I sent an e-mail to one of my colleagues last night about a bill introduced in the state of Minnesota that would potentially allow managed care companies to replace inpatient psychiatrists with nonphysicians. She thought that was consistent with the managed-care model of high volume and low quality inpatient treatment. She also reminded me of the concept that inpatient units used to be a place where people came to heal. Over the years that I worked in inpatient settings it is apparent that severe psychiatric disorders take their toll and it takes a lot to recover. Many people are admitted with acute hypertension, dehydration, malnutrition and weight loss, tachycardia, acute blood loss, and any number of stressful physical conditions in addition to their primary psychiatric diagnosis. At least half of the patients admitted to the acute psychiatric inpatient units have been using alcohol, cocaine, or other intoxicants that worsen their physiological state. In some cases such as catatonia, the psychiatric illness alone is life-threatening. Before there were effective treatments some forms of catatonia had an 85% mortality rate.
Not too long ago when we had more functional inpatient treatment people had time to recover. It was not uncommon to see patients with bipolar disorder take at least 2 to 4 weeks to recover from an acute episode. Inpatient psychiatrists and nursing staffs were experts in supportive care and patience invariably left the hospital in much better condition than they came in. That is no longer the case. Today the artificial pressure to make money restricts inpatient care to a number of days rather than weeks. That is well below the time frame that it takes for any of the known psychiatric medications to actually work. In the case of the patient with mental illness and substance abuse disorder, they may have only completed detoxification stage by the day of discharge. They leave the hospital in only slightly better shape than they came in. In many cases, their families were trying to assist them prior to admission and they discovered they could not help.
I don't think that there should be any mistake that the current system is driven strictly by cash flow and the cash flow to psychiatry has always been limited. The business of managed care companies is not to give patients with severe psychiatric disorders the time they need to heal. The business of managed care companies is to make money and use any rationalization along the way to do that. Those currently include the idea that you should only be on an inpatient unit if you are acutely suicidal or aggressive. The other consideration is that the inpatient atmosphere should not be designed with patient comfort in mind, because we all know that if is too comfortable - somebody might want to stay longer than the system wants them to.
George Dawson, MD