Ruminations

Curbing "Boutique" Psychiatrists

"[The ministry's data shows] that there are some physicians in Ontario who are providing a high volume of psychotherapy to a small number of patients for an extended period of time, with uncertain clinical benefit, while also limiting access for new patients."
Ontario Ministry of Health and Long-term Care report

"Any physician who cultivates dependence is not practising evidence-based care. This can be very problematic."
"There are a number of psychiatrists in the GTA [greater Toronto area] who, based on reports, see fewer than 30 or 40 patients per year."
"There are many patients who are being seen by psychiatrists who need more than 24 hours of care per year."
"If the government doesn't fund other human resources for those individuals, where will they go?"
"I think the problem with the current system is it's a bit of a wild, wild west. We haven't implemented quality metrics. We are funding lots of things that don't fall into that evidence-based category and yet evidence-based therapies are not funded."
Javeed Sukhera, president-elect, Ontario Psychiatric Association

Illustration by Joe Morse

Among those who think that the government of Ontario's proposed cuts to limit funding for psychotherapy could end up with a redistribution of psychiatric care in a more equitable way is Dr. Mario Elia, practising in London Ontario, who is also an adjunct professor at Western University. In his community, he stated, outpatient OHIP-funded psychotherapy is "almost impossible to access". None of the 76 psychiatrists practising in London accept referrals for ongoing psychotherapy.

The vast majority, he says from his perspective as a family physician, are "doing their utmost to see as many patients as possible, as efficiently as possible to save as many lives as possible". However, he comes across psychiatrists who it appears haven't accepted new patients in years. A situation Dr. Elia finds puzzling since he believes most evidence-based psychotherapy is limited to a defined period of time.

The situation he reflects upon is one where within a single city MD-psychotherapists can conceivably gather within an affluent area to provide ongoing, unlimited therapy sessions for a population that becomes very well-serviced, while other areas are left with an overwhelming need that cannot be responded to in the absence of psychotherapists willing to provide service there.

The glaring geographic and socioeconomic discrepancies between affluent Ontario communities with two to three psychiatry practices per 10,000 people sits in stark contrast to other communities or areas even within single city where 0.6 psychiatrists per 10,000 people is the norm.Toronto alone has 3.5 psychiatrists in contrast, per 10,000 residents.

The new announcement of the government of Ontario's proposal to limit psychotherapy funding is generally viewed with a degree of alarm. The need for psychiatric counselling has never been greater, particularly among the young, yet there is a noted scarcity of medical professionals in the field and the need to schedule appointments with mental-health professionals results in frustratingly-long waits.

Some physicians, however, claim to welcome cuts that could "curb boutique psychiatrists" with their focus on business and who "over-treat the worried well". Although the Ontario Ministry of Health has not formally announced planned funding cuts, they were included in a briefing document received by an arbitration board considering a contract dispute between the Ontario Medical Association and the ministry.

The suggestion included in the document is to limit OHIP funding to 24 hours of psychotherapy each patient per year to save an annual projected $13 million for the government. According to Dr. Mary Fernando, such cuts represent a "death sentence" for suicidal patients, precisely the concern expressed among Ontario psychiatrists and GP-psychotherapitsts.

The term "boutique psychiatrists" refers to mental health professionals who deign to see fewer than two new patients each month; they keep servicing the same patients over and over again, and are thus less likely to agree to see other patients, particularly poor patients, recent immigrants or patients who have recently been hospitalized for severe psychiatric illness.

A February study published in the Canadian Journal of Psychiatry found about one-third of Ontario psychiatrists accept less than two new patients on average each month. Those same psychiatrists have 1,041 sessions with 69 patients throughout the space of a year. While at the opposite end, 27 percent of psychiatrists take on a new patient each day, with 2,274 appointments with 680 different people yearly.

Since only medical doctors can bill to OHIP that leaves an insufficient number of psychiatrists to meet the public need. The majority of psychotherapy is performed in the province by clinical psychologists and licensed therapists, often with social work backgrounds who are funded either by private insurance or by out-of-pocket payment, hence the allure of situating in prosperous areas. This is the reality of a two-tier system for mental health care in the province.