Backward to Nowhere

TO THE EDITOR: Dr. Becker’s (1) Open Forum essay in the October 2015 issue is an excellent, disturbing, and accurate wake-up call describing how political, social, pharmaceutical, and insurance company policies have eroded and diminished the psychiatrist’s role in training for and providing effective leadership and collaborative care to meet the contemporary needs of individuals coping with severe and persistent mental illness while attempting to live in the community. But it omits another vitally important piece of the puzzle: the role of health care corporations.

From 1980 until 1994, I was professor and chairman of psychiatry at the Milwaukee Campus of the University of Wisconsin School of Medicine at Madison (2). The department was located in an inner-city general hospital during the days before insurance parity, and our faculty and residents provided care to a population of largely indigent, uninsured, and Medicaid patients. Over 15 years, five inner-city hospitals providing psychiatric care merged or went bankrupt, and the remaining few coalesced into three large, allegedly “not for profit” health care corporations. Cut-throat competition, managed care guidelines, managers trained in business schools, and ill-advised state legislation led to a situation that I described in “A Piece of My Mind” for JAMA (3) as a “health care holocaust.”

Driven by its bottom-line mentality, the largest corporation, brandishing its motto “No Margin, No Mission,” could not make sufficient profit to maintain our inpatient unit, closing it down and ending our newly accredited residency program—the pipeline for psychiatrists in a region that desperately needs them. Currently, all three not-for-profit and one for-profit corporation recruit and hire full-time well-paid psychiatrists, who prefer a bountiful salary free of the administrative burden of private practice. Some provide only inpatient care, functioning as “hospitalists,” and those who see outpatients often work under productivity constraints that encourage them to shun Medicaid patients and sometimes Medicare patients as well.

One result is that Milwaukee is known nationwide for a poorly coordinated, underfunded, and understaffed public behavioral health system, with high recidivism rates. It is now desperately attempting to upgrade in the face of a shortage of well-trained psychiatrists and a reluctance by the not-for-profit corporations to share the burden of admitting poorly reimbursed and sometimes disruptive patients, whom they judge to be incompatible with their pristine inpatient units, and to collaborate in interdisciplinary outpatient care in community settings.

There is also the sad fact that salaried psychiatrists owe fealty to the corporation that pays them, rather than to their state or national organizations, which formerly provided an opportunity for collegiality and a potential for effective political action.

Erewhon or not, Dr. Becker and I, presumably along with a silent cadre of elderly retired psychiatrists, grieve for a profession going backward to nowhere.