We're all on drugs

a lesson in never looking at the numbers too closely or else you'll see the invisible hand of capitalism is rammed straight up your rectum

Today I made the mistake of looking how many patients I have on controlled substances. Since my serious medical event prompting me to get some time off, I am only recently getting back to work, but I have between 600-800 patients on some form of a controlled substance. Most of these patients have ADHD, but a few have treatment refractory anxiety or panic attacks for which they regularly require a small RX of benzodiazepines, which is appropriate when it essentially gives someone their life back, since that’s kind of the whole point of this field.

So I tried to figure out if I had 600-800 patients with ADHD and Anxiety and I was seeing them regularly, what that would amount to in private practice billing. Just to get a sense of how much is being made from/exploited from me. Now, you see, we can do followups at HMO-land via secure/text message. We refill meds and meet the patient at least every 1.5 years. That being said, most patients have complicated situations and I meet them more often. Most of them would benefit from being seen monthly, but my own wait list, 4 years in, is over 2 months for a routine followup.

Getting my calculator out, thats, at 5 minutes a refill, 50 hours/month minimum just to keep the lights on (And that’s assuming zero back and forth or difficulties with the pharmacy which has been the norm last few years). In a private practice it is expected you’d see controlled RX patients monthly, and the HMO assumes that the “system” does the following (it doesn’t really).

If I was in private practice, 600 patients would be $1.8 million in billing per year. Even a panel of 400 patients would be $100,000 MONTHLY income to the tune of $1.2 million in annual billing. A modest 200 patients would be $50,000 monthly aka $600,000 annually. At an HMO pace of 10 patients a day, about 60 per week (minus secure message encounters) thats about 200-240 patients a month, then add on all the patients essentially required to be managed via email and you can see how the HMO is raking in money by trying to “Extend the reach” of psychiatry without actually offering any real infrastructure to do so effectively.

Looking at the numbers more objectively it becomes bleedingly apparent that the system is designed to fail both patients AND physicians and therapists. I’m not sure there is a way to practice with these kinds of numbers ethically in what amounts to an HMO essentially forcing doctors to practice “as if” they were in private practice, but also unable to cap their total patient load, relying instead on attrition to manage the total panel (number of patients a doc is responsible for) which favors the docs who essentially do nothing but readily dispense prozac and adderall and seroquel with little to no followup (if your doc resembles this, congrats, you have one of the aforementioned dead-eyed MDs that inhabit the hallowed halls of HMO hell).

So what is this system, really? Is it something mirroring what public health would look like in a medicare for all world? possibly. If we follow the ‘industrialized medicine’ pathway, we end up with an even worse version of denial of care through actuarial violence, AKA murder by spreadsheet.

I’m not sure how I’m supposed to safely manage 6-800 controlled RX patients, and squeeze in a suicidal patient when I have a 2 month wait time for a routine followup. Something is deeply broken, and it’s not the people working in the system. It’s labor theft from physicians, plain and simple. It’s just a matter of time before someone manages to crunch the numbers and file a successful lawsuit.