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Martin A. Goldstein, M.D., and Thomas P. Kalman, M.D., of the psychiatry department at New York Hospital-Cornell Medical Center, surveyed 100 psychiatrists in full-time private practice in Manhattan to see whether objective data would back up the "pervasive subjective impressions of practitioners' pessimism, disillusionment, and general unhappiness" that are the subject of so much discussion among psychiatrists.
While the full force of the managed care juggernaut was late in coming to New York, it began to make significant inroads between 1993 and 1995. During that period, managed care penetration grew from 23 percent to 31 percent statewide. In New York City during those years, the increase was even more dramatic--up more than 50 percent, from 18 percent penetration to 29 percent, Goldstein pointed out.
As in other parts of the U.S., psychiatrists in New York have felt the impact of managed care more than have other physicians, being the only specialists that have to deal with "superspecialized managed care," namely, the spread of behavioral health carveout companies that are in business solely to review mental illness treatment, Goldstein noted.
He acknowledged, however, that psychiatrists are not united in viewing managed care as evil, with many of them working with or even being proponents of the concept as a way to reduce abuses, enhance access to care, and rein in cost. The controversies surrounding managed care have "polarized" APA, he said.
In an effort to quantify the impact of managed care on nonsalaried private practitioners and to see whether numbers back media accounts of turmoil attributable to managed care, the researchers developed a survey that asked psychiatrists about practice characteristics such as managed care participation, economic factors such as annual revenues and fee schedules, attitudes toward managed care, and satisfaction with their careers. It was sent along with a stamped return envelope to 100 randomly selected psychiatrists who were in full-time private practice in Manhattan and were at least three years out of residency; 43 percent returned completed questionnaires, which were anonymous.
While 46 percent of the respondents said that they participated in one or more managed care plans, managed care is even more pervasive in the lives of their patients, the researchers found. Nearly 90 percent of the respondents noted that in the preceding year at least one prospective new patient had inquired about whether the psychiatrist was included in a particular insurer's plan.
The consequences in the shift to managed care in New York City since 1993 were apparent in responses to the revenue-related survey questions. While annual gross revenues from patient care remained relatively steady for all private practice psychiatrists from 1993 to 1995, considerable differences appeared between revenues for those who participated in managed care and those who didn't, Goldstein said. For the three-year period, managed care participants reported annual patient care revenues that were between 20 percent and 23 percent lower than their private practice colleagues. Nationwide, physician income declined by about 5 percent during the same period.
Psychiatrists whose practice did not include managed care patients reported an average psychotherapy session fee of $168, while managed care participants billed an average fee of $157, he pointed out. Only seven respondents (18 percent) said that the number of psychotherapy sessions they were conducting had increased by at least 5 percent during the study period.
The much-talked-about practice changes were also evident in the survey responses of about 62 percent of psychiatrists who said they have begun to provide psychopharmacological care for patients receiving psychotherapy from a nonphysician therapist. Of this group, 28 percent stated that the amount of medication backup they do has increased since 1993, when managed care increased its penetration in New York. It appears, however, that these psychiatrists are troubled by the medication backup role, with about three-fourths admitting that this activity has heightened their anxiety about liability exposure compared with cases where they deliver both types of care to a patient.
Not surprisingly, respondents unanimously agreed that providing medication management in tandem with psychotherapy was "more gratifying than monitoring medication alone," Goldstein said, but many respondents expressed a concern that they would lose income if they refused to perform medication backup only.
This distress over reduced opportunities to provide psychotherapy was borne out by the survey's questions about practice satisfaction. The results, Goldstein said, "validate a depiction of these psychiatrists as unhappy physicians whose ideals and values are increasingly at odds with evolving patterns and systems of health care delivery."
The responses pointed to a significant decline in satisfaction with private practice over the three years from 1993 through 1995, attributable to the subgroup of psychiatrists who participate in managed care plans, he explained.
In 1993 there was little difference in satisfaction levels between these psychiatrists and their colleagues who avoided managed care participation. Goldstein noted that 83 percent of respondents said that practice was more difficult now than it was in 1993, while 70 percent indicated they would find it hard to deliver an enthusiastic recommendation for a career in psychiatry to graduating psychiatry residents.
There was also a pervasive feeling among these New York psychiatrists that because of managed care they are faring much worse economically than other specialists.
As for the psychiatrists who decided to steer clear of managed care patients, the reason most often cited for this choice was concern about confidentiality. Other reasons mentioned by at least half of the respondents were inadequate fees and "comfort in the solvency and security of their practices," he said.
But demoralization aside, these data clarify the dilemma for private practice psychiatrists: "Without managed care participation, a practitioner may lack an adequate flow of new patients, so the future may mandate a reconciliation to lower earnings and [increased] administrative oversight for those intent on private practice," Goldstein suggested.
That none of six managed care organizations he contacted was accepting additional psychiatrists on its provider panels indicates that for psychiatrists, "the fear of declining patient flow without participation in managed care so far outweighs the decreased compensation for working in such settings."
(Psychiatric News, July 18, 1997)