Mohammed T. Abou-Saleh

698 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYcompanies often ‘‘carve out’’ the management of mental healthservices by subcontracting it to managed behavioral healthcarecompanies with specialized expertise in mental health benefitsmanagement 11 . Such companies rarely have any expertise ingeriatrics, and do not appreciate its differences from general adultpsychiatry 12 . These companies have often ageist attitudes builtinto their coverage utilization guidelines, and inappropriatelylimit treatment or completely deny it, especially involvingmembers with Alzheimer’s disease, which they do not view as acovered psychiatric disorder. To the extent that managed care haspenetrated Medicare, this practice has made the practice ofgeriatric psychiatry unnecessarily burdensome for many Americanpsychiatrists.PRIVATE PRACTICE AS A BUSINESSAnother important factor in discussing this type of psychiatricpractice is the awareness that it is a business, and that the patientsare customers. As such, it behooves the psychiatrist to organizethe practice and to provide services in ways that answer the needsof these customers. The psychiatrist may help the patient to definethese needs, provide information about them, alter them, or aidthem in various ways. The psychiatrist may need to refusepatients’ requests when professional judgment dictates this.American consumers, especially the adult children of geriatricpatients, are becoming increasingly distrustful of the healthcaresystem and doctors. If the psychiatrist does not do a good job ordoes not adequately address at least some of the patient’s needs(and/or their adult child’s needs), the psychiatrist may lose thatpatient’s business. Thus, it is clear that the interaction betweenthem is an exchange of service for payment. By providing acomprehensive service, as mentioned above, the psychiatrist mayprovide more services in more locations, which is often verysatisfying and helpful to patients. At the same time, the businessopportunities for income are maximized. In a community-basedprivate practice, people are often referred to the individual doctor,rather than to a hospital, a university or a public clinic where theymay be assigned a doctor. Patients may be referred because of thedoctor’s quality of service, reputation or relationships with thereferring party. These qualities therefore become significantaspects of the psychiatrist’s success in business as well as clinicalpractice.Important factors in satisfying the patient/customer include:1. Cost: reasonable fees and/or helpfulness and knowledgeabilityin filling out insurance claims.2. Accessibility: convenient and comfortable office location andsurroundings.3. Availability: the availability of the psychiatrist to go to thepatient if needed (e.g. to consult at a medical hospital if thepatient is admitted by another physician for a physicalailment, or to see the patient at home, in a nursing home, oran assisted living facility) is very important. The convenienceof the geriatric psychiatrist going to where the patient lives,rather than the patient coming to the doctor’s office, is veryattractive to family caregivers responsible for transportation.The viability of this form of practice, in private practice,depends upon arrangements with facilities that ensure anadequate volume of patient visits for each trip to the facility.4. Scheduling: flexibility to see patients at convenient timeswithout excessively long delays in scheduling appointments.This is crucial, since many frail patients are brought by theiradult children who work.5. Communications: the ability to contact the psychiatrist quicklyand easily at need (e.g. by telephone by the patient and, whenappropriate, by the patient’s family). This includes thewillingness of the psychiatrist to return such phone callsquickly, and the friendliness and accuracy of the psychiatrist’ssecretary or answering service. It also includes the ability andwillingness of the psychiatrist to speak to the patient (andfamily) about his/her symptoms, illnesses and treatments in aclear and patient manner.6. Concern: the feeling that the therapist has a genuine interestand concern for the patient. This feeling of concern extends tothe patient’s interactions with the office staff. This is anespecially vital factor for the older population 13 .7. Confidence: patients need to feel that the psychiatrist knowswhat the patient’s problem is and has an idea about what canbe done. The doctor does not need to define answers, but mustindicate a grasp of the situation and some ideas for anapproach to it. This helps to provide a structure to what isoften a strange and frightening experience. Empathy with thepatient’s distress is very helpful in this, as is reassurance to thepatient that his/hers is not the worst case the doctor has everseen (a common fantasy).There are only limited data available on income and workloadfor geriatric psychiatrists as a group. For all psychiatrists, 1998median annual gross income was $171 490 (a 3.5% increase from1997) and annual net income was $118 630 (a 4.33% increase from1997). This was the second lowest income of the 20 largestspecialties (above general practitioners) surveyed by MedicalEconomics that year. The rate of inflation in the year 1997–1998was 1.6%. Comparable 1998 income data for all US physiciansshow an annual gross income of $256 290 (down 0.7% from 1997)and a net income of $163 940 (up 2.2%); for non-surgicalspecialties the gross income was $227 300 (up 1.7%) and the netincome was $147 140 (up 2.4%) 14 . When these data are comparedto the median annual net income for psychiatrists in the USA in1989, which was $103 570 (the fourth lowest of 15 office-basedspecialties surveyed that year; the only doctors who made lesswere general practitioners, family physicians and pediatricians) 15 ,we find that the income of psychiatrists had risen 14.5% in thatperiod. The median net income for all fields of medicine rose justunder 25% during the same period, while the cumulative inflationrate added up to 35%.Although most American psychiatrists see few or no geriatricpatients, this trend is changing somewhat. There were over 5400out of the over 36 000 members of the American PsychiatricAssociation who expressed an interest in geriatrics during their1997–1998 Professional Activities (Biographical) Survey 16 . Themembership of the American Association for Geriatric Psychiatryhas grown to over 1800 17 and interest among general psychiatristsis increasing. In 1991, the American Board of Psychiatry andNeurology first administered a Board Certifying subspecialtyexamination in geriatric psychiatry. As of September 2000, therewere 2508 individuals who have passed this examination 18 .In 1996, 18% of American general psychiatrists had geriatriccaseloads exceeding 20% of their practices 19 . Overall, in this 1996survey of 970 responders, an average of 14.0+17.7% of theirpsychiatric patients were aged 65+ 19 , compared to 8.4% found ina 1987 study 20 . When psychiatrists who provide a higherproportion of geriatric services (more than 20% of their caseload—HGPs) were compared to those who were low-volumeproviders with the elderly (less than 20% of their workload—LPGs), it was found that the HPGs spent proportionately lesstime in their offices (although still spending most of their timethere), more time in hospitals and significantly more time innursing homes, than LPGs 19 . In view of relatively low numbers ofpsychiatrists with a specific interest treating the elderly, when themedical and general communities know that a particularpsychiatrist is a geriatric specialist, there is usually no shortageof patients needing these services.