Follow-Up Appointments Often Hard to Arrange

A survey of mental health facilities in the Boston area by individuals posing as patients recently discharged from an emergency department with mental illness found a remarkably low rate of available follow-up appointments—a finding that may come as no surprise to psychiatrists in every area of the country.

The survey, published as a letter to the editor in the August Annals of Emergency Medicine, found that of 64 sites that were contacted, only eight offered appointments, and only four offered "patients" an appointment within a two-week period.

"Disappointing but not surprising" is how psychiatrist J. Wesley Boyd, M.D., Ph.D., the lead author of the letter, described the results in an interview with Psychiatric News. "What this speaks to in my mind is the under- or de-valuation of psychiatric care."

He is with the Cambridge Health Alliance Department of Psychiatry and the Department of Psychiatry at Children's Hospital Boston.

Two study personnel (including a psychiatry resident who was also a coauthor of the letter and a college student applying to medical school) posed as patients insured by the Blue Cross Blue Shield of Massachusetts Preferred Provider Organization, the largest insurer in Massachusetts. They called every in-network mental health facility within a 10-mile radius of downtown Boston, claiming to have been evaluated in an emergency department (ED) for depression and discharged with instructions to obtain a psychiatric appointment within two weeks.

According to Boyd, when necessary the "patients" left a message and made a second call attempt.

("Facilities" contacted in the survey included mental health clinics, hospitals with psychiatric departments, and neighborhood clinics in the Boston area.)

Boyd explained that the survey was originally designed to be a comparison of private insurance and Medicaid, and because reimbursement is so low in the Massachusetts Medicaid plan that virtually no private practice psychiatrists participate, the survey was confined to facilities and did not include private-practice clinicians.

The phone calls were first made to the Blue Cross facilities, and the results were so poor that Boyd and his students did not proceed with calling the Medicaid facilities.

The principal reasons for failure to make an appointment were that calls were not returned or that the facility required patients to have an in-system primary care provider. Six sites stated that they needed more information before scheduling an appointment.

Assuming that the six sites would have offered timely appointments, Boyd estimated that the highest number of facilities that would have had appointments available within the two-week period for all 64 sites that were called was 10 (15.6 percent).

He also added that the requirement by facilities that patients have an in-system primary care provider is one that does not typically apply to any other medical service and constitutes what he called a form of "stealth rationing."

"Psychiatry is underreimbursed and a money-losing specialty for hospitals, yet they have to offer psychiatric services," he noted. "So how do you limit the [financial] pain? By limiting the access as much as possible. That doesn't happen if people need cataract surgery or a hip replacement or an MRI."

In the Annals letter, Boyd stated that a third of homeless individuals and more than half of all prison and jail inmates have mental illness and that the nation's EDs have become "de facto psychiatric wards, with 79 percent of emergency physicians reporting that their hospitals board psychiatric patients for whom appropriate treatment resources could not be found, sometimes for days."

In remarks to Psychiatric News, Boyd said an architect friend of his who designs hospitals has informed him that he now designs EDs to include space and beds for boarded psychiatric patients. "So we are now actually designing emergency departments with space and room for boarding patients who can't get care," he said.

The causes of this dearth of available follow-up care are multiple, but Boyd said a principal problem is the low reimbursement for psychiatric care. "We call for higher reimbursement," he said. "That is more than an economic issue; it is a social and cultural and political issue. We are reimbursing poorly for services necessary to patients who can't adequately advocate for themselves, something that speaks very poorly of our culture."