, you are barking up the wrong megaflora on the wrong planet.
Rather, as with much of public policy, the ACA is shaped by lobbying and negotiations with many factions, well-funded corporate interests chief among them. While the armature might be an effort for the greater public good, the results are very, very far from collectivism or socialism.
Further, federal policy towards psychiatric care is fully informed by pharmaceutical interests, their allies in organized psychiatry, and the formerly Astro-turfed pseudo-patient organizations (who have lost their funding from pharma but whose mission lives on).
(In the UK, only incredibly hard work for decades by psychiatrists such as Ashton, Lader, Healy, the Critical Psychiatry Network, and now cepuk.org has managed to counterbalance to some extent the above pharma-oriented interests in public debate.)
As for the academicians and commercial psychiatrists running the APA: Wouldn’t it be amazing if the demise of clinical psychiatry were accidentally engineered by Regier, Kupfer, Frank, and Gibbons who, in pursuit of becoming billionaires from ACA-mandated national psychiatric testing, got control of the DSM-5 and APA policy-making, lobbying, and government connections?
(Regier here with some advance PR http://www.cnsspectrums.com/aspx/articledetail.aspx?articleid=1444 I refer you again to the new APA CEO Saul Levin’s connections in Washington, DC. )
Products of Psychiatric Assessment Inc. would be most valuable if they could be positioned as replacing clinician judgment, always so variable in reliability. Thus, the APA could move to the forefront in scienciness by proposing that psychiatrists become experts in interpreting tests and matching psychopharmacology to the results. (One can imagine the pretty graphs; Stephen Stahl, white courtesy telephone please.)
This explains why inter-rater reliability for DSM-5 diagnoses was so unimportant field trials were never completed, and poor results were explained away http://1boringoldman.com/index.php/2012/10/31/but-this-is-ridiculous/ The variable human element will not be involved if diagnosis is determined by testing. The DSM-5 taxonomy is not intended to be of use to clinicians.
Psychiatric Assessment Inc. wags the DSM-5, the DSM-5 moneypot wags the APA leadership, and the APA leadership designs the place for psychiatry within US medical care.
That is also why the APA seems to have a tin ear when it comes to the interests of its members. It’s an oligarchy. And y’all pay your dues for this?
Egalitarian ideology never leads to egalitarian results. Look at schools. The poor and middle class are stuck and those who can afford it get the best. This is exactly what will happen with psychiatry.
If you want to call ACA fascist instead of socialist that’s fine with me. It’s top down collectivism. And I won’t argue that cronies made out like bandits. They always do. How much was Chavez worth when he died?
Most of these gilded KOLs made their fortune from their political connections, not from building a better mousetrap. Read their musings in the throwaway journals. They are almost all Fabian socialists in public persona, but capitalists when they think no one is looking.
Altostrata,
You and Dr. O’Brien probably agree more than you’d think. The idea of one-size-fits all and central command and control does come more from the socialists and communists among us though, while they still belong to the oligarchy. And, socialism didn’t prevent Europe from having its own issues in psychiatry or their hospitals.
My view is that socialist promises are just another ruse to deceive the masses while they do whatever they want, and another reason for us to fight amongst ourselves more than against them. I remember seeing a shareholder vote on executive compensation that was shut-down on a ridiculous technicality. Also, I vaguely recall Dr. Dawson once mentioned a movement within the APA that went nowhere. Point being that it makes little difference whether you’re a libertarian or a socialist or even a nihilist. What you say doesn’t matter.
On another note. Who said this or thinks this The variable human element will not be involved if diagnosis is determined by testing. I had a laugh reading that. How do they propose to take out the human element of the patient answering the questions. Dr. Carroll pointed out to me how high the false positives on these tests are and that is even before many patients get wise and learn how to skew the results.
I actually do agree with most his last post. I think emergency health services ought to be like the fire department. While I don’t think it’s a right, I think it’s a damn good idea for a local government or community provide that. Notice I said local.
Everything the federal government gets involved in to make more accessible goes up in price. Look at college tuition. College education is the next bubble that will be hitting the proverbial fan soon.
If single payer had passed instead of ACA, there would still be calls for collaborative care. Demand is either going to be reduced by cost to the patient and the invisible hand or rationing. There is no third option.
I’m sure Psychiatric Assessment Inc. and Kupfer, Frank, and Gibbons are driven by the purest free-market motivations, not to mention the pharmaceutical companies who truly have redefined medicine.
Discussing whether ACA is collectivist or fascist or whatever is a gigantic waste of time. Meanwhile, tick-tock, if you’re a psychiatrist, the opportunity to shape your own professional destiny is slipping away.
My practice is fine. It’s cash for clinical, and the rest is forensic. I’m booked through July. I’m just stunned by the ship of fools who are following pied pipers who have no stake in the game.
Lieberman is foolish, but the people following him are worse. Any leader with courage and integrity asking the troops to take a leap of faith will go first. But he’s not sticking his neck out for anyone. After this weekend, he will retire comfortably back into the ivory tower. He’s captain of the Titanic but he’s got his own private helicopter lined up to take him out of harm’s way. How quaint it must have been to go down with the ship.
