On drugs and health insurance

I've written here before about America's seeming love affair with prescription drugs, and how it seems like the interests of our largest pharmaceutical companies seem to have taken precedence over the interests of the public health. This article from the New York Times, published last weekend, demonstrated another element to the problem, describing the role of the insurance companies in the process of determining and dispensing medical care.

Alone with his psychiatrist, the patient confided that his newborn had serious health problems, his distraught wife was screaming at him and he had started drinking again. With his life and second marriage falling apart, the man said he needed help.

But the psychiatrist, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.”

Like many of the nation’s 48,000 psychiatrists, Dr. Levin, in large part because of changes in how much insurance will pay, no longer provides talk therapy, the form of psychiatry popularized by Sigmund Freud that dominated the profession for decades. Instead, he prescribes medication, usually after a brief consultation with each patient. So Dr. Levin sent the man away with a referral to a less costly therapist and a personal crisis unexplored and unresolved.

Medicine is rapidly changing in the United States from a cottage industry to one dominated by large hospital groups and corporations, but the new efficiencies can be accompanied by a telling loss of intimacy between doctors and patients. And no specialty has suffered this loss more profoundly than psychiatry.

The Times article goes on to report that as of 2005, only 11% of psychiatrists provided any kind of talk therapy at all, a figure that has probably declined further in recent years. As mentioned above, the impact of insurance companies is likely to blame.

Recent studies suggest that talk therapy may be as good as or better than drugs in the treatment of depression, but fewer than half of depressed patients now get such therapy compared with the vast majority 20 years ago. Insurance company reimbursement rates and policies that discourage talk therapy are part of the reason. A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session.

Of course, there are thousands of psychiatrists who still offer talk therapy to all their patients, but they care mostly for the worried wealthy who pay in cash. In New York City, for instance, a select group of psychiatrists charge $600 or more per hour to treat investment bankers, and top child psychiatrists charge $2,000 and more for initial evaluations.

That last paragraph is a bit disturbing, and seemingly part of a broader trend. Say what you will about mental health issues, and whether or not psychological disorders have become overdiagnosed--we should all be able to agree that the treatment choices available to us should be determined by our doctor and our own personal preferences, not by the whims of the insurance companies who we are now forced to use as an intermediary.

It's somehow unsurprising that insurance company policies tend to steer us toward the choices that most benefit large pharmaceutical companies. When two large corporations--a pharmaceutical company and an insurance company--get together, do we really expect that an individual's health is the first priority? I certainly don't, and it's a big part of why I believe that solving our health care problems must not rely on insurance companies' determinations of what constitutes proper treatment.

[New York Times]