Who will care for the crazy?
She was 18 and had been found hanging by a noose. But the moment I saw her insurer, I knew she was one of the lucky ones. First of two parts.

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By J.B. Orenstein

May 25, 2000 | Rachel came to our E.R. one afternoon shortly before Christmas. She had been found by a friend who came to visit her -- suspended by a rope around her neck.

The chart in my hand conjured up vivid images even before I entered her room. A portrait that pretty much matched her reality: not particularly pretty, her skin pallid, pasty; long, full, frizzled brown hair, indifferently gathered by a dark scrunchy. She wore dark grunge-style clothes: dark plaid shirt and jeans, a choker and metallic bangles. Couple of earrings, but not excessively pierced or tattooed. Uncommunicative. Vacant eyes. She told me too little for me to properly judge if she was inarticulate or merely silent.

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It didn't much matter, thanks to a single word on the chart: Kaiser.

Nowhere have the ravages of bottom-line scrutiny of modern medical practices so thoroughly gutted the ability to provide care for patients than psychiatry. It is akin to post-AIDS Africa: direly afflicted, worse with each acid day. And if a single story can portray a ruinous state of psychiatry today, perhaps it is the story of Rachel (not her real name) because she received routine-or-better care.

Not only did she have insurance, but hers was the only easy one to work. Kaiser provides (relatively) ample psych benefits and I wouldn't have to grovel, beg or lie in order to get her a bed somewhere. The most time-consuming task an E.R. doctor performs, in proportion to tangible benefit to the patient, is arranging for a psychiatric admission with an insurer. There is no extreme to which these voices on the phone will not try to push us to deny an admission. A fellow E.R. doc recalls being asked if he -- the E.R. doc -- had gone to the house to determine if his patient actually owned the gun with which he was threatening to commit suicide.

The benefits provided by insurance companies for mental illness are starvation rations. Reimbursement to providers for face-to-face services have been cut in half over the past 10 years. Dr. John Iglehart in the New England Journal of Medicine described typical benefits as consisting of "a maximum of 20 outpatient visits and 30 hospital days each year." They make Scrooge look like Raoul Wallenberg. With Kaiser Permanente, at least, getting through the door was far less of a Kafkaesque nightmare. They have beds and psychiatrists and are generally willing to marry them to the patient.

The E.R. is the current front line of psychiatric care. For the suicidal, the homicidal, the terrorized-by-voices, we have become the "de facto dumping ground," says the chairman of psychiatry at Inova Fairfax Hospital, Dr. Thomas Wise. A poor choice. A physical ailment can be readily summarized and packaged, without fear of shame or indignity, in the space of a few short questions and answers. At least enough to move a patient through an immediate crisis and into decisions regarding treatment and hospitalization. This we do well. Psychiatric illness, a disorder of mind and emotion, is also a malady with varying rates of therapeutic success, just like heart or liver disease. And we train, minimally, for these emergencies, too.

But the true pathologies are buried and layered beneath deceptions, embarrassment, anger. It can take hours to establish the true degree and nature of illness. Scratching the surface of a problem, an E.R. doctor's true specialty, in a psych patient only reveals another level of constructs to keep out strangers. When we're the ones to whom these patients are sent, everyone suffers.

Next page | With Rachel I did my job -- actually that's a lie
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