Psychiatrist, Advocate for Patient Care

Chapter 11: Patient-Centered Care Faces Many Challenges

How I Practiced Psychiatry: Part II


To be able to provide my professional services, I needed to be paid. One might say that being paid reinforced my behavior of continuing to provide psychiatric care.


I preferred a payment arrangement in which the patient and I both had skin in the game. I have written about this elsewhere in the book, but I wanted to repeat this here. When the physician and patient both have financial skin in the game, it directly affects how they interact with each other and their expectation of positive or useful outcomes. I embraced this financial test, and so did many of my patients.


As I see it, the challenges to maintaining a future for patient-centered psychiatry depend on how we define and pay for treatment of psychiatric conditions. To a great extent, ever since Congress passed Medicare and Medicaid in 1965, and more so after Congress passed the Affordable Care Act in 2010, the decisions about paying for care start with politicians in the halls of the Congress. Then the decisions are off-loaded to an army of bureaucrats spread across the country, empowered by Congress and at the direction of the President, in order to administer the laws. In this manner, Washington D.C.’s medical care establishment is directly or indirectly responsible for the regulations and oversight forced upon politicians and bureaucrats in State Capitals. State and local politicians have considerable sway in how to apply the implicit and explicit laws imposed by Congress and administrative bureaucracies.


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