A Note from Dr. Jain

After I graduated from residency training and fellowship, I took up a salaried job providing insurance-based health care for a period of 3 years. America is deep in debate about much-needed health care reform and we all hope that much-needed change will be delivered. But in this time of confusion and chaos, I have decided that as a physician who is deeply committed to delivering quality health care, I am not willing to accept the severe limitations put upon me by managed care. Health care reform must offer flexibility to allow physicians to make treatment decisions responsibly and judiciously but based on what would be most helpful for their patients. Outlined here are just some of the deep concerns and the realities of managed care that have led me to make this difficult decision.

  • • I am a psychiatrist trained to provide both medications and psychotherapy and believe that in many situations a combination is superior to one or the other. I work with many therapists in the community and wish to be able to encourage my patients to seek psychotherapy when I feel that this will be of benefit. Under managed care, this care model was made problematic. My training background has been beyond the standard psychiatric residency program. I am a member of the American Psychoanalytic Association and have undergone training at the Dallas Psychoanalytic Center. I also did a year of research fellowship in Mood disorders and Advanced psychotherapy where I participated in psycho-pharmaceutical research but I also studied short term therapies like Mentalization-based therapy, interpersonal and cognitive-behavioral psychotherapy. Since coming to Las Vegas, I have obtained additional training in Dialectical Behavioral Therapy and have continued with pursuing advancements in my psychopharmacological expertise as well. I provide comprehensive care that comes from one clinician integrating both psychotherapy and medication treatments and provide the convenience of "one stop shopping".
  • After dealing with insurance companies, I quickly was made aware why most psychiatrists provide only medication management visits and no therapy. Under managed care rules, medication visits usually have no mandated time restrictions, but in order to be paid enough by insurance companies most psychiatrists have now been forced to use this category of visit to see 4-5 patients in an hour, meaning only an average of 7-13 minutes of face-to face interaction with their patients. That is 7-13 minutes to see how you are doing, discuss medication changes if needed, write prescriptions and also document all this in your chart! Not much time to discuss or explore what changes have happened in you life since you saw the physician, let alone what may have led to stress or despair in the first place. A study published in the Archives of General Psychiatry in August 2008 looked at 14,000 office visits to psychiatrists over the last 10 years and found that today’s psychiatrists get reimbursed by insurance companies at a lower rate for a 45-minute psychotherapy visit than for three 15-minute medication visits. Thus, the cycle was set up and the percentage of psychiatrists doing psychotherapy with their patients has dropped significantly.
  • As I tried to practice under this model, I found myself feeling that I could not give enough time to my patients even though I never double booked. I often finished late as I tried to give my patients as much time as I could, and all the notes were left to the end of the day. Not to mention returning phone calls, talking to insurance companies about authorization of medications and sessions, justifying to disability companies why I placed a severely depressed person on a medical leave of absence, filling FMLA paperwork, etc. It seemed like more of my energy was going to my practice rather than to my patients!
  • Studies have shown that psychiatrists that provide psychotherapy prescribe fewer medications on an average than those that don’t. It was not surprising to me then that I encountered more and more new patients who, in my opinion, were over medicated, had not had a medication change in years even though their treatment was not working, or who were on a larger number of medications than I thought were necessary. It is my humble professional opinion that even without getting into deeper therapy sessions, good medication management needs more time than 7-13minutes (unless, perhaps, you are stable on your medications and simply seeking refills).
  • While some insurance plans do allow (in some instances) a patient to see both a psychiatrist and a therapist, this is not the norm. Even if this is the case, there is little to motivate the psychiatrist to spend the time necessary on collaborated care with the therapist and to keep each other abreast of treatment progress and changes they see or are needed. In theory this collaboration can happen, but in practice when most psychiatrists are seeing a patient for 7-13minutes and they are reimbursed a flat fee irrespective of whether they called the patient’s therapist or not, you can imagine that only the most dedicated physicians will make that effort and that, too, not as frequently as one would like. And that’s not even mentioning collaborating with the patient’s primary care physicians and other specialists that they maybe seeing. This is important, especially when medications are involved and due diligence must be taken to avoid drug interactions and coordinate monitoring of blood work and other tests that may be needed periodically. Under the current care model, few psychiatrists are able to dedicate the time for this and rely on the patient to do all of this themselves.
  • Another aspect of treatment that is “dropped” under the current model is the simple task of weighing patients on each visit, as this also adds time to the visit and may be skipped due to time constraints. Though it seems a simple omission, it is the best way to monitor a patient’s potential weight gain or loss on any given medication, and is important in my view. Psychiatric medications get a bad name sometimes as “all causing a lot of weight gain” but that is more about insufficient monitoring and close supervision in addition to dietary advice and other precautions that maybe necessary.
  • Quick medication visits without therapy, and treatment of a patient without consultation with other doctors can easily lead to addictions. Addiction is a disease of secrets and patients with this problem are often not forthcoming about what they are taking. You hear more and more about people getting controlled substances from different doctors and accidentally overdosing or hurting themselves. We may wonder; how did the doctor not pick up on this and intervene to help those addicted patients that have not yet come to the realization that they have a problem? Physicians can periodically drug test their patients and obtain reports from the Drug Enforcement Agency as to whether a patient has filled other prescriptions that could be dangerous in combination with what they are prescribing. In Nevada, this information is available online to all physicians, but I think it is grossly underused.
  • Also, very importantly, I believe that the secret of success for many patients is family and social support. I believe that a key component to good treatment is educating a person and, if they are willing and give consent, educating their loved ones who are an integral part that person’s treatment and recovery. Under the current managed care model, there is little or no incentive for practitioners to involve family or to take the time to educate them on the patient’s road to recovery.
  • Lost in the current managed care model is responsiveness of most doctors. The referring physicians and therapists that know me will attest to the fact that even in a managed care setting mentioned above, I tried to be as thorough as possible and provided timely reports to them and promptly coordinated care with other treating professionals. I have also always been available to my patients via email and phone. At the place I last worked, due to the volume to patients the clinic saw, sometimes patients complained that their messages were not passed on to me.  I would tell most of my patients that if they did not hear back from me by the end of the day than I did not receive their message and that they should call again. I plan to eliminate the chances of missing messages by having a limited patient base that is manageable and having an answering machine as the only go-between my patients and I (those who prefer call backs than email replies). Additionally, we often find out that either our doctor is not taking our insurance, or our employers shop for a different plan, or we ourselves are transitioning from one job to another. Since I will not be on any insurance panels, disruptions in care due to coverage changes can be minimized.
  • Another large reason for my decision is privacy. This is something that is often a concern that my patients bring up: privacy. Insurance companies are increasingly requiring detailed documentation from doctors that they then turn around and sometimes use against you when it is time to renew benefits and coverage. This results in difficulty establishing an atmosphere of trust, where one is free to discuss anything and everything that ails an individual. Many providers get around it by writing broad and general statements like, “ Discussed work and relationship issues,’’ “ Talked about substance use issues,” or “Explored intimacy and sexual life” (not even saying ‘issues’ sometimes to avoid implying problems implicitly). It is my contention that the intimate details of your personal life should not be divulged to an outside party. As I have opted out of the insurance panels, your records will be absolutely confidential. I can generate a receipt that you can submit for reimbursement from the insurance company, but all that it will show is the service provided (medication management & /or psychotherapy) and possibly the diagnosis (some insurance companies need the diagnosis to determine whether they reimburse you or not). If you wish that I release more information to them for reimbursement, then I will absolutely do that on your behalf. You have control on who can access your records.
  • Lastly, I would like to speak of freedom from third party intrusion and control. This is another reason I have opted out of the managed care model. I think it is simple common sense: the patient and the doctor, together, should determine the treatment and length of time necessary, not insurance companies. But often that is not the case with managed care, as they only authorize a predetermined number of sessions and prior authorization is required for any additional sessions. Sometimes, despite good justification, additional services are denied.  Denials based on unnecessary and wasteful treatment is understandable, but psychiatric and psychological care decisions are so personal and individualistic that it is unfair to say that 12 sessions would work the same for 2 different patients with depression. It does not take into account any personal and psycho-social circumstances that might make a treatment not ‘fit’ in the ‘12 session authorizations’. 

