What's Killing Psychiatry?
Managed-care companies say they're improving the way psychiatrists do business. And psychiatric drugs have never been more effective.
By Lisa Birk
NOVEMBER 17, 1997: Your mother died nine months ago, and you're sad. Really sad. You sleep 14 hours a day, wake up tired. Drink a couple beers before work. It takes three times as long to do the office billing. Your colleagues make comments. You go home, call your managed care company for a referral.
A high school graduate answers, asks your zip code and your problem. You stutter -- this is private stuff, and she's typing it into a computer. You mention your mother died. You don't mention the beer.
The first appointment runs long, 20 minutes. The psychiatrist asks a dozen questions. Eating regularly? Sleeping well? Concentrating? Drug allergies? He doesn't ask about drinking, so you don't mention it. Hey, you can stop anytime you want.
Fifteen minutes later you walk out with a prescription for Prozac. Call if you have diarrhea.
At the next appointment, the doctor asks what "outcomes" you'd like. Better concentration, less sleeping, you say. Together, you decide that meeting those goals will mean success, and that's when you'll stop therapy.
The next six appointments go pretty much the same, except you feel a little better. The doctor asks the same questions; you answer. You never talk about your mom. Or the drinking. There isn't time, and anyway, you don't really know the guy. Are you gonna tell him your most intimate secrets? Besides, he keeps looking at the clock.
The Prozac kicks in after a month or so. Your sleep pattern normalizes, you're quicker at work, and life doesn't seem so bleak. Success, right?
After the last appointment, you feel odd, empty maybe. You can't quite figure out why. Sure, you are quantifiably better (except for the drinking), but you don't feel quite satisfied, quite . . . human. Pills did something to your synapses -- allowed them to absorb more joy, alleviated some symptoms -- but no one has listened. No one has heard about you. Was that therapy? You shrug it off, pick up your last prescription and head home. Maybe have a couple of beers, watch Jeopardy.
Another success for modern psychiatry.
Remember the archetypal Woody Allen psychiatrist? The one bathed in soft light, head cocked, listening to Woody's story for 50 minutes every week? If that archetype were an animal, he'd be on the endangered list.
The premise of traditional psychiatry was that the individual mattered. The doctor's insight and empathy mattered, and the patient's story and feelings mattered. Those values were reflected in the practice of psychiatry itself. Referrals were word-of-mouth, based on a knowledge of patient and therapist. Confidentiality was the basis of the relationship. Treatment sometimes included drugs, but always included talk therapy, in which the patient had the psychiatrist's full attention. The length of treatment was a private matter between doctor and patient.
The premise of the new psychiatry is that profit matters. Profit depends on efficiency, and efficiency is based on statistics. Same as any other industry. How long does it take the average worker to bolt a fender onto a car? A worker who takes longer knows he has to speed up or lose his job.
The principles of managed heath care, which now govern the psychiatric treatment of all but the very rich, apply the same efficiency standards to therapy. How long does it take the average doctor to "fix" the average patient's depression? How can efficiency be improved? The result of this approach is that every element of therapy is becoming mechanized; at worst, psychiatry has become a matter of referrals by zip code, over-reliance on medication, and treatment whose duration is determined by statistics-wielding bureaucrats.
What happens when a profession charged with the most delicate of tasks -- treating the human psyche -- is driven by the most mechanistic sciences -- statistics, chemistry, economics? This story is about who benefits and who loses under this new system of mental health care, and what is happening to psychiatry itself.
The idea of managed care evolved in response to a crisis: in the mental health field, as in all health care fields, costs skyrocketed in the '70s and '80s. Doctors could charge whatever they wanted, and did. Patients could receive services indefinitely, or as long as their insurance company paid the bills. Psychiatrists had a financial incentive to prolong treatment.
Managed care reversed that. The financial benefit now lies in reducing the time spent in treatment. And though the details vary from one health care company to another, the principles do not. Health care companies control costs by means of two mechanisms: a gatekeeper and "capitation."
