NYT: Talk Doesn't Pay, So Psychiatr

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http://mobile.nytimes.com/2011/03/06/health/policy/06doctors.xml

By GARDINER HARRIS

Published: March 06, 2011

DOYLESTOWN, Pa. - Alone with his psychiatrist, the patient confided that his

newborn had serious health problems, his distraught wife was screaming at him

and he had started drinking again. With his life and second marriage falling

apart, the man said he needed help.

But the psychiatrist, Dr. Levin, stopped him and said: " Hold it. I'm not

your therapist. I could adjust your medications, but I don't think that's

appropriate. "

Like many of the nation's 48,000 psychiatrists, Dr. Levin, in large part because

of changes in how much insurance will pay, no longer provides talk therapy, the

form of psychiatry popularized by Sigmund Freud that dominated the profession

for decades. Instead, he prescribes medication, usually after a brief

consultation with each patient. So Dr. Levin sent the man away with a referral

to a less costly therapist and a personal crisis unexplored and unresolved.

Medicine is rapidly changing in the United States from a cottage industry to one

dominated by large hospital groups and corporations, but the new efficiencies

can be accompanied by a telling loss of intimacy between doctors and patients.

And no specialty has suffered this loss more profoundly than psychiatry.

Trained as a traditional psychiatrist at Reese Hospital, a sprawling

Chicago medical center that has since closed, Dr. Levin, 68, first established a

private practice in 1972, when talk therapy was in its heyday.

Then, like many psychiatrists, he treated 50 to 60 patients in once- or

twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his

peers, he treats 1,200 people in mostly 15-minute visits for prescription

adjustments that are sometimes months apart. Then, he knew his patients' inner

lives better than he knew his wife's; now, he often cannot remember their names.

Then, his goal was to help his patients become happy and fulfilled; now, it is

just to keep them functional.

Dr. Levin has found the transition difficult. He now resists helping patients to

manage their lives better. " I had to train myself not to get too interested in

their problems, " he said, " and not to get sidetracked trying to be a

semi-therapist. "

Brief consultations have become common in psychiatry, said Dr. S.

Sharfstein, a former president of the American Psychiatric Association and the

president and chief executive of Sheppard Pratt Health System, land's

largest behavioral health system.

" It's a practice that's very reminiscent of primary care, " Dr. Sharfstein said.

" They check up on people; they pull out the prescription pad; they order tests. "

With thinning hair, a gray beard and rimless glasses, Dr. Levin looks every bit

the psychiatrist pictured for decades in New Yorker cartoons. His office, just

above Dog Daze Canine Hair Designs in this suburb of Philadelphia, has matching

leather chairs, and African masks and a moose head on the wall. But there is no

couch or daybed; Dr. Levin has neither the time nor the space for patients to

lie down anymore.

On a recent day, a 50-year-old man visited Dr. Levin to get his prescriptions

renewed, an encounter that took about 12 minutes.

Two years ago, the man developed rheumatoid arthritis and became severely

depressed. His family doctor prescribed an antidepressant, to no effect. He went

on medical leave from his job at an insurance company, withdrew to his basement

and rarely ventured out.

" I became like a bear hibernating, " he said.

Missing the Intrigue

He looked for a psychiatrist who would provide talk therapy, write prescriptions

if needed and accept his insurance. He found none. He settled on Dr. Levin, who

persuaded him to get talk therapy from a psychologist and spent months adjusting

a mix of medications that now includes different antidepressants and an

antipsychotic. The man eventually returned to work and now goes out to movies

and friends' houses.

The man's recovery has been gratifying for Dr. Levin, but the brevity of his

appointments - like those of all of his patients - leaves him unfulfilled.

" I miss the mystery and intrigue of psychotherapy, " he said. " Now I feel like a

good Volkswagen mechanic. "

" I'm good at it, " Dr. Levin went on, " but there's not a lot to master in

medications. It's like '2001: A Space Odyssey,' where you had Hal the

supercomputer juxtaposed with the ape with the bone. I feel like I'm the ape

with the bone now. "

The switch from talk therapy to medications has swept psychiatric practices and

hospitals, leaving many older psychiatrists feeling unhappy and inadequate. A

2005 government survey found that just 11 percent of psychiatrists provided talk

therapy to all patients, a share that had been falling for years and has most

likely fallen more since. Psychiatric hospitals that once offered patients

months of talk therapy now discharge them within days with only pills.

Recent studies suggest that talk therapy may be as good as or better than drugs

in the treatment of depression, but fewer than half of depressed patients now

get such therapy compared with the vast majority 20 years ago. Insurance company

reimbursement rates and policies that discourage talk therapy are part of the

reason. A psychiatrist can earn $150 for three 15-minute medication visits

compared with $90 for a 45-minute talk therapy session.

