Addressing the shortage of psychiatrists: What keeps us from seeing more patients?

Recently I was contacted by a reporter who wanted to speak to me about why it’s so difficult for patients to find a psychiatrist. She’d found me by Googling “Why psychiatrists don’t take insurance” and already had read an article I’d written with that title. That day, it had snowed hard enough that most of my patients had canceled; the grocery store had closed; and I had plenty of time to chat with a reporter. The other thing I noted – perhaps because other psychiatrists had unexpected free time because of the snow – was that Maryland Psychiatric Society’s listserv was getting a lot of posts. The posts focused on issues to do with maintenance of certification (MOC) or with the fact that every physician in the state was now going to be required to have a CME credit on opioid prescribing for licensure renewal, and there would be a requirement for physicians to take a course on substance abuse to renew their CDS registration. The hope is that these courses will reduce deaths caused by narcotic overdose, and the courses would be required for all physicians without regard to whether they are relevant to their practice.

The reporter and I started with a discussion of why so many psychiatrists have chosen not to accept health insurance (myself included). She then told me about an insured man who had been diagnosed with schizophrenia and substance abuse who was unable to get an appointment with a psychiatrist. She asked me an interesting question: “Don’t psychiatrists want the challenge of treating the difficult cases?” The patient in question never did find a psychiatrist in time and he ended up committing a murder then dying by suicide – an awful tragedy that highlights access to care problems.

In addition to a private practice, I have worked in community mental health centers, and I discussed how that setting is often better suited for patients with serious psychiatric illnesses. More services are offered, and having a variety of mental health professionals in the same facility promotes better coordination of care between psychiatrists, therapists, and case managers, as well as with family, residential care providers, and day programs. The problem is that demand for treatment at outpatient clinics is high, and sometimes the waits for an initial appointment are long, or clinics even may stop accepting new patients at times when they get overloaded.

We talked about the logistics and trade-offs of working in a clinic vs. a private practice, and the reasons why working full time in a high-volume clinic might lead physicians to want a change after a few years. And then the reporter asked me another interesting question – with such long waits, why don’t the clinics hire more doctors? I explained that there was a shortage of psychiatrists and began to talk with her about demands on physician time that take time away from patient care. With the e-mails flying about MOC and new course requirements, it was a place to start, but the snow was still falling, and she heard a lot about the factors that drain physician time and money, both limiting how many patients a psychiatrist can see and driving up the cost of care.

By the time I got off the phone, I decided to tally all of the things that we are required to do to see patients. I was able to get some quick help on the listserv, from friends, and on Twitter.

Every time an agency or insurance company sets up a requirement for a physician, there is a small diversion of time. There is no limit on how many different requirements can be set or whether they need to be relevant to the physician’s work. While I realize there is little sympathy for physicians who, for the most part, are still blessed to earn a good living while doing meaningful work, these diversions add hours to a doctor’s day and cause them to burn out more quickly. So the insurance company that demands that a physician devote 20 minutes to get authorization to prescribe a medication that costs pennies a pill is actually harming society. And no one oversees the big picture.

That said, here was the list we came up with of factors that drain time and money in a clinical practice. Please note that some of these items – for example, uncompensated time returning calls to patients or keeping clinical records – are just part of being a doctor; they’re not something that should be eliminated. Similarly, issues related to having a space to work are part of having a business. I wanted the list to be complete to illustrate the demands on a psychiatrist, not to suggest that none of these things are important. Obviously, some doctors are faster or slower at certain tasks, and people vary greatly in how much time they devote to clinical practice vs. teaching, research, or writing articles for Clinical Psychiatry News. I obtained information in a very quick and casual manner; none of this should be construed as scientific.

Here is the list:

• Maintenance of certification requirements and testing. This is required every 10 years and one estimate was that the cost to register, take the test, and purchase review materials came to $2,800, with a time investment of about 50 hours. Some specialties are pushing back against MOC, and some physicians are forgoing board certification. Psychiatrists who subspecialize usually do MOC for general psychiatry and all their subspecialties.

