Social Policy in Ontario

Yes, the stigma has faded, but traditional barriers to treatment are only getting worse.

To understand the gap, consider how efficient our public health care system has become at treating physical versus psychological conditions.

Thanks to medicare, no one with a physical ailment goes untreated (and almost no one gets special treatment). If waiting lists grow too long, the public complains, the press clamours for action, physicians cry foul and politicians swing into action.

Mental health, however, is still a different story. Long waiting lists that would never be tolerated for surgery or cancer care are the norm for psychiatry, with many patients unable to get urgently needed followup appointments.

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A glimpse into the future of health care in Ontario

In future, the mismatch between supply and demand is destined to grow dramatically worse, unlike anything we have ever seen before, unless we do something about it.

But as Ontario’s government has discovered in recent months, reforming a crippled system is no easy matter. The latest debate pits politicians against doctors, but also provokes internecine sniping among psychiatrists, while their patients languish on wait lists.

We face a seemingly irreconcilable problem of limited supply (practitioners), limitless demand (patients), and sometimes endless ailments, thanks to a confluence of factors:

First, the availability of psychiatrists is skewed by both geography and demography. Many of these specialists are concentrated in the big cities, and are closer to retirement age than other physicians, suggesting the current shortage will become even more acute in outlying areas.

Second, we will witness an explosion in demand as people who once suffered in silence find their voices, seeking the treatment they need and deserve. One in five Canadians suffers from mental illness, but barely one in three of them currently seek help — a proportion that is bound to change as attitudes shift.

Third, mental distress typically takes longer to treat than physical trauma. Medicare is magnificent at fixing a broken leg as a one-off, at a fixed cost; our public health system isn’t quite so proficient at treating a mood disorder that can be a lifetime challenge, requiring continued followup.

Ontario has tried since last year to address one pressure point on the system: the work habits of psychiatrists who are paid with public funds. It has not gone well.

Without innovative new approaches to treatment, the rising cost curve will place unprecedented pressure on already soaring health budgets. We have long worried about our aging population, but it is our reckoning with mental health that will truly challenge the system.

The Progressive Conservative government is trying to recalibrate the fee schedule for psychiatrists, so as to redeploy their services. Since February, the Ministry of Health and the Ontario Medical Association have been discussing how to resolve ongoing disagreements over “inappropriate or overused physician services,” with the government focusing on psychotherapy, a sophisticated form of “talk therapy” that can be costly over time.

“Claims utilization data also suggests 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,” according to a ministry submission.

The government proposed a new OHIP cap of 48 sessions (24 hours) of psychotherapy annually per patient, after which psychiatrists would be paid just 50 per cent of the fee for any additional hours with that patient, worth about $13 million a year. The suggestion provoked furious pushback from some practitioners.

Dr. Javeed Sukhera, head of the Ontario Psychiatric Association, dismissed the dollar figure as a pittance that would shortchange people, insisting that time spent with a patient should be left entirely to a doctor’s discretion. But in a publicly funded health care system, where the most effective treatments must be scaled up to deal with rising demand based on empirically proven metrics, how much time is too much time — and money?

The outcry is akin to the OMA’s protests when my Toronto Star colleague Theresa Boyle pressed for access to the list of doctors who billed OHIP the most. Boyle’s purpose was not to prove misappropriation, but to point out misallocation of resources — for example, by overpaying for procedures in radiology and ophthalmology that can be performed faster than before, while other services such as psychotherapy take as long as ever.

Sukhera’s association counters that the way to reduce wait lists is to recruit more psychiatrists, not reduce their face time with patients. Given that it takes at least nine years of medical training for every new psychiatrist, however, there is no overnight solution to the current shortage.

In any case, the larger point isn’t the money but the misallocation. The goal of these proposed fee changes is to nudge practitioners into reallocating the time they spend with existing patients, thereby opening up more appointment slots for patients who go unseen — and unheard.

This is what emergency room doctors call “triage.” If psychiatrists are spending too much time talking with the “worried well,” while neglecting the most urgent and desperate cases, we will all pay the price.

A 2014 study showed that fully half of Toronto psychiatrists were seeing far fewer patients than their colleagues outside the big cities, and that most of these cases were unlikely to be severe (given that these patients had no prior psychiatric hospitalizations). While these psychiatrists took on few new patients, their counterparts outside the big cities were opening their doors to far more people, including those with complex case histories.

The study pointed to Australia’s decision to add psychologists and social workers to the universal health care system as a way of making mental health treatment more widely available, while redeploying psychiatrists more cost-effectively for consultations in complex cases.

Another 2019 study found that about one-third of psychiatrists in the province accept less than 24 new patients a year, compared to the most active practitioners who take on more than 300 new patients a year. The reality for psychiatry today is that it is being severely rationed, creating a two-tier system marked by arbitrariness and unfairness.

How can we meet the massive unmet demand for mental health services, now and in the future? The process is emotionally freighted and politically fraught, because everyone demands answers but detests the solutions.

As Dr. Jeffrey A. Lieberman, a former head of the American Psychiatry Association, writes in his definitive history “Shrinks: The Untold Story of Psychiatry,” the field has evolved dramatically over the past century. Where once psychiatry was dominated by psychoanalysis that dwelled on childhood traumas, subsequent empirical research led to greater success with more concrete psychotherapy and later, cognitive-behavioural therapy (CBT), which emphasizes problem-solving in the here and now. Experience shows that CBT yields impressive results with far shorter treatments, and can be delivered by other regulated health care practitioners, not just psychiatrists.

If the latest fight over fees is any indication, practitioners will resist change and politicians will run away from it. But just as psychiatrists believe that unresolved conflict can benefit from talk therapy, they should remain open to discussing change without lapsing into defence mechanisms.

Part of the solution is leveraging our limited number of psychiatrists in the most medically effective (and cost-effective) manner. One way is to encourage them to offer consultations, overseeing and conferring with teams of other practitioners — such as psychologists, social workers, nurses and addiction counsellors — trained in life-saving and life-changing therapy. In the same way that OHIP now pays nurse-practitioners and pharmacists to deliver services once reserved for physicians, it should extend the fee schedule to other providers.

We might as well accept that our mental health spending will increase significantly over the years. All the more reason to start reallocating funds wisely now.

To do otherwise would be to deny reality. And in psychiatry, as in politics, that’s always a bad idea.

Martin Regg Cohn is a columnist based in Toronto covering Ontario politics.

https://www.thestar.com/politics/political-opinion/2019/07/24/mental-health-reform-is-no-easy-matter.html