What's killing psychiatry?

Part 4

by Lisa Birk

For managed care companies, time is money. They work to reduce time spent on treatment, number and length of appointments, and length of hospitalization. Capitation encourages that approach. And gatekeepers enforce it.

The financial and administrative pressure on professionals to treat clients faster is enormous. Psychiatrists get paid less and less and see more and more patients. In 1991, public sector psychiatrists made $90 per half-hour session. Six years later, they make half that. (The private sector isn't faring much better.) The incentive, just to stay even, is to increase the caseload, to pack the work week with patients and leave little time for follow-up and other "collateral care" -- soothing a patient's landlord, talking with someone's mother.

The easiest route is to choose a prescription over talk therapy. After all, a psychiatrist can see many more patients -- and maybe attain his old salary level -- if he sticks to a set of questions and a pill.

This leaves psychiatrists in both the private and public sectors with a difficult choice: do I care more about personal gain or ethical treatment?

Dr. Milt Freudenberg*, a psychiatrist with almost 30 years' experience, explains. By the early 1990s, competition from managed care had diminished his practice from 30 patients to 10. To supplement his income he joined a hospital, where care was managed and statistical averages dictated treatment.

"I was pressured to give prescriptions to patients [who] didn't need them, and asked to keep people [in the hospital] shorter or longer depending on their insurance," he says. "They'd say, `Don't be in a hurry to terminate this patient. He's got good insurance.' " After a number of such incidents, Freudenberg quit in disgust. "I wasn't comfortable with the level of care," he says. "But my children are grown, my house is paid for. If I were 35 and had four young kids, I don't know what compromises I'd make."

Patricia Hayward, a psychiatric nurse, has a similar story to tell. In five years, her employer, Community Healthlink, in Worcester, nearly doubled her "direct care" (therapy) expectations -- and her paperwork -- without alleviating other obligations. She left, she says, rather than give unethical care, but not before considering the alternative.

"I never did this," she says, "but you start to think of ways to cut corners. Like you're supposed to have the patient's chart and check the dosage before you give a shot, but if it wasn't there, you'd say, I know the dose, and you'd think about just giving the shot. Or someone would come in for therapy, and you'd find yourself thinking about paperwork or returning phone calls. If your mind starts wandering during therapy, that's like dropping the baby."

Hayward's and Freudenberg's experiences are typical of managed mental health care, claims Dr. Sam Holden*, a psychiatrist with over 30 years' experience and an appointment at a prominent university. "Insurance companies guide people into `What you need is what we pay for, and what we pay for is Prozac,' " says Holden. He and Freudenberg could cite a half-dozen psychiatrists they knew who had quit in despair.

"Everywhere there's a squeeze on to keep [therapists] from spending too much money," says Dr. Henry Grunebaum, a clinical professor at Harvard Medical School and a psychiatrist with over 30 years' experience. "They all have gatekeepers now. And most gatekeepers are not trained professionals, and even if they are, they don't know the [patient]."

He compares the fate of mental health patients to that of new mothers who get 24 hours of hospitalization. "Many [mothers] are ready to go home after a day, but some should stay two days, some should stay two weeks. [The gatekeepers] make people conform to arbitrary standards." And that, say many psychiatrists, is tough on patients -- even those in non-managed care settings.

Ronnie Darlington agrees. Her 22-year-old son Keith was admitted to a Department of Mental Health hospital for paranoid schizophrenia in January of 1995 and released in April. In June 1995 he committed suicide. Keith was a Medicaid patient, and Medicaid at the time was administered by a managed care company, Mental Health Management of America. Any release decision would have come from a gatekeeper at the company, based on a clinical report from the hospital.

Ronnie Darlington thinks her son's release came too soon. "I look back now," says Darlington, "and I think, it was too fast to be diagnosed, too fast to accept [and] too fast out of the hospital.

"His psychiatrist was destroyed when they discharged him," says Ronnie, "but they [psychiatrists] are just cogs in the wheel. It's the change-purse holder who's running the wheel. The psychiatrists are being told, `Now listen. Let's get this person going here.' "

Back to part 3 - On to part 5

Lisa Birk is a freelance writer living in Cambridge.