Satisfaction of Manhattan Psychiatrists With Private Practice
Satisfaction of Manhattan Psychiatrists With Private Practice
The purpose of the study was to determine the relationship between participation in managed care organizations (MCOs) and professional satisfaction and income among psychiatrists in private practice. One hundred randomly selected New York City psychiatrists, all voluntary faculty at the same medical college, received questionnaires. Results were analyzed for 40 respondents and showed that MCO participants were significantly less satisfied with practice than non-MCO participants. Gross revenues were level for years 1993-1995; however, those psychiatrists engaged in managed care had approximately 20% lower annual incomes than those not on a provider panel. Implications for the future of psychiatry are discussed, including a shift away from psychotherapy to medication management. The authors question whether cost-containment efforts are warranted for outpatient treatment.
Few developments in organized medicine have progressed as rapidly as the emergence of managed care in the US in the 1990s. While not new, such managed systems have newly dramatic prevalence. The common purpose of all managed care approaches is the control of health care expenditures, theoretically without compromising the quality of care administered and the well-being of patients. More than 58 million Americans receive medical care under the auspices of such organized systems. Even in New York City, where the establishment of managed care organizations (MCOs) was long resisted and where their growth lagged well behind that in other parts of the country, the recent expansion of such systems has been explosive. Between 1993 and 1995, managed care penetration in New York State increased from 23% to 31%, with a greater than 50% increase in New York City for the same period (from 18% to 29%).
Mental health care, long feared as an enormously expensive item for insurance companies, has been an area of cost control for managed care. Initially, cost-control efforts were directed toward reducing inpatient expenditures, since hospitalization accounted for the bulk of costs. Later, MCOs reduced outpatient treatment as patients were shifted from hospitalization to community-based management. In fact, among all medical fields, only psychiatry has seen the emergence of super-specialized management entities. Organizations such as Merit Behavioral Care, American Psych Management, and dozens more are routinely employed by MCOs to manage the mental health benefits of enrollees.
American psychiatry has met the advent of managed care with varying combinations of trepidation, hysteria, ignorance, and not unexpectedly, some demoralization. The American Psychiatric Association (APA) has become polarized by both fierce critics and ardent supporters of behavioral health care management within its ranks. The position of the former was well-summarized by Iglehart: "The application of managed-care principles to mental health and substance-abuse services has provoked unprecedented turmoil in the profession by eroding the autonomy of practitioners, squeezing their incomes, and forcing them into constricted new roles." Conversely, proponents advocate that managed care offers enhanced access to care for more people and accept the premise that constraints on open-ended care are necessary to prevent abuses. Other psychiatrists support efforts at health care reform, hoping that control over escalating costs will be followed by parity of insurance coverage for treatment of mental disorders.
Since as many as 70% of insured Americans who receive mental health care do so through managed care systems, practitioners will inevitably be affected in various ways. However, despite the obvious need to assess the impact of managed care on psychiatry, there has been surprisingly little useful information available about the impact of managed care on private practice, still the predominant delivery mode of outpatient psychiatric treatment in the US. The literature currently consists of 3 types of material: numerous highly subjective, tabloid-style articles; a few large, informal surveys; and a small number of systematic surveys of heterogeneous groups of mental health professionals.
A large 1988 overview of psychiatrists' professional activities documented a decline in private practice treatment and a dramatic diversification of practice settings. The investigators attributed these trends to economic pressures, principally the growth of MCOs. The proportion of psychiatrists listing private practice as their primary work activity declined from 58% in 1982 to 45% in 1988. The same study also documented the extensive prevalence of cost-shifting (ie, psychiatrists charging higher fees to their private, non-managed care patients) across a broad range of services.
A 1995 multidisciplinary survey of psychotherapists (including psychiatrists, psychologists, social workers, and others) documented a reduced psychotherapy caseload among 43% of respondents, increased use of time-limited techniques in 51%, and reduced income among 61% of psychiatrists. This survey also noted that 63% of responding psychiatrists reported an increase in disallowed claims due to the influence of managed care.
Another study suggested that psychiatrists engaged in group practice may fare better economically than solo practitioners, reporting an increase in group practitioners' incomes of 6.7% from 1992 to 1993. This finding surprised the investigators (the Medical Group Management Association), who noted that psychiatrists are not expected to do well under managed care because these organizations typically restrict psychiatrists' practice to medication management. This survey (albeit with a response rate of 20%) indicated that psychiatrists' incomes decline as their managed care participation increases.
