Ontario’s proposed cuts welcomed by critics of ’boutique psychiatrists’ who over-treat wealthy patients

By | April 23, 2019

While Ontario doctors have denounced a government proposal to limit funding for psychotherapy, some physicians say they would welcome cuts that “curb boutique psychiatrists” who “over-treat the worried well.”

The Ontario Ministry of Health and Long-term Care has not announced the planned cuts, but they were included in a briefing document submitted to an arbitration board that is currently considering a contract dispute between the ministry and the Ontario Medical Association.

The document states that 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.”

The document suggests limiting OHIP funding to 24 hours of psychotherapy per patient per year would save the government $ 13 million annually.

The cuts are a “death sentence” for suicidal patients, said Dr. Mary Fernando, echoing the concern among the province’s psychiatrists and GP-psychotherapists.

The president-elect of the Ontario Psychiatric Association, Javeed Sukhera, on Twitter, urged his community to “contact their MPPs ASAP.”

But the proposed cuts could also push so-called “boutique psychiatrists” to spread out their services. The term refers to a psychiatrist who sees less than two new patients a month. Rather, they keep seeing the same patients over and over again. They are less likely to see poor patients, recent immigrants, or patients who have been recently hospitalized for severe psychiatric illness.

A study published in the Canadian Journal of Psychiatry in February found that about one third of Ontario psychiatrists accept fewer than two new patients per month. On average, they have 1,041 sessions with 69 patients in a year. On the other end of the spectrum, 27 per cent of psychiatrists take on a new patient each day and have 2,274 appointments with 680 different people each year.

Only medical doctors are able to bill OHIP, but there aren’t enough psychiatrists to meet the need, so the majority of psychotherapy in the province is performed by clinical psychologists and licensed therapists, many of whom have a social work background. Generally, they are funded either by private insurance or by out-of-pocket payment.

In contrast, medical doctors can charge the province $ 160 per hour to do unlimited amounts of psychotherapy on any patient who they believe needs the treatment.

Effectively, this creates a two-tier system for mental health care in Ontario.

And there are glaring geographical and socioeconomic discrepancies in who might find an MD-psychotherapist. Affluent Ontario communities such as Oakville and Guelph have two to three psychiatry practices per 10,000 people, while cities like Windsor and Brantford have roughly half that. Even within a single city there can be disparities: Scarborough has 0.6 psychiatrists per 10,000 people while Metro Toronto has 3.5.

Put another way, MD-psychotherapists can theoretically flood an affluent area and provide ongoing, unlimited therapy sessions for a well-serviced population, even if the need is not obvious and overwhelming.

Dr. Mario Elia, a family physician in London, Ont., and adjunct professor at Western University, is among those who think that the proposed cuts could redistribute psychiatric care in a more equitable way.

Outpatient, OHIP-funded psychotherapy is “almost impossible to access” in his community, he said.

As far as he is aware, none of the 76 psychiatrists practising in London are accepting referrals for ongoing psychotherapy.

He is quick to say that the vast majority of these are “doing their utmost to see as many patients as possible, as efficiently as possible to save as many lives as possible.”

Nevertheless, he sometimes comes across psychiatrists who don’t seem to have accepted a new patient in many years. Elia finds this curious, as he believes most evidence-based psychotherapy is generally limited to a defined period of time.

Ontario Psychiatric Association president-elect Sukhera, himself a child psychiatrist, agrees.

“Any physician who cultivates dependence is not practising evidence-based care,” he said. “This can be very problematic.”

He also understands the concern about boutique psychiatry.

“There are a number of psychiatrists in the GTA who, based on reports, see fewer than 30 or 40 patients per year,” he said.

Yet he has been very vocal in opposition to the cuts, which he thinks might have unintended consequences and hurt patients who need ongoing, long-term therapy.

“There are many patients who are being seen by psychiatrists who need more than 24 hours of care per year,” he said, citing, for example, adults with psychotic disorders such as schizophrenia under community treatment orders or children in residential care.

“If the government doesn’t fund other human resources for those individuals, where will they go?”

To address concerns about boutique psychiatrists, Sukhera would like to see a move towards measurement-based care.

“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 evidenced-based therapies are not funded.”

Matt Strauss is a critical care physician and assistant clinical professor at McMaster university. He is a fellow in global journalism at the Munk School of Global Affairs at the University of Toronto.

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