Claudia M. Gold

Many will sink with healthcare ship

By Claudia M. Gold
January 25, 2010

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‘PLEASE REFILL Emily’s prescription,’’ the message read. “Dr. Jones, her psychiatrist, is no longer accepting her insurance.’’ I stared at the words for a few moments before I slumped into my chair, overcome by a feeling of helplessness.

One year earlier, Emily had come to see me in my pediatrics practice, where I treated her for attention deficit hyperactivity disorder (the details have been changed to protect the patient’s privacy). Over time it had become clear to me that her problem was much more complex. Finally, things reached a crisis point, and I sent her to the emergency room after she told me she was afraid she would hurt someone.

I wrote a column for the Globe describing the difficulty I had getting a psychiatrist to see her. But with persistence, I succeeded in transferring her to a psychiatrist. She engaged in weekly psychotherapy with a person she trusted and came to depend on. The psychiatrist and psychologist, part of the same practice, worked as a team, and could care for Emily in a way that I was not able to do. Equally importantly, her mother now recognized the value of this treatment.

A few weeks before I received this message, I saw Emily. Though I was no longer treating her ADHD, she just wanted to “check in’’ and let me know how she was doing. When I walked into the room, I was astounded at the transformation. For all of our previous visits, Emily had sat huddled in the corner of the exam table. She had made it clear that she just wanted to leave, and greeted all of my attempts to engage her in conversation with hostility. But that day was different. Her face was open and alive. She looked at me directly as she told of her success in school.

When I realized now that we were back at square one, my initial reaction of helplessness quickly turned to anger. But it was not clear where to direct it. First I became angry at Emily’s mother. Didn’t she understand, after all this time, that I could not provide the level of care Emily needed? But she had been bringing her children to our practice since they were born. Of course she would turn to us for help. Next, my anger went to the psychiatrist for dropping my patient. A conversation with his office showed me that he was not the right target either.

No, the appropriate target of my anger and frustration was clearly the out-of-state insurance company. There comes a point when due to the combination of high administrative costs and low reimbursement, it may cost a practice money to see a patient. In addition, the administrative complexities of Emily’s policy are enormous. The insurer withholds a certain percentage of the doctor’s payment, known as a “risk pool withhold’’ until the end of the year. The company, not the doctor, earns interest on that money, and if the company has a bad year, the doctor does not receive the money. If a practice has too many patients on insurance plans with high administrative costs and low reimbursement, that practice cannot remain financially viable.

So now I must resume the arduous process of getting help for Emily. She lives in a rural part of New York where mental health resources are severely limited. Finding another therapist-psychiatrist pair who accepts her insurance will be difficult. I fear that we will be on a slippery slope. She is a vulnerable teenager who now has to deal with the incomprehensible abandonment by her therapist (her family could not afford a weekly fee even if it were reduced). She will likely resist trusting another person.

I think of our health care system as a large, slow-moving ship that is headed for a precipice. Particularly toxic is the combination of a health insurance industry wielding huge power and a seriously undervalued system of primary care and mental health care. This serves to undermine prevention and early intervention. Unless we do something to change the direction of this ship - and that seems less likely after last Tuesday’s election in Massachusetts dealt a serious blow to the less-than-perfect reform plan - the ship will go down, and Emily and many like her will go with it.

Claudia M. Gold is a pediatrician who practices in Great Barrington.

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