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By Michael DeWitt, M.D.
As psychiatrists today we find ourselves frustrated trying to treat patients who have life-threatening but treatable conditions. I wrote the following article in an effort to educate the general public about the conditions under which we now practice. I offer it here in hopes that my colleagues will come forward and share their stories.
One recent Saturday I met a delightful young person, a bright university student accomplished in athletics and academics; in short, a child of promise. In recent months, however, she had developed a major depressive disorder. On Friday she had lost all hope. She was discovered five hours after taking a potentially lethal overdose in secret. Public safety officers responded with skill and efficiency. They took her to a local general hospital where she received excellent medical care. I was informed of her situation by a university psychologist, because I have a contract with the university to provide emergency psychiatric care.
Thankfully she stabilized quickly from the overdose. Ironically, her dream is to be a doctor, specifically an oncologist.
My initial treatment plan consisted of a brief psychiatric hospitalization at another local general hospital that has a psychiatric unit. There her treatment could be continued by doctors I know, who are familiar with this university, and have ongoing relationships with personnel there.
Once I got the patient's insurance card, the odyssey began. The card said, "US Healthcare," an omen to someone more cynical than I am.
I called the number, and an automated response answered "Aetna/US Healthcare." After an interminable wait, I spoke with someone to try to arrange precertification for psychiatric inpatient treatment. I was told that mental health benefits are managed by Human Affairs International and given another number. That makes it corporation number three. When I called that number, I learned that "those benefits are carved out in North Carolina" to the fourth corporation, Merritt Behavioral Care. I called the company, which verified coverage and told me a "clinician" would call me.
Eventually I was called, and I explained that this patient had been hospitalized overnight after an overdose and identified the hospital. The clinician immediately interjected that this hospital was not approved on this plan. I politely said that that was not my concern and then added, with sarcasm, that when someone is unconscious and has taken a potentially lethal overdose, saving that life takes priority over hospital selection. In fairness to this clinician, she listened attentively and with genuine concern and agreed that my patient needed hospitalization.
I called the first participating plan hospital, but it had no available beds. I ultimately arranged transfer to the second on the list. I had now spent three hours and 15 minutes on this case, of which at most 75 minutes were spent with the patient and her family. At least-or so I thought-I had assisted the patient in getting transferred to a safe place for definitive care.
On Sunday morning university personnel informed me she was about to be released by the hospital! She returned to her dormitory that afternoon, where the psychologist had already alerted housing personnel to be aware of her situation and provide assistance as needed. On Monday I learned that counselors at the university had stretched themselves and their heavy schedules to see this woman. In fact, they made plans for her living situation and academic status to accommodate her illness.
The insanity of modern medical economics became apparent after asking a few simple questions: Who provided what treatment, and who paid for it? Also, where did the patient's premium dollars go?
The last question first: At least four corporations make money from the patient's premium. The purpose of three of these corporations is to "control costs." A stay of less than 24 hours at the receiving hospital in Durham will be paid by the insurance company. As you can guess, this is at a drastically discounted rate, a rate that other reasonable and closer hospitals could not afford or, I expect, they would have been in the network.
Now let's look at the treatment. The individuals who responded and got the patient to the general hospital were public safety officers employed by the university. The psychologist who assisted with arrangements at the time of emergency and spoke with the family before my meeting with them is employed by the university. So was the other psychologist who made the specific living arrangements and academic plans for the patient after discharge. I will also be paid by the university for my time. It is unclear whether the general hospital and physicians who provided lifesaving treatment will be paid. I was told by the clinician that this hospital is not in the network. The hospital may not be paid at all, though it has incurred all the expense of treating her and pays the salary of the emergency room physician. The attending physician, who cared for the patient during her overnight admission at this general hospital, didn't expect to be paid and said he didn't care. The hospital either ends up paying by providing care for free or charges the patient and her family, who will be appropriately upset about having to pay for treatment that they assumed was covered by their insurance.
Let me point out a few of the more subtle problems. At least three corporations will make a profit "cutting costs" and in doing so create such a complicated situation that my time, and therefore my charges, are approximately triple what they would have been in a more sane system. Total costs for this treatment event were increased by the so-called cost-cutters, but that cost will be paid primarily by tuition dollars.
The vast majority of excellent care given this young woman was provided by people who will not be paid by the insurance company on which this family relies. If the university or I attempted to charge the company, we would not be paid.
As I was wrapping things up with this young woman, I said, "Hang in there. I may need an oncologist some day." She smiled; her hope was alive. I congratulated myself for saying just the right thing-something encouraging and affirming, something that brought back the perspective of the future for her.
Then I got to the car and wondered, Should I really be encouraging a young person to become a doctor at a time when providing the best treatment requires us to negotiate an obstacle course and ends up thwarting our decisions?!