Thursday, June 16, 2011

What If Psychotherapy Required Physician Referral?

I didn't think much of it when my own physician wrote me some kind of order or prescription for 12 sessions of physical therapy a couple months ago, maybe just whether my medical insurance would claims for additional sessions differently. But a few days ago I was surprised to read in a physician forum a discussion of possible ramifications if physical therapists were allowed to treat patients directly, that is without referral from a physician. I had always assumed that patients could self refer to physical therapists in much the same way they can to psychotherapists.

This led me to wonder what it would be like if one could only engage the services of a psychotherapist with an order from the physician, maybe not necessarily even a psychiatrist. Maybe this would only apply to reimbursement. In other words you could self refer at will provided you paid cash, but perhaps there would be reimbursement from healthcare payers only with physician referral. Maybe it already works this way for some carriers.

How would this impact a typical psychotherapy practice? How would physicians determine whether to refer for psychotherapy? Would they get to know better the psychotherapists to whom they referred? It already seems to me that even psychiatrists might find it difficult to find a local psychotherapist who provides the type of psychotherapy best suited to a patient's particular problem. I suspect most physicians lump it all together as psychotherapy or counseling and don't know the difference between psychoanalysis and dialectical behavior therapy or between family system psychotherapy and primal scream. Certainly it would seem that physicians might be inundated with marketing efforts by psychotherapists clamoring for referrals. Maybe physicians would thus learn something about psychotherapy methods. Or would busy physicians just ignore it all and blindly authorize whatever treatment they are patients requested?

Under such a system might there be more communication, real collaboration, between physician and psychotherapist? Would it be easier or more difficult for patients to get treatment? What would be the impact on health care costs overall? Would such a policy solve problems or just create new ones?


  1. Physicians used to be required to refer to psychotherapists historically for the psychotherapist to be paid. Some plans still require a physician referral for care to be authorized.

    The first question to be answered would be 'does your physician know enough about mental health or addiction to refer?

    The second question to be answered would be " how would the physician determine who was a competent psychotherapist for this particular problem or patient?

    The third question to be answered would be
    "what is the physician's liability of there is harm done to the patient by the psychotherapist?"

    Some plans mandate or encourage that the psychotherapist communicate with the patient's physician. Some patients don't give a consent because they don't want the psychotherapist to talk to the physician.

    Most physicians are extremely busy and hard to contact so it becomes a difficult task for the psychotherapist to accomplish.

    A voluntary approach with common sense communications - a when needed approach - makes sense to me rather than to add another mandate to either physician or psychotherapist.

  2. Wonderful points and questions, anon. I suspect you are a psychotherapist. The liability issue is interesting. My office policy makes it clear that when I collaborate the psychotherapist is an independent professional, and I assume to responsibility. But pts. often have a relationship with a psychotherapist prior to coming to me for meds. I believe, too, that patients have a right to choose the psychotherapist without my approval, altho that can create some sticky situations. I also believe that almost always the physician and psychotherapist should communicate, except perhaps when the physician is not involved in treating the same problem as the psychotherapist. One of my pet peeves is the psychotherapist who doesn't respond when I try to make contact. Usually the excuse is that they don't have consent from the pt. Next time I plan to just ask them to call me back, and see if I get a response.

  3. I went to a physical therapist a few times for low back pain to get some exercises. No doc involved, I just made the appointment and went. Can't remember if I submitted it to insurance or just paid...