Psychiatric Units Across Mass. Face Shut Down

Several community hospitals in central and western Massachusetts have closed or are considering closing their psychiatric units. Some major Boston teaching hospitals are worried, in this economy, about how to keep this money-losing service afloat.

Dr. Paul Summergrad, head of the psychiatry department at Tufts Medical Center, joined us to explain why the problem is so acute.

Bob Oakes: Why are so many psychiatric units facing shut down?

Dr. Paul Summergrad: Psychiatric units in both general hospitals, and there are also private psychiatric hospitals, are generally underpaid for their services compared to the cost of providing care. And that becomes very challenging to provide care, if you're constantly losing money on the care of those services.

So generally speaking, psychiatric units are not money makers in hospitals. Is that generally speaking or is that pretty much across the board?

I think that's pretty much across the board. You know, if you look at the way in which hospitals are reimbursed, care generally falls into three or four different buckets in terms of who pays for care: Medicare, Medicaid and then the commercial insurers, and then there's a smaller component of free care in the state because of health care reform.

Both Medicare and Medicaid may roughly cover the costs of care or lose a little bit, but the amount of patients who are cared for under Medicaid is relatively small, and then hospitals make up the difference in the care that's provided to commercially-insured individuals.

But when you look at psychiatry, you lose money to a significant degree on Medicaid -- Medicaid has been cut back because of state budget cutbacks, and also it's a much larger percentage of the total care that's provided, and on the commercial insurance side, there's no place to make up the shortfalls from Medicare and Medicaid.

Your point of view as a professional in the field: Are insurance companies, private insurance companies — Blue Cross Blue Shield, Harvard Pilgrim, Tufts — not paying enough for the psychiatric services delivered?

I think it's not just them, it's also that there are fourth-party companies. Because of those large, national for-profit companies, it's lowered the reimbursement for all hospitals. Now can hospitals stay in business, can they make it — some of the private psychiatric hospitals have been able to.

The units in the general hospitals, though, are particularly stressed because they've got larger expenses because of being in general hospitals, and often there are patients who are more medically complicated, and the costs of providing that care are greater than the reimbursements from those commerical insurers.

Is there a bias against mental health care?

I think there is. It's very hard to talk about mental illness. If I say the word mental illness to you, you may think of schizophrenia, you may think of somebody who is psychotic or who is homeless. But the reality is that mental illness and mental health care involve a whole range of different kinds of illnesses — everything from anxiety to patients with substance abuse to patients with