ADAPTING TO MANAGED MENTAL HEALTH CARE

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Go to Cultural Anthropology and Fairy Tale site, Bent Lorentzen

Do Suicides Return a Bigger Profit than Treatment?

by Bent Lorentzen

200 years ago, some of America's mentally ill were publicly flogged. Many were chained in dank wards far from public view. Along came humanitarians, like Boston's John McLean and Moses Sheppard of Baltimore, and the advent of private psychiatric hospitals with quality treatment as the operative word. But something terrible, according to many experts, has happened in the past four years.

Even as Hillary and Bill touted health care for all, and one of the President's friends committed suicide, mental illness became a political scapegoat while health management organizations (HMOs) and insurance companies ripped mental health benefits to shreds. Sure, these corporations articulate a need to reevaluate the "quality" of all health care with cost-effective criteria but they also lobbied Congress to block a recent proposal to put the treatment of suicidal depression on par with cancer treatment. Some hospitals are fighting back. Not with controversy. But by adapting.

Is it working?

This article is an intimate view of this situation from all sides. Some of the names here have been changed to protect the anonymity of patients but the events described are verifiable.

For several years, D.C.-resident Doug has been battling post traumatic stress disorder and depression. The same year White House Chief-of-Staff, Vince Foster, committed suicide, Doug's sister attempted to take her own life. She succeeded with an overdose in December of '95. That loss triggered in Doug a series of events which led him to separate from his wife and to a phone booth off I-95 near Boston in a last-ditch plea for help on a hot line. State troopers, alerted to a possible suicide attempt, descended around Doug's car. Doug agreed to be taken to Lahey Clinic in Burlington, Massachusetts. Lacking a psychiatric unit, he was transferred to the Boston University-administered Human Resources Institute (H.R.I.).

After spending 24 hours in what Doug described as a "feces-smeared hellhole of a unit," H.R.I. transferred Doug to the psych unit at Boston's Beth Israel Hospital because his insurance company would not pay for private psychiatric hospitalization.

In verifying H.R.I.'s conditions, a spokesperson there said, "The inpatient acute unit? It's pretty rough up there. I won't lie to you."

Following ten days of crisis intervention and medication-induced stabilization, a social worker arranged for his transfer to an innovative partial hospitalization/partial residence program at the campus-like McLean Hospital in Belmont, Massachusetts. Singers James Taylor and Ray Charles have confirmed treatment there. Sitting on a knoll, the 240-acre forested facility has also been the refuge for several well-known politicians.

For considerably less than $100 a night, Doug paid out-of-pocket for nightly sleeping at the once-visionary children's cottage: Hall Mercer. Looking much like a Buckminster Fuller design gone awry, Hall Mercer houses three dozen clients participating in a 7-day-a-week partial hospitalization program. Most have temporarily lost their ability to function in society. Only three years ago, many would have been prescribed--with insurance company approval--a lengthy inpatient stay. Doug was admitted into the Mood and Anxiety Partial Program (MAPP).

For ten years, Joanne, a Rhode Island single mother of four, had been in treatment for depression. In January of '96, her psychiatrist determined that she was slowly committing suicide because of an eating disorder. He and a consulting MD arranged a three-month stay at Remuda Ranch in Arizona, an intensive eating disorders facility. Still enrolled with her ex-husband's insurance company, Metro-West Travellers, Joanne fought tooth and nail together with her doctors to finally put Remuda Ranch on their "providers" list. But that took a half year, during which time her ex-husband's work-related insurance company changed to Blue Cross Blue Shield Health Mate 2000 Rhode Island. They, according to Joanne, did not initially recognize her eating disorder as an illness warranting a stay at Remuda Ranch. Instead, she was rushed to a local hospital for two weeks where she was tube-fed. In last minute negotiations, Joanne was given the option of short-term treatment at local hospitals--none of which offered, in her words, "effective eating-disorders treatment."

"All I'm trying to do," said Joanne tearfully, "is give my kids a better quality of life than I had as a child. But my insurance companies are f------g me over."