The gatekeeper, often not a trained therapist -- or even familiar with the tenets of therapy -- is a bureaucrat who approves, reduces, or denies a doctor's treatment plan. Capitation is a limit, or cap, on the amount of money allotted per patient per year. If the cost of a patient's annual treatment falls short of the cap, the company makes money. If it exceeds the cap, the company loses money. The equation is simple: less care means more profit.
The managed care system was designed to stabilize costs, and on that front it has succeeded. Nationwide, health care inflation, once in the double digits, was down to just 3 percent in 1996, according to the National Alliance for the Mentally Ill.
Locally, too, costs are down. Massachusetts hired a managed care company to run Medicaid mental-health care in 1992. The Medicaid mental-health budget is down 22 percent. The state anticipates an additional 15 percent decrease in the next few years. Private sector costs have followed a similar pattern.
What has allowed those savings, in part, has been a new generation of drugs based on advances in the understanding of brain chemistry. While business concerns were altering the way mental health treatment was financed, science was altering the way it could be administered.
The new drugs -- more effective than their predecessors, with fewer side effects -- were truly revolutionary. They were cheaper than talk therapy (a year of Prozac runs about $1000, whereas talk therapy with a psychiatrist costs several thousand more), and they could ameliorate symptoms very effectively. Depressed? Take Prozac. Anxious? Take Xanax. Schizophrenic? Take Clozaril.
The new drugs, to be sure, have spawned some miraculous stories. Dr. Joseph Coyle, chairman of the Consolidated Department of Psychiatry at Harvard Medical School, tells of one patient, a man from a lower-middle-class background who was the first in his family to go to college. His second year in medical school, he developed schizophrenia.
"We tried everything," says Coyle. "High-dose Haldol, low-dose Haldol, everything, but he just sat in his room. He was not alive for eight years. After Clozaril came out, we tried him on that. He woke up! Last I heard, he was finishing his Ph.D."
But Clozaril, like most drugs, has limitations. Roughly one-half to two-thirds of patients respond poorly. And even for those who do respond Lazarus-like, there are other issues. What does it mean to have a lifelong mental illness? How does the illness affect future possibilities in love and work? Studies show that the best outcomes for patients on medication are for those who also get talk therapy, who get help adjusting to their new self.
A 1992 National Institute of Mental Health study of depression and relapse showed that those who fared best received medication and talk therapy. Eighteen months after a 16-week treatment program, those treated exclusively with medication relapsed at a rate of 50 percent, while those who also received talk therapy had a 33 percent relapse rate. Still high, but significantly lower than the drugs-only approach.
The authors' conclusions? Talk therapy matters. And 16 weeks is not enough treatment for those with major depression. This at a time when many managed care companies permit just 20 appointments per year, and often authorize no more than eight. Is managed care costing more than it saves? A study designed to test that hypothesis would be massive and expensive. The answer is not yet known.
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.' "
Over the last six years, the average hospitalization at McLean, a Harvard-affiliated mental hospital, has dropped from 70 days to 13. For Medicaid patients, the average hospitalization for September of 1996 was 7.8 days. Yet most drugs take three to four weeks to stabilize people.
Few would argue that long hospital stays are inherently good, or that pure talk therapy is more effective than some of the new medications. The question is, has the pendulum swung too far?
Psychiatrist Frederick Schiffer thinks it has. He is suing insurance giant Blue Cross Blue Shield of Massachusetts, alleging that it pressures clinicians at every turn to give less care faster. He contends that Blue Cross limits patient access to eight appointments per year while "falsely advertising" benefits of 20. He also claims that the company terminated therapists who advocated for more care.
Susan Leahy, director of media relations for Blue Cross Blue Shield, disputes those charges. She concedes that Blue Cross gatekeepers approve appointments eight at a time, but believes the practice is justified. "Blue Cross is using basic nationwide managed care principles," she says.
