Moreover, no psychiatrist will be listed by name, address, and telephone number in the Blue Cross/Blue Shield of Connecticut Directory of Participating Physicians in BlueCare (the HMO with which PsychCare is involved). Members and their primary care physicians will not be able to determine whether a community psychiatrist is participating in PsychCare Inc. and, therefore, will not be able to choose a qualified psychiatrist. In fact, much of the time members will not be evaluated and treated by psychiatrists. Members and their physicians will have to call an 800 telephone number to be directed by a PsychCare Inc. "referral service" to the "most suitable provider." According to Dr. Robert Ostroff, medical director of PsychCare Inc., their 30 psychiatrist investors currently represent "275 professionals" affiliated with them. Inspecting the lobby directory in an office building where one of these 30 psychiatrist investors is practicing makes one aware of a remarkable and sudden increase in social workers and nurse practitioners working in these offices.

After a 20 percent risk withhold, PsychCare rates 45-minute psychotherapy sessions, CPT 90844, at $60, no matter what the training of the actual provider of services is. (In Connecticut Title XIX pays $47.50 for such psychotherapy.) Shorter psychotherapy sessions, CPT 90843, or medication management, CPT 90862, are rated at $40, while psychiatric inpatient visits, after the first day, rate $44. Deductibles and copayments are taken off these rates: copayments for CPT 90844 are $10 for the first five visits, $25 thereafter. Hence, from the sixth visit onward PsychCare's actual outlay is $35 for a 45-minute psychotherapy session, $15 for shorter psychotherapy sessions or medication management.

This fee schedule will enable PsychCare to cover an entire year's once-weekly 45-minute psychotherapy for less than the statutory minimum of $2,000 per calendar year for psychiatric outpatient services, mandated by Connecticut law for all HMO membership contracts signed in the state. Since it would be extremely difficult for a psychiatrist to maintain an office with payments of $60 for an hour of psychotherapy, in addition to uncompensated time for authorizations, treatment plan and treatment outcome forms, medical records, and billing and financial records, it is very clear that people will be discharged from medically necessary treatment. That is the purpose of the vise. How will the 30 psychiatrist owners of PsychCare Inc. treat their patients? Simple! People will be seen by part-time or full-time social workers and nurse practitioners at a direct cost of approximately $25 an hour.

The $35 difference between PsychCare's $60 rate for CPT 90844, or the $75 difference between PsychCare's $100 for two CPT 90843 sessions, and the $25 direct hourly pay to mid-level professionals will go for overhead and a neat substantial profit to the owner-investor psychiatrists.

PsychCare Inc. retains the right to terminate the contract with participating psychiatrists for causes including, but not limited to, 10 listed possibilities. Among them: "The Provider engages in any activity to disrupt PSI's business or the business of any payor" (emphasis added) and "PSI determines, in its discretion (emphasis added), that Provider does not qualify or meet applicable standards of recredentialing." Furthermore: "The Provider agrees that all proprietary information. . . including. . . reimbursement methods and rates (emphasis added), network information. . . is the sole property of PSI. The Provider further agrees to keep this proprietary information strictly confidential. . . ."

The contract between PsychCare Inc. and Blue Cross/Blue Shield of Connecticut is worth $5 million to $6 million a year. Thirty psychiatrists have put up $5,000 each, that is, PsychCare has an apparent initial capitalization of $150,000. A 10 percent profit on sales a year, not unreasonable in a business venture, would amount to $500,000, or approximately $17,000 a year for each psychiatrist investor in return for an initial investment of $5,000. Not bad for an investment! But such potential profits would be realized on the backs of our fellow citizens and from the blood and sweat of Connecticut psychiatrists by denying medically appropriate and necessary psychiatric treatment to unsuspecting members of Blue Cross/Blue Shield of Connecticut. The membership contracts of these citizens do not specify that they and their physicians will not be able to access a psychiatrist directly and to choose whom they want to see; that much of the time they will not be treated by psychiatrists but by surrogate mid-level "therapists"; that they can get only evaluation and very brief psychiatric services; that when appropriate, services get to be more prolonged they may be denied and dubbed "medically unnecessary"; that they can be treated only for Axis I disorders; and that_according to a current ploy of HMO's_the treatment of Axis II disturbances such as borderline personality disorder, schizotypal personality disorder, or narcissistic personality disorder, or of chronic mental illnesses may not be authorized.

I call on APA's leadership to establish a binding code of ethical conduct for psychiatrist administrators and psychiatrist investors in managed care ventures. If such psychiatrists do harm to patients whose welfare they have sworn to uphold by taking the Hippocratic Oath, they should be removed from membership in APA.

It is outrageous that APA's Consultation Service, supported by funds from members' dues, participated in setting up this program, which can be viable only by denying medically necessary services by psychiatrists to desperately ill citizens, medical services to which they are entitled by their health insurance contracts.

Connecticut psychiatrists have an additional concern: an officer of the Connecticut Psychiatric Society is one of the founders of and investors in PsychCare Inc. Participation by persons who hold office in APA and its district branches in enterprises such as PSI, one of whose existential goals is to limit or deny psychiatrically and medically appropriate and necessary treatment by psychiatrists to patients, raises serious issues for APA.

Robert Stern, M.D., Ph.D.

New Haven, Conn.

(Psychiatric News, December 6, 1996)