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April 10, 2015 at 06:45 AM
(Bloomberg Business) — The profession of psychiatry didn’t have a place for a patient like Derek Ward in the months before he brutally murdered his mother and then killed himself.
Voices had crowded the 35-year-old’s head. The once-successful personal trainer now spoke of drones spying on him and the CIA infiltrating his Long Island, N.Y., apartment.
For months, his mother Pat Ward, a well-respected English professor, had been franticly trying to get him an appointment with a psychiatrist. Yet dozens of doctors said they either didn’t take his insurance or wouldn’t see patients with Derek’s complex condition.
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Many simply never returned her calls. At one Long Island hospital, four doctors to whom she was referred told Pat their next appointment was three months away — an all-too-typical wait time, according to Ward’s brother, Robert Lubrano, a Catholic priest who helped her in her quest.
In the $100 billion mental health industry made up of doctors, clinics and hospitals, the hard cases — patients with government-funded insurance, psychosis or a history of drug addiction — are sometimes finding it nearly impossible to get help. Instead, a growing number of psychiatrists, hit with cuts from insurers, are focused on cash-paying patients with easier-to-treat conditions. The government-funded community clinics, meant to serve as the safety net, are at capacity after funding cuts during the recession.
“I think it is one of the greatest public health crises we are facing today,” says Ron Honberg, the national director for policy at the National Alliance on Mental Illness who sees “tragic situations” all around the country.
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So while Pat Ward, 66, waded frantically through a labyrinth of rejection — a maze negotiated by untold thousands every year — Derek drifted toward the abyss. Finally, she landed that elusive appointment for Oct. 31, but it would come too late. The last threads holding Derek to reality were about to snap.
“My sister is dead because she couldn’t get Derek an appointment with a doctor.”
Three days before the scheduled visit and four days after his medication ran out he killed Pat with a kitchen knife, decapitating her and dragging her body and severed head into the street outside their home in Farmingdale, New York. It was a crime so gruesome that a passerby thought it was a Halloween prank. Derek then walked to nearby railroad tracks and threw himself in front of a commuter train.
No doubt Derek’s psychosis killed him and his mother that day. Yet even in such an extreme case, the Wards’ family and friends also blame a mental-health system in which fewer doctors are willing to care for those who need help the most.
“My sister is dead because she couldn’t get Derek an appointment with a doctor,” says Lubrano, who talked to Pat almost daily about her struggles.
An increasing number of doctors have been dropping insurance as demand grows from easier to treat, high-dollar cash clients — the anxious Wall Street bankers, worried soccer moms or depressed college graduates, who don’t usually phone them in the middle of the night or pose a safety threat.
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Since 2005, the number of psychiatrists taking private insurance or Medicare has dropped almost 20 percent, to 55 percent, as of 2010, according to a study in the Journal of the American Medical Association. That compares with other specialties where 93 percent take private insurance and 86 percent take Medicare.
The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and the Patient Protection and Affordable Care Act (PPACA) — Obamacare — were supposed to help level the playing field by requiring individual and small-employer insurance plans to include mental health benefits. Yet because of the low reimbursement rate paid by many of those plans, few doctors will take them, and those who do have long waits.
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Central Nassau Guidance & Counseling Services, a publicly funded mental-health clinic near where the Wards lived, doesn’t take any of the plans sold on the PPACA exchange, which reimburse doctors 40 percent less than other insurance, says Jeffrey Friedman, the clinic’s chief executive officer. It already loses an average of $20 a visit for a privately insured patient, he says.
In Maryland, only 14 percent of the 1,154 psychiatrists listed in-network for plans sold in 2014 on the PPACA insurance exchange had an appointment available within 45 days, according to a recent study by the Mental Health Association of Maryland.
Meanwhile, states had cut mental-health funding by $4.35 billion following the recession, including money that helps support community clinics, according to the National Alliance on Mental Illness. While that trend began to reverse itself in 2013 as the economy healed, mental-health spending is still below pre-2009 levels.
Insurance companies have followed the downward trend as they try to control rising medical costs. While many doctors have been squeezed, psychiatrists say it is especially bad for them. Florida Blue, a Blue Cross & Blue Shield company, paid $72 for a standard office visit with a psychiatrist while a primary-care doctor got $134 for a visit requiring a similar amount of time, according to 2014 billing documents obtained by the American Psychiatric Association.
Florida Blue takes a number of factors into account when determining reimbursement rates, says spokesman Paul C. Kluding. These include the number of providers available in the same medical field, the geographic area of particular providers, the insurance products that the providers participate in and the type of medical services provided to its members, he says.
“When providers choose not to participate in network, there’s no protection for patients against balance billing or exorbitant chargers.”
The insurance industry’s job is to get the best value for its customers and the rates insurers pay are based on negotiations with doctors, says Clare Krusing, a spokeswoman for America’s Health Insurance Plans (AHIP).
“Health plans negotiate with providers to ensure patients get the best value for their health-care dollars,” says Krusing. “When providers choose not to participate in network, there’s no protection for patients against balance billing or exorbitant chargers.”
Money isn’t the only issue. Many psychiatrists, particularly those in private practice, won’t take appointments with more complex patients like Derek Ward, who often have histories of drug dependency, multiple hospitalizations and deep psychosis. They say those types of patients are too time consuming, especially after hours, according to interviews with more than a dozen doctors and patient advocacy groups. One doctor says he also worries they could a pose greater risk of physical violence.
“In solo practice, they might not have the infrastructure for dealing with the needs of patients with multiple concerns — social problems, income instability or housing issues,” says Harold Pincus, vice chairman of psychiatry at Columbia University.
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Into this sea change came the Wards.