So why is anyone listening to this nonsense? Or paying dues to a quisling organization?
As I pointed out elsewhere, the rank and file at the APA supporting this are turkeys voting for Thanksgiving. Supposed experts in human behavior who are easy marks. The irony.
Long post. These are my own musings and I might be off on some of the details. I also don’t pretend that they are an exhaustive analysis of the health care system here.
I think that there are a number of factors which have been operating for decades which have brought up to the current situation.
The primary factor, which I will call spiritual, is the shift in the contract each physician has with their patients from a social contract to a business contract. To differentiate these I will use the example of seeing a neighbor changing their tire. In the social contract I offer to help my neighbor without expecting any material reward. (I may get a plate of cookies in return later, but that is not expected.) I am helping to strengthen the social bonds of the community. If I walk over to my neighbor and tell her that I will help her with her tire but it will cost her $20, then I am using a business contract. My offer may be accepted, but I am not strengthening the social bonds of the community. Instead I am weakening them because my neighbor is less likely to offer me help should I need it.
Physicians have always had to balance the social contract and business contract aspects of their work. I think that historically the social contract took precedence more often. One treated patients and made allowances for those who could not afford the usual fee for care.
In the past decades several forces have driven the practice of medicine toward an overwhelming preponderance of the business contract at the expense of the social contract.
One of these was the establishment of the RVU which is a price-fixing scheme that has had the effect of increasing reimbursement for doing procedures more and talking with patients less. Generally the development of the social contract takes time and is hard to express when patients are being seen as if they are on an assembly line. By rewarding the more rapid performance of procedures, physicians who had more of a business-contract orientation were able to make vastly more money than those who had more of a social-contract model. (When people say doctors make too much money they don’t realize that the salary range across all doctors is at least 20 fold.) With money comes influence, and therefore those who subscribed to the business-contract model were able to push the health-care system in that direction. I recall in residency hearing health care administrators change the label of those we cared for from “patients” to “clients” to “customers”.
Another factor is the use of lawsuits to settle malpractice claims. While there can be debate about the monetary cost of malpractice litigation, there is no doubt about the cost to the social contract. The threat of litigation pushes health-care providers toward a business contract model. And the more the business contract model is used the more likely patients are to use lawsuits as a way of rectifying perceived wrongs. A feedback cycle is set up that is destructive to the social contract.
As those pushing health-care toward a business contract model gained power, they formed corporations which were increasingly focused on using the provision of health care as a way to make profit. Profit is not money that is made from doing work. Profit is extra money that is made from owning capital or extra money made off the work other people (employees) are doing. These corporations purchased practices, turning physicians into employees, eliminating their ability to choose to follow a social contract model, and they have manipulated markets to make it hard for physicians who want to follow more of a social contract model to survive.
Note that it doesn’t matter if a system is socialist or capitalist, non-profit or whatever. The key is on how the social contract and business contracts are balanced. I knew of a “not-for-profit” health-care organization which kicked people out of the hospital after their insurance ran out. They had a wonderfully altruistic social contract mission statement. When I brought up the hypocrisy to an administrator I was told “no money, no mission.” The organization failed to see how their focus on the business contract made it impossible to be consistent with their social contract mission statement.
I think a lot of doctors went into medicine because they wanted a strong social contract with their community. But that is becoming less and less of an option. I see this conflict between the social contract model and the business contract model as a battle for the soul of healthcare. I don’t know how that battle will end, and I don’t know what solutions exist. But we have to keep looking for them.
Note: I have focused on this tension between the social contract and the business contract as it comes out in healthcare. It really exists in many other industries and the pervasive shift seems to be toward the exclusively business contract model.
I’m wondering why a psychiatric residency is even necessary under this system.
Just live at the beach and read psychopharm textbooks for a year.
Even that probably overqualifies you. I know how this is going to end up. Cheapest enzos for anxiety, cheapest SSRI/SNRI for depression and Seroquel for everything that doesn’t cover. How do I know this? This is what happens in the armed forces.
Hey, I’m with all you guys about the KOL honoraria scam, but that has nothing to do with why collaborative is being pushed.
Dr. Arpaia,
Even though I have used the term ‘social contract’ in my own life (with those in the business world who heard it, not having a clue what I was taking about), I wasn’t able to apply it to the bigger picture like you just did here Thanks for spelling it out for me. Ever consider touching base with Dr. Pho over at KevinMD;com? I don’t know how you get articles posted there, but this looks like something that would resonant with his readers.
The only other thing I would add is that the social contract is a fragile thing. Some think it can be dictated, but it can’t. Outside influences can provide the environment for it, which mostly means leaving it alone or they can destroy it., but they can never mandate it; it has to grow organically (if you’ll pardon me for using a business buzz-word here, but I don’t know how else to say it.)
Arby
Thanks. I will check out KevinMD.
Psychiatry knocked itself off by allowing the identification with pharma and breaking the contract with patients. This didn’t need to happen.
In the UK, the “consulting psychiatrist” has been a member of the “team” for quite a while.
JEEZ you are getting more replies than Carlat used to get!