Competition from psychologists and social workers - who unlike psychiatrists do

not attend medical school, so they can often afford to charge less - is the

reason that talk therapy is priced at a lower rate. There is no evidence that

psychiatrists provide higher quality talk therapy than psychologists or social

workers.

Of course, there are thousands of psychiatrists who still offer talk therapy to

all their patients, but they care mostly for the worried wealthy who pay in

cash. In New York City, for instance, a select group of psychiatrists charge

$600 or more per hour to treat investment bankers, and top child psychiatrists

charge $2,000 and more for initial evaluations.

When he started in psychiatry, Dr. Levin kept his own schedule in a spiral

notebook and paid college students to spend four hours a month sending out

bills. But in 1985, he started a series of jobs in hospitals and did not return

to full-time private practice until 2000, when he and more than a dozen other

psychiatrists with whom he had worked were shocked to learn that insurers would

no longer pay what they had planned to charge for talk therapy.

" At first, all of us held steadfast, saying we spent years learning the craft of

psychotherapy and weren't relinquishing it because of parsimonious policies by

managed care, " Dr. Levin said. " But one by one, we accepted that that craft was

no longer economically viable. Most of us had kids in college. And to have your

income reduced that dramatically was a shock to all of us. It took me at least

five years to emotionally accept that I was never going back to doing what I did

before and what I loved. "

He could have accepted less money and could have provided time to patients even

when insurers did not pay, but, he said, " I want to retire with the lifestyle

that my wife and I have been living for the last 40 years. "

" Nobody wants to go backwards, moneywise, in their career, " he said. " Would

you? "

Dr. Levin would not reveal his income. In 2009, the median annual compensation

for psychiatrists was about $191,000, according to surveys by a medical trade

group. To maintain their incomes, physicians often respond to fee cuts by

increasing the volume of services they provide, but psychiatrists rarely earn

enough to compensate for their additional training. Most would have been better

off financially choosing other medical specialties.

Dr. Louisa Lance, a former colleague of Dr. Levin's, practices the old style of

psychiatry from an office next to her house, 14 miles from Dr. Levin's office.

She sees new patients for 90 minutes and schedules follow-up appointments for 45

minutes. Everyone gets talk therapy. Cutting ties with insurers was frightening

since it meant relying solely on word-of-mouth, rather than referrals within

insurers' networks, Dr. Lance said, but she cannot imagine seeing patients for

just 15 minutes. She charges $200 for most appointments and treats fewer

patients in a week than Dr. Levin treats in a day.

" Medication is important, " she said, " but it's the relationship that gets people

better. "

Dr. Levin's initial efforts to get insurers to reimburse him and persuade his

clients to make their co-payments were less than successful. His office

assistants were so sympathetic to his tearful patients that they often failed to

collect. So in 2004, he begged his wife, Levin - a licensed talk therapist

herself, as a social worker - to take over the business end of the practice.

Ms. Levin created accounting systems, bought two powerful computers, licensed a

computer scheduling program from a nearby hospital and hired independent

contractors to haggle with insurers and call patients to remind them of

appointments. She imposed a variety of fees on patients: $50 for a missed

appointment, $25 for a faxed prescription refill and $10 extra for a missed

co-payment.

As soon as a patient arrives, Ms. Levin asks firmly for a co-payment, which can

be as much as $50. She schedules follow-up appointments without asking for

preferred times or dates because she does not want to spend precious minutes as

patients search their calendars. If patients say they cannot make the

appointments she scheduled, Ms. Levin changes them.

" This is about volume, " she said, " and if we spend two minutes extra or five

minutes extra with every one of 40 patients a day, that means we're here two

hours longer every day. And we just can't do it. "

She said that she would like to be more giving of herself, particularly to

patients who are clearly troubled. But she has disciplined herself to confine

her interactions to the business at hand. " The reality is that I'm not the

therapist anymore, " she said, words that echoed her husband's.

Drawing the Line

Ms. Levin, 63, maintains a lengthy waiting list, and many of the requests are

heartbreaking. On a January day, a pregnant mother of a 3-year-old called to say

that her husband was so depressed he could not rouse himself from bed. Could he

have an immediate appointment? Dr. Levin's first opening was a month away.

" I get a call like that every day, and I find it really distressing, " Ms. Levin

said. " But do we work 12 hours every day instead of 11? At some point, you have

to make a choice. "

Initial consultations are 45 minutes, while second and later visits are 15. In

those first 45 minutes, Dr. Levin takes extensive medical, psychiatric and

family histories. He was trained to allow patients to tell their stories in

their own unhurried way with few interruptions, but now he asks a rapid-fire

series of questions in something akin to a directed interview. Even so, patients

sometimes fail to tell him their most important symptoms until the end of the

allotted time.

