'We Can't Disenfranchise Patients Who Suffer From Orphaned Illnesses'

Last week, ICES, a provincially funded organization that evaluates health care delivery and outcomes released a study on the supply on access to psychiatric care in Ontario that confirmed that most psychiatrists across Ontario provided consultations, pharmacotherapy, or evidence-based psychotherapy and were more likely to see seriously ill patients identified as having a psychiatric hospital admission.

However, they were concerned that there was a mismatch between supply and population need because in regions where psychiatrists are more plentiful, they tended to see fewer patients for longer periods of time.  The worst transgressors were seeing fewer than 40 unique patients a year.

This, they hypothesized, was due to the lack of criteria constraining the frequency of, duration of, and indications for psychotherapy resulting in some psychiatrists electing to provide care to a small number of patients who were reliable, mildly impaired, and easy to care for rather than providing consultations or acute care to seriously ill, unstable mental health patients.  These psychiatrists were taking advantage of the system for their own ease.

They concluded that psychiatrists’ scope of practice should be questioned and that we look to other countries for possible solutions, citing the United States as an example.  In the U.S., health maintenance organizations have created mental health “carve-outs,” in which psychologists and other allied mental health professionals provide psychotherapy at lower rates, and U.S. Medicaid/Medicare psychiatrists are paid an hourly fee that is more than twice as high for pharmacotherapy and psychiatric consultations as for psychotherapy.

Well I am one of the psychiatrists whose practice style fell into a category that they considered undesirable, the inference being that I have “elected” to avoid dealing with anything difficult or mess without consequence to my income.  The study suggests that my practice style is not in the interest of patient access to psychiatric care.  In fact, my practiced contradicts every one of their presumed reasons for having a small population of patient who are seen intensively in psychiatric care and yes that includes psychotherapy that occurs for longer than 45 minutes a session, more frequently that once a week and for longer than 16-20 sessions.  I will address one of the flaws in their reasoning in this blog.

I do not treat “easy patients”.  I treat patients that few are willing to treat in outpatient care.  In fact, although seriously ill, my patients cannot find anyone else to provide the appropriate outpatient care, and typically go without.  I treat patients, who do not qualify for our mental health care system safety net.  There is nowhere to admit them on an urgent basis even when they are at risk of death.  I treat them as outpatients, even when by all measures, medical and psychiatric; they should be in hospital, because there are no alternatives.  I treat adults with chronic severe eating disorders.  These patients are often medically compromised as well as debilitated by their eating disorders and their co-morbid psychiatric ailments.  I can best illustrate this by way of example.

Over the last few months, I have been treating a young woman whose anorexia nervosa is so severe, that she has had two heart attacks that have left her with permanent cardiac damage.  She is often in the early stages of heart failure, something usually occurs only in the elderly and can potentially lead to death.  Her eating disorder and her co-morbid psychiatric disorders directly result in behaviours that continue to place her at risk of further damaging her heart.  They certainly interfere with her cardiac recovery and will mean that she will not achieve as complete a recovery.  If she had schizophrenia or bipolar disorder or any other primary mental health diagnoses of comparable severity, there would be a whole menu of options I could potentially access (and while these services are also limited or hard to access, at least they exist), including inpatient care,  or intensive outpatient programming.  Having anorexia nervosa as the primary diagnosis, excludes her from these supports. 

Needless to say, there are days, where I have spent hours working with her.  Sometimes, the time span is longer that what the government will remunerate.  Sometimes, the time is spent working with her is provided in a manner that is not remunerated at all.  In fact, in deciding to treat the most complex and seriously ill eating disorder patients, I make less income that if I chose to work with any other patient population.  However, that is beside the point.  Both she and her family could not find another psychiatrist to care for her as an outpatient.  In fact, without intensive psychiatric outpatient care, she might not have survived the last few months.  She is not yet out of the woods, but she is alive. 

I do not “elect” to care eating disorder patients because they are easy and reliable, I elect to care for them because it is my duty as one of the very few psychiatrists who are trained and experienced in the  of patients with severe eating disorders.  To limit my ability to bill OHIP for the work I have done, as the report suggests, would have made it impossible to care for severely ill complex patients who have nowhere else to go.  We have to be careful to ensure that when we make changes to the system, that we do not further disenfranchise patients who suffer from orphaned illnesses.  Too many patients already die from eating disorders every year without concern from the mental health care system.  Let us not add to that number because of the inferences gleaned from one study.