Jack, a Florida resident, has suffered from a life-long personality problem. One hot, muggy day in Miami he called his psychiatrist, saying, "I'm gonna' kill myself." Suddenly a Dade County Sheriff's helicopter hovers like an angry bee overhead, spotbeam illuminating the phone booth for the two deputy cruisers that screamed in on the scene. Against his will, he is taken to Jackson Memorial Hospital in Miami, where he is "Baker-acted," meaning that he will be observed for a minimum of three days in a glass cage housing dozens of men and women with critical psychiatric conditions. One doctor, a nurse along with three hulking "counsellors" make up the treatment team. There are no group therapy sessions and a T.V. up on a wall blares unceasingly in the only space patients can sit.

Jackson Memorial would not comment on these conditions, except to say that there has been severe service cutbacks in recent years.

Jack's family has seen this happen before but are aghast at the conditions. He is released to their care but takes flight for Massachusetts. After going on a spending binge and becoming suicidal again, he winds up at McLean's Hall Mercer. His insurance company says he can stay thirty days. But two weeks into his treatment at the MAPP/partial residence program, he "runs away" to a nearby hotel.

"I couldn't sleep," he said. "Three people in my cubicle snored, the food was awful and the place freaked me out." But now his insurance company won't pay for further treatment at McLean. "They said, 'if I'm well enough to go to a hotel, I'm well enough to be on my own.'" Things between Jack and his family deteriorate and he becomes suicidal again. This time he is taken to a 17-patient psych unit at Deaconess Hospital in Boston. But his insurance company will only authorize two weeks of inpatient treatment. His family has allegedly disengaged themselves from Jack. And the hospital's social worker can only find accommodations in a homeless shelter. Jack's last words as he fades into America's growing homeless subclass: "I don't care anymore."

In 1991, Janice resided at Pozes-2, a locked unit at the Menninger Psychiatric Clinic in Topeka, Kansas specializing in treating women who had been molested as children. A vast, forest-shrouded campus adjacent to the Governor's Mansion by the Kansas River, many of the clients received inpatient treatment for six months or more. While in a dissociated state (she has multiple personality disorder), she escaped on a wild trip to Oregon. When she finally came to her senses a week later, she was rushed back to Menninger where her insurance company did not balk at her continued treatment. Today she is homeless on the beaches of Los Angeles, having fallen through the cracks because, in her words, "I had to finally get on Medicare and used up my lifetime inpatient cap on psychiatric hospitalization. I've been raped, ridiculed, eat garbage, and don't give a shit anymore."

Said one psychiatrist who insisted on anonymity, "lots of chronically ill patients are falling through the cracks because managed care and insurance companies are making patient-care decisions based purely on economics. Perhaps if more mentally ill patients and their families would sue the HMOs or insurance companies after poor treatment resulted in a suicide attempt, the tide would change."

Bob Lawton, Director of McLean Hospital's Dissociative Disorders and Trauma Partial Program, empathized with this sentiment. "The pendulum," he said, "seems to have swung from one extreme to the other. One extreme, several years ago, was when there was too much money put into long term inpatient care. The pendulum has swung the other direction, now, where there is not enough money put into the care that many really need. It would be nice if HMOs & insurance companies could realistically look at what patients need in a cost effective way. The government could do a better job. I would hope the pendulum would swing more to the middle so that the control of services is done by the clinicians providing the services."

McLean Hospital, until recently ranked as the number one psychiatric hospital in America by US News and World Report, is considered by many experts to be leading the charge to meld the economic pressures of managed health care with effective treatment of chronic mental disorders. After all, it is a teaching hospital for the country's oldest university: Harvard.

But it comes at a cost.

Rumors of selling the hospital property and consolidating its services to Massachusetts General Hospital preceded an unprecedented layoff of nearly sixty employees in recent months along with work-hour reductions of another forty. In the past couple of years, mansion-like cottages on the campus have been boarded up, food services and maintenance subcontracted, and 190 beds don't exist anymore. In 1995, the average length of stay at McLean was 14 days. Compare that to 96 days in 1985. All this is the direct result of insurance company and managed care dictates. Readmissions are being analyzed to determine if shorter stays contribute to the exacerbation of illnesses. However, the data may be skewed due to the recent propensity to transfer poorly insured patients to local general hospitals.

