Psychiatrist productivity in public-sector behavioral healthcare is a provocative topic of great interest to both CEOs and psychiatrists. This article is an attempt to identify factors represented in this tension between quality of care and fiscal responsibility.
Community behavioral health organizations have experienced considerable fiscal pressure since the 1980s. Decreased funding, coupled with constant or even increasing community pressures for services, has led to the introduction of productivity expectations for all clinical staff and/or downsizing of organizational capacity. Of all the clinicians in behavioral healthcare organizations, psychiatrists are often the most obvious target for questions regarding fiscal accountability.
One obvious reason is related to psychiatrists' salaries. Physicians have persisted in intense and time-consuming training programs for psychiatric specialization and command salaries usually exceeding CEOs' salaries. The disparity between the salaries of psychiatrists and other treating professionals can create the sense that the higher salaries are undeserved; however, competitive salaries are required to attract and retain high-quality medical staff. Additionally, incentive plans based on productivity in community mental health centers are often difficult to implement for medical staff.
Market forces frequently conspire to make recruitment and retention of psychiatrists a challenge. For example, in one western state, psychiatrists were being recruited to a local corrections facility for $250,000 per year. Unsurprisingly, this created stress on the local inpatient facilities, as their psychiatrists were lured away to the more lucrative positions. Ultimately, the salaries for inpatient psychiatrists were adjusted upward by the state government's executive branch. A similar example occurred in a southern state: In response to increased need due to the Iraq war, psychiatrists in the community sector were recruited to VA facilities at salaries significantly higher than the salaries offered by community mental health centers.
Fiscal cutbacks not only threaten our ability to recruit and retain psychiatrists; they have forced psychiatrists into the role of “medication experts.” This is unfortunate because psychiatrists are among our most highly trained staff. Many have the talent and experience to lead in other ways; however, this drive to place psychiatrists in medication-prescribing roles usually isn't driven by a lack of competence on their part. Rather, in challenging financial times, it is necessary for senior management to ask “What can only you do for us?” rather than “What can you do for us?”
Several years ago, Dr. Morrison had a psychiatrist ask him if he could diversify his clinical offerings and carry a general outpatient therapy caseload along with his medication management duties. Dr. Morrison responded, “Of course you can—so long as you're willing to be paid at the same rate as a clinical social worker.” The point is, we have a lot of skilled people who can do outpatient therapy; we don't have many who can prescribe and monitor medications.
Like all clinicians, psychiatrists should be evaluated on the basis of their value, not just their cost. Attempts to look at only the clinical productivity of psychiatrists may be shortsighted. In most organizations, treatment planning is an activity that defines what services will be rendered for a given consumer and whether the organization will be paid for them. Rules vary from state to state, but generally independently licensed clinicians can initiate treatment plans on their own. Clinicians who aren't licensed usually have to have the plans reviewed and co-signed by more senior clinicians—often psychiatrists, although, depending on the state statute, other clinicians can serve in this role. Reviewing/co-signing treatment plans is usually not a reimbursable activity and typically wouldn't show up on a productivity report. Yet this important review function enables organizations to bill for services rendered by case managers and other clinicians lacking independent licensure. Psychiatrists in many organizations enable other disciplines to carry out their specific treatments. Therefore, the oft-considered strategy of decreasing psychiatric services in lean times can backfire and actually weaken the organization.
Even when we look at psychiatrists' productivity directly, we find that the actual scheduling of physician time also presents numerous challenges. Medication checks are usually 15- to 20-minute visits, and psychiatric evaluations tend to last 45 to 60 minutes (although some agencies have 30-minute psychiatric evaluations). A full day scheduled this densely can appear daunting, but it would yield a highly productive psychiatry staff. However, the no-show rate for scheduled appointments can easily range from 15 to 30% for medication checks and up to 50% for psychiatric evaluations. Without appropriate scheduling management, these missed appointments have a devastating effect on psychiatrists' productivity. Solutions such as overbooking or other creative scheduling strategies can help. Remember, too, that child and adolescent psychiatry patients require longer appointments because of parent, guardian, and/or teacher involvement.