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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.

Why is it so hard to find a psychiatrist in Toronto? Part 1

Usually my online activity focuses on updates about my practice locations and thoughts about electronic medical records. Lately the question of why it is so hard to get psychiatric care in Toronto (or anywhere in Ontario, for that matter) seems to be coming up a lot more often – patients I have seen, trying to access treatment, or people I know personally. Even pulling strings there isn’t much I can do for my own friends or family because it seems that the services are just not out there.

Why we are in this predicament is a somewhat complicated question to answer but it is important for the public to think about. Our society likes to talk a lot about destigmatizing mental health and doing more for people in a vague and noncommittal sense but without accurate knowledge of our present situation we will not make any progress. I will start tackling this with my perspective from the ground, and most likely it will require a multi-part answer that spans many posts.

The highly simplistic answer to the question of why it is hard to find a psychiatrist is that there are simply not enough psychiatrists. Currently, the Coalition of Ontario Psychiatrists estimates that there is a shortage of about 200 psychiatrists in the province of Ontario. It is simply difficult to see one because there are not enough of us doing this kind of work. The more interesting questions are why there are not enough psychiatrists and whether the psychiatrists who are in practice are actually using their time as efficiently as possible.

The money 

Let’s get this one out of the way first. According to ICES data (a non-profit health care research institute) from 2015-2016, psychiatry is currently the lowest paid Ontario specialty. That was surprising news to me to read – I thought we were second or third lowest, but it turns out we recently had the dubious privilege of being at the very bottom. Comparing averages, it’s about a third of what an ophthalmologist makes, and we do the same amount of post-graduate training. That, perhaps, does not take into account the fact that many psychiatrists only work part-time and it is an attractive specialty for that reason. Maybe psychiatric work is easier too – I’ve never been an ophthalmologist, so I don’t really know how they compare. It’s also important to make the usual caveat that billings don’t take into account overhead costs, and psychiatry is a relatively low-overhead specialty with little need to invest in equipment and staff, depending on how one practices (paper charts, no secretary, only doing psychotherapy for a small population – keeps costs down). But, in any case, most people would probably not try to argue that psychiatry stands out among medical specialties for high earning potential.

Recent developments have actually made the income gap worse. In arbitration with the Ontario government, physicians were awarded an across-the-board return of “redress monies” during arbitration with the provincial government (i.e. the across-the-board cuts unilaterally imposed by the previous Liberal government were reversed). This is a flat-rate percentage that applies to all specialties. That means the higher-billing specialties get back a higher dollar amount than the lowest-paid specialties. Comparing psychiatry to ophthalmology, the difference in the average increase is $20,998 according to the OMA section on psychiatry. That’s about enough money to pay for all of my secretary needs for a year, or my office rent.

My opinion (and I don’t have data to back this up) is that when you see a psychiatrist, the person sitting across from you is there for one of two reasons – 1) they love the profession and they couldn’t really see themselves doing anything else, or 2) they couldn’t match to the specialty of their choice and they ended up in psychiatry as a back-up profession. I doubt they did it for the money, though. Now, in this line of work we want people to do it because they love it. However, there may be bright young people who thought about it, and then considered the fact that if they went into psychiatry, they likely (now) would not be able to afford to buy a house in the city where they trained (Toronto is the largest training program in Canada, if not the largest in North America). If there was another specialty they also were considering, other factors being equal, they would probably opt for more money. 

The money factor doesn’t make it easier to recruit people into this profession. The overall average billings are only part of the picture, when it comes to money, however. In order to understand how we got where we are now, we also need to look at another important monetary factor that influences psychiatrist behaviour – the fee structure – and that’s a topic for another post. 

Office move (again) & Why do you move so often?

This month I left the ADHD Clinic to focus on my work at the Asian Clinic at Hong Fook and for Sioux Lookout First Nations Health Authorities. I will also be winding down my private practice slowly over time, but will continue to see existing patients who are in the middle of treatment. The office space I am using is at 2238 Dundas St. W. Suite 306, south of Dundas West subway station (turn right when you get out of the station, and it is the building after the Pizza Nova).

FAQ: Why do you move offices so often?

