Geriatric Psychiatric Outpatient Care: The Private Practice Model in the USA Elliott M. Stein and Gary S. Moak

INFLUENCES ON PRIVATE PRACTICE

For the purposes of this chapter, we will define private practitioners as independently employed or self-employed psychiatrists who work alone or in small groups. These practitioners provide treatment to patients who individually seek their help, and who pay for services received, primarily with Medicare health insurance benefits. Notwithstanding the current and ongoing, large-scale reorganization occurring in the American health care system, private practice remains a widespread model of medical practice in the USA. In many ways it has served as a starting point for the pattern of care provided in the other settings mentioned above. Many of the techniques discussed below are applicable to other models of treatment. Older patients seek care from private practitioners or other mental health providers with varying degrees of utilization and satisfaction^1,2 .

Private practices are essentially private businesses, typically started, owned and operated by the individuals providing and/or supervising the clinical services provided. They may be small businesses, comprised of a single individual or several associated people, or they may be larger groupings of multiple people joined together to provide psychiatric/psychological treatment, or be part of a large medical multi-specialty affiliation. Such groups may grow to include dozens, or even hundreds of providers, becoming large businesses in the process. This chapter will focus on the smaller entities which are more typical and more common, although there are market forces which are encouraging practitioners to join together in larger groups to achieve both economies of scale, and to better negotiate with third-party payers of services, and other caregiving entities.

The private practice of medicine in the USA has evolved as a cottage industry within a historically unsystematized, free-enterprise, fee-for-service climate. Changing lifestyle preferences and demographics among young physicians are having some impact on this pattern. From its inception in 1965, the Medicare system had a built-in prejudice against the provision of outpatient psychiatric services. There was a discriminatory 50% patient co-payment requirement for all psychiatric treatment services delivered outside of an acute care hospital setting (unlike all other covered medical services, for which the patient co-payment is 20%)³. In 2008, this co-payment requirement was addressed by a new law which will gradually phase out the discrimination over a several year period until 2014, when there will be parity between payments for physical and psychiatric treatment⁴. This limitation on Medicare insurance coverage had constrained provision of these services to the elderly. Over the past 10–15 years, however, much greater influence has been felt from a multitude of other outside forces, at times impeding geriatric psychiatry practice^3,5 , but in some cases expanding it. These forces (to list a few) include: efforts by the federal government to rein in Medicare spending^6,7; the penetration of health maintenance organizations (HMOs) into Medicare; the advent of federal nursing home reform regulations; the growing presence of health care agency accrediting bodies, such as the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) and the National Council of Quality Assurance (NCQA); the creation by the American Board of Psychiatry and Neurology of subspecialty board examinations in geriatric psychiatry; social attitudes (e.g. public attitudes about medical care and doctors, as well as about mental illness and psychiatric care); the influences of physician attitudes⁸ and medical malpractice litigation⁹; the availability of newer psychopharmacologic agents (including their increased acceptance by the public and their increased utilization by primary care physicians); patient finances; and folklore and ‘common sense’ of both the professional and the general population. Geography also is a factor, as there is significant regional variation among practitioners and communities in different areas of the country, as well as variations in payment rates and public (Medicare/Medicaid) and private (HMOs and other managed care companies) monitoring and regulation. Some geriatric psychiatry practices have adopted the use of physician extenders, such as nurse practitioners or physician assistants, to enhance the scope of treatment options. Adaptation of geriatric assessment and treatment principles has been slow, for the most part, in private general and psychiatric medical practice. Nevertheless, successful practitioners need a working knowledge of these forces in order to function. As a field which is now well into its adolescence in the USA, there are a growing number of examples of psychogeriatric care models that have proven generally applicable. In fact, the fee-for-service system in the USA has thus far been a relative failure in geriatrics, since it has not incorporated many of the accepted principles of geriatric care¹⁰. Some varying approaches have been tried by practitioners, but most still follow the above-noted model. The incursion of managed care HMOs into the Medicare system held out promise to change this state of affairs. HMOs, in theory, employ methodologies such as integrated delivery systems, screening, prevention and case management that are ideally suited to geriatrics¹¹. Their track record has been disappointing, however, and their approach to managing mental health care has been largely ineffective for the elderly. Managed care companies often ‘carve out’ the management of mental health services by subcontracting it to managed behavioural health care companies with specialized expertise in mental health benefits management¹². Such companies rarely have any expertise in geriatrics, and do not appreciate its differences from general adult psychiatry¹³. These companies have often ageist attitudes built into their coverage utilization guidelines, and inappropriately limit treatment or completely deny it, especially involving members with Alzheimer’s disease, which they do not view as a covered psychiatric disorder. To the extent that managed care has penetrated Medicare, this practice has made the practice of geriatric psychiatry more difficult, as the seniors enrolled in these plans typically may only receive services from health care providers who are contracted with them. This limits their access to care which might otherwise be available.