That, Schiffer contends, is just the problem. After the first eight appointments, he says, it becomes harder to persuade the gatekeeper the patient needs another eight. As for firing the psychiatrists -- well, there are two different accounts. Leahy says the company did it to provide patients with more "variety" (now, she says, clients can choose a social worker, a psychologist, or a psychiatrist). Schiffer says they did it to save money.
On this much, Schiffer and Leahy agree: in 1993, Blue Cross bought out Bay State Health, a managed care company. By early 1994, it had terminated 85 percent of BSH's psychiatrists, leaving 8000 patients looking for new clinicians.
Leahy says that Blue Cross paid for hundreds of patients to continue seeing their original doctors for up to a year, although she couldn't provide documentation "because we don't have those records." Schiffer believes the company did it to intimidate practitioners into requesting fewer appointments.
Many clinicians feel similarly, but few are willing to say so publicly. Several interviewed for this story requested aliases, and one refused to speak at all, even on background, citing "complications."
Privately, many say managed care companies attempt to serve two masters: patients and executives in a for-profit corporation. Inevitably somebody loses, they say, and that somebody is usually the patient.
Richard Sheola is more sanguine. Sheola is CEO of Massachusetts Behavioral Health Partnership, the company that administers mental health services to state Medicaid patients. He believes the two masters are yoked, pulling in the same direction: Partnership, he explains, profits not just from spending less than the cap, but also from administering better care.
When Partnership contracted with Massachusetts to manage the state's Medicaid mental-health program, the contract stipulated that some of Partnership's profit would come from meeting a set of "performance standards." Some of those performance standards are administrative (paying claims within a certain number of days) and some are therapeutic (finding a person in crisis a hospital within three hours). Meet those standards and both the company and the patients benefit.
Sheola believes the program is working well for everyone. In its first year managing Medicaid's mental-health services, Partnership met or exceeded all 10 performance standards and ran in the black. He and others associated with Partnership point proudly to the fact that the Alliance for the Mentally Ill of Massachusetts (AMI), a grassroots organization for the mentally ill and their loved ones, received just three complaints about Partnership in the company's first 11 months of operation -- a phenomenally low number, considering that Partnership serves 80,000 patients.
But the number of complaints is hotly disputed. The Boston AMI office sticks by the figure of three, but other AMI representatives say that can't be accurate. Ronnie Darlington, whose experience with her son's tragic early release led her to work as an assistant advocate for AMI of Western Mass, says she receives 12 to 15 complaints about Partnership a month at her office alone. Mostly, she says, people complain about clockwatchers. They complain that treatments and hospital stays are far too short, jeopardizing their loved ones.
Practitioners I've spoken to say that in a decade, or two at the most, psychiatry as we know it will be extinct.
The ranks of traditional practitioners are dwindling, and managed care has changed the focus of psychiatric training from individual evolution to quick fixes. "The residents know psychotherapy intellectually but hardly ever see a patient for more than a year," says Cecilia Mikalac, a psychiatrist who leads an annual seminar at UMass Medical School.
Sam Holden puts it a different way: "It's as if a surgeon-in-training saw part of the surgery -- opening up the patient, seeing the tumor -- but left before learning how to take it out," he says. "Would you want that surgeon to operate on you?"
We are living through a paradigm shift in our understanding of human beings and how they work, perhaps as great -- and as disorienting -- as the publication of Darwin's Origin of Species. If Darwin's theory of evolution made us feel less divine, perhaps the new drugs, the reduction of the brain to a series of chemical functions, make us feel less human.
Few would choose to go back to the days before Clozaril, when an anti-schizophrenic drug gave patients tics and contortions and Parkinson's-like shaking. But what if the patient had the benefit of the powerful new drugs, complemented by the skilled and artful practice of traditional psychotherapy? Thanks to the collision of managed care and psychiatry-by-prescription, we may never know.
Lisa Birk is a freelance writer living in Cambridge.
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