Managed care organizations, both nonprofit and for-profit, and insurance companies insist they make individual care decisions based on quality and on what is in the best interest of the enrollee's group. For-profit organizations also must return a profit to the investors. And this may mean that when moneys grow scarce, services for the more chronically ill will be limited so that all the enrollees of an insurance company or managed care organization can be allotted benefits. Thus also, a highly complicated and business-like tack is taken by these corporations to compute the "quality" of care metered to someone chronically ill. Statistics and risk-factoring are indulged. There is even speculation that suicide risk is determined not in terms of a human life lost but in terms of what treatment might mean financially to the corporation. This is the extreme. The New England Journal of Medicine began a series in September of 1996 on the new frontiers in the quality of health care and how that "quality" is being redefined by corporate pressures in ways that might actually be beneficial in the long run.

In the long run....

What McLean has done--many hospitals are paying close attention--is to interface novel, short-term, aggressive, cognitive behavior therapy regimes with a patient's social and family environment. Thus have sprouted the Bipolar and Psychotic Disorders Program (BPDP), MAPP, Alcohol and Drug Program, and many other specialized partial programs tailored to the corporate push for more cost-effective treatment. But the process, the transition, is proving painful to many.

Nancy Pruett, Ph.D., came to McLean after working in Paris. She has been a clinical team manager since MAPP's inception in March, 1995. She believes, as do most who work with the MAPP program, that the transition to shorter inpatient stays and increased partial hospitalization programs is good. "Because of the increased pressure to have short stays in both residential and partial programs," she said, "the treatment issues addressed tend to be of a here-and-now nature: what is currently disturbing a patient from being able to function in the community. We take a no nonsense approach and address the most critical issues first. Our mission is to get them back in the community and to get them to a lesser level of containment."

Peter Chorus, MD, has been on the medical staff at McLean since 1967. He is now MAPP's medical director. His face grew pained when asked what was behind the recent and dramatic reduction in services to patients. "It's not an easy question to answer as to whether they [HMOs & insurers] are motivated financially or concern for the patient. It's both. Some people take a long time to feel a trust in the program. And some people show a burst after only a month in the program. HMOs and insurance companies question the continued use of the program if the patient doesn't show progress."

Asked if he's seen problems with the insurance company push to quickly discharge patients, Dr. Chorus said, "Yes... I mean that's what you worry about: the suicidality of patients. The other thing that's very hard is trying to convince the managed care people [that] patients might need a program as a support not to do something impulsive, commit suicide or something like that. You might not show progress at first. But if you jerk away what's being offered it might be a disaster but you can't prove that until it happens. I've seen situations more on the inpatient services where a patient might be discharged prematurely. Yes I have seen disasters."

Boston's WCVB Channel 5 Chronicle of September 18 investigated the "mis-managed care" of HMOs. A judge ordered that Keith Darlington be treated in a state hospital for six months. Two months later Keith was sent home, his family thinking that Charles River Mental Hospital had worked a miracle on their son. Keith promptly committed suicide. His parents say they believe the clinical staff at the hospital were "wonderful but were encouraged to prematurely let persons out."

That leads to another problem in mental health treatment. What about state run facilities? In a rush to put black ink on state ledgers, governors are cutting back on services. Massachusetts' governor Weld's privatization initiatives has closed down state hospitals and has put care of state mentally ill out to bid. "Privatization has been a catastrophe," says Matthew Dumont, M.D., a psychiatrist at Westboro State Hospital. But this claim is repudiated by the Department of Mental health. "No," counters Dr. Dumont, "The whole thing stinks of money; the insurance industry has the entire health care industry by the neck. To have the profit making institutions being the deciders on what the appropriate treatment is and the duration of that treatment is to have wolves deciding how many sheep should stay in the coral."

Further investigative reporting by WCVB found Psychologist Paul K. Ling, Ph.D. alleging that his requests to HMO Blue of Massachusetts for more sessions with patients put him on a black list. He and Frederic Schiffer, M.D. of Harvard Medical School brought suit against Blue Cross Blue Shield (BCBS) of Massachusetts accusing it of deliberately frustrating insured patients and their doctors. Richard Cornell, M.D., former Chief Medical Officer of BCBS said, "There's no conspiracy." But Mark Hudson, who worked the phones for BCBS has testified that the phone system is set up to avoid payment by putting people on hold up to an hour. "I often," he said, "heard screaming, crying by patients wanting help."

Mark alleges that his position, before being fired for "excessive absenteeism by BCBS," consisted of fielding phone calls from insurees requesting psychotherapy. With a high school diploma, he claims that he was told to make up diagnoses on the patient's permanent record. Nancy Langman-Dowart, BCBS Mental Health Director, shook her head in the interview, saying, "Phones are staffed by clinicians. No one is asked to make up diagnoses. It doesn't happen."

