comscore Reimbursements control mental health services | Honolulu Star-Advertiser
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Reimbursements control mental health services


As a teenager, I recall my father’s passion for his work as a psychiatrist. He was deeply intrigued by the complexity of the human mind and body and pondered the relationship between mood and medication. Fascinated and inspired by the healing that often took place by helping people gain an understanding of their behaviors through a combination of talk therapy and pharmaceuticals when indicated, he integrated the art and science of a physician. I remember that therapy sessions were always 50 minutes because to speak with him during the workday, I would need to call at 10 minutes to the hour.

Sadly, as recently highlighted by The New York Times, it is no longer financially viable for psychiatrists to provide skilled counseling or psychotherapy. Now only a small minority continues to provide this critical service routinely to all patients. The primary driver is medical insurance reimbursement. A psychiatrist earns far more by seeing multiple patients each hour, tending primarily to medication management.

Psychiatrists are physicians who have completed a minimum three-year residency program beyond medical school and internship. Psychologists, on the other hand, do not attend medical school. Instead, they earn doctoral degrees in psychology with a focus either on research or counseling. Though a different educational process, the training is also quite extensive. The mainstay of their practice is talk therapy, for which many are well trained. However, in almost all states they do not have prescriptive rights.

Legislative attempts to give psychologists prescriptive rights have met strong opposition. According to the AMA, "a psychologist’s education and training does not equip them with the ability to prescribe potentially dangerous psychotropic drugs."

Nevertheless, New Mexico approved prescriptive rights for psychologists in 2002, and Louisiana, in 2004. Psychologists also have the ability to prescribe medication in the military and in the Indian Health Service.

A current proposal in Hawaii would require psychologists to earn a master’s degree in clinical psychopharmacology, pass a national examination and meet specific requirements for clinical experience. They would also have to maintain a collaborative agreement with a physician. A bill just passed the state Senate for a pilot study with these parameters and is awaiting consideration by the House.

One of the most common reasons for seeking mental health services is major depression. Lifetime chances for an episode of depression in the United States are, by some estimates, as high as 20 percent. Frequent symptoms include reduced self-esteem, depressed mood, low energy, trouble concentrating, weight changes and sleeping problems. Most professionals agree that patients with major depression of moderate severity improve best with a combination of medication and counseling.

The problem is that in private practice it is uncommon for psychiatrists and psychologists to work together under the same roof. Obviously, if the psychiatrist is only managing medication and the psychologist is doing all of the counseling, the patient is best served by a team approach. Unfortunately, close collaboration can be hard to come by.

As it happens, primary care doctors diagnose and medically treat the majority of cases of major depression in the United States. Sadly, it is even less common for primary care doctors and psychologists to work closely together. In fact, in a primary care setting, depression is still often missed.

One of the goals of the patient-centered medical home, a centerpiece of health care reform, is to close this gap. Optimal management of mental health problems, especially for major depression, requires early diagnosis, medication management and counseling as appropriate in a collaborative setting. If we can heal our health care system, we will all feel better.

Ira Zunin, M.D., M.P.H., M.B.A., is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to


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