The Good Med Check III: Time Is Money

(Continued from The Good Med Check II: Getting to Know You)

Shorter visits to the psychiatrist translate into more than lower cost to the patient and higher income for the doctor.

Blogger Steven Balt commented on my first post in this series: "And be sure to get it all done in the 15 minutes you're allotted for each patient!!" Come to think of it, the usual pejorative label actually reads "15 minute med check." Steve refers to this as a "cookie-cutter treatment mentality" and tells us he works part-time in a community mental health center. I surmise that means sicker patients with fewer resources and less discretion on the part of the psychiatrist in determining the schedule. More likely than not many if not most patients could use more than 15 minutes even for a med check. In my practice, however, I have the luxury of determining how often I schedule patients. Maybe I'm spoiled. Even if I schedule a different patient every 15 minutes, many of the visits take less than five minutes, so I can spend more time with others. And we all pray for late cancellations and no-shows on busy days, so we can get some (administrative) work done.

The tradition of the 50 minute hour has raised expectations in psychiatry more than any other medical specialty that patient and doctor will have time to chat. It's not just about psychotherapy. Both patient and psychiatrist complain that loss of such relaxed visits resulted from a need to limit payment. As psychiatrists have moved away from the 50 minute hour because of financial considerations patients have questioned the now standard practice of charging almost as much for a medication management encounter as they might have to pay for full session psychotherapy, or the converse, from the psychiatrist pointed view, of getting paid little more for what really occupies an entire hour than they can charge four (or more) times in that same hour. But what does the psychiatrist really get paid for? Not just time.

Consider treatment of two patients for an entire year. One patient gets 50 minute sessions weekly while the other gets four 15 minute medication management encounters during the same year. The psychiatrist still likely spends equivalent amounts of time with administrative work like prescription refills, and each of the two cases represents similar risk of a professional liability lawsuit. Yet the annual revenue for the two patients differs dramatically. This should explain to some degree the apparent discrepancy in the two fees charged. And while some patients still want to spend lots of time talking to the doctor, or actually doing psychotherapy, others resent having to present themselves more than once a year just to get that prescription renewed. After all, if something goes wrong they know they can always schedule an earlier appointment.

Shorter visits make for more flexible scheduling too. Double booking full session psychotherapy means someone has to reschedule or sit it out for an hour in the waiting room. But when you double book medication management encounters accommodating both patients requires only that one wait for an extra 10 to 15 minutes. This makes it more feasible to schedule an encounter earlier to address a problem that cannot wait the usual interval. The same applies to phone calls. Some psychiatrists still seem to interrupt psychotherapy sessions for "emergency" phone calls (a bad idea in my book), but a fifteen minute med management encounter means postponing that call fifteen minutes at most, making interruption unnecessary.

(Continued in The Good Med Check IV: Getting Physical)