Baltimore's Sheppard and Enoch Pratt Hospital, another forested facility founded in 1853, has had to sell much of its land to the adjoining Towson State University. Moses Sheppard, a deeply spiritual man who actively helped Baltimore's poor and assisted freed negroes of Maryland to migrate to Africa, was aghast at the treatment "the insane" received. At that time, the mentally challenged poor were chained and often publicly flogged. This inspired Moses Sheppard to found an "asylum free from any political domination or control."

Insurance companies and managed health organizations are lobbying Congress to pass increasingly stringent psychiatric care limitations. The recent woes of the mental health care parity ammendment is an example. On April 23, 1996, in a 100-0 vote, the U.S. Senate passed the Domenici Wellstone mental health parity amendment attached to the Kennedy Kassebaum Health Care Bill. The amendment would have forced health care managers/insurers to provide the same consideration for psychiatric conditions as with any other medical condition. The House yanked out the rider in Committee. With the support of Senator Kennedy and Republican Domenici, the mental health parity amendment was re-introduced by being attached to the Veterans Administration Housing and Urban Development Bill. This time it passed through both Houses, and was signed into law by Clinton on October 25. Mental health treatment in America is generally viewed as secondary to the medical treatment of traditionally organic illnesses.

To be fair, major insurers/HMOs nationwide are showing incredible losses. Kaiser, with a Massachusetts enrolment of 43,000, lost nearly $4 million in the past half year. HMO Blue, into which Bay State recently consolidated and the largest enroller of clients, lost over $17 million in the same period. Increasingly, these insuring organization have to cut costs and manage health care in areas never before considered their purview, including a dramatic reassessment of mental health benefits. In the Sept. 2, 1996 cover story of U.S. News & World Report, HMOs were rated according to the quality of care they provided. Ironically, nowhere in the three-article story was mental health treatment given even cursory discussion.

Hoping that parity between mental health care and that of organic problems be firmly adopted, McLean's Dr. Chorus shook his head: "It's clear that mental health problems are as biological as any illness. Depression is biological. You can trace the biological origins of manic-depressive diseases. Schizophrenia is a physical illness. That's not to say there are not psycho-social components that skew the mix. You always have to understand if a person has such an illness they are affected in their living space too, and are traumatized by having this disease and so psychotherapy is always helpful along with medication. If you look at eating disorders, there's always depression mixed in, there's always a little OCD [obsessive-compulsive disorder] mixed in there. Eating disorders can lead to death. Look at Karen Carpenter. I don't think there's any doubt that such illnesses have a biological base. They should be treated on par. It's silly to see it any other way."

Patrick Carnes, Ph.D., an internationally recognized authority on surviving trauma-related addictions and author of several books, sees the problem culturally. "We have a health care crisis in that what we're really creating is a mental health 'homeless.' Therapy is good for everybody. It should be a right, just like education and medical care. It is the shortest course that I can see to transforming many of the larger ills of our culture. What with constant wars and mass starvation? Make therapy available to people. What we're doing instead, for the same reason we're creating the homeless (it's about money and priorities), is creating a subclass of people. There are many who deserve and need therapy, and we will be a much stronger nation if we foster a Danish-like openness where perhaps a future generation will be functional enough to address our serious world problems."

This echoes author Robert Bly's assertion that many of America's deeper ills are the result of a socially accepted denial about mental illness. "Ninety-six percent of America is either dysfunctional or in denial," he said. Robert Moore, a Jungian psychologist friend of Bly agreed: "Our world has come to the point where not only can we commit personal and systematic suicide because of unresolved childhood issues, but we can destroy the very planet. Most men are in gross denial of this blatant fact."

Iceland's Throstur Bjorgvinnson, a Harvard and Queens University (Ontario) doctorate's intern at McLean Hospital, said, "My biggest cultural shock in coming into this country was seeing how terribly patriarchical and cruel mental patients are treated by insurance companies. We, in Iceland and Denmark, would never let people fall through the cracks like this because someone's welfare is everyone's responsibility. That's in the interest of the nation. It will cost more in the long run to not appropriately address a person's mental health now than later when it becomes a much bigger problem. There have been so many studies which have shown that implementing good treatment programs at the early portion of an illness saves a lot of money.

