Author's note: In the aftermath of the Sandy Hook School shootings in Newtown, Connecticut on December 14, 2012, I was reminded of an article I wrote for Psychiatric Times magazine during 1997, five years after I completed my residency training. Sadly, not only has nothing happened to change conditions in psychiatry for the better, but the grip of third party insurers on mental health care providers has only tightened. The issues which this article raises are even more important to address today than they were 15 years ago, when the piece was published. That is truly tragic.
I share this commentary of mine with you to give you insight into how the next potentially suicidal or homicidal individual might well be treated in any emergency room in America.
It was a bad combination, I'll allow that. The call from the emergency room reached me the Saturday morning after I had finished reading Ayn Rand's "Atlas Shrugged." I hadn't gotten a lot of sleep, partly because I finally reached page 1,168 around midnight, partly because I couldn't get my mind off John Galt, Hank Rearden, Francisco d'Anconia, Dagny Taggart and the rest of Rand's characters. Before I drifted off, I was already drawing parallels between the current state of psychiatry and Rand's fictional world in which the mind is denigrated, and autonomy and free will nearly stamped out."We have a problem," the crisis worker in the emergency room informed me. "There's a young man here who came in with serious suicidal ideation, but the HMO won't authorize hospitalization."
"You mean they don't want to pay," I said wryly.
"They don't want to pay," she chuckled.
"Tell me the history," I said. I got out of bed and went to the den. Long calls early in the morning disturb my wife. This sounded to me like the beginning of a long call.
The history, with minor changes to protect confidentiality, is as follows: A 23-year-old African American male had been brought to the emergency room by his aunt about 5 a.m. The young man, jilted by a woman he loved, had rented a hotel room. Alone. There, after writing a suicide note and drinking an entire bottle of vodka, he called friends to say "good-bye," that he would be dead by morning. He planned to suicide by leaping out his 22nd story window. It was the second time in as many weeks that he had expressed his desire to do away with himself. Only after his family and his friends begged him for hours did he agree to let his aunt bring him to the hospital. His blood alcohol level was nearly .300.
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I asked whether the patient were on any medications and learned that a week earlier he had been placed on a starting dose of an SSRI, but that he had complained that the medicine made him feel more agitated, not less depressed. He described feeling as if he were "jumping out of his skin."
"What's the insurance company's reasoning for not authorizing the admission?" I asked.
"I made the mistake of telling them that he 'contracts for safety.' So they want him treated in 'intensive outpatient therapy."'
"What's that?"
"I don't know. I assume it means we should get him an appointment very soon."
"Ask for a doc-to-doc," I told her.
The HMO doctor paged me, and I returned his call. "I think we have a fairly simple situation," I started. I told him the details of the case. "So," I concluded, "given the fact that the patient is male, suffering with major depression, not responding well to his antidepressant, at risk for continued substance abuse and expressing serious suicidal ideation for the second time in just two weeks, I was hoping we could admit him to a locked unit."
"But I was told the patient came willingly to the emergency room and is contracting for safety."
"He came with his aunt," I allowed. "He desperately wants to go home and did pledge he wouldn't do himself in. Those things are true. But we can't know, of course, whether he'll have a change of heart-another wave of grief, perhaps a disappointing phone call from his ex-girlfriend-that would send him over the edge. And he has every risk factor for suicide: his gender, his Axis I condition, the fact that his medication isn't helping and is causing him side effects, his substance abuse."
"Wrong," the reviewer said. "He has every risk factor but one."
"What's that?" I asked.
"He hasn't actually tried to kill himself."
"True," I allowed. "Not yet."
The "not yet" probably rankled the HMO doctor. It was, I suppose, a bit contentious on my part. "It's my position that he doesn't merit hospitalization," he said crisply. "Now, if you'd like to examine him personally and call me back with more data, perhaps something might change. But, given what I've heard, he should be seen in 'intensive outpatient.' That's my best clinical judgment."
That last statement was the trip wire that explosively connected the moment with my reading Ayn Rand the night before. It was John Galt who came to mind, the man who orchestrates the departure of the world's intellectual and industrial leaders from the world stage, leaving behind a society without creativity or commitment. I thought particularly of one line in his soliloquy to the world: "Do not help a holdup man to claim that he acts as your friend and benefactor...Do not help them to fake reality. That fake is the only dam holding off the terror, the terror of knowing they're unfit to exist; remove it and let them drown; your sanction is their only life belt."
"You don't have clinical judgment," I told the HMO doctor, the holdup man.
"Excuse me?"
"You can't hear the case impartially because you're motivated to not spend money. If this young man were your son, or anyone you cared about, you would hospitalize him. You would be very worried about his safety. You know that. I know it."
