The Med Check Racket: More Controversy

A reader from Carlisle, Pa., writes:

If Dr. Miller has ever practiced in a community mental health setting, she gives no evidence of it in her article. The title itself being offensive, the suggestion that “the economics might be clear” eludes me. The economics are not at all clear to me.

I am employed (and therefore have no personal stake in the fee schedule whatsoever) by a community mental health center that serves two counties in south-central Pennsylvania. My practice includes, I am told, about 1,400 patients, the vast majority of them without insurance other than Medicaid and/or Medicare. Many of these patients have no coverage for prescription medications, or have a carrier whose formulary is so restrictive as to require many hours of a nurse’s time to "prior auth" a mainstream medication, or to beg the drug rep for samples.

So, 1,400 patients, 40-hour/week work schedule: You do the math. The med-check “racket” here provides service for patients to which they would not otherwise have access.

The reader was offended by my post “The Med Check Racket,” which appeared on this blog in July, and in the August print edition of Clinical Psychiatry News.  He is in good company; my article was so offensive to Dr. Anne Hanson,  my co-blogger/author and good friend,  that she responded the following week with her own post titled, “Those Evil Med Checks,” where she talks about her clinical work in the prisons.  If you haven’t read it, please do.

I have worked at a number of  community mental health centers. When I finished residency, I worked half-time at a CMHC, while I simultaneously began a private practice. I left that job to become medical director of a different CMHC, a position that enabled me to learn about the finances of public mental health clinics. 

Since 1998, I have consulted part-time to the Johns Hopkins Community Psychiatry Program, and for a few years, I volunteered for HealthCare for the Homeless. I do know at least a little about community psychiatry.

“The Med Check Racket” was titled by a friend who complained to me about a private practice psychiatrist who sees him for 15 minutes every 6 months and asks a few, checklist-style, questions. I borrowed his comment as a title because I thought it was provocative, but I did not intend it to be offensive. Obviously, I was wrong!

I still believe that it does our profession no good to have patients who walk away feeling they have not been heard, and that psychiatry is too complicated to put every patient into a med-check slot, regardless of what they require. But I believe that the term “racket” is reserved for fee-for-service practices where the physician makes more money by seeing more patients. I don’t believe it’s a term that anyone would apply to an over-taxed, under-funded setting where the doctor is paid a set salary (often well below private practice rates), regardless of how many, or how few, patients s/he sees.

The issues for private practice are different from those of clinics or prisons. In an outpatient practice, the psychiatrist often does not have an easy means to communicate with the psychotherapist. It requires obtaining and transmitting a release form, then taking time to call the therapist or to send notes.  Care may be fragmented. In a clinic setting, while the psychiatrist does not do the psychotherapy, a single chart is shared among team members – including the psychiatrists, psychotherapists, nurses (to give depot injections, check vital sign, and do psychotherapy), and case managers. The therapists and case managers are often in communication with residential care providers and day program personnel, and they are able to relay pertinent information to the psychiatrist.

In the Community Psychiatry Program at Johns Hopkins, the therapist attends the routine 90 day review visits with the psychiatrist and patient in the same room.

In addition to issues related to communications and information exchange, clinic/prison care is often provided at little or no cost to the patient, and the psychiatrist is salaried. In Maryland, state regulators require that patients in publicly funded Outpatient Mental Health Centers be seen every 90 days, and psychiatrists don’t have the leeway to either recommend or accommodate a less frequent schedule. Patients may well be aware that the system is overtaxed, and the décor at every clinic I have worked at leaves no one doubting that finances are tight.  

Still, I am perplexed by the ratio of 1 psychiatrist to 1,400 patients. The expectation at every clinic I have worked in has been that a full-time (40 hour/week) psychiatrist is responsible for the care of roughly 300 patients.

Certainly, this reflects life in a major city, one with two large psychiatric training programs, where it is possible to recruit  physicians. There are areas of the country where the supply of psychiatrists simply does not meet the demand, and the available psychiatrists should be lauded for providing the care that no one else wants to give, even if it means they are stretched too thin. If, however, the clinic setting is unable to attract psychiatrists because the salaries being offered are not commensurate with what other area psychiatrists earn, then the system (not the doctor) should be criticized for expecting one doctor to care for 1,400 patients.

So the evil med check racket: It seems it’s a way not only for insurance companies to minimize their expenses and to leave at least some patients feeling unheard, but also to divide us as a profession when it comes to appreciating what we each do.  

—Dinah Miller, M.D.

DR. MILLER is the author of two new novels, Home Inspection and Double Billing and she is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work.