A: After my time at the Sherbourne office (2 offices ago, now) I learned that sharing resources with the right people is important to be able to create an effective synergy. Moving around has been part of an effort to find the places and the people who are the best fit at that point in time. My needs and clinical interests have also changed over time (student health, then ADHD and neurodevelopmental conditions, and now psychological trauma), hence the changes in location. I have found that keeping mobile helps to strike a balance between being able to change settings to pursue my interests and and maintaining continuity of care so I can follow patients who require long-term treatment.

Buddhism and Psychiatry Fellowship

It’s official… I jumped through all of the registration hoops and I am back at U of T for a clinical fellowship in Buddhism and Psychiatry.

I attended the orientation session for Clinical Fellows last week. I wasn’t sure what I would get out of it but came away with the insight that there are so many people who know more than I do about particular things, so if we collaborate more we will be more productive. This was in the context of publishing more papers (it’s U of T, after all) but I think it applies to many things in my life.

When I look back on things I wrote about 1 or 2 years ago, a lot of it had to do with running an office and DIY electronic medical records. Having been there and done that I would say in retrospect that it makes more sense for me to let someone else do that so I can focus on other things. It really isn’t efficient to manage an office and practice medicine at the same time, and even though doing everything yourself may keep more money in your pocket it’s really a drag on quality of life. It’s not really all about maximizing billable hours (that means seeing patients!) either. I found out that a lot of the satisfaction in this work comes from having some quiet time to look up the answer to an interesting question or just look out the window.

Doing the fellowship so far has given me a new appreciation for learning and it has been a good excuse to dig deeper into Buddhist philosophy and psychology than ever before. It is also kind of amazing how being “officially” a clinical fellow seems to give permission to talk to other people and share ideas. Hopefully it will be a good year of collaboration and producing something new and creative. Maybe get a couple of papers published too.

p.s. Not to worry – my private practice is still going. It’s full – but still running.

Are we dinosaurs?

This morning I heard someone speaking on the CBC about the proposed Physician Services Agreement, and this evening I paid for my office insurance for the year and as an aside I worked out my overhead costs – roughly 25% of my billings, not including taxes. It really drove home the current economic reality for physicians. If we agree to the new PSA all previous cuts from government unilateral action will stay, and doctors’ fees will be funded at a level that is expected to keep up with growth in demand for service. We’re not going to be making more money, and between cuts and inflation our actual income is going down.

It occurred to me that it would cost me less in overhead to treat fewer patients. If I didn’t take new patients I wouldn’t have to have a website so they could find me. I wouldn’t have to handle as many phone calls or deal with as many scheduling issues so I wouldn’t have to hire staff. I could rent part of an office by the day, and not buy furniture. I might not have to keep an electronic medical record, and if I didn’t have that, I wouldn’t have to have electronic fax service either. If I didn’t have electronic systems I could probably get away without paying insurance against Cyber security disruptions. Provided I could still fill my schedule, I could bill the same amounts as I do now. Sadly, given the demand for psychiatric services, one could probably make this work fairly easily.

Supposing that money follows creation of value, you would think it doesn’t make sense to try to run a tiny practice and see the same bunch therapy patients every week. Publicly funded health insurance is a strange market-distorting effect, though, such that running a small therapy practice might actually do better financially than running a more complex one with more patients.

Here’s another thing to consider, though – in the next few years, the funding agreements are likely to change. Someone once told me that people who do the kind of work I do in private practice are on the way out, and I told her we would change when the funding model changed. Looking back, maybe we were both right. One psychiatrist treating one patient is turning into a luxury that we cannot afford as a society with massive government debt, an aging population to look after, and an economy propped up by a massive housing bubble. It probably would not be wise to put more money into services that only benefit a handful of people even at the best of times. Whether we like it or not we are most likely moving into an era of one-off consultations, group-based treatment, and possibly even hard caps on the number of individual visits per year. As much as I like individual therapy, these are probably changes that need to happen, so that there won’t be a financial incentive to shrink instead of grow. Throwing more money into a process that doesn’t work efficiently probably isn’t good in the long run. Being in a city the size of Toronto and still struggling to be seen by a psychiatrist is a sign that something isn’t right. I think we should still do individual visits – there is a place for that – but they should be a lot more precious. Another possible benefit (questionable benefit to the doctors affected, maybe) of the squeeze on the solo practitioner is that it might drive more psychiatrists out of the big cities, especially where the cost of doing business is very high. This might just improve access across the province.

