Limited access to providers between appointments

Psychiatric providers are reimbursed for billable hours, meaning time spent directly in patient care or appointments. Psychiatry is reimbursed at primary care rates but unlike primary care, most follow up appointments require a 30 minute time slot, whereas primary care follow ups are scheduled for 15-20 minutes. The latter means that our overall revenue is less and therefore the ability to fund administrative time is less. Administrative time is when there is a slot scheduled in the day for the provider to go over emails, messages, call pharmacies, write letters, and to answer calls. Most primary care offices alot a certain amount of administrative time, paid, to take care of these responsibilities. Psychiatric offices often are unable to provide paid administrative time and if there is time allotted it is often short, meaning 30 minutes.

Psychiatry notes are more complex and require more information than primary care notes, so most administrative time is utilized to complete the notes needed to bill insurance or ensure quality care (record of past treatments and items discussed). So, the ability to respond to questions or communications outside of appointments is very, very limited if at all available. Medication changes, pharmacy changes, emails, etc take at least 10 minutes to respond to as a provider must look up the last note to assess plan of care, document the interation (email, phone call, etc), and if there is a controlled substance involved a federal report must be run first to make changes or even transfer the medication to another pharmacy. On average, in my own office, I receive about 10-20 communications outside of appointment times - EACH DAY. Let's say, I answered 10 of the communications, at 10 minutes (average) each, that would be an extra 100 minutes added to the beginning or end of my day. If I did that five days a week, that would be an extra 500 minutes - unpaid which is 8.33 hours. So you see that would be equal to an average work day. I work through my lunch and don't take breaks; so that option is not possible either (which is common for most providers).

Why can we not bill for that time? Insurance companies do not pay for telephone or electronic interactions; nor communication with your pharmacy nor prior authorization completion and coordination. They also do not pay for creation of letters or form completion.

It is a common assumption that if a patient is paying cash for visits, communication between appointments should be included in the previously paid rate. Liken that to paying a hair dresser to cut your hair and requesting advice, touch ups, assistance with purchasing hair care products, or help with styling issues between appointments. I am not aware of any hair stylists that do that, as they are a service based industry as is healthcare.

Unfortunately, my licensing fees, certification renewals, malpractice insurance, general insurance, property insurance, worker's compensation insurance, and continuing education requirements cost thousands of dollars a year. The latter does not include the cost for eight years of education nor the extra integrative training I have completed. Then there are the expenses of running an outpatient practice, which consists of rent, internet, software to prescribe and document; phone (for us text and fax), email platforms, websites, accountants, payroll providers, office supplies, etc.. As you can see, it costs thousands to practice as a provider, with psychiatry being no exception.

Many providers choose to concentrate on inpatient care versus outpatient care as it affords the ability to do things like vacation without a major impact on patient care as well as negates things like calls to pharmacies, insurance companies, prior authorizations, and communication between appointments delaying free time and family time.

I try to provide the best care I can, while taking care of myself to ensure that my mental health is optimal. I offer the ability to text and email us directly -which is something often only seen with Concierge Psychiatry. I also offer brief therapy and coaching; which is also not standard practice. I care about my patients and want to provide the best care I can - with boundaries I teach my patients to implement.

Insurance has made psychiatry very, very difficult and the state of the world compounds everything. We are all doing the very best we can with what we have. Thanks for listening to me ramble.

Sincerely,

Christine Pebbles