Rationing Mental Health Care, Part One.

Anyone who has tried getting mental health help knows that it can be very difficult to find. Clearly, there isn’t enough care available to satisfy the need that’s out there. One look at the recent shameful stories about Canadian Forces Veterans who are unable to access adequate mental health resources for widespread problems like PTSD, provides a glimpse into the problem.

There are significant practical, philosophical and economic issues at play in terms of how much care should be provided, particularly within our publicly funded healthcare system. This is not a simple problem with a simple answer, and I’m not offering one.

I will say this: serious, widespread, public, adult conversations on these issues need to be happening, and they are not. Our public discourse resembles cheerleading squads chirping at each other with ideological, “gotcha” sound bites. Real decisions are being made by a small minority, with little input, that do have significant impacts on all of us.

I want to demonstrate though, how these decisions, made by politicians and an expansive healthcare bureaucracy, worlds away from those on the front lines, affect the care that is available. Make no mistake, health care is rationed, including mental health care. And if you want to talk about changing how we ration it, we need a better understanding of how it works now.

We Have Two-Tier Healthcare

Let’s get this out of the way right now. We do not have “free” healthcare, and we do not come close to providing for all the healthcare needs of the population. Dental, prescription drugs, ambulance services… there’s a long list. Some things (doctors visits, many expenses associated with hospital stays, etc.) are paid for by governments from tax revenues, and many other things are not covered. Including, most notably for our discussion, psychotherapy delivered by anyone other than a physician.

For many, psychotherapy may be the most effective treatment for their mental illness, or at least part of that treatment. Those with means to pay for it privately, or who have insurance whether from work or elsewhere, can access it with relative ease (though locating the right therapist for your needs may be difficult). If you don’t have the means, your chance of accessing psychotherapy is much lower.

In the remainder of this post, we’ll look at a few ways that access to care is rationed.

Rationing Psychiatrists

In our system, psychotherapy provided by physicians is normally covered by provincial health insurance. We all know that family physicians are far too busy with far too many patients to be able to regularly provide any kind of psychotherapy. That leaves psychiatrists.

The first way we ration psychiatrists is by limiting the number we produce. If you’re not familiar, after they’ve completed medical school, psychiatrists need to complete a typically five year residency training program to become psychiatrists. There are only a certain number of residency spots available across the country, which means only a certain number of new Canadian-trained psychiatrists each year. The number of those positions are determined based on government funding.

Whereas in the past, many psychiatrists may have simply opened up a private practice, it’s more common now for them to take a position in a hospital or some type of outpatient clinic. There are advantages to doing so, not the least of which is financial. Such positions often pay overhead costs that would otherwise be the responsibility of the psychiatrist (office rent, supplies, admin staff, etc.). Using very round numbers, a psychiatrist who might generate $300k/yr in fee-for-service billings can avoid up to $100k in expenses this way.

The downside is the position will require the psychiatrist giving up some autonomy. For example, the types of patients they see, how many they see, how long they can book appointments for, and to some degree even the types of care they provide may be dictated by the organization.

And there aren’t a lot of clinics that will hire psychiatrists to spend most of their time doing psychotherapy.

Rationing Psychologists and Other Therapists

While psychologists, social workers and other counsellors who provide psychotherapy are not covered by provincial health insurance plans, there are usually some places where you can receive some psychotherapy without needing to pay out of pocket.

Generally these are government funded mental health or other clinics, who hire a number of staff to run programs that provide a variety of services to their designated clientele.

Again, the clinic management and its associated budget will dictate the number of allied health workers who are hired, the structure of the programs (what type and how many sessions are provided).

It goes without saying there are not nearly enough of these no-charge services to meet the demands of everyone looking for (or who would benefit from) psychotherapy.

Bottom Line

If you want access to psychotherapy, unless you luck out and find a psychiatrist who does a lot of therapy as part of their practice, or your work has a very generous Employee Assistance Program (which tends to recognize the value of psychotherapy in getting people back to work sooner), you’re going to have to pay.

(Again, I’m not saying that rationing care in some way is a bad thing. What I think is a bad thing is when we refuse to honestly talk about how our health system actually works, and how we may want it to change.)

But have you ever wondered why so few psychiatrists, even those in private practice, actually do much psychotherapy? In the USA it’s largely that most HMO’s won’t pay for it, or at least pay much for it. But that wouldn’t happen here in Canada, would it?

The followup to this post takes a bit of a deep dive into how provincial fee schedules for physicians influence care.

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