Between these few data-based surveys and the subjective diatribes that pour forth (eg, "Managed Care May Save the Profiteers but Kill the Doctors," "Earning a Living: A Blueprint for Psychiatrists," and "Reversing Managed Denial"), there exist several informal surveys purporting to reflect the state of psychiatric practice in this age of economic change.
A 1993 survey of the heads of regional Private Practice Committees of the APA offered the following impressions:
Psychiatrists as a group have grave misgivings about their future and that of their profession. A sense of anxiety and foreboding was expressed even by those practitioners who personally were doing well. Words such as scared, depressed, anxious, apprehensive, confused, subdued, pessimistic, and demoralized were used in nearly all the returned questionnaires. Many indicated that incomes were declining or were being maintained only by the expenditure of a great deal of extra effort. Most said that professional autonomy had been severely eroded by managed care and other forms of oversight.
A New York Times review of the effects of managed care on the practice of psychotherapy across professional disciplines further reported lowered incomes, diminished autonomy, and general discouragement with private practice. A 1995 Wall Street Journal series detailed changes in psychiatric practice made by managed care. One article focused on insurers' practice of pressuring psychiatrists and other clinicians to minimize psychotherapy and emphasize medication for patients:
Managed care companies, with their mandate to cut costs, make no bones about their preference for treating mental health problems with drugs. Not only do they limit coverage for psychotherapy, they often pay psychiatrists more per hour to supervise drug treatment than to provide counseling.
Another article in the Wall Street Journal series reported the malaise and discouragement of practitioners, while detailing the conflicts within the profession described above. Noting the 12% decline in US medical school graduates who chose psychiatry residency training between 1988 and 1994, the authors asserted that one consequence of the economic deterioration of the practice climate is diminishing interest in the specialty by medical students.
Given the conflicting passions aroused by managed care, it is striking that so few data exist to inform the debates that rage among psychiatrists. This dearth of empirical information prompted our study--an attempt to more systematically quantify the state of private psychiatric practice in a part of New York City and to assay the mood, attitudes, and professional satisfaction of a group of practitioners in the mid-1990s.
The purpose of the study was to determine the relationship between participation in managed care organizations (MCOs) and professional satisfaction and income among psychiatrists in private practice. One hundred randomly selected New York City psychiatrists, all voluntary faculty at the same medical college, received questionnaires. Results were analyzed for 40 respondents and showed that MCO participants were significantly less satisfied with practice than non-MCO participants. Gross revenues were level for years 1993-1995; however, those psychiatrists engaged in managed care had approximately 20% lower annual incomes than those not on a provider panel. Implications for the future of psychiatry are discussed, including a shift away from psychotherapy to medication management. The authors question whether cost-containment efforts are warranted for outpatient treatment.
Few developments in organized medicine have progressed as rapidly as the emergence of managed care in the US in the 1990s. While not new, such managed systems have newly dramatic prevalence. The common purpose of all managed care approaches is the control of health care expenditures, theoretically without compromising the quality of care administered and the well-being of patients. More than 58 million Americans receive medical care under the auspices of such organized systems. Even in New York City, where the establishment of managed care organizations (MCOs) was long resisted and where their growth lagged well behind that in other parts of the country, the recent expansion of such systems has been explosive. Between 1993 and 1995, managed care penetration in New York State increased from 23% to 31%, with a greater than 50% increase in New York City for the same period (from 18% to 29%).
Mental health care, long feared as an enormously expensive item for insurance companies, has been an area of cost control for managed care. Initially, cost-control efforts were directed toward reducing inpatient expenditures, since hospitalization accounted for the bulk of costs. Later, MCOs reduced outpatient treatment as patients were shifted from hospitalization to community-based management. In fact, among all medical fields, only psychiatry has seen the emergence of super-specialized management entities. Organizations such as Merit Behavioral Care, American Psych Management, and dozens more are routinely employed by MCOs to manage the mental health benefits of enrollees.