PRIVATE PRACTICE AS A BUSINESS

Another important factor in discussing this type of psychiatric practice is the previously mentioned idea that geriatric psychiatry is a business. As such, the patients are to be considered as customers. Furthermore, at times, other physicians, and additional referring sources, may also be regarded as customers. As such, it behoves the psychiatrist to organize the practice and to provide services in ways that answer the needs of these customers. The psychiatrist may help the patient to define these needs, provide information about them, alter them or aid them in various ways. The psychiatrist may need to refuse patients’ requests when professional judgment dictates this. American consumers, especially the adult children of geriatric patients, are becoming more and more concerned about the availability of health care, its costs, its efficacy and its risks. At the same time they are becoming more educated and aware of health care issues and, due in large measure to the availability of health-related information from the internet, and other mass media sources, more knowledgeable about treatment options and risks, although this knowledge may be of variable accuracy. If the psychiatrist does not do a good job or does not adequately address at least some of the patient’s needs (and/or their adult child’s needs), the psychiatrist may lose that patient’s business. The interaction between them, therefore, has aspects of an exchange of service for payment. Providing a comprehensive service, as mentioned above, is often very satisfying and helpful to patients. At the same time, the business opportunities for income are maximized. In a community-based private practice, people are often referred to the individual doctor, rather than to a hospital, a university or a public clinic where they may be assigned a doctor. Patients may be referred because of the doctor’s quality of service, reputation or relationships with the referring party. These qualities therefore become significant aspects of the psychiatrist’s success in business as well as clinical practice. Important factors in satisfying the patient/customer include:

1. Cost: reasonable fees and/or helpfulness and knowledgeability in filling out insurance claims. Acceptance of the patient’s insurance coverage in payment for the services.

2. Accessibility: convenient and comfortable office location and surroundings. The psychiatrist may decide to provide more services in more locations.

3. Availability: the availability of the psychiatrist to go to the patient if needed (e.g. to consult at a medical hospital if the patient is admitted by another physician for a physical ailment, or to see the patient at home, in a nursing home, or an assisted living facility) is very important. The convenience of the geriatric psychiatrist going to where the patient lives, rather than the patient coming to the doctor’s office, is very attractive to family or caregivers responsible for transportation. Because of the time and effort, as well as the distraction from other activities, the viability of this form of practice, in private practice, depends upon the numbers of people who may need services in that area or location; sometimes arrangements can be made with facilities that ensure an adequate volume of patient visits for each trip to the facility.

4. Scheduling: flexibility to see patients at convenient times without excessively long delays in scheduling appointments. This is crucial, since many frail patients are brought by their adult children, who may work.

5. Communications: the ability to contact the psychiatrist quickly and easily at need (e.g. by telephone by the patient and, when appropriate, by the patient’s family). This includes the willingness of the psychiatrist to return such phone calls quickly, and the friendliness and accuracy of the psychiatrist’s secretary or answering service. It also includes the ability and willingness of the psychiatrist to speak to the patient (and family) about his/her symptoms, illnesses and treatments in a clear and patient manner.

6. Concern: the feeling that the therapist has a genuine interest and concern for the patient. This feeling of concern extends to the patient’s interactions with the office staff. This is an especially vital factor for the older population¹⁴.

7. Confidence: patients and involved family members need to feel that the psychiatrist knows what the patient’s problem is and has an idea about what can be done. The doctor does not need to provide definite answers, but must indicate a grasp of the situation and some ideas for an approach to it. This helps to provide a structure to what is often a strange and frightening experience. Empathy with the patient’s distress is very helpful in this, as is reassurance to the patient that his/hers is not the worst case the doctor has ever seen (a common fantasy).

8. Understanding: A related skill is being aware of and addressing, when needed, those concerns, preconceptions, prejudices, fears, needs, worries and expectations which may interfere with the provision of services to the identified patient; these can be the patient’s feelings or those of the family member(s) involved. They may include fears of being controlled, a bias against doctors, psychiatrists, medications or hospitals, belief that the patient’s problematic behaviour is wilful, concerns of financial worries, caregiver stress or the feeling that coming for help is a sign of weakness or failure, the presence of partial information, such as information gleaned from pharmaceutical advertising, news reports about medications, or the neighbour’s experience with a particular drug, or the expectation that the doctor has an easy answer to the problem.

