Psychiatry’s Underground Economy
By M. Levinson, MD;; 10/1/14

I read with interest two articles within the July issue of Psychiatric Times: Dr Richard Friedman’s “Issues in Psychodynamic Psychiatry” and Dr Thomas Insel’s “The Paradox of Parity.” Both of these articles were thoughtful and timely, and helped me clarify a point of view that I have thought about for some time. It seems that a substantial cohort of psychiatrists conduct their practices of what might best be called an “underground economy”: a process of services and charges disconnected from the conventional constructs by which these activities are presumably measured.

Despite all of the work which has gone in the descriptive-based DSMs, CPT codes, and RVUs (relative value units), which presumably categorize and put values on various psychiatric interventions, a large amount of psychiatrists simply charge because of their time (regardless how they are spending it clinically) and at rates that reflect the valuation that they place on it—a value generally determined by years of training, years in reality, and any additional post- residency certification (eg, fellowships, psychoanalytic training).

The two articles covered a great deal of territory; however, both reference the difficulties and pitfalls that occur when one tries to translate the concept of psychiatry—the most personal, individualized, and subjective of medical disciplines—into data points that can be used inside service of evidence-based medicine.

Friedman questions our current preoccupation with evidence-based criteria, is wary of a growing trend that restricts clinical psychiatry to the brain on the expense of your brain, and is critical of an diagnostic system that cannot take into account unconscious forces. He fears restricting the scope of psychiatric practice and argues that you have some psychotherapy patients that simply a psychiatrist should treat.

Insel, a consummate scientist and researcher, seems more invested in evidence- based medicine and also the potential of integrating data derived from research into clinical practice. However, he acknowledges that “parity” in mental health could possibly have unintended negative consequences. He is particularly concerned that this same research might be used just as one excuse for limiting some psychiatric treatment. He also notes the startling (but seldom acknowledged) proven fact that only 55% of psychiatrists accept noncapitated insurance.

I, too, have concerns about the rise of evidence-based medicine. Not only in the way might affect insurance compensation, but in addition in the way might further bring about a disconnect between psychiatry as envisioned by DSM, CPTs, and RVUs, and just how the art of clinical psychiatry is definitely practiced by many clinicians.

The year 2013 was big for psychiatry: there were the expansion of CPT codes along with the launching of DSM-5. The former was really important in that it eliminated the overly simplistic medication management code and encouraged the use of Medical Evaluation and Management (E & M) codes, particularly as add-ons for psychotherapy. It also introduced separate codes, 90839 and 90840, for providing psychotherapy for high-risk crises patients.

These developments were praised through the American Psychiatric Association and also have resulted in better reimbursement rates. However, it strikes me how little discussion there has been in the psychiatric press or at the various symposiums, conferences, and grand rounds that I have attended about how exactly clinicians are in fact choosing to apply these CPT changes. Do the E & M add-ons refer specifically to pharmacology and/or comorbid medical problems? Or, can a psychiatrist legitimately argue that a lot of medical training and practice allow many elements of the doctor-patient relationship to be noticed through the lens of medical evaluation and management? The lack of discussion about these tips suggests in my opinion a disconnect relating to the academic and medicoeconomic forces behind instituting these CPT changes and actual clinical practice.

I cannot recall how often I have been warned throughout my more than 30-year career that psychiatrists have to be prepared for the “new model,” where we might inevitably be part of your “multispecialty team.” Our work will be limited to what only we could do: psychopharmacology, diagnostics, crises, and inpatient work. More recently, the buzzword has been that our work is going to be, naturally, “evidence-based” (as determined by “research”).

I know that many psychiatrists spend a lot of their time working collaboratively with nonmedical therapists (that's great) and a large amount of us restrict ourselves to pharmacology only (which I think is unfortunate). I also recognize that few folks are completely proof against these economic forces. Yet, I also see a good amount of evidence that many folks, old and young, carry on and seek solo, office-based, fee-for-service, private practice. And those of us who engage in this world of personal practice, RVUs, and evidenced-based models often seem far removed from your actual commitment we devote to our patients.

I doubt that most psychiatrists who provide psychotherapy, specially those attuned to transference-based models, charge their patient more or less for a session depending on how suicidal or impulsive that patient is over a given day (in spite of the existence of the 90839/90840 codes). I also wonder how most of us determine our E & M add-ons. Do most psychiatrists really quantify the E & M effort for each individual session, or possibly it a greater portion of an issue of taking into consideration how assessment of medication, medical illness, etc, average over treatment?

Who can argue with all the importance of research? It is essential to the advancement of our field as well as the health individuals patients. Yet, for evidence-based medicine to get meaningful, it should inform and turn into informed by clinical practice and become mindful of the unintended consequences that encourage the real economy of psychiatric services to visit “underground.” Despite all the slicing and dicing of psychiatry in a multitude of RVUs, diagnostic categories, and CPT codes, it remains to appear how accurately these constructs reflect how clinical services are supplied and compensated for by much of rank-and-file psychiatry.




“Under the care of Leo J. Borrell, M.D. since December 2001, I have seen a remarkable improvement in my mother’s condition. She is responding dramatically to the new regiment Dr. Borrell has prescribed”

- Beth Rose


Feb 3, 2008

The Interdisciplinary Team; The Role of the Psychiatrist

by Dr. Leo J. Borrell, featured in Assisted Living Consult for November/December 2006. A HealthCom Media Publication