As I discuss career options with a group of third year medical students, I imagine a marketing brochure for psychiatry residencies in a world of mental health parity:
The brain is undeniably the most complex organ of the human body. Treatments for diseases of the mind and brain require the intricate understanding of chemistry, physiology, and anatomy common to all branches of medicine, as well as the ability to step outside of oneself to objectively observe personality and emotion. The psychiatrist must tolerate the unsettling awareness of the mysterious relationship between mind and matter, and must help others find their own answers to the mysteries of the human condition. No wonder that the masters of medicine-those who work in the vast field of interventional psychiatry-are so valued by society.
The time has come for my transition from psychiatric residency to psychiatric practice. The prospect of six-figure incomes suggests reward, at last, for years of work and debt. For the employers, under the guarantee of income and benefits lies the expectation of productivity. This productivity is not measured by patient satisfaction, symptom improvement, or reduced morbidity. Rather the name of the game is the RVU, and the way to get more RVUs is to see more patients in whatever time is available. I am grateful for the opportunity to earn good money in the service of a challenging and rewarding career. But I am also aware of the striking difference between the salaries of psychiatrists and the salaries of many other physicians. As a former practitioner of one of medicine’s more lucrative specialties, I find myself comparing my apparent value now with my value then. Why is my work now worth less than half as much as my work as an anesthesiologist?
At the end of a night in the crisis service last week I walked past a group of patients huddled in the cold, waiting for the doors of the walk-in clinic to open. As I looked at their tired faces, I realized the desperation they must feel to leave homes or homeless shelters at such a cold and early hour, and make the trek to the clinic by foot or by bus. Their pains were certainly as great as the pains of any of my patients presenting for surgery. But for some reason there is less outrage over their lack of care than would be the case for a group of patients with untreated diabetes, appendicitis, or heart disease standing outside a hospital. I realized that like many in society, I had unwittingly accepted the scene before me as adequate care for the mentally ill.
The RBRVS, or resource-based relative value scale, was instituted by Medicare in 1992 in an attempt to standardize payments for physician services. Relative value units, or RVU’s, are assigned to physician services based on three main factors: physician work, practice expenses, and the cost of liability insurance. Physician work is determined by several factors including time required for the service, the technical skill and physical effort, the mental effort and judgment, and the amount of stress experienced by the physician due to the risk to the patient. To arrive at the fair value’ of services, the number of relative value units is multiplied by a universal dollar value, and adjusted slightly for practice location according to regional cost of living indices.
In theory, this approach to payment provides a level playing field for physicians. Payments for a cholecystectomy, for example, reflect the fortitude one must have to cut into someone’s body and the time required for surgery and postoperative care. Medicare strictly adheres to this formula, but in the world of private insurance some physicians’ relative value units are more valuable than others. In my region, for example, Medicare has decided that the relative value of a unit of physician work is about $38. The largest third-party payer in the area will pay psychiatrists, pediatricians, or family physicians about $50 per value unit. But orthopedists and radiologists, or podiatrists providing orthopedic services, are paid $100 per value unit.
What accounts for the difference in payment? If not due to stress, physical or mental effort, risk, technical proficiency, or practice cost, where does the difference come from? Certainly not from supply and demand, as in my area it is much easier to see an orthopedist this week than to see a psychiatrist within the next month. Does the lower reimbursement reflect decades of poor negotiating? Are psychiatrists more likely to succumb to modesty and self-effacement? Do psychiatrists have so great a level of job satisfaction that they don’t worry about money? I wonder if the difference reflects a much larger problem– that psychiatrists have bought into a societal impression that mental health is less valuable than physical health.
Support for this last concern can be found when one looks at the funding of mental health services in general, and the tacit acceptance of the funding situation by psychiatrists and other mental health caregivers. My insurer is required by statute to provide coverage for mental health services up to about $2000 per year. On the other hand, there is no limit on payment for orthopedic injuries. The insured alcoholic is covered for the $1800 surgeon’s fee for a fractured kneecap- and more for the incidental hospital bill and the bills for physical therapy. If the alcoholic strikes his head, the radiologist receives $1200 to look at the MRI. And if he abruptly stops drinking for a week, the hospital is paid tens of thousands of dollars to help him through withdrawal– only to turn him out to drink again. Yet to treat the primary alcoholism, the insurer will pay $2000. And if the patient has spent $2000 for treatment of depression earlier in the year, the insurer will continue to pay for kneecap fractures and MRIs, but not for treatment of the underlying cause of these injuries-alcoholism. And other comparisons are equally dramatic. My insurer will pay $70,000 or more for cardiac bypass to reduce a person’s risk of a heart attack, but only $2000 per year for treatment of the same person’s depression, to reduce risk of suicide. The narcotic addict is allowed $2000 for treatment of heroin addiction, vs. hundreds of thousands of dollars for a secondary HIV infection.
The relatively low payments received by psychiatrists can be blamed to some extent on psychiatrists themselves. They accept their own devaluation when they sign for lower salaries or when they accept limitations on their ability to practice psychotherapy. They allow administrators and others without medical training to dictate treatment plans. I am reminded of the late 1980’s when anesthesia was becoming perceived as a technical trade, and was challenged by the expanding statutory roles of nurse anesthetists. Rather than narrowing anesthesiology, the answer to devaluation was found by moving into critical care and pain medicine and asserting the roles of anesthesiologists as physicians. Similarly, cardiologists did themselves and their patients well when they laid claim to angioplasty, and called themselves interventional’. The new technology brought public respect and money, which then yielded an explosion of new treatments. I don’t know what the parallel path for psychiatrists will be, but it is vital that as insights develop into brain function, psychiatrists lay claim to them, grasp them, and never let them go. There is nothing like a brain procedure to grab society’s interest and respect. In fact, I posit that the simple adoption of the term Interventional Psychiatry’ would increase the funding of psychiatrists and psychiatric research by 20%.
The low priority of mental health services to society is, of course, a complex issue. Stigma, lack of lobbying resources, and denial of the impact of mental illness certainly play roles in the lack of public interest and investment in mental health. Resources are thin for the unemployed and uninsured mentally ill, and the field of psychiatry deserves kudos for attempting to meet the needs of this population in return for little financial gain. But for patients with resources, we must recognize and advocate that mental health care is as important as treatment for a torn ACL, and deserves equitable reimbursement. The abilities to laugh, to work, and to love are as vital as the ability to return to beach volleyball. Psychiatrists must realize that at some point, expectations of relatively low reimbursements and medical standing become self-fulfilling prophecies, as our society tends to value those most who value themselves. The correction of societal bias and the resultant devaluation of our services will require constant efforts to educate, negotiate, and assert the value of mental health care in a healthy society. And psychiatrists, as the voices, faces, and business representatives of mental health, will raise the status and treatment of their patients as they work to raise the scientific, and yes, economic, status of themselves as physicians.