• CME. Twenty to 50 hours per year depending on your state, and presumably physicians choose courses that enrich their ability to practice medicine. This can be expensive, depending on how the physician decides to get these credits, and many valuable learning events do not qualify for CME.

• Writing clinical notes. Again, this is part of routine medical care. Notes must justify the CPT codes on insurance claims, and very specific areas of inquiry and examination are needed to justify billing specific codes. Agency requirements may be different from what is clinically indicated for the care of the patient, and this uses some of the appointment time in a way that may not be helpful to medical care. Copying, faxing, or sending notes to other clinicians and time spent requesting records all add to the mix. One psychiatrist noted that the overall administrative responsibilities for seeing patients takes half an hour for every hour spent with a patient. Others estimated that anywhere from 30 minutes to 2 hours per day are devoted to writing notes, and some mentioned doing this in the evening at home. One child psychiatrist with a large high-volume practice noted that he is required to keep charts until a patient reaches adulthood, and that storing, locating, and shredding charts was a time drain.

• Billing the patient. One private practice psychiatrist estimated this takes approximately 8 hours a month, include record-keeping and rebilling patients who failed to pay. Some psychiatrists have a secretary or billing staff.

• Patient insurance. Time spent preauthorizing care, including time spent to preauthorize hospitalizations or to justify each day of inpatient treatment. (No time estimates were offered.)

• Filing claims. The psychiatrists I spoke with who participate with insurers all had support staff to do this.

• Preauthorizing medications. This was by far the biggest complaint by psychiatrists. One noted that it had taken her 2 hours the night before to get a medication authorized; another had spent an hour that day on it. Another rough figure I got was 20-60 minutes a week, and it was noted that preauthorization often is required for very inexpensive medications. Another psychiatrist said her office manager spends a couple of hours a week on preauthorizations and that she had to give her a raise to get her to agree to do it. Personally, I feel insurance companies should not be permitted to divert physician time away from care for inexpensive medications. Does it really make sense to have a physician spend 20 minutes of uncompensated time getting authorization for a medication that costs $10 a month?

• Paperwork related to being credentialed with insurance companies. This was estimated at 40 minutes every 3 months.

• Credentialing. Cost and paperwork for malpractice insurance varies by state and, some malpractice agencies require doctors to do specific forms of training. In addition, practicing requires renewal of a DEA number, CDS renewal (in Maryland), and state licensure.

• Electronic medical records (EMR). Medicare has provided financial incentives to doctors for the meaningful use of certified electronic health record (EHR) technology to improve patient care and now penalizes doctors who do not have this technology. One psychiatrist told me that she spent hundreds of hours working on this, but something went wrong so she is still penalized. Another said she spent 3 hours in a 3-month period attesting to her compliance with meaningful use. Everyone I spoke to said using an electronic record – related to Medicare’s meaningful use or not – increased the time it takes them to write notes. One psychiatrist reduced her clinical care to 1 day a week, and I left a community clinic when the effort of learning to use EPIC overwhelmed me.

• E-prescribing. One colleague in New York wrote, “E-prescribing takes up a lot of time, especially since I don’t do it during sessions. For a noncontrolled medication, it’s maybe 4-5 minutes per prescription. For controlled, it’s 3-4 minutes more, because I have to check I-STOP and use the token, and then record the I-STOP number. And for all prescriptions, I hand write an entry in the medication record, just for backup.” She noted it took several hours to set up the system. Most psychiatrists still spend significant time calling in prescriptions that patients have forgotten to request during appointments, and pharmacists often call to have refills authorized. This can be quite time consuming, and sometimes refills are requested automatically for medications the patients no longer take, and time spent on hold can be significant. My own experience was that e-prescribing took significantly longer than paper prescribing, and that handing a patient a prescription during a session is simply part of medical care and not a “drain,” per se.

• Secretarial. No one was able to give me an estimate of how many hours per week were spent directing, managing, and training support staff, or of how many hours this freed up to see patients. One psychiatrist in a large practice noted that they have 32 full- and part-time professions, including 3 psychiatrists; they participate with insurance, and this requires 18 full-time support staff.

• Office-related issues. Rent – this is both taste and geographically driven, and there are several ways to come by office space. Other factors are time related to restocking supplies, furnishings, technological hardware, phones, faxes, pagers, mobile lines, postage, technology support, cleaning, and assorted office-related issues. I have no time estimates on this; some people have support staff who do most of it, and again, this is part of the routine practice of having a business. It takes time, but it’s not irrelevant. Also, time is spent keeping an office both OSHA and HIPAA compliant.

• Hospital/agency-related requirements:

– Risk management seminars.

– CPR training.

– Health maintenance (required TB testing and flu shot).

• Required learning modules. When I worked 4 hours a week at a hospital clinic, there were many requirements. I watched modules on how to use elevators in buildings I never entered, how to place a central line, hand-washing and infection control, and how to store chemicals I never used. I believe that Maryland state employees may be required to have training in trauma-informed-care.

• Uncompensated time returning calls/communications to patients, families, other clinicians, and prospective patients who then decide not to come in, as well as filling out paperwork for disability claims, other agencies, and writing letters for patients. While this also is part of routine medical care, several people mentioned that other professionals can bill for this work and that insurers can force unnecessary care because only face-to-face treatment gets reimbursed, so issues that might be resolved on the phone or by telepsychiatry then require an office visit.

One colleague was kind enough to examine her own full-time practice and sum up her activities. She came up with an estimate that she devoted 40 hours per month to administrative issues that divert time from seeing patients. This did not include the time she recently devoted to MOC.

Obviously, I want to make the point that part of the psychiatrist shortage is related to the fact that there are administrative demands – many that don’t improve clinical care – that decrease the number of patients we can see and increase the cost of care. In addition to the weekly toll, many of these time drains are frustrating, and serve as disincentives to seeing patients with what time is available. The statistics prove that psychiatrists are less willing than other specialists to participate with insurance networks, and I suspect the litany of clinically irrelevant requirements may lead to earlier retirement by people who might otherwise be willing to practice for more years.

One might ask, at what point do we fight back against spending our time meeting the agendas of agencies and insurers when they aren’t relevant to the care that is needed to help patients?

With thanks to Dr. Mahmood Jarhomi, Dr. Patricia Sullivan, Dr. Sue Kim, Dr. Laura Gaffney, Dr. Maria Yang, Dr. Marsden McGuire, Dr. Annette Hanson, Dr. Robert Herman, Dr. Kimberly Hogan Pesaniello, Dr. Peter Kahn, Dr. Mark Komrad, Dr. Susan Molchan, Dr. Suzy Nashed, and Dr. Rebecca Twersky-Kengmana.

Dr. Miller is coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University Press, 2011).

Recently I was contacted by a reporter who wanted to speak to me about why it’s so difficult for patients to find a psychiatrist. She’d found me by Googling “Why psychiatrists don’t take insurance” and already had read an article I’d written with that title. That day, it had snowed hard enough that most of my patients had canceled; the grocery store had closed; and I had plenty of time to chat with a reporter. The other thing I noted – perhaps because other psychiatrists had unexpected free time because of the snow – was that Maryland Psychiatric Society’s listserv was getting a lot of posts. The posts focused on issues to do with maintenance of certification (MOC) or with the fact that every physician in the state was now going to be required to have a CME credit on opioid prescribing for licensure renewal, and there would be a requirement for physicians to take a course on substance abuse to renew their CDS registration. The hope is that these courses will reduce deaths caused by narcotic overdose, and the courses would be required for all physicians without regard to whether they are relevant to their practice.

The reporter and I started with a discussion of why so many psychiatrists have chosen not to accept health insurance (myself included). She then told me about an insured man who had been diagnosed with schizophrenia and substance abuse who was unable to get an appointment with a psychiatrist. She asked me an interesting question: “Don’t psychiatrists want the challenge of treating the difficult cases?” The patient in question never did find a psychiatrist in time and he ended up committing a murder then dying by suicide – an awful tragedy that highlights access to care problems.

In addition to a private practice, I have worked in community mental health centers, and I discussed how that setting is often better suited for patients with serious psychiatric illnesses. More services are offered, and having a variety of mental health professionals in the same facility promotes better coordination of care between psychiatrists, therapists, and case managers, as well as with family, residential care providers, and day programs. The problem is that demand for treatment at outpatient clinics is high, and sometimes the waits for an initial appointment are long, or clinics even may stop accepting new patients at times when they get overloaded.

We talked about the logistics and trade-offs of working in a clinic vs. a private practice, and the reasons why working full time in a high-volume clinic might lead physicians to want a change after a few years. And then the reporter asked me another interesting question – with such long waits, why don’t the clinics hire more doctors? I explained that there was a shortage of psychiatrists and began to talk with her about demands on physician time that take time away from patient care. With the e-mails flying about MOC and new course requirements, it was a place to start, but the snow was still falling, and she heard a lot about the factors that drain physician time and money, both limiting how many patients a psychiatrist can see and driving up the cost of care.

By the time I got off the phone, I decided to tally all of the things that we are required to do to see patients. I was able to get some quick help on the listserv, from friends, and on Twitter.

Every time an agency or insurance company sets up a requirement for a physician, there is a small diversion of time. There is no limit on how many different requirements can be set or whether they need to be relevant to the physician’s work. While I realize there is little sympathy for physicians who, for the most part, are still blessed to earn a good living while doing meaningful work, these diversions add hours to a doctor’s day and cause them to burn out more quickly. So the insurance company that demands that a physician devote 20 minutes to get authorization to prescribe a medication that costs pennies a pill is actually harming society. And no one oversees the big picture.

That said, here was the list we came up with of factors that drain time and money in a clinical practice. Please note that some of these items – for example, uncompensated time returning calls to patients or keeping clinical records – are just part of being a doctor; they’re not something that should be eliminated. Similarly, issues related to having a space to work are part of having a business. I wanted the list to be complete to illustrate the demands on a psychiatrist, not to suggest that none of these things are important. Obviously, some doctors are faster or slower at certain tasks, and people vary greatly in how much time they devote to clinical practice vs. teaching, research, or writing articles for Clinical Psychiatry News. I obtained information in a very quick and casual manner; none of this should be construed as scientific.

Here is the list:

• Maintenance of certification requirements and testing. This is required every 10 years and one estimate was that the cost to register, take the test, and purchase review materials came to $2,800, with a time investment of about 50 hours. Some specialties are pushing back against MOC, and some physicians are forgoing board certification. Psychiatrists who subspecialize usually do MOC for general psychiatry and all their subspecialties.

• CME. Twenty to 50 hours per year depending on your state, and presumably physicians choose courses that enrich their ability to practice medicine. This can be expensive, depending on how the physician decides to get these credits, and many valuable learning events do not qualify for CME.

• Writing clinical notes. Again, this is part of routine medical care. Notes must justify the CPT codes on insurance claims, and very specific areas of inquiry and examination are needed to justify billing specific codes. Agency requirements may be different from what is clinically indicated for the care of the patient, and this uses some of the appointment time in a way that may not be helpful to medical care. Copying, faxing, or sending notes to other clinicians and time spent requesting records all add to the mix. One psychiatrist noted that the overall administrative responsibilities for seeing patients takes half an hour for every hour spent with a patient. Others estimated that anywhere from 30 minutes to 2 hours per day are devoted to writing notes, and some mentioned doing this in the evening at home. One child psychiatrist with a large high-volume practice noted that he is required to keep charts until a patient reaches adulthood, and that storing, locating, and shredding charts was a time drain.

• Billing the patient. One private practice psychiatrist estimated this takes approximately 8 hours a month, include record-keeping and rebilling patients who failed to pay. Some psychiatrists have a secretary or billing staff.

• Patient insurance. Time spent preauthorizing care, including time spent to preauthorize hospitalizations or to justify each day of inpatient treatment. (No time estimates were offered.)

• Filing claims. The psychiatrists I spoke with who participate with insurers all had support staff to do this.

• Preauthorizing medications. This was by far the biggest complaint by psychiatrists. One noted that it had taken her 2 hours the night before to get a medication authorized; another had spent an hour that day on it. Another rough figure I got was 20-60 minutes a week, and it was noted that preauthorization often is required for very inexpensive medications. Another psychiatrist said her office manager spends a couple of hours a week on preauthorizations and that she had to give her a raise to get her to agree to do it. Personally, I feel insurance companies should not be permitted to divert physician time away from care for inexpensive medications. Does it really make sense to have a physician spend 20 minutes of uncompensated time getting authorization for a medication that costs $10 a month?

• Paperwork related to being credentialed with insurance companies. This was estimated at 40 minutes every 3 months.

• Credentialing. Cost and paperwork for malpractice insurance varies by state and, some malpractice agencies require doctors to do specific forms of training. In addition, practicing requires renewal of a DEA number, CDS renewal (in Maryland), and state licensure.

• Electronic medical records (EMR). Medicare has provided financial incentives to doctors for the meaningful use of certified electronic health record (EHR) technology to improve patient care and now penalizes doctors who do not have this technology. One psychiatrist told me that she spent hundreds of hours working on this, but something went wrong so she is still penalized. Another said she spent 3 hours in a 3-month period attesting to her compliance with meaningful use. Everyone I spoke to said using an electronic record – related to Medicare’s meaningful use or not – increased the time it takes them to write notes. One psychiatrist reduced her clinical care to 1 day a week, and I left a community clinic when the effort of learning to use EPIC overwhelmed me.

• E-prescribing. One colleague in New York wrote, “E-prescribing takes up a lot of time, especially since I don’t do it during sessions. For a noncontrolled medication, it’s maybe 4-5 minutes per prescription. For controlled, it’s 3-4 minutes more, because I have to check I-STOP and use the token, and then record the I-STOP number. And for all prescriptions, I hand write an entry in the medication record, just for backup.” She noted it took several hours to set up the system. Most psychiatrists still spend significant time calling in prescriptions that patients have forgotten to request during appointments, and pharmacists often call to have refills authorized. This can be quite time consuming, and sometimes refills are requested automatically for medications the patients no longer take, and time spent on hold can be significant. My own experience was that e-prescribing took significantly longer than paper prescribing, and that handing a patient a prescription during a session is simply part of medical care and not a “drain,” per se.

• Secretarial. No one was able to give me an estimate of how many hours per week were spent directing, managing, and training support staff, or of how many hours this freed up to see patients. One psychiatrist in a large practice noted that they have 32 full- and part-time professions, including 3 psychiatrists; they participate with insurance, and this requires 18 full-time support staff.

• Office-related issues. Rent – this is both taste and geographically driven, and there are several ways to come by office space. Other factors are time related to restocking supplies, furnishings, technological hardware, phones, faxes, pagers, mobile lines, postage, technology support, cleaning, and assorted office-related issues. I have no time estimates on this; some people have support staff who do most of it, and again, this is part of the routine practice of having a business. It takes time, but it’s not irrelevant. Also, time is spent keeping an office both OSHA and HIPAA compliant.

• Hospital/agency-related requirements:

– Risk management seminars.

– CPR training.

– Health maintenance (required TB testing and flu shot).

• Required learning modules. When I worked 4 hours a week at a hospital clinic, there were many requirements. I watched modules on how to use elevators in buildings I never entered, how to place a central line, hand-washing and infection control, and how to store chemicals I never used. I believe that Maryland state employees may be required to have training in trauma-informed-care.

• Uncompensated time returning calls/communications to patients, families, other clinicians, and prospective patients who then decide not to come in, as well as filling out paperwork for disability claims, other agencies, and writing letters for patients. While this also is part of routine medical care, several people mentioned that other professionals can bill for this work and that insurers can force unnecessary care because only face-to-face treatment gets reimbursed, so issues that might be resolved on the phone or by telepsychiatry then require an office visit.

One colleague was kind enough to examine her own full-time practice and sum up her activities. She came up with an estimate that she devoted 40 hours per month to administrative issues that divert time from seeing patients. This did not include the time she recently devoted to MOC.

Obviously, I want to make the point that part of the psychiatrist shortage is related to the fact that there are administrative demands – many that don’t improve clinical care – that decrease the number of patients we can see and increase the cost of care. In addition to the weekly toll, many of these time drains are frustrating, and serve as disincentives to seeing patients with what time is available. The statistics prove that psychiatrists are less willing than other specialists to participate with insurance networks, and I suspect the litany of clinically irrelevant requirements may lead to earlier retirement by people who might otherwise be willing to practice for more years.

One might ask, at what point do we fight back against spending our time meeting the agendas of agencies and insurers when they aren’t relevant to the care that is needed to help patients?

With thanks to Dr. Mahmood Jarhomi, Dr. Patricia Sullivan, Dr. Sue Kim, Dr. Laura Gaffney, Dr. Maria Yang, Dr. Marsden McGuire, Dr. Annette Hanson, Dr. Robert Herman, Dr. Kimberly Hogan Pesaniello, Dr. Peter Kahn, Dr. Mark Komrad, Dr. Susan Molchan, Dr. Suzy Nashed, and Dr. Rebecca Twersky-Kengmana.

Dr. Miller is coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University Press, 2011).

Recently I was contacted by a reporter who wanted to speak to me about why it’s so difficult for patients to find a psychiatrist. She’d found me by Googling “Why psychiatrists don’t take insurance” and already had read an article I’d written with that title. That day, it had snowed hard enough that most of my patients had canceled; the grocery store had closed; and I had plenty of time to chat with a reporter. The other thing I noted – perhaps because other psychiatrists had unexpected free time because of the snow – was that Maryland Psychiatric Society’s listserv was getting a lot of posts. The posts focused on issues to do with maintenance of certification (MOC) or with the fact that every physician in the state was now going to be required to have a CME credit on opioid prescribing for licensure renewal, and there would be a requirement for physicians to take a course on substance abuse to renew their CDS registration. The hope is that these courses will reduce deaths caused by narcotic overdose, and the courses would be required for all physicians without regard to whether they are relevant to their practice.

The reporter and I started with a discussion of why so many psychiatrists have chosen not to accept health insurance (myself included). She then told me about an insured man who had been diagnosed with schizophrenia and substance abuse who was unable to get an appointment with a psychiatrist. She asked me an interesting question: “Don’t psychiatrists want the challenge of treating the difficult cases?” The patient in question never did find a psychiatrist in time and he ended up committing a murder then dying by suicide – an awful tragedy that highlights access to care problems.

In addition to a private practice, I have worked in community mental health centers, and I discussed how that setting is often better suited for patients with serious psychiatric illnesses. More services are offered, and having a variety of mental health professionals in the same facility promotes better coordination of care between psychiatrists, therapists, and case managers, as well as with family, residential care providers, and day programs. The problem is that demand for treatment at outpatient clinics is high, and sometimes the waits for an initial appointment are long, or clinics even may stop accepting new patients at times when they get overloaded.

We talked about the logistics and trade-offs of working in a clinic vs. a private practice, and the reasons why working full time in a high-volume clinic might lead physicians to want a change after a few years. And then the reporter asked me another interesting question – with such long waits, why don’t the clinics hire more doctors? I explained that there was a shortage of psychiatrists and began to talk with her about demands on physician time that take time away from patient care. With the e-mails flying about MOC and new course requirements, it was a place to start, but the snow was still falling, and she heard a lot about the factors that drain physician time and money, both limiting how many patients a psychiatrist can see and driving up the cost of care.

By the time I got off the phone, I decided to tally all of the things that we are required to do to see patients. I was able to get some quick help on the listserv, from friends, and on Twitter.

Every time an agency or insurance company sets up a requirement for a physician, there is a small diversion of time. There is no limit on how many different requirements can be set or whether they need to be relevant to the physician’s work. While I realize there is little sympathy for physicians who, for the most part, are still blessed to earn a good living while doing meaningful work, these diversions add hours to a doctor’s day and cause them to burn out more quickly. So the insurance company that demands that a physician devote 20 minutes to get authorization to prescribe a medication that costs pennies a pill is actually harming society. And no one oversees the big picture.

That said, here was the list we came up with of factors that drain time and money in a clinical practice. Please note that some of these items – for example, uncompensated time returning calls to patients or keeping clinical records – are just part of being a doctor; they’re not something that should be eliminated. Similarly, issues related to having a space to work are part of having a business. I wanted the list to be complete to illustrate the demands on a psychiatrist, not to suggest that none of these things are important. Obviously, some doctors are faster or slower at certain tasks, and people vary greatly in how much time they devote to clinical practice vs. teaching, research, or writing articles for Clinical Psychiatry News. I obtained information in a very quick and casual manner; none of this should be construed as scientific.

Here is the list:

• Maintenance of certification requirements and testing. This is required every 10 years and one estimate was that the cost to register, take the test, and purchase review materials came to $2,800, with a time investment of about 50 hours. Some specialties are pushing back against MOC, and some physicians are forgoing board certification. Psychiatrists who subspecialize usually do MOC for general psychiatry and all their subspecialties.

• CME. Twenty to 50 hours per year depending on your state, and presumably physicians choose courses that enrich their ability to practice medicine. This can be expensive, depending on how the physician decides to get these credits, and many valuable learning events do not qualify for CME.

• Writing clinical notes. Again, this is part of routine medical care. Notes must justify the CPT codes on insurance claims, and very specific areas of inquiry and examination are needed to justify billing specific codes. Agency requirements may be different from what is clinically indicated for the care of the patient, and this uses some of the appointment time in a way that may not be helpful to medical care. Copying, faxing, or sending notes to other clinicians and time spent requesting records all add to the mix. One psychiatrist noted that the overall administrative responsibilities for seeing patients takes half an hour for every hour spent with a patient. Others estimated that anywhere from 30 minutes to 2 hours per day are devoted to writing notes, and some mentioned doing this in the evening at home. One child psychiatrist with a large high-volume practice noted that he is required to keep charts until a patient reaches adulthood, and that storing, locating, and shredding charts was a time drain.

• Billing the patient. One private practice psychiatrist estimated this takes approximately 8 hours a month, include record-keeping and rebilling patients who failed to pay. Some psychiatrists have a secretary or billing staff.

• Patient insurance. Time spent preauthorizing care, including time spent to preauthorize hospitalizations or to justify each day of inpatient treatment. (No time estimates were offered.)

• Filing claims. The psychiatrists I spoke with who participate with insurers all had support staff to do this.

• Preauthorizing medications. This was by far the biggest complaint by psychiatrists. One noted that it had taken her 2 hours the night before to get a medication authorized; another had spent an hour that day on it. Another rough figure I got was 20-60 minutes a week, and it was noted that preauthorization often is required for very inexpensive medications. Another psychiatrist said her office manager spends a couple of hours a week on preauthorizations and that she had to give her a raise to get her to agree to do it. Personally, I feel insurance companies should not be permitted to divert physician time away from care for inexpensive medications. Does it really make sense to have a physician spend 20 minutes of uncompensated time getting authorization for a medication that costs $10 a month?

• Paperwork related to being credentialed with insurance companies. This was estimated at 40 minutes every 3 months.

• Credentialing. Cost and paperwork for malpractice insurance varies by state and, some malpractice agencies require doctors to do specific forms of training. In addition, practicing requires renewal of a DEA number, CDS renewal (in Maryland), and state licensure.

• Electronic medical records (EMR). Medicare has provided financial incentives to doctors for the meaningful use of certified electronic health record (EHR) technology to improve patient care and now penalizes doctors who do not have this technology. One psychiatrist told me that she spent hundreds of hours working on this, but something went wrong so she is still penalized. Another said she spent 3 hours in a 3-month period attesting to her compliance with meaningful use. Everyone I spoke to said using an electronic record – related to Medicare’s meaningful use or not – increased the time it takes them to write notes. One psychiatrist reduced her clinical care to 1 day a week, and I left a community clinic when the effort of learning to use EPIC overwhelmed me.

• E-prescribing. One colleague in New York wrote, “E-prescribing takes up a lot of time, especially since I don’t do it during sessions. For a noncontrolled medication, it’s maybe 4-5 minutes per prescription. For controlled, it’s 3-4 minutes more, because I have to check I-STOP and use the token, and then record the I-STOP number. And for all prescriptions, I hand write an entry in the medication record, just for backup.” She noted it took several hours to set up the system. Most psychiatrists still spend significant time calling in prescriptions that patients have forgotten to request during appointments, and pharmacists often call to have refills authorized. This can be quite time consuming, and sometimes refills are requested automatically for medications the patients no longer take, and time spent on hold can be significant. My own experience was that e-prescribing took significantly longer than paper prescribing, and that handing a patient a prescription during a session is simply part of medical care and not a “drain,” per se.

• Secretarial. No one was able to give me an estimate of how many hours per week were spent directing, managing, and training support staff, or of how many hours this freed up to see patients. One psychiatrist in a large practice noted that they have 32 full- and part-time professions, including 3 psychiatrists; they participate with insurance, and this requires 18 full-time support staff.

• Office-related issues. Rent – this is both taste and geographically driven, and there are several ways to come by office space. Other factors are time related to restocking supplies, furnishings, technological hardware, phones, faxes, pagers, mobile lines, postage, technology support, cleaning, and assorted office-related issues. I have no time estimates on this; some people have support staff who do most of it, and again, this is part of the routine practice of having a business. It takes time, but it’s not irrelevant. Also, time is spent keeping an office both OSHA and HIPAA compliant.

• Hospital/agency-related requirements:

– Risk management seminars.

– CPR training.

– Health maintenance (required TB testing and flu shot).

• Required learning modules. When I worked 4 hours a week at a hospital clinic, there were many requirements. I watched modules on how to use elevators in buildings I never entered, how to place a central line, hand-washing and infection control, and how to store chemicals I never used. I believe that Maryland state employees may be required to have training in trauma-informed-care.

• Uncompensated time returning calls/communications to patients, families, other clinicians, and prospective patients who then decide not to come in, as well as filling out paperwork for disability claims, other agencies, and writing letters for patients. While this also is part of routine medical care, several people mentioned that other professionals can bill for this work and that insurers can force unnecessary care because only face-to-face treatment gets reimbursed, so issues that might be resolved on the phone or by telepsychiatry then require an office visit.

One colleague was kind enough to examine her own full-time practice and sum up her activities. She came up with an estimate that she devoted 40 hours per month to administrative issues that divert time from seeing patients. This did not include the time she recently devoted to MOC.

Obviously, I want to make the point that part of the psychiatrist shortage is related to the fact that there are administrative demands – many that don’t improve clinical care – that decrease the number of patients we can see and increase the cost of care. In addition to the weekly toll, many of these time drains are frustrating, and serve as disincentives to seeing patients with what time is available. The statistics prove that psychiatrists are less willing than other specialists to participate with insurance networks, and I suspect the litany of clinically irrelevant requirements may lead to earlier retirement by people who might otherwise be willing to practice for more years.

One might ask, at what point do we fight back against spending our time meeting the agendas of agencies and insurers when they aren’t relevant to the care that is needed to help patients?

With thanks to Dr. Mahmood Jarhomi, Dr. Patricia Sullivan, Dr. Sue Kim, Dr. Laura Gaffney, Dr. Maria Yang, Dr. Marsden McGuire, Dr. Annette Hanson, Dr. Robert Herman, Dr. Kimberly Hogan Pesaniello, Dr. Peter Kahn, Dr. Mark Komrad, Dr. Susan Molchan, Dr. Suzy Nashed, and Dr. Rebecca Twersky-Kengmana.

Dr. Miller is coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University Press, 2011).