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Mental care can be hard to find

Survey shows many roadblocks to aid in Boston facilities

By Chelsea Conaboy
Globe Staff / July 21, 2011

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Massachusetts patients with top-flight medical insurance may still find it difficult to get the mental health services they need, according to research from Harvard doctors released today that provides fresh evidence of a crisis in psychiatric care.

Researchers at Cambridge Health Alliance and Beth Israel Deaconess Medical Center called 64 mental health facilities within a 10-mile radius of downtown, posing as patients with Blue Cross Blue Shield insurance who were evaluated for depression at emergency departments and discharged with instructions to get a psychiatric appointment within two weeks.

Just four facilities could accommodate an appointment that soon, the researchers said. At four others, appointments were available - but more than two weeks later.

Fifteen facilities, about 23 percent, never returned the call, even after a second attempt. Another 23 percent told callers that patients had to have a primary care doctor within that facility’s system to be seen by a psychiatrist.

With those odds, “it’s quite unlikely that a severely depressed person could persevere’’ to get care, said Dr. Steffie Woolhandler, an author and former Cambridge Health Alliance primary care physician now at City University of New York.

The study was submitted to the Annals of Emergency Medicine but declined for publication on the grounds that it needs to be replicated on a larger level. Instead, the journal asked the authors to submit their results as a letter to the editor, scheduled to be published today.

The study grew out of concern from physician trainees in psychiatry that patients seen in the emergency department were unable to get follow-up care, Woolhandler said.

Dr. J. Wesley Boyd, a Cambridge Health Alliance psychiatrist, said he has seen mental health services squeezed in recent years by internal policies and shrinking reimbursements to physicians and clinics.

Cambridge Health Alliance is one of the largest in-patient mental health providers in the state but has scaled back services in recent years. Because of a reduction in state aid, Cambridge Health Alliance cut adult psychiatry beds about 39 percent, to 89. It also limited outpatient services to patients living within the hospital’s direct service area or those with a primary care doctor in the system.

The latter requirement, Boyd said, amounts to “a secretive way of rationing of care.’’ Hospital systems don’t put up such roadblocks for patients seeking high-paying imaging services or surgery, he said.

“Until psychiatry is better reimbursed, and this is not just an insurance issue, this is a social and cultural issue . . . there are going to be extreme limitations on services that are available to patients,’’ said Boyd, whose own private practice is at capacity, requiring him to turn away patients.

The state Legislature is considering a dramatic shift in the way hospitals and doctors are paid. Instead of receiving a payment for each service rendered, providers would receive a lump sum to cover all of a patient’s care. A leading consumer advocacy group, Health Care for All, said it believes the proposed payment system would encourage doctors to forge connections with patients before the onset of a major psychiatric episode, thus keeping people well and avoiding costs.

The Harvard study “reflects the kind of upside-down priorities of our health care payment system, where specialty care is very well remunerated and mental health is almost a stepchild of the health care system,’’ said Brian Rosman, research director of the consumer group.

Woolhandler, an advocate for a single-payer health system, said she worries that the proposed payment system may encourage hospitals to focus on healthy patients and avoid caring for people with high-cost mental illnesses.

Blue Cross Blue Shield spokesman Jay McQuaide took issue with the study, describing the researchers as opponents of private insurers who were trying to extract higher reimbursement rates for themselves.

McQuaide said the study was “an attempt to publicly pressure the state’s health plans, like Blue Cross, to pay these clinicians more money which, frankly, is disappointing.’’

The authors dismissed that claim, saying that only two of the five authors are psychiatrists and the real goal of the study was to examine access to mental health care.

McQuaide said that Blue Cross would be concerned if doctors in its network were turning away patients or, worse, not returning phone calls. Enrollees can call the customer service line listed on their insurance card if they are having trouble.

“We would find them an appointment,’’ he said.

Chelsea Conaboy can be reached at cconaboy@boston.com.