For these major reasons and more, I am no longer willing to participate in a care model that I myself would not subscribe to.

True health care reform is needed and long overdue. This may be especially true with mental health care. Psychiatry and psychological services are different than many other fields in medicine. An appendectomy is a standard surgical procedure that surgeons in different parts of the country can closely replicate. But as you move away from procedure-based medicine, the quality of care delivered by a family physician, internist and psychiatrist can be vastly different based on their unique abilities. Our society has accepted paying lawyers differing rates based on what they bring to the table with their expertise and acumen but we hesitate in recognizing quality health care. Health care reform must address the central issue of physician economic incentives. We need to value the time doctors spend with patients. Instead of being encouraged to squeeze in appointments and rush through office visits, doctors should be incentivized to take the time to counsel and guide, along with improving their communication with patients, not only in person, but over the phone and on the Internet.

Likewise, I believe we should be incentivizing quality care. I fully endorse standardization where possible, evidence-based medicine and care, and utilization reviews that make physicians more accountable for the care they are providing and to cut down unnecessary spending. But this is not what is built into the system. As President Obama pointed out, many insurance companies are reporting record profits in these troubled times when everyone has had to make sacrifices. That is a conflict- of-interest. Insurers use their size and superior financial resources to coerce hospitals and doctors to accept lower reimbursement. Insurers go to great lengths to identify and discriminate against consumers who may be sicker and less profitable. As a physician who is sympathetic to the big picture health care reform debate, I would like to see health care reform that rewarded quality care and not quantity care.

I am confident in the treatment model I now practice here at Cairn Center, and I believe that overall health costs with my treatment approach will be less in the long run for an individual who hopes to participate in their treatment and achieve higher productivity and all that they can achieve in life when not plagued by psychiatric and psychological burdens.

This is why I have opted out of the managed health care system. This is why I have started the Cairn Center.