In multi-specialty groups and integrated academic health systems like mine, psychiatry struggles not to lose money. This economic anomaly stems from a system that biases economic rewards (i.e., gives more money) more for doing things (“procedures”) than for thinking and talking to patients. And it’s not just between specialties, but within: general medicine loses money; procedural subspecialties like cardiology and gastroenterology make money. And a cardiologist, gastroenterologist, or dermatologist, for example, who wants to earn more will devote more time and effort to procedures, shying away from low-reimbursement time with patients.
Care of patients with diabetes mellitus illustrates the dysfunction in America’s healthcare non-system today. Diabetes is a life-long disease. Patients age more rapidly than peers without the disease. Their organs degrade and blood vessels clog. But close monitoring, tight disease management, and behavioral factors like diet and exercise can combat many of these effects and prolong life and function. That’s good for people and saves money. But in our current system, doctors and hospitals aren’t rewarded for these low-tech, long-term, preventative interventions. It’s better for the bottom line to do the many late-stage extensive procedures these patients are likely to require: fixing retinas, bypassing coronary arteries, transplanting kidneys, amputating limbs. And most insurers seek to maximize profits not by cost-effective long-term care and prevention, but by finding ways to encourage people who become sick to leave their programs.
I can’t predict how or when we will see genuine healthcare reform in the United States. But the skyrocketing costs of health expenditures in our country, which buy only mediocre outcomes, dictate that things will need to be fixed and soon. And I have to believe that covering all our people with good health care will demand a cost-effective system, emphasizing prevention and effective long-term care. This, in turn, will require investment and uniformity in information technology, standardization of optimal practice, and—at long last—due attention to behavior. The behavior of our population—whether diet and exercise or compliance with prescribed treatments—is a huge driver of medical costs and an obvious target for attention in the New World Order. I believe that in the system to come, psychiatrists will play a role of great importance, as experts in behavior and specialists in conditions that commonly exacerbate other diseases. Stay tuned.
-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry