Regulating the Practice of Psychiatry


Experts in the field of psychiatry discuss the differences between other specialties and psychiatry as well as the inconsistency within psychiatry itself.

Peter Salgo, MD: Is the problem with the old way of thinking of psychiatry as distinct from physiology, biochemistry, and neurology? That it’s somehow unique in its own silo and it’s not subject to the rational approach that other specialties are subject to?

Joe Avelino, RN, BSN, MHSA, CPHQ: I want to go back to the comment I mentioned earlier. In our ER [emergency department] we do have some of our psychiatrists using, as I said, not necessarily protocols but order sets. That’s becoming more common. But we also have some of our old-school doctors who prefer not to do it, and they would rather start their own set of orders once the patient gets admitted again, based on our bylaws, within 24 hours on the unit. The second comment, and Henry alluded it, with readmission, we are penalized in hospitals—1% to 3% of our Medicare reimbursement for overall readmissions greater than 30 days. Fortunately for us, we don’t have that challenge, but for hospitals that cater to the behavioral health population, which also has the problem and challenge of increased readmission, it could be punitive in a sense. Best practice there is about 17% to 18% readmission rate. We’re overall about 15%. There are more of those government-regulated guidelines that are becoming adamant in the future and will impact hospital reimbursement.

Rahn Bailey, MD, DFAPA: That sets up a remarkably timely point. The reality is we may end up with more government intervention and government regulations in that setting because many doctors in practice argue that they don’t want to better police ourselves, upgrade our focus, and be more empirically based. I mentioned the part about Wake Forest earlier. I had early experience as a medical director with a big state hospital in Alabama about 15 years ago, and it was just the opposite then. We saw many of the same problems: doctors practicing for many small private practices within the state hospital setting. which also led to inconsistencies. Patient experiences were remarkedly different of us when I came here. Trying to reassure patients who walk in our hospital—in general your experience should be the same, with a normative approach in how we handle your 5150 [involuntary hold], as Joe mentioned earlier. Those are all issues that for some degree of conformity and uniformity make sense for us, otherwise we’re all likely to really lose some measure of control and that won’t be good for psychiatry.

Joe Avelino, RN, BSN, MHSA, CPHQ: Remember back in the days when we had core measures to meet the acute myocardial infarction, congestive heart failure, community-acquired pneumonia, and surgical-site infection and how you would be penalized for that? Is there 1 of psychiatry with any of those diagnoses? No, not at this time at least. 

Henry Nasrallah, MD: There isn’t. But you know, Joe, if I were in charge of Medicaid or Medicare, I would mandate the use of long-acting injectables. They’re spending a ton of taxpayers’ money. Schizophrenia cost over $100 billion every year, and the biggest chunk is inpatient care. Imagine how much money can be saved and invested in other social programs and medical health programs if we can save. This is just 1 disease. I believe in rewards, not carrots and sticks. 

Yes, the government is doing penalties, which is the stick. But I would give the psychiatric physician who is treating a patient with schizophrenia a monetary award for every year the patient goes by without a single admission. I would give them an award, and I would also give an award for the patient. Why just the physician? Incentivize the patient, reward them for staying well, and maybe they will accept the long-acting injectable. I don’t mind paying a little money to the patient to accept taking long-acting injectables in case they have resistance. But I would reward both the physician and the patient to take the best option that prevents them from the agony of hospitalization, the damage to their brain, and all the disability and negative consequences. They lose their life. Basically, our young people are losing their life at the prime of life. At age 20 they’re done for. They’re like Alzheimer patients for the rest of their life.

Rahn Bailey, MD, DFAPA: Today I pulled some data on that point. There’s a study by Mark Pennington in 2015 that looked at 16 studies showing that this cost analysis is well documented, saving $6000 to $32,000 per hospitalization. You’re right, Henry. You make a very timely point. It is a cost measure that’s appreciable and documented. The reality is we are making bad choices, but they’re not in a vacuum. They’re costing more, and the system is often overburdened with high cost. 

As Joe mentioned, I’m in Los Angeles. I’ve got a 72-bed hospital in inner-city Los Angeles, about a mile or so from the University of Southern California, in downtown, and we’re capped at 45 nonpaid beds, although I’m certified for 72 beds. That cap occurs because the state decides how much money there is to pay for the beds that are there. Better to use those beds for persons who are first break and will need initial level care rather than have a lot of patients come and repeat when we could have avoided that. There’s a financial arm to this that we could manage better.

Peter Salgo, MD: If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your inbox.

Transcript Edited for Clarity

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