"To separate drug or alcohol addiction from other illnesses just perpetuates a vicious cycle that goes from generation to generation. I just don't understand why this society is making these short-term and narrow sighted decisions about treatment. Cost cutting now will mean bigger costs in the future. There is no limitation in Iceland placed by insurance companies. Everyone has access to the treatment equally. The treating doctor makes the determinations as to what a patient gets. Sometimes the resources are limited though. Of course, there are only 250,000 people in Iceland. "

The tall, red-haired intern's view is tempered by pragmatism. "But in Iceland, too, there is a trend toward partial programs and reduced inpatient stays, absolutely, and it is not pressured by insurance companies. It makes clinical sense to keep a client in his or her own environment as much as possible while they are being treated. So what is happening here may not be all that bad so long as insurance companies don't get too much power over the doctors."

Bob Lawton agrees. "I think it's mostly beneficial that there is less long term hospitalization. Many who used to stay for several months could have been as well if not better treated with a partial program that had as its goal dealing with the problems they has as well as assimilating them into the community. For the most part, this transition to partial hospitalization as stimulated by HMOs and insurance companies and the economics has better served the patients. I don't think that's true of every patient; some could still benefit from long term inpatient stays: those chronically suicidal or deeply self-injurious."

He added, "I honestly don't see a lot of people who fall through the cracks, become homeless, because of HMO or insurers restricting mental health benefits."

Helen, a McLean Hospital patient battling anorexia neurosis, depression and alcoholism for over a year sighed when asked if she knew of people falling through the cracks because of the hospital's budget woes. "There are many people who are smart and who have a lot to offer to this world but who may never have that chance because their minds are chronically affected and insurance companies won't let them have treatment. Right now I know a lot of good people this is happening to. For me, I am grateful to McLean and what I am learning with the help of all these Harvard interns."

Sixteen-year-old Katrin's grandfather died in post-war Germany. She could not stop crying after the church service. Her father took her to the local doctor in northern Germany, who said, "Her behavior is just bad. Why don't you take her out and give her a good beating."

"Well," said Katrin, "I got a good beating with a riding whip. And this really caused a revolt in me. I just felt so insulted and hurt... and cried even more."

Next day she was taken the to the only psychiatrist in the region, who admitted her to a university hospital. Her doctor diagnosed schizophrenia and treated her with restraints and forcing convulsions with insulin overdoses.

Now nearly sixty, she has assimilated well into the MAPP program at McLean. Her schizophrenia diagnosis is no more. "For the first time in years I feel very hopeful. I can work sometimes four hours a day. But it hasn't always been easy here in America, especially in the last few years."

She was hospitalized in the 1970's at Danvers State Hospital in Massachusetts. "It was an experience. Everybody got clothes and were well fed and treated. There were all kinds of programs." She shook her head. "But now all these state programs are gone. Danvers has closed. Even here at McLean's things are sometimes hard. But McLean's adaptation to less money is just incredible. I am really learning a lot about myself and how to make that work at home and in the community."

Doug, whom we met at the beginning of this article, is doing well and has reintegrated with his community. His feelings about all this: "I think it's a crime what's happening with insurance companies and their power over treatment. I know of so many who have become homeless because of that, especially because of the Medicare lifetime cap on inpatient treatment, and I've heard stories about people committing suicide because they were denied treatment. Cognitive Behavioral Therapy, as done at MAPP, isn't for everyone. Some just can't hack its aggressive, take-responsibility format. It's about slowly rebuilding thinking habits that play into emotions and behavior. But it worked for me, and for most whom I've met at McLean's. I know a Dr. O'neill at McGill University in Montreal who thinks it's the ideal program to make intensive therapy cost-effective for the Canadian health system."

But the process of adapting to these for-profit pressures is hurting a lot of people. A counsellor at Boston's Healthcare for the Homeless said, "Yes, definitely there are many people we see coming through here who need a lot of psychiatric help but couldn't get it because of insurance and can't keep up with holding their homes together. They become homeless. They'll come in for their appointments, get meals at the soup kitchens, and they go back to their little spaces in the parks. It's kind of sad but it's happening more and more."

As if symbolic of those many no longer receiving needed care, a patient at McLean who was recently discharged because his insurance company wouldn't continue paying had nowhere to go except to sleep homeless in the forest encompassing the hospital. A forest that may soon be sold and literally turned into a graveyard.

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