Why is it so hard to find a psychiatrist in Toronto – Part 2 (Fee structures, and intrinsic motivation)

My last post on this topic addressed the overall money picture of psychiatrists compared to other medical specialties. On a gross level this probably impacts our ability to recruit psychiatrists into the field – getting enough new psychiatrists to compensate for and replace the huge cohort of psychiatrists nearing retirement age who will exit the field in the next decade or so.

The other way that money affects access to psychiatric care is the models by which psychiatrists are compensated. The overall amount of money may impact how people are attracted to this kind of work but the way that money is distributed affects how psychiatrists spend their time.

We know that if you pay people enough money that they don’t have to worry about it, then their behaviour will be motivated by other concerns – the desire to do their job well, to self-actualize, or to serve some higher cause (see Daniel Pink’s work on extrinsic and intrinsic motivation). For a psychiatrist, behaviour driven by intrinsic motivation might include taking on challenging cases mostly for the satisfaction of resolving them or to help one’s colleagues, seeking out new skills and therapy modalities in order to provide more effective care, staying up to date on the literature, teaching students, advocating for our patients, or taking a bit of extra time to collaborate and discuss a case on the phone with other treatment providers. These are things we need psychiatrists to do, even if it is not direct patient care. I would also argue that it is not possible to motivate people to engage in these behaviours simply by providing financial incentives or penalties. For example, OHIP pays an extra 15% premium for psychiatrists to accept patients who have just been discharged from hospital or who have had a recent suicide attempt, but Rudoler et al in 2017 found that this strategy was not effective in changing practice patterns. It is not clear from the study why this is the case – perhaps it was just not enough extra money, but it also may be that the nature of that behaviour is such that you cannot motivate people to do it by paying them more money.

On the other hand, there are certain kinds of practice patterns that probably are influenced by fee structures in fee-for-service care. Psychiatrists at this point probably do not earn enough that we can just ignore money altogether and 100% pursue personal fulfilment in our work, so some of our decisions are made based on what activities are most lucrative.

To provide additional context, some psychiatrists are paid on a sessional model, where we are paid a certain rate for a certain amount of our time, regardless of the activity that time is spent on. Others have a salary-based model. However, most work on a fee-for-service basis under OHIP, meaning we bill government insurance for the services that are provided.

There are two types of fees – those that are time-based, and those that are not. Time-based fees require the doctor to directly treat the patient for a certain amount of time. The standard psychiatric care and psychotherapy fee codes are time-based. The non-time-based fees are generally consultations – assessing a patient and writing a report. Up to 76 minutes, the fee is the same regardless of how much time is spent with the patient and doing the report.

For psychiatrists who mostly focus on time-based fees, the incentive is to spend more time with less complicated patients in order to generate less non-billable time, such as prescription renewals by fax, phone calls, or collaborating with other professionals. This only makes sense – if there is no way to make more money, it’s better to make the work easier. This leads to the kinds of very small psychotherapy practices (“low-volume practices”) that people sometimes complain about – more on this in another post.

On the other hand, another kind of practice is incentivized for psychiatrists who focus on increasing their hourly rate by doing more consultations per hour. These “consult factories” take advantage of the fact that the fee for a consultation is the same whether it takes 15 minutes or an hour to do the consultation. To some extent this may encourage efficiency (e.g. if you can spend less time doing a report by dictating it instead of typing, you can do the same amount of work in less time and be rewarded for it). However, there are some drawbacks to this system as well. Psychiatrists can only bill for one consult per year (after that, they have to use the time-based fee for psychiatric care), therefore, psychiatrists who focus on doing consultations are discouraged from following up with the patients they consult on because doing so causes their income to decrease. It also incentivizes doing short consultations of dubious value. Doing a thorough assessment and writing a thoughtful report can actually decrease one’s hourly rate to less than the time-based psychiatric care fee, if it takes too long to write the report. Also, the main value of the consultation lies in the treatment recommendations, and usually, it is expected that the referring family doctor should be doing all of the work. Last I heard, the fee structure for family doctors does not encourage them to spend a lot of time with psychiatric patients, either, so the patient ends up in more or less in the same situation they were in before they had the consultation and they don’t actually get much treatment.