American psychiatry has met the advent of managed care with varying combinations of trepidation, hysteria, ignorance, and not unexpectedly, some demoralization. The American Psychiatric Association (APA) has become polarized by both fierce critics and ardent supporters of behavioral health care management within its ranks. The position of the former was well-summarized by Iglehart: "The application of managed-care principles to mental health and substance-abuse services has provoked unprecedented turmoil in the profession by eroding the autonomy of practitioners, squeezing their incomes, and forcing them into constricted new roles." Conversely, proponents advocate that managed care offers enhanced access to care for more people and accept the premise that constraints on open-ended care are necessary to prevent abuses. Other psychiatrists support efforts at health care reform, hoping that control over escalating costs will be followed by parity of insurance coverage for treatment of mental disorders.
Since as many as 70% of insured Americans who receive mental health care do so through managed care systems, practitioners will inevitably be affected in various ways. However, despite the obvious need to assess the impact of managed care on psychiatry, there has been surprisingly little useful information available about the impact of managed care on private practice, still the predominant delivery mode of outpatient psychiatric treatment in the US. The literature currently consists of 3 types of material: numerous highly subjective, tabloid-style articles; a few large, informal surveys; and a small number of systematic surveys of heterogeneous groups of mental health professionals.
A large 1988 overview of psychiatrists' professional activities documented a decline in private practice treatment and a dramatic diversification of practice settings. The investigators attributed these trends to economic pressures, principally the growth of MCOs. The proportion of psychiatrists listing private practice as their primary work activity declined from 58% in 1982 to 45% in 1988. The same study also documented the extensive prevalence of cost-shifting (ie, psychiatrists charging higher fees to their private, non-managed care patients) across a broad range of services.
A 1995 multidisciplinary survey of psychotherapists (including psychiatrists, psychologists, social workers, and others) documented a reduced psychotherapy caseload among 43% of respondents, increased use of time-limited techniques in 51%, and reduced income among 61% of psychiatrists. This survey also noted that 63% of responding psychiatrists reported an increase in disallowed claims due to the influence of managed care.
Another study suggested that psychiatrists engaged in group practice may fare better economically than solo practitioners, reporting an increase in group practitioners' incomes of 6.7% from 1992 to 1993. This finding surprised the investigators (the Medical Group Management Association), who noted that psychiatrists are not expected to do well under managed care because these organizations typically restrict psychiatrists' practice to medication management. This survey (albeit with a response rate of 20%) indicated that psychiatrists' incomes decline as their managed care participation increases.
Between these few data-based surveys and the subjective diatribes that pour forth (eg, "Managed Care May Save the Profiteers but Kill the Doctors," "Earning a Living: A Blueprint for Psychiatrists," and "Reversing Managed Denial"), there exist several informal surveys purporting to reflect the state of psychiatric practice in this age of economic change.
A 1993 survey of the heads of regional Private Practice Committees of the APA offered the following impressions:
Psychiatrists as a group have grave misgivings about their future and that of their profession. A sense of anxiety and foreboding was expressed even by those practitioners who personally were doing well. Words such as scared, depressed, anxious, apprehensive, confused, subdued, pessimistic, and demoralized were used in nearly all the returned questionnaires. Many indicated that incomes were declining or were being maintained only by the expenditure of a great deal of extra effort. Most said that professional autonomy had been severely eroded by managed care and other forms of oversight.
A New York Times review of the effects of managed care on the practice of psychotherapy across professional disciplines further reported lowered incomes, diminished autonomy, and general discouragement with private practice. A 1995 Wall Street Journal series detailed changes in psychiatric practice made by managed care. One article focused on insurers' practice of pressuring psychiatrists and other clinicians to minimize psychotherapy and emphasize medication for patients:
Managed care companies, with their mandate to cut costs, make no bones about their preference for treating mental health problems with drugs. Not only do they limit coverage for psychotherapy, they often pay psychiatrists more per hour to supervise drug treatment than to provide counseling.
Another article in the Wall Street Journal series reported the malaise and discouragement of practitioners, while detailing the conflicts within the profession described above. Noting the 12% decline in US medical school graduates who chose psychiatry residency training between 1988 and 1994, the authors asserted that one consequence of the economic deterioration of the practice climate is diminishing interest in the specialty by medical students.
Given the conflicting passions aroused by managed care, it is striking that so few data exist to inform the debates that rage among psychiatrists. This dearth of empirical information prompted our study--an attempt to more systematically quantify the state of private psychiatric practice in a part of New York City and to assay the mood, attitudes, and professional satisfaction of a group of practitioners in the mid-1990s.
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