A reader from Carlisle, Pa., writes:

If Dr. Miller has ever practiced in a community mental health setting, she gives no evidence of it in her article. The title itself being offensive, the suggestion that “the economics might be clear” eludes me. The economics are not at all clear to me.

I am employed (and therefore have no personal stake in the fee schedule whatsoever) by a community mental health center that serves two counties in south-central Pennsylvania. My practice includes, I am told, about 1,400 patients, the vast majority of them without insurance other than Medicaid and/or Medicare. Many of these patients have no coverage for prescription medications, or have a carrier whose formulary is so restrictive as to require many hours of a nurse’s time to "prior auth" a mainstream medication, or to beg the drug rep for samples.

So, 1,400 patients, 40-hour/week work schedule: You do the math. The med-check “racket” here provides service for patients to which they would not otherwise have access.

The reader was offended by my post “The Med Check Racket,” which appeared on this blog in July, and in the August print edition of Clinical Psychiatry News.  He is in good company; my article was so offensive to Dr. Anne Hanson,  my co-blogger/author and good friend,  that she responded the following week with her own post titled, “Those Evil Med Checks,” where she talks about her clinical work in the prisons.  If you haven’t read it, please do.

I have worked at a number of  community mental health centers. When I finished residency, I worked half-time at a CMHC, while I simultaneously began a private practice. I left that job to become medical director of a different CMHC, a position that enabled me to learn about the finances of public mental health clinics. 

Since 1998, I have consulted part-time to the Johns Hopkins Community Psychiatry Program, and for a few years, I volunteered for HealthCare for the Homeless. I do know at least a little about community psychiatry.

“The Med Check Racket” was titled by a friend who complained to me about a private practice psychiatrist who sees him for 15 minutes every 6 months and asks a few, checklist-style, questions. I borrowed his comment as a title because I thought it was provocative, but I did not intend it to be offensive. Obviously, I was wrong!

I still believe that it does our profession no good to have patients who walk away feeling they have not been heard, and that psychiatry is too complicated to put every patient into a med-check slot, regardless of what they require. But I believe that the term “racket” is reserved for fee-for-service practices where the physician makes more money by seeing more patients. I don’t believe it’s a term that anyone would apply to an over-taxed, under-funded setting where the doctor is paid a set salary (often well below private practice rates), regardless of how many, or how few, patients s/he sees.

The issues for private practice are different from those of clinics or prisons. In an outpatient practice, the psychiatrist often does not have an easy means to communicate with the psychotherapist. It requires obtaining and transmitting a release form, then taking time to call the therapist or to send notes.  Care may be fragmented. In a clinic setting, while the psychiatrist does not do the psychotherapy, a single chart is shared among team members – including the psychiatrists, psychotherapists, nurses (to give depot injections, check vital sign, and do psychotherapy), and case managers. The therapists and case managers are often in communication with residential care providers and day program personnel, and they are able to relay pertinent information to the psychiatrist.

In the Community Psychiatry Program at Johns Hopkins, the therapist attends the routine 90 day review visits with the psychiatrist and patient in the same room.

In addition to issues related to communications and information exchange, clinic/prison care is often provided at little or no cost to the patient, and the psychiatrist is salaried. In Maryland, state regulators require that patients in publicly funded Outpatient Mental Health Centers be seen every 90 days, and psychiatrists don’t have the leeway to either recommend or accommodate a less frequent schedule. Patients may well be aware that the system is overtaxed, and the décor at every clinic I have worked at leaves no one doubting that finances are tight.  

Still, I am perplexed by the ratio of 1 psychiatrist to 1,400 patients. The expectation at every clinic I have worked in has been that a full-time (40 hour/week) psychiatrist is responsible for the care of roughly 300 patients.

Certainly, this reflects life in a major city, one with two large psychiatric training programs, where it is possible to recruit  physicians. There are areas of the country where the supply of psychiatrists simply does not meet the demand, and the available psychiatrists should be lauded for providing the care that no one else wants to give, even if it means they are stretched too thin. If, however, the clinic setting is unable to attract psychiatrists because the salaries being offered are not commensurate with what other area psychiatrists earn, then the system (not the doctor) should be criticized for expecting one doctor to care for 1,400 patients.

So the evil med check racket: It seems it’s a way not only for insurance companies to minimize their expenses and to leave at least some patients feeling unheard, but also to divide us as a profession when it comes to appreciating what we each do.  

—Dinah Miller, M.D.

DR. MILLER is the author of two new novels, Home Inspection and Double Billing and she is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work.

