The old reality for many psychiatrists was a private practice filled with long-term patients who paid $100 or more for 50 minutes of talk. The new reality? Managing medication for up to 30 new patients a week for half the hourly fee—and answering to case managers who aren't even doctors.
No wonder the number of U.S. medical school graduates in psychiatric residencies dropped nearly 12%—to 3909 from 4447—between 1988 and 1994.
The blame—or the credit—goes to managed care, the catchall term for the revolution that has swept through both the medical and mental health care fields in recent years. Desperate to cut runaway health insurance costs, most companies have axed longstanding fee-for-service plans and instead steer employees seeking psychiatric treatment to health maintenance organizations or specialized managed-care firms.
These organizations decide the type and amount of care patients receive. Psychiatrists have to get with the program—and agree to its treatment plans and fee schedules—or watch the bulk of their practices disappear. Only the rare psychiatrist can attract private patients wealthy enough to pay for traditional psychotherapy without the benefit of insurance.
Health maintenance organizations, fee for service and the care of patients with acute myocardial infarction