And Now…

I have been practicing as a psychiatric mental health nurse practitioner for two years now. I have built a case load. I work in an amazing clinic with some of the best practitioners and people I know. I have made a difference to many of my patients. But every day we talk about how to sustain the model of care that those I work with believe to be the ideal way to treat mental health concerns. The reason is not because of job dissatisfaction, poor patient outcomes or lack of work. Instead, it is because we are part of a broken healthcare system that doesn’t acknowledge or recognize the value of the profession I love or the education I have. It does not allow reimbursement for many of the things we do every day—things that at times are absolutely lifesaving.

If I saw patients for 15-minute visits and only prescribed medications I could make a much higher salary, up to twice what I make now. I would be recruited by many clinics and insurance companies would reimburse for services. Would I know my patients well? Most likely not. Would my patients feel connected in times of crisis? Not likely. Could I be as safe or thorough as I am now? Absolutely not. Would I feel like a successful PMHNP? Definitely not. I instead see patients for 45-60 minutes. I both prescribe medications and do psychotherapy. I do not rush to make decisions. I know my patients well. I remember their medical conditions and their health history. I got a trauma certification because I saw the tremendous need. I read about therapies and medicines constantly. I am good at my job and part of a strong, dedicated team. In my clinic I also have the benefit of an entire team with all different specialties—therapy, eating disorders, pediatrics. recreation therapy, health and fitness, addiction, veterans, and crisis. If I am not sure how to help one of my patients, I have so many resources to turn to.

So why are we always talking about how to sustain the model? The reasons are revenue related and insurance related. Practicing the way we want to does not bring in large reimbursements from insurance. If I see my patients for 60 minutes doing both psychotherapy and medication management, my clinic is reimbursed only $8 more than if I see them for 30 minutes. This level of reimbursement does not help cover clinic overhead, fund necessary pro bono cases, cover malpractice insurance or pay the fee for a collaborating psychiatrist. When I want to enlist the help of a recreational therapist or our health coach insurance companies refuse to reimburse so the burden falls on the patient or if they are unable to pay, the clinic. Even if I want to call in another nurse practitioner to help me assess and treat a patient to prevent hospitalization only one of use is reimbursed by insurance, despite how much is saved if a hospital stay is not required. I am fortunate to work in a place where we provide the care regardless, because we are invested in quality care, but because of this there are financial obstacles. When I think about how many more people we could help if this wasn’t the case it makes our efforts seem small.

The concerns in our industry however are not only financial. There are concerns about the lack of mental health facilities. There are concerns about places who treat those with mental health concerns in ways that are inhumane. There are concerns about waiting lists to get care and the lack of clinics that will accept patients with certain insurance. For example, when a clinic accepts Medicaid that can be audited at any time. While this has the potential to be an effective way to assure quality it is actually a process that is distressing an unfair. The audits are based on minimal information and providers only need to check the box to pass. The patients are never spoken to, the clinics are not toured, and the auditors are not interested in the work that is being done. What if these audits looked, not at a checklist but at the interactions that are taking place and the patient perceptions and outcomes? The stress of the audits and negative interactions are leading clinics to stop accepting Medicaid resulting in an even greater problem with access to care for those who are most vulnerable.

There are further problems with people who are in the industry for the wrong reasons and the pop up “universities” churning out students who are not prepared to practice in the mental health arena safely and humanely. It is more than a little disheartening to see providers who jam their schedules and prescribe medications without thought just to increase income. These providers care more about the paycheck than the purpose and often do more harm than good with the way they practice. Our jobs are so much more than our prescription pads and 15 minutes every 3-6 months is certainly not enough time to fully evaluate how a patient is doing, especially when trust and rapport are crucial. And then there are those entering the mental health industry that have attended pop-up, low quality schools that can memorize enough to pass boards but don’t have nearly enough knowledge to practice solo and don’t realize what they don’t know. For graduates from reputable universities and rigorous programs there is still so much to learn after graduation and beyond, but when the foundation isn’t there how are patients not at risk?

And lastly, let’s talk about the competition in the mental health industry. The competition between clinics. The competition between psychiatrist and nurse practitioners or physician assistants. The competition between prescribers and therapists. The competition between those who believe in medication assisted treatment for addiction and those who see this as trading one addiction for another. The competition between inpatient and outpatient care providers. The bottom line is this…there are more than enough people for all of us to care for. There is not a shortage of people who require ongoing services and resources. We do not need to speak ill of others or be stubborn about our way being the right way. Each of us can have our ideas and areas of expertise. Each of us can recognize when we are not the best fit for someone. Each of us can seek the help of another professional who might know more or better. We are operating in a broken system and each of us who attack another member of the system is damaging it further. Competing with others in the profession instead of supporting them is only moving the system farther away from the ideal and hurting those who need us most.

I do not pretend to have all the answers, not even some of them, but I do know that MASSIVE changes are needed, and I know that just going with what is happening is not only ignoring the problems but perpetuating them. I challenge each person working in mental health to keep talking. To reach out to colleagues and make connections. To write to your government or participate in calls to action. But mostly I challenge you to remind yourself every day of your why. Why is your work important. Why the quality of the care you provide is your responsibility. Why each of us needs to be part of a solution and a movement to change things.