THE BLOG
05/20/2011 08:34 am ET Updated Jul 20, 2011

Psychiatry: How Low Can We Go?

In a recent New York Times article, "Talk Doesn't Pay, So Psychiatry Turns to Drug Therapy," written by Gardiner Harris, the sad truth of what was once a noble profession, psychiatry, now a shambles of its former self, is accurately described. Mr. Harris used his interviews with psychiatrist Donald Levin, M.D. and his wife, Laura Levin, M.S.W., and their practice in Philadelphia to describe, in considerable detail, the "new" psychiatry.

Dr. Levin was trained during the "old" days when psychotherapy and knowing one's patients were the cornerstones of the practice of psychiatry. The 50-minute psychotherapy hour was the rule. Dr. Levin, as he and his wife freely discuss, has seen the light -- the new, economic light -- which now rules his and many psychiatric practices. By 2005, only 11 percent of psychiatrists practiced any kind of psychotherapy, now called "talk therapy." This percentage has undoubtedly shrunk since then; psychotherapy and the 50-minute hour are psychiatry's equivalent of high button shoes. Not talking earns a great deal more than talking.

The Times article reports that in the old days, Mr. Harris "knew his patients' inner lives better than he knew his wife's; now, he often cannot remember their names." In the same old days, "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 the urge to help his patients manage their lives better. "I had to train myself not to get too interested in their problems," he told the Times, "and not to get sidetracked trying to be a semi-therapist." 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."

Dr. Levin has had to give up his old ways for the new. There are a number of reasons for the "new" ways. When he returned to his solo, private practice after a 15-year stint in a clinical hospital practice group, Dr. Levin found that the fees that insurance companies would pay for "talk therapy" were just too low. He could have accepted less money and provided time to patients even when insurers did not pay sufficiently, but, he told The New York Times, "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. Would you?"

"I miss the mystery and intrigue of psychotherapy," he said. "Now I feel like a good Volkswagen mechanic." He went on: "I'm good at it ... 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." He cleverly compares Hal to psychotherapy and the monkey/bone to himself and the "not much to master" medications.

As the New York Times article states, "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." In 2004, Laura Levin, M.S.W., a licensed talk therapist, took over the business end of the practice. With admirable zeal, "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 also imposed a variety of extra fees on patients: $50 for a missed appointment, $25 for a faxed prescription refill and $10 extra for a missed co-payment and who knows how much for writing or calling in a prescription.

Dr. Levin's practice is based on the approximately 11- to 12-minute "hour," seeing 40 patients each day for approximately 11 minutes each. The remaining four minutes allow for social niceties, ushering a patient in and out, offering them the chair, and getting the next chart, all of which adds up to 15 minutes.

Ms. Levin candidly says, "This is about volume ... 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."

Before we feel sorry for the economic plight of the Levins, searching desperately to maintain their lifestyle and send donations, let us examine the math. Insurance companies pay approximately $100 per 15-minute "drug" visit. Private patients pay more. Dr. Levin, by his own accounting, sees 40 patients a day, which at $100 a visit comes to a total of $4,000 per day. Then there is the co-pay. That amount of co-pay ranges up to approximately $50 and averages $40. To the $4,000 per day, therefore, one must add $1,600, the total rising to $5,600 per day. Then, one must add other income from charges made directly to the patients by Ms. Levin, for such things as missed appointments and faxing, calling or writing prescriptions, averaging, let us say, $30 per appointment. These charges add another $1,200 per day -- raising the grand total income to $6,800 a day. Assuming a five-day work week, this totals $34,000 a week, roughly $170,000 a month, and $1,620,000 per year (allowing for one month off for vacations, holidays, etc., assuming he takes them and works five days a week. If he works six days a week, increase all the numbers by 20 percent. If he takes fewer vacations and holidays, you do the math). By his own statement, he needs to maintain his lifestyle and can't go back on that.

Dr. Ricker, a physician, psychiatrist and psychoanalyst working in Los Angeles, Calif., operates the "old" way, treating patients with psychotherapy/psychoanalysis. As Dr. Levin would put it, Dr. Ricker is Hal. He makes 11 percent as much as Dr. Levin, which he still considers a princely sum. Psychotherapy sessions last one hour. Drug evaluations take one to two hours. Drug management meetings are usually 30 minutes to one hour. He works approximately 47 hours a week. His 11 percent also includes his wife/business partner/office manager/secretary, a masters graduate of Columbia University. They also run a non-profit treatment center for disturbed adolescents. He doesn't get paid for that, which would probably cause Ms. Levin apoplexy, because psychiatry is a "volume" thing and he manages to not just "waste" two to four minutes per patient but an entire day each week on his project. Add in those eight hours and he works 55 hours per week.

The tidbits we offer about Dr. Ricker are not at all for the sake of demonstrating his saintly virtues (to some, this might be evidence of foolishness) but to offer a point of comparison.

Psychopharmacology is not a "not much to know" field of medicine. It is a "we don't know enough" field and therefore requires all we can do for its improvement. To ride the misguided waves of insurance companies' seeming largesse makes all of us poorer for it. We pay in both obvious and not-so-obvious ways. We all pay more for our medical insurance, psychiatric care, prescriptions, deductibles, co-pays, etc., the costs of which continue to skyrocket. But, far worse than that, we all pay the ever-increasing price of systematically declining and increasingly inferior psychiatric care. If one really believes that psychopharmacology is a "not much to know" field of medicine, a new job is definitely in order.