There are only limited data available on income and workload for geriatric psychiatrists as a group. For all psychiatrists, 1998 median annual gross income was $171 490 (a 3.5% increase from 1997), and annual net income was $118 630 (a 4.33% increase from 1997). This was the second lowest income of the 20 largest specialties (above general practitioners) surveyed by Medical Economics that year. The rate of inflation in the year 1997–1998 was 1.6%. Comparable 1998 income data for all US physicians show an annual gross income of $256 290 (down 0.7% from 1997) and a net income of $163 940 (up 2.2%); for non-surgical specialties, the gross income was $227 300 (up 1.7%) and the net income was $147 140 (up 2.4%)¹⁵. When these data are compared to the median annual net income for psychiatrists in the USA in 1989, which was $103 570 (the fourth lowest of 15 office-based specialties surveyed that year; the only doctors who made less were general practitioners, family physicians and paediatricians)¹⁶, we find that the income of psychiatrists had risen 14.5% in that period. The median net income for all fields of medicine rose just under 25% during the same period, while the cumulative inflation rate added up to 35%.

Although most American psychiatrists see few or no geriatric patients, this trend is changing somewhat. There were over 5400 out of the over 36 000 members of the American Psychiatric Association who expressed an interest in geriatrics during their 1997–1998 Professional Activities (Biographical) Survey (unpublished data, courtesy of the American Psychiatric Association, 2000). The membership of the American Association for Geriatric Psychiatry has grown to over 2000 (unpublished data, courtesy of the American Association for Geriatric Psychiatry, 2009), and interest among general psychiatrists continues to increase. In 1991, the American Board of Psychiatry and Neurology first administered a Board Certifying subspecialty examination in geriatric psychiatry. As of December, 2008, there were 2953 individuals who have passed this examination (data courtesy of the American Board of Psychiatry and Neurology, www.abpn.com/cert_statistics.htm, 2009).

In 1996, 18% of American general psychiatrists had geriatric caseloads exceeding 20% of their practices¹⁷. Overall, in this 1996 survey of 970 responders, an average of 14.0–17.7% of their psychiatric patients were aged 65+, compared to 8.4% found in a 1987 study¹⁸. When psychiatrists who provide a higher proportion of geriatric services (more than 20% of their case load – HGPs) were compared to those who were low-volume providers with the elderly (less than 20% of their workload – LGPs), it was found that the HGPs spent proportionately less time in their offices (although still spending most of their time there), more time in hospitals and significantly more time in nursing homes, than LGPs¹⁷.

In 2002, the National Survey of Psychiatric Practice¹⁹ found the proportion of HGPs had increased to 26.0% of respondents, and 28.1% of respondent members of the American Psychiatric Association (a 55% increase from the 1996 survey). Of the HGPs, 31% were Board Certified in Geriatric Psychiatry. These geriatric psychiatrists saw approximately three-times as many geriatric patients and five-times as many patients with dementia as the non-HGP general-ist psychiatrists. Nonetheless, most did not have exclusive geriatric practices. Of note is the finding of a wide range of annual incomes among the respondents.

The 2008 report of the Institute of Medicine highlighted the existing and future shortfall of geriatric medical care providers, including geriatric psychiatrists^19,20. At that time there was calculated to be one Board certified geriatric psychiatrist for every 11 372 older Americans, and that, by 2030, if training programmes continued at their current rates, there would be only one for every 20 195 older Americans²¹.

A significant impediment to the collection of data on the work done by geriatric psychiatrists and the income generated by this work has been the inability to differentiate those individuals who provide services to the older population from the work of other psychiatrists. The Medicare system has not differentiated general psychiatrists from geriatric specialists. In May, 2009, the Centers for Medicare and Medicaid Services (CMS), the United States federal agency which administers the Medicare programme, approved the creation of a specialty identification code for Geriatric Psychiatry (personal communication, American Association for Geriatric Psychiatry, 2009), as a recognized specialty, beginning in April, 2010. Individuals who choose to do so, may register with Medicare as having a subspecialty in this area. This will allow information to be collected as to the work load, diagnosis and treatment provision and income generated by these practitioners.

There may be changes in the future, but currently there are relatively low numbers of psychiatrists with a specific interest in treating the elderly. When the medical and general communities know that a particular psychiatrist is a geriatric specialist, there is usually no shortage of patients needing these services. However, at the time of this writing, the economic downturn in the United States along with the projections of future medical costs, together with the current governmental motivation to make changes in the nation’s health care system, make uncertain the nature and form that medical care, and specifically geriatric psychiatry care, will take.

OFFICE PLANNING AND DESIGN^22,23

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