HEALTH REFORM AND THE FUTURES OF PRIMARY CARE AND PSYCHIATRY
John Geyman, M.D.
What does health care reform have to do with the futures of primary care and psychiatry? A lot, and most of it is still under our collective radar screen.
Both fields are essential to our health care system, both face critical shortages even as the demands for their services are increasing. Demands are accelerating as the Affordable Care Act (ACA) starts to provide greater access to care for millions of previously uninsured patients. And in both cases, the ACA will not do much to relieve these shortages.
How serious are these shortages? Hospital systems seeking to link up with accountable care organizations and patient centered medical homes are finding it difficult to recruit primary care physicians—their highest priority. Almost 20 percent of positions are unfilled. (1) The supply lines for primary care and psychiatry are meager compared to present and future needs. Just 12 percent of all practicing physicians are in primary care today. Only 8.4 percent of graduates of U.S. medical schools opted for graduate training in family medicine in 2013 (2); for psychiatry, that number was 4.2 percent. (3)
Primary care and psychiatry have much in common. Both are undervalued and under reimbursed. Both involve face-to-face time with patients to evaluate and manage their problems with continuity over long periods of time. As health care has become a largely for-profit industry, procedures (such as surgical or imaging procedures) have been much more highly reimbursed than cognitive care that is the backbone of primary care and psychiatric practice. As a result, primary care specialties and psychiatry are near the bottom of incomes among clinical specialties. We have a continued mismatch between system needs and the supply of physicians to meet them.
These are some of the trends over recent years that exacerbate shortages in both fields (4):
• Inadequate reimbursement that often fails to cover physician costs (e.g. Medicaid patients).
• Increased office overhead to keep up with paperwork and billing, driving many primary care physicians into hospital-
• Shift from self-employed practice to employment by hospital systems that drive physicians to see more patients per hour and be more “productive” through shortened office visits.
• Increasing dissatisfaction with primary care practice. (5)
• Shift of practice from mental illness to mental health, leaving a vacuum in the care of serious mental illness (e.g. schizophrenia,
• Deinstitutionalization of mental illness care, with contraction or closure of many public mental hospitals.
• Inadequate reimbursement for “talk” therapy.
• Lack of insurance coverage for many psychiatric services.
• The practices of some 90 percent of psychiatrists are now involved with “med checks”, short visits without time to listen and understand patients’ problems; most psychiatrists avoid care of the seriously mentally ill in favor of those with much less serious mental health problems such as anxiety disorders.
We are left today with well-entrenched specialty maldistribution in our physician workforce. As a result, as the ACA brings higher demand for care with more newly insured patients, we have:
• Restricted access to care—it is hard to find a primary care physician, especially in rural areas ; among psychiatrists, 55 percent accept Medicare patients while only 43 percent will see Medicaid patients; (6) 55 percent of the country’s 3,100 counties have no practicing psychiatrists, psychologists or social workers, as a result of attrition and budget cuts. (7)
• Increased use of emergency rooms, increased fragmentation and costs of care; loss of continuity and depersonalization of the
• 5 percent of the adult U.S. population suffers from serious mental illness; over the last 20 years, the number of patients qualifying for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) has gone up by 250 percent for adults and by 35-fold for children. (8)
• Our jails are filled with the seriously mentally ill (e.g. the biggest jail systems—Cook County in Chicago, Los Angeles County and New York City have more than 11,000 prisoners under treatment compared to a combined total of 4,000 in the three largest state- run mental hospitals. (9)
While the ACA does make some efforts to address these problems—such as providing limited and temporary boosts to primary care physician reimbursement, requiring parity of mental health care with that of physical illness, and enabling states to establish “health homes” for the mentally ill—these are far too limited to make a dent in the above problems. We need to make fundamental reforms that will, over a generation or two, rebuild the primary care and psychiatry workforce. Even with the ACA, many holes in insurance coverage will remain, reimbursement through a flawed fee-for-system (FFS) will be inadequate, and much of the demand for primary care and mental illness care will go unmet.
All this can be fixed, over time, with an intertwined strategy that includes universal access through a single-payer system of national health insurance (H.R. 676 in the House of Representatives), together with physician payment reform (two possible approaches have been suggested in earlier Health Care Disconnects blogs) (10, 11), and changes in medical education that would be enabled by predictable reimbursement aligned to national needs.
A single-payer financing system would simplify billing and health care administration, thereby reducing physicians’ “hassle factor” and restoring needed time for direct patient care. It would also enable reform of our present payment distortions between primary care and other time-intensive specialties (such as psychiatry and geriatrics) and the procedure-oriented non-primary care specialties. These steps could begin to correct shortages in time-intensive specialties and rebalance a physician workforce that will better meet growing needs for care.
1. Japsen, B. Doctor, nurse vacancies soar amid Obamacare rollout. Forbes, December 8, 2013.
2. Biggs, WS, Crosley, PW, Kozakowski, SM. Results of the 2013 National Resident Matching Program: Family medicine. Family Medicine 45 (9): 647-651, 2013.
3. Moran, M. More graduates choose psychiatry in 2013 Match. Psychiatric News Update, April 19, 2013.
4. Geyman, JP. Challenges to the future of psychiatry: Parallels with primary care. Psychiatric Annals 44 (1): 69-72, 2014.
5. Hoff, T. Practice Under Pressure. Piscataway, NJ. Rutgers University Press, 2010: 43-48.
6. Pear, R. Fewer psychiatrists seen taking health insurance. New York Times, December 11, 2013.
7. Fields, G, Dooren, JC. For the mentally ill, finding treatment grows harder. Wall Street Journal, December 21, 2013.
8. Angell, M. The crazy state of psychiatry. In Brooks, D. (ed) The Best American Essays 2012. New York, 2012.
9. Fields, G, Phillips, EE. The new asylums: Jails swell with mentally ill. Wall Street Journal, September 26, 2013.
10. Gimlett, DM. Primary care payment quick fix. Health Care Disconnects, posted September 12, 2013.
11. Kemble, S. Is fee-for-service really the problem? Health Care Disconnects, posted October 19, 2013.
One liner: Primary care and psychiatry are already spread too thin to meet growing demands for essential care..
Abstract: Primary care specialties and psychiatry are all critical shortage fields fundamental to the success of health care reform. They share common characteristics—undervalued, time-intensive, and pressured by reimbursement systems to spend less time with patients. The Affordable Care Act raises demands on these fields but falls far short of ways to address their shortages. Another strategy is discussed.
Tag lines: Primary care; psychiatry; Affordable Care Act; mental illness; mental health; access to care; single payer; Medicare; Medicaid.