A reader from Carlisle, Pa., writes:

If Dr. Miller has ever practiced in a community mental health setting, she gives no evidence of it in her article. The title itself being offensive, the suggestion that “the economics might be clear” eludes me. The economics are not at all clear to me.

I am employed (and therefore have no personal stake in the fee schedule whatsoever) by a community mental health center that serves two counties in south-central Pennsylvania. My practice includes, I am told, about 1,400 patients, the vast majority of them without insurance other than Medicaid and/or Medicare. Many of these patients have no coverage for prescription medications, or have a carrier whose formulary is so restrictive as to require many hours of a nurse’s time to "prior auth" a mainstream medication, or to beg the drug rep for samples.

So, 1,400 patients, 40-hour/week work schedule: You do the math. The med-check “racket” here provides service for patients to which they would not otherwise have access.

The reader was offended by my post “The Med Check Racket,” which appeared on this blog in July, and in the August print edition of Clinical Psychiatry News.  He is in good company; my article was so offensive to Dr. Anne Hanson,  my co-blogger/author and good friend,  that she responded the following week with her own post titled, “Those Evil Med Checks,” where she talks about her clinical work in the prisons.  If you haven’t read it, please do.

I have worked at a number of  community mental health centers. When I finished residency, I worked half-time at a CMHC, while I simultaneously began a private practice. I left that job to become medical director of a different CMHC, a position that enabled me to learn about the finances of public mental health clinics. 

Since 1998, I have consulted part-time to the Johns Hopkins Community Psychiatry Program, and for a few years, I volunteered for HealthCare for the Homeless. I do know at least a little about community psychiatry.

“The Med Check Racket” was titled by a friend who complained to me about a private practice psychiatrist who sees him for 15 minutes every 6 months and asks a few, checklist-style, questions. I borrowed his comment as a title because I thought it was provocative, but I did not intend it to be offensive. Obviously, I was wrong!

I still believe that it does our profession no good to have patients who walk away feeling they have not been heard, and that psychiatry is too complicated to put every patient into a med-check slot, regardless of what they require. But I believe that the term “racket” is reserved for fee-for-service practices where the physician makes more money by seeing more patients. I don’t believe it’s a term that anyone would apply to an over-taxed, under-funded setting where the doctor is paid a set salary (often well below private practice rates), regardless of how many, or how few, patients s/he sees.

The issues for private practice are different from those of clinics or prisons. In an outpatient practice, the psychiatrist often does not have an easy means to communicate with the psychotherapist. It requires obtaining and transmitting a release form, then taking time to call the therapist or to send notes.  Care may be fragmented. In a clinic setting, while the psychiatrist does not do the psychotherapy, a single chart is shared among team members – including the psychiatrists, psychotherapists, nurses (to give depot injections, check vital sign, and do psychotherapy), and case managers. The therapists and case managers are often in communication with residential care providers and day program personnel, and they are able to relay pertinent information to the psychiatrist.

In the Community Psychiatry Program at Johns Hopkins, the therapist attends the routine 90 day review visits with the psychiatrist and patient in the same room.

In addition to issues related to communications and information exchange, clinic/prison care is often provided at little or no cost to the patient, and the psychiatrist is salaried. In Maryland, state regulators require that patients in publicly funded Outpatient Mental Health Centers be seen every 90 days, and psychiatrists don’t have the leeway to either recommend or accommodate a less frequent schedule. Patients may well be aware that the system is overtaxed, and the décor at every clinic I have worked at leaves no one doubting that finances are tight.  

Still, I am perplexed by the ratio of 1 psychiatrist to 1,400 patients. The expectation at every clinic I have worked in has been that a full-time (40 hour/week) psychiatrist is responsible for the care of roughly 300 patients.

Certainly, this reflects life in a major city, one with two large psychiatric training programs, where it is possible to recruit  physicians. There are areas of the country where the supply of psychiatrists simply does not meet the demand, and the available psychiatrists should be lauded for providing the care that no one else wants to give, even if it means they are stretched too thin. If, however, the clinic setting is unable to attract psychiatrists because the salaries being offered are not commensurate with what other area psychiatrists earn, then the system (not the doctor) should be criticized for expecting one doctor to care for 1,400 patients.

So the evil med check racket: It seems it’s a way not only for insurance companies to minimize their expenses and to leave at least some patients feeling unheard, but also to divide us as a profession when it comes to appreciating what we each do.  

—Dinah Miller, M.D.

DR. MILLER is the author of two new novels, Home Inspection and Double Billing and she is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work.