Insurance silencing talk therapy

3/7/2011

DOYLESTOWN, Pa. -- Alone with his psychiatrist, the patient confided that his newborn had serious health problems, his distraught wife was screaming at him, and he had started drinking again.

With his life and second marriage falling apart, the man said he needed help.

But the psychiatrist, Dr. Donald Levin, stopped him.

"Hold it. I'm not your therapist. I could adjust your medications, but I don't think that's appropriate," Dr. Levin said.

Like many of the nation's 48,000 psychiatrists, Dr. Levin, in large part because of changes in how much insurance will pay, no longer provides talk therapy, the form of psychiatry popularized by Sigmund Freud that dominated the profession for decades. Instead, he prescribes medication, usually after a brief consultation.

So Dr. Levin sent the man away with a referral to a less costly therapist and a personal crisis unexplored.

The practice of medicine is rapidly changing in the United States from a cottage industry to one dominated by large hospital groups and corporations, but the new efficiencies can be accompanied by a telling loss of intimacy between doctors and patients. And no specialty has suffered this loss more profoundly than psychiatry.

Dr. Levin, 68, first established a private practice in 1972, when talk therapy was in its heyday.

At that time, like many psychiatrists, he treated 50 to 60 patients in once or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart.

Back then he knew his patients' inner lives better than he knew his wife's; now he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.

Dr. Levin has found the transition difficult. He now resists helping patients to manage their lives better.

"I had to train myself not to get too interested in their problems," he said, "and not to get sidetracked trying to be a semi-therapist."

Brief consultations have become common in psychiatry, said Dr. Steven Sharfstein, a former president of the American Psychiatric Association and the president and chief executive of Sheppard Pratt Health System, Maryland's largest behavioral health system.

"It's a practice that's very reminiscent of primary care," Dr. Sharfstein said. "They check up on people; they pull out the prescription pad; they order tests."

Dr. Levin's office has matching leather chairs along with African masks and a moose head on the wall. But there is no couch or daybed; Dr. Levin has neither the time nor the space for patients to lie down anymore.

"I miss the mystery and intrigue of psychotherapy," he said. "Now I feel like a good Volkswagen mechanic."

"I'm good at it," Dr. Levin went on, "but there's not a lot to master in medications."

The switch from talk therapy to medications has swept psychiatric practices and hospitals, leaving many older psychiatrists feeling unhappy and inadequate.

A 2005 survey found that just 11 percent of psychiatrists provided talk therapy to all patients, a share that had been falling for years and likely has fallen more since. Psychiatric hospitals that once offered patients months of talk therapy now discharge them within days with only pills.

Recent studies suggest that talk therapy may be as good as or better than drugs in the treatment of depression, but fewer than half of depressed patients now get such therapy compared with the vast majority 20 years ago.

Insurance reimbursement rates and policies that discourage talk therapy are part of the reason. A psychiatrist can receive $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session.

Competition from psychologists and social workers -- who unlike psychiatrists do not attend medical school, so they can often afford to charge less -- is the reason talk therapy is priced at a lower rate. There is no evidence that psychiatrists provide higher quality talk therapy than psychologists or social workers.

Of course, there are thousands of psychiatrists who still offer talk therapy to patients, but they care mostly for the wealthy who pay in cash. In New York City, select psychiatrists charge $600 or more per hour to treat investment bankers, and top child psychiatrists charge $2,000 and more for initial evaluations.

When he started in psychiatry, Dr. Levin kept his own schedule in a spiral notebook and paid college students to spend four hours a month sending out bills. But in 1985, he started a series of jobs in hospitals and did not return to full-time private practice until 2000, when he and more than a dozen other psychiatrists with whom he had worked were shocked to learn that insurers would no longer pay what they had planned to charge for talk therapy.

"At first, all of us held steadfast, saying we spent years learning the craft of psychotherapy and weren't relinquishing it because of parsimonious policies by managed care," Dr. Levin said.

"But one by one, we accepted that that craft was no longer economically viable."

He could have accepted less money and could have provided time to patients even when insurers did not pay, but, he said, "I want to retire with the lifestyle that my wife and I have been living for the last 40 years."

"Nobody wants to go backward, money wise, in their career," he said. "Would you?"

Dr. Levin would not reveal his income. In 2009, the median annual compensation for psychiatrists was about $191,000, according to surveys by a medical trade group.

Dr. Louisa Lance, a former colleague of Dr. Levin, practices the old style of psychiatry from an office next to her house, 14 miles from Dr. Levin's office. She sees new patients for 90 minutes and schedules follow-up appointments for 45 minutes. Everyone gets talk therapy.

Cutting ties with insurers was frightening because it meant relying solely on word-of-mouth, Dr. Lance said, but she cannot imagine seeing patients for just 15 minutes. She charges $200 for most appointments and treats fewer patients in a week than Dr. Levin treats in a day.

"Medication is important," she said, "but it's the relationship that gets people better."

Dr. Levin said the quality of treatment he offers is poorer than when he was younger.

Years ago, he often saw patients 10 or more times before arriving at a diagnosis. Now, he makes that decision in the first 45-minute visit.

"You have to have a diagnosis to get paid," he said with a shrug. "I play the game."

In interviews, six of Dr. Levin's patients said they liked him despite the brief visits.

"I don't need a half-hour or an hour to talk," said a stone mason who has panic attacks and depression and is prescribed an antidepressant. "Just give me some medication, and that's it. I'm OK."

Dr. Levin was astonished that patients admire him as much as they do.

"The sad thing is that I'm very important to them, but I barely know them," he said.