What's killing psychiatry?

Part 5

by Lisa Birk

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.

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Lisa Birk is a freelance writer living in Cambridge.