Psychiatry's Lesson for Universal Health Care

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As President Obama tries to remake the American health care system, the gutting of psychiatry by insurance company policies and other administrative forces is a good lesson in what to avoid.

The endless red tape inherent in dealing with many insurers and the loss of professional autonomy to insurance company "reviewers," has led many of the best and brightest psychiatrists and psychologists to accept no insurance reimbursement at all. Psychiatrists have, if you will, acted out Atlas Shrugged, Ayn Rand's cautionary tale of what can happen when institutions throttle individuals. They've walked away and taken their gifts as healers with them. In fact, when I refer patients to other mental health care professionals, it's very challenging for me to find clinicians I consider in the top echelons of my field who will accept third party reimbursement of any kind. A brain drain has siphoned off access to some of the wisest counsel available in psychiatry, except for those willing to pay cash, and I believe the same could happen (or greatly accelerate where it already is happening) in other medical specialties.

The influence of insurance company policies has also led to the public being served by professionals from allied health fields, such as clinical nurse specialists. The need or desire for these companies to save money, which will only be accelerated by the current Obama plan, means social workers and nurses are the preferred providers of psychotherapy and medication evaluations to those battling depression and schizophrenia and bipolar disorder. This phenomenon could find its reflection in the firm ground of internal medicine and endocrinology and obstetrics and other specialties yielding to intellectual quicksand, in which the knowledge and skills of physicians often disappear from the landscape entirely.

There's nothing inherently wrong with getting your health care from physician assistants and nurses. But these folks didn't go to medical school, and didn't complete residencies, and if I were confronting a serious condition I'd want to be treated by people who had. I'd pay for it out of my own pocket. And my guess is that we'll end up having to.

Oh, one more thing_ Not only did many psychiatrists walk out on the system, lots of the ones who stayed let their practices be shaped by insurance company reimbursement policies that pay them more to prescribe medications than to talk to people. So there are a whole bevy of shrinks who'll see you for ten minutes once a month and just write you a prescription. It actually pays pretty well, even if it leaves them out of seventy percent of what can restore patients-effective, expert psychotherapy. That medical art is in danger of extinction.

See, Obama's eight principles for overhauling health care address economics, access, prevention, safety and cost. They don't address how to preserve the core of the world's most successful, powerful, inventive health care system ever: the contributions and creativity and commitment of America's physicians.