March 5, 1999

By James M. Slayton, M.D., M.B.A.

How many widgets can you create in a clinical session? Many psychiatrists have been facing exactly that question for the last few years, though they may not see it in those stark terms.

More and more, our clinic-based colleagues have been asked to provide more billable patient sessions per hour or per clinical session worked. Some have financial penalties assessed in their paychecks for "underproduction," while others may receive bonuses when they work harder. To understand why productivity-based compensation has become so pervasive, one must consider the fundamental economics of the health care industry as it has evolved.

For example, managed behavioral health company "A" has been willing to pay a clinic $1 million a year for the clinical work hours of several psychiatrists and other mental health professionals. In 1999 the company now wants to pay only $900,000, a 10 percent decrease, for that same volume of patient visits. The company continues to pay on the basis of number of patients seen. If the clinic expands capacity by a similar amount, the $1 million in overall compensation is preserved. The psychiatrists and their colleagues thus avoid a cut in pay.

How does one achieve an improvement of such magnitude? For some clinics, overbooking a psychiatrist's schedule may compensate for "no-show" patients. With some public sector clinics reaching a 50 percent no-show rate, reducing or eliminating this problem can provide large numerical gains in numbers of patients seen. The downside to this approach, however, is evident when everyone scheduled shows up. The psychiatrist then is compelled to speed up if he or she values the idea of finishing the clinical session at a reasonable time. Our primary care colleagues, in fact, have witnessed overbooking in their clinics for years and may fall behind in seeing their patients in a given day.

Other methods used to improve psychiatrist productivity have been to eliminate the direct communication from the patient to the psychiatrist. Instead, an assigned "primary clinician" for that patient gathers the information and presents it to the psychiatrist. This triage function helps to preserve the doctor's time where the issue is routine, such as a short-term medication refill for a stable patient who missed an appointment. The psychiatrist must be able to rely on the work of his or her colleagues in such cases and have a low threshold for calling the patient directly if there are larger or unanswered areas of concern.

Other methods to improve productivity, including a reduction in time allowed to see each patient, are familiar to many psychiatrists. Recently, a colleague of mine chose to leave a job at a Boston-area clinic when administrators reduced the standard session from 15 minutes to 12 minutes per patient. He did not want to face the hassle of seeing five patients per hour instead of four.

Perhaps the greatest reason for annoyance among our colleagues is a feeling of being "disrespected as sweatshop employees" when they are expected to churn out patients at a rapid, predictable rate. They argue that in a healthy population, it would be easier to manage the work in a predictable fashion, but that psychiatric patients have concerns and occasional crises that defy such stringent time boundaries. Such practices diminish the connectedness with patients that compelled many of us to become psychiatrists in the first place.

Health systems that have chosen to implement such stringent standards for their psychiatrists have experienced high M.D. turnover, given the burnout factor that can occur. Compensation that rewards psychiatrists for this kind of hard work can be helpful in keeping those high performers who are not bothered by this kind of work environment.

Health care analysts predict a decrease of compensation from managed care companies to the psychiatric clinics and hospitals of up to 5 percent for each of the next four years. If these companies pay less per clinical contact but still reimburse by volume of patients seen, health systems can preserve their revenues by improving their clinicians' productivity. The days of the fixed-salary psychiatrist with an "unmanaged" patient schedule appear to be numbered.

Dr. Slayton is a member of APA's Committee of Early Career Psychiatrists and directs a public-sector clinic in Massachusetts.