" There was a guy who came in today, a 56-year-old man with a series of business

failures who thinks he has A.D.D., " or attention deficit disorder, Dr. Levin

said. " So I go through the whole thing and ask a series of questions about

A.D.D., and it's not until the very end when he says, 'On Oct. 28, I thought

life was so bad, I was thinking about killing myself.'  "

With that, Dr. Levin began to consider an entirely different diagnosis from the

man's pattern of symptoms: excessive worry, irritability, difficulty falling

asleep, muscle tension in his back and shoulders, persistent financial woes, the

early death of his father, the disorganization of his mother.

" The thread that runs throughout this guy's life is anxiety, not A.D.D. -

although anxiety can impair concentration, " said Dr. Levin, who prescribed an

antidepressant that he hoped would moderate the man's anxiety. And he pressed

the patient to see a therapist, advice patients frequently ignore. The visit

took 55 minutes, putting Dr. Levin behind schedule.

In 15-minute consultations, Dr. Levin asks for quick updates on sleep, mood,

energy, concentration, appetite, irritability and problems like sexual

dysfunction that can result from psychotropic medications.

" And people want to tell me about what's going on in their lives as far as

stress, " Dr. Levin said, " and I'm forced to keep saying: 'I'm not your

therapist. I'm not here to help you figure out how to get along with your boss,

what you do that's self-defeating, and what alternative choices you have.'  "

Dr. Levin, wearing no-iron khakis, a button-down blue shirt with no tie, blue

blazer and loafers, had a cheery greeting for his morning patients before

ushering them into his office. Emerging 15 minutes later after each session, he

would walk into Ms. Levin's adjoining office to pick up the next chart, announce

the name of the patient in the waiting room and usher that person into his

office.

He paused at noon to spend 15 minutes eating an Asian chicken salad with Ramen

noodles. He got halfway through the salad when an urgent call from a patient

made him put down his fork, one of about 20 such calls he gets every day.

By afternoon, he had dispensed with the cheery greetings. At 6 p.m., his waiting

room empty, Dr. Levin heaved a sigh after emerging from his office with his 39th

patient. Then the bell on his entry door tinkled again, and another patient came

up the stairs.

" Oh, I thought I was done, " Dr. Levin said, disappointed. Ms. Levin handed him

the last patient's chart.

Quick Decisions

The Levins said they did not know how long they could work 11-hour days. " And if

the stock market hadn't gone down two years ago, we probably wouldn't be working

this hard now, " Ms. Levin said.

Dr. Levin said that the quality of treatment he offers was poorer than when he

was younger. For instance, he was trained to adopt an unhurried analytic calm

during treatment sessions. " But my office is like a bus station now, " he said.

" How can I have an analytic calm? "

And years ago, he often saw patients 10 or more times before arriving at a

diagnosis. Now, he makes that decision in the first 45-minute visit. " You have

to have a diagnosis to get paid, " he said with a shrug. " I play the game. "

In interviews, six of Dr. Levin's patients - their identities, like those of the

other patients, are being withheld to protect their privacy - said they liked

him despite the brief visits. " I don't need a half-hour or an hour to talk, "

said a stone mason who has panic attacks and depression and is prescribed an

antidepressant. " Just give me some medication, and that's it. I'm O.K. "

Another patient, a licensed therapist who has post-partum depression worsened by

several miscarriages, said she sees Dr. Levin every four weeks, which is as

often as her insurer will pay for the visits. Dr. Levin has prescribed

antidepressants as well as drugs to combat anxiety. She also sees a therapist,

" and it's really, really been helping me, especially with my anxiety, " she said.

She said she likes Dr. Levin and feels that he listens to her.

Dr. Levin expressed some astonishment that his patients admire him as much as

they do.

" The sad thing is that I'm very important to them, but I barely know them, " he

said. " I feel shame about that, but that's probably because I was trained in a

different era. "

The Levins's youngest son, , is now training to be a psychiatrist, and

Dr. Levin said he hoped that his son would not feel his ambivalence about

their profession since he will not have experienced an era when psychiatrists

lavished time on every patient. Before the 1920s, many psychiatrists were stuck

in asylums treating confined patients covered in filth, so most of the 20th

century was unusually good for the profession.

In a telephone interview from the University of California, Irvine, where he is

completing the last of his training to become a child and adolescent

psychiatrist, Dr. Levin said, " I'm concerned that I may be put in a

position where I'd be forced to sacrifice patient care to make a living, and I'm

hoping to avoid that. "

Doctors Inc.: Articles in this series are examining recent shifts in medical

care.

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