I don’t really like reading what I’m writing. I love coming into my office and handing things off to my secretary, who I don’t have to share with anybody, and seeing my patients, some of whom I’ve gotten to know over a number of years. I have a view from my office of a tree-lined street and the pace is relatively relaxed. At what point will this hobby become too expensive to maintain, and talking about “my patients” is a thing of the past? It’s hard to say, but it does feel strange to think of oneself as possibly one of the last of a group that may soon disappear. I like to think that we can find a way to adapt – become more efficient and effective, and be compensated for doing it. With another opportunity to negotiate with the government, now may be our chance.

Improving email efficiency – ONE-Mail on desktop

For the doctors using ONE-Mail, the Ontario government’s secure email service, it is now possible to connect to your ONE-Mail service using desktop software (MS Outlook or Apple Mail). Instructions are here. They are simple and take 5-10 minutes to implement.

I am not sure how long it has been possible to do this but I’m sure these instructions weren’t available when I first signed up for ONE-Mail. I think it does introduce a possible security concern whereby downloaded email messages could be compromised; therefore it is advisable to use hard drive encryption. In terms of the risk of email being inadvertently forwarded or replying with the wrong email address, I believe it may be slightly higher than when using a webmail app because one could be accessing work and personal email from the same software.

In any case, I have found that it does make the email much more usable as it decreases the time spent reading and replying to messages, and it facilitates good email hygiene (checking messages daily, early in the day). The ability to quickly manipulate (trash, archive, reply) an email message also allows for an “inbox zero” strategy to be implemented whereby emails are cleared, filed, or acted upon immediately rather than allowed to accumulate.

A counter-argument to downloading messages introducing a security vulnerability is that avoiding the secure email address because it is too cumbersome to access the webmail app then could lead to use of personal email addresses for office-related communication. In that case, there is no point having a secure work email address if you don’t use it.

I continue to encourage patients to call instead of send emails as email is inherently insecure regardless of what server is being used. However, when email must be used and precautions are taken to avoid including personal health information it may be a valuable practice management tool.

Advocacy work

Last month CityTV covered some grassroots advocacy work that Dr. Yusra Ahmad, a psychiatrist friend and colleague organized. I find it inspiring that even in this economic climate physicians are still taking time to volunteer and do the work that needs to be done.

There was an article in the Toronto Star covering the event as well. In my mind, this kind of work makes a strong statement – to the physician who volunteers his or her time for anything, the cause is worth more than the dollars that time would bring if spent in the office, so the rest of us should pay attention.

Getting involved with health care

I wanted to send a quick shout out to my colleague and friend Dr. Anh Tran for putting together a new website with some of our colleagues. You can check it out here at www.carenotcuts.ca. What I like most about the latest round of government cuts is that it got people who would otherwise never have become political to be political. It has made advocates out of people who would otherwise have gone on with life as usual. Threats to health care may give us a better democracy, and for those of us more personally affected, if nothing else we have great motivation right now to reflect on the state of our lives and make moves we never would have made if we weren’t challenged.

OSCAR and survivalists

It has been a bit over a year since I started using OSCAR and coming up on a year that I’ve been with my current OSCAR service provider. I’ve learned a few things along the way that I thought were worth sharing.

The first topic I thought I’d tackle is something I’ll call EMR survivalism, which I believe highlights some important aspects of the psychology of OSCAR. According to Wikipedia, survivalism is “a movement of individuals or groups (called survivalists or preppers) who are actively preparing for emergencies, including possible disruptions in social or political order, on scales from local to international.”