"I resent..."
"I have nothing more to say to you." I hung up. It was the right thing to do, but I was worried. I was speaking for the hospital and speaking my mind at the same time. There could be repercussions. Needing reassurance, I went back to the bedroom and picked up my copy of Atlas Shrugged. I flipped to Hank Rearden's speech to a panel of judges trying him for his refusal to surrender Rearden Metal to the state.
"If you choose to deal with men by means of compulsion, do so," Rearden told them. "But you will discover that you need the voluntary cooperation of your victims, in many more ways than you can represent. And if your victims should discover that it is their own volition-which you cannot force-that makes you possible. . . I will not help you to disguise the nature of your action."
My beeper went off again 15 minutes later. A female physician informed me that she was an out-of-state reviewer called in when a physician reviewer from the HMO and the psychiatrist-on-call disagree. "It's a little like mediation."
"Except you're paid by the other side," I said, trying to put humor in my voice.
"Let's stick to the case, if we can."
I described the patient in detail for her.
"I'm afraid I agree with the last reviewer," she said. "If you feel differently, you're free to admit the patient. We're not saying you shouldn't. We're just saying that, at this time, we can't assure you reimbursement. In fact, payment would be unlikely."
The Rand philosophy was so fresh in my mind, I couldn't resist applying it. "We're not in the business of giving away our services," I said. "We offer free care to indigent patients regularly. This patient has insurance. You would have to pay for his treatment."
"Whether you admit the patient is up to you," she repeated.
"No," I said. "I don't think so. I think when the insurer refuses payment that is tantamount to deciding that the individual ought not be admitted. I don't want to participate in that kind of shoddy care. I won't be part of it. Where should I send your patient?"
"What?"
"Tell me where to send him. I'll put him in an ambulance to any facility you choose. If you shop him around, eventually you'll come up with the answer you're looking for. You've got mine. He needs admission. And you'd have to pay for it."
This time, the reviewer was the one to hang up.
I felt energized. I was telling the truth to an insurance reviewer. I wondered whether I might lose my job. About an hour passed before my beeper chirped again. It was the emergency room. "They've approved the patient for a 23-hour holding bed," the crisis worker said.
"We have those?" I asked.
"It's just a bed on the regular locked unit. But I think they pay less for it. Or maybe they're just saying we shouldn't expect to get paid for it for very long."
"Oh." I felt I had won a partial victory. "I was pretty firm with the out-of-state reviewer," I said. "I guess they figured better safe than sorry."
"Maybe. I also called the HMO with another piece of information. It seemed to get them more anxious."
"What was that?"
"There's a family history of suicide. The patient's uncle and cousin both took their own lives."
I shaved, worrying all the while what would happen if the administration of the hospital learned of my battle with the HMO. Perhaps I could have found some middle ground. I picked up "Atlas Shrugged" again. John Galt lectured me:
There are two sides to every issue: one side is right and the other is wrong, but the middle is always evil. The man who is wrong still retains some respect for the truth, if only by accepting the responsibility of choice. But the man in the middle is the knave who blanks out the truth in order to pretend that no choice or values exist, who is willing to sit out the course of any battle, willing to cash in on the blood of the innocent or to crawl on his belly to the guilty...who solves conflicts by ordering the thinker and the fool to meet each other halfway. In any compromise between food and poison, it is only death that can win. In any compromise between good and evil, it is only evil that can profit. In that transfusion of blood which drains the good to feed the evil, the compromiser is the transmitting rubber tube...When men reduce their virtues to the approximate, then evil acquires the force of an absolute.
I felt better. I had shrugged off an HMO this once. But a sense of melancholy took hold during the days that followed. For the truth is I am still Galt's man in the middle. I indirectly (by virtue of my hospital salary) take money from insurance companies who do not have the best interest of my patients at heart. I am still available to talk on the phone with physician reviewers who have "sold out" and pretend to continue doctoring while actually scamming money from people in pain. I usually even manage to address them with feigned respect. I fill out forms to get permission to treat patients from professional looters directly responsible for the increased rate of suicide in my state.
What we should do, all of us, is shrug. We should collectively refuse to accept HMO insurance for our good services. That would preserve the integrity of our profession, take us out of the middle and put us on solid moral ground. If other specialties followed suit, no consumer would pay for managed care coverage. We would stand for the truth-in individual lives and in society. Ultimately, we would force a reengineering of the health care delivery system in the direction of conscience. But it would be a long, terribly risky and costly journey.
I don't pretend we are about to take it. We are not prepared to tell the complete truth or act on it. That level of moral courage, I suppose, is truly the stuff of fiction.
I've never read "The Fountainhead." I think I'll pick it up.
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