All of this means that it is difficult to find a psychiatrist because there are not enough of us, and the ones who are in practice are often not taking patients in order to make their lives easier, or they are only seeing people for one-off visits. The practice of seeing new patients on a regular basis and treating them for several months or years until their condition improves is not as lucrative. There are certainly psychiatrists who work that way despite the obstacles, but the billing system does not steer people in that direction (and even if all of us worked that way, there might still not be enough of us).

There is an addition issue with the fee codes in the sense that they have not changed to keep up with the changing nature of psychiatric practice. This is also the case in other specialties as well, but while other specialties benefit from this (mainly procedure-based specialties, where the fee is the same but technology allows the procedure to be done in less time), psychiatrists are arguably worse off.

The evolving reality of psychiatric treatment is that we are getting better and better at working in multi-disciplinary teams; the psychiatrist can handle medications and consult on difficult cases, and there are social workers, administrative staff, and psychotherapists to provide the other kinds of assistance that patients need. Technology even allows for asynchronous care – patients and physicians don’t even need to connect at the same time. This is great – a psychiatrist can leverage the power of other people, and technology, in order to be more productive. However, the funding models we work with are still rooted in the old-fashioned model of a solitary psychoanalystic working with a paper, a pen, and a couple of chairs, in a private office that does not include any other professionals.

One would not expect a surgeon to do an operation without the anesthesiologist and the OR nurses. However, the way psychiatry is funded in Ontario, that is more or less what we expect from psychiatrists. There was a time when all a psychiatrist needed was an office, a filing cabinet, and pen and paper. There is a lot that a psychiatrist can do with just those tools. But it is limited and we can do better now. However, we are still stuck with the same fee codes from the time when all psychiatrists did was talk therapy and write prescriptions and that was enough for the population. Even if we want to work with other people, there is little public funding for non-psychiatry mental health care, and there is no provision in the billing codes for supervising treatment provided by another professional. So, even if we want to, we can’t hire allied health staff to work for us and it costs us money to take time out of the work day to collaborate with other professionals. There is some token provision allowing OHIP billing for electronic consults and phone consultations, but most of the time the fee is so little it doesn’t realistically cover the time it takes for the referring doctor to write a referral and for the consultant to bill for the service provided, let alone provide the service itself.

Basically, since indirect care and collaboration are not (or only minimally) covered under OHIP, psychiatrists don’t want to take phone calls or talk to other doctors or professionals, because it costs us money to do that. There is a disincentive to have a lot of patients under one’s care because more patients means more complications and more non-billable activity. Therefore, a small practice is better, and a consultation-only model where no ongoing care is provided, might be even better than that (at least from the perspective of income alone).

Can this all be solved by spending more money? I’m not sure. It may be the case that more money is never enough, and it will not be affordable to pay psychiatrists enough that we can just focus on doing our jobs without thinking about earning more money. I’m not sure what the income threshold is for that. I can say that I have personally found sessional fees to be very liberating – if I can just put in my time doing what is needed, in my opinion, and I know that I will earn enough, then I will try to spend the time doing something productive. Paying physicians in this way requires having faith that we are not going to spend our time on the clock checking Facebook or reading email. However, I believe that highly-trained and intelligent people with altruistic inclinations are unlikely to be satisfied getting paid for doing nothing. It is much more satisfying to do some sort of productive activity. Maybe we could even see more innovation and creative activity – problem-solving systems issues, blue-sky thinking, trying to find greater efficiencies – if doctors are paid enough and left to their own devices. Right now, it’s too easy to think, “I’m not getting paid to worry about that stuff”. It is clearly self-serving to advocate for dramatic increases in income with vague promises of productivity, but I think as psychiatrists we can replicate the effect of having enough money to not have to worry about it, by looking for alternate funding sources – salaried positions, sessional funding from other organizations, and also moving to lower-cost jurisdictions and keeping a frugal lifestyle, so that the money we do get goes further and there are fewer obstacles to exercising our intrinsic motivation.

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