Survivalists

OSCAR users – looking to survive catastrophe? Photo from nytimes.com

I have noticed this kind of survivalist mentality can to be one factor that draws people to OSCAR. From my perspective (and please note I’m not trying to paint all OSCAR users with the same brush, here), the prototypical OSCAR survivalist is an individualistic physician who is looking to maintain control over clinical infrastructure and patient records – in essence, one who believes that the physician bears ultimate responsibility for the care provided and therefore must also strive to maintain complete control over their clinical infrastructure and patient records. Such an individual may be suspicious of abuses of power by large corporations, inappropriate intrusions into clinical decision-making by administrators, government snooping and surveillance, and potentially preventable disasters / outages that disrupt clinical work. From the perspective of a survivalist, OSCAR seems very attractive – allowing one to maintain control over patient data and to prepare for the worst – power outages, networks going down, hardware failure, theft, EMR provider failure – at least in theory.

Does it actually work that way in practice? My best answer so far: sort of.

Does the average physician with some inclination to learn about computers know enough to effectively maintain server hardware, set up a secure network, and monitor for intrusions? I suspect not – at least not as much as a specialist would know. Also, it’s ongoing maintenance and a mental diversion that takes us away from doing what we’re good at (and what brings in the money) – looking after patients.

Is it cost-effective for the average physician or small clinic to retain in-house IT support? I would say no.

Does the average physician have access to the infrastructure needed to maintain EMR functionality in the face of unanticipated disruptions – redundant and separate internet connections with sufficiently high upload speeds, independent power supplies, ready access to replacement components in case of hardware failure, backup server with automatic switchover in case of primary server failure? Possibly, but it’s not very efficient to set all of that up for one individual system. It would probably be much more cost-effective (and environmentally friendly) to pool resources and share server space in a dedicated, secure server facility – in other words, a cloud solution.

So, why go through all the trouble of setting up an in-house OSCAR solution at all? I believe it’s the same reason why people buy farmland in the country, stockpile supplies, and build bunkers. My hypothesis is that the kind of people who worry about a zombie outbreak, nuclear attack, and foreign invasion are similar, in ways, to a subset of the people who use OSCAR.

Fallout shelter

Are OSCAR users the kind of physicians who would build a place like this? Image from spiritmeetsbone.me

There are arguments for and against this way of living; in the event that nothing happens, it seems more efficient not to worry and trust in the people in charge. In the event of catastrophic failure in social order, though, the people with canned goods, medical supplies, and ammunition lining their basements look like they had a good idea. I suppose that whether or not it was “the right thing” to set up your own OSCAR server looks different depending on whether you’ve had years of reliable service from an EMR provider or you bought into a lemon and the company went belly-up or just didn’t pick up their phone when you needed them, leaving you stranded.

Is there a third way? I think there might be – and it comes down to trust and cooperation. In the event of a world-ending scenario I’m inclined to think that the people who prepare but also cooperate with others stand the best chance of doing well. Blind trust and obstinate self-sufficiency are two extremes, and let’s face it – not everybody is going to have a country estate with a bomb shelter to fall back to. So, too, with OSCAR – by sharing resources, hardware, and infrastructure, individual physicians could have access to more reliable EMR service with lower overhead and possibly better security and maintenance expertise, without needing to put the keys in the hands of institutions or companies that may or may not come through. I’m talking about a co-op situation – physicians pooling their resources to run their own OSP (Oscar Service Provider), hire support staff, and put together a server farm. At the end of the day we are responsible for the work we do and the people we hire, so I think we need to know at least something about the computer systems we use, as well. However, we don’t have to do it alone.

As far as I know, the OSCAR co-op doesn’t exist yet. So for now, unless a doctor can do everything independently, the next best option is to find an OSP they trust, and for the extra-paranoid among us, keep a backup system handy.

Practice update

My secretary, An, will be away until January 24. In the meantime, I will be handling my phone and fax machine (just like old times!) If you call the office it is likely that nobody will pick up, but please leave a message and I will endeavor to return your call promptly. I will be able to access my messages on weekdays even when I am not in the office.

An used to give appointment reminders by phone – I will not be able to do this while she is away. Automated email appointment reminders are high on the priority list but I have not gotten there yet – still working on getting electronic fax capabilities for consultation reports and switching to OSCAR-based billing, behind the scenes.

The office will also not be accepting new referrals for the first few months of 2015, to allow me to work through the waiting list, which is already several months long.

Thanks, and happy New Year to everyone.