Defending direct pay: Psychiatrists say model works

Dr. Beecher, like Dr. Muñoz, said he felt the main advantage of direct pay to be the patient relationship. “Psychotherapy is developing a personal narrative. Who am I in the world? What am I doing? What is the plan gonna be? Good psychotherapy helps the patient rationalize his or her own position,” he said. “Meanwhile, so many of my colleagues in psychiatry are struggling with this question of, what am I doing? Who am I working for, the patient, or the CEO of a health care organization?”

Dr. Beecher said many of his colleagues stopped taking insurance “because we were becoming slaves to coding, trying to coordinate everything so that we could get paid, then we wouldn’t, and we were arguing with the insurers – it was just awful,” he said. Switching to direct pay “re-established psychiatry as a legitimate and valuable service with the patient as the center of the doctor’s attention.”

For her part, Ms. Diehl said NAMI’s report “shows that consumers face huge barriers to psychiatric care and scrimp on necessities in order to pay for it. Direct pay resolves some problems but creates others. We need a middle ground,” she said.

Dr. Beecher acknowledged that the poorest patients are denied the level of care that even the most reasonable and accessible direct-pay practice can offer. With his patients who had Medicaid, he did what he could to bridge the gap. Medicaid does not reimburse direct-pay appointment fees, but prescriptions written by direct-pay providers are paid for, and Dr. Beecher would intervene to make sure patients received the right medications. He also connected with their primary care physicians, explaining drug choices, and provided patients with copies of their notes to allow them to share them with other providers.

A more lasting and innovative solution to help low-income patients access direct-pay quality care would be to “support waivers and experiments in the states that would give patients access – maybe even with a debit card” to funds that can be used for direct pay, Dr. Beecher said.

Enormous sums of public money are going into health care organizations, he said, but “the way it’s now designed is a top-down system deciding what the benefits should be, how they’re administered, who’s getting the money. None of that allows the patient to be the driver of the system.”

Waivers for direct pay “could get the power in the hands of the patient,” he said. “There’s a lot of resistance to doing it. But it works.”