Posted by noa on November 2, 2000, at 8:29:08
In reply to Pdocs, posted by Lisa Simpson on November 2, 2000, at 5:31:47
It may be that people are using "pdocs" to mean slightly different things.
Me? When I write "pdoc" I am referring to my psychiatrist, who specializes in psychopharmocology. I see him once a month. I also see a psychotherapist twice a week--he is a psychologist.
In the US, access to "pdocs" varies by what type of insurance you have. Many people have "managed care" types, as in HMO's (Health Maintenance Organizations) or PPO's (Preferred Provider Organizations) for example. In managed care, you usually have what is called a "primary care" doctor, who is like a gatekeeper to any specialties. So, in order to see any specialists, you might have to get a referral from your primary care physician. However, primary care doctors often are burdened with disincentives for referring to specialists. In addition, the managed care companies pose restrictions on how many visits to specialists, and often offer an extremely limited list of specialists who belong to the managed care plan. As a patient, you might spend a lot of time on stupid paperwork just to be able to see a specialist---requesting a referral, going to pick up the referral, etc.
With mental health, a lot of managed care companies use behavior health management subcontractors to do the gatekeeping. This often involves calling someone and telling them why you need to see a mental health professional, and they determine if you do need it, and how many visits they approve. To continue after these first visits end, you have to get reauthorization from this behavior health management co. And, usually, the pdoc or other mental health professional has to jump through tons of hoops to please them, writing reports, answering all kinds of beuraucratic questions, setting specific goals and timelines for treatment, etc. The pdocs, et. al, end up spending more time on this stuff than on seeing patients--it is ridiculous. More and more pdocs are joining big group practices so they can pool their administrative resources to deal with managed care. But then, you feel more and more like you are dealing with a clinic environment and less like visiting a private doctor.
In the managed care model, it is often the case that the specialist then has to write a report to the primary care doctor about the treatment.
On the other hand, if you have a more open insurance plan, you can choose any doctor you would like. If they are a participant in your insurance, the doctor often does the paper work, and you pay the doctor your portion, and they bill the insurance for the rest. But usually, you have to pay the doctor and then submit bills to the insurance company for reimbursement. Non-managed care plans are usually a good deal more expensive, and are often not offered as a choice to employees. Oh yes, that is a key factor in US health care---health insurance is often provided through the employer. It used to be that many employers paid all or most of the cost, but over the years, more and more employees pay increasing shares of the cost of insurance. YEt, we are still restricted to the choices offered through our employers. Getting insurance through such a group makes sense, tho, because groups can negotiate better deals than individuals. BUT, this leaves the employee with limited choices.
One problem here in the US is that insurance companies often don't provide the same amount of coverage for mental health as they do for other health care. Since insurance is regulated at the state level, some states do require what is called parity for mental health services, but other states do not. So, you might have a good insurance plan with liberal coverage for most things, but limited coverage for mental health. Sometimes, you might have a regular (non-managed care) insurance, but with managed care just for mental health.
Usually, managed care pays for medication management but only limited therapy.
Still another issue is that more and more pdocs are not participating with any health insurance plans, leaving the patient to pay either the entire fee themselves, or having to pay and then request reimbursement from their insurance. But, the insurance will reimburse a percentage of what THEY believe the doctor should charge, not what the doctor actually charges. For example, if the pdoc charge $200 for an initial evaluation, the insurance company might pay 75% of what they deem "usual and customary" fees, which may be something in the range of $110, for instance (it varies by location), leaving the patient to pay the majority of the cost.
The reason these pdocs are not dealing with insurance anymore is pretty obvious--if there are people who will pay the full fee in cash, why would they accept a much lower amount(if you are on a plan, you are not allowed to make the patient make up the difference between the fee and what the insurance feels the fee should be), and have to get bogged down in paper work, etc.?
But, this leaves us with a two tiered system--private docs for those who can affort it, and docs who participate in insurance and are therefore affordable. BUT, sometimes the choice of docs is extremely limited and those practices are packed, making it hard to get appointments, and making communication with the doctors quite difficult.
Others here may have more info and insight to explain our system.
Also, you might like to see the web site of the Coalition of Mental Health Professionals and Consumers:
www.nomanagedcare.com
poster:noa
thread:47994
URL: http://www.dr-bob.org/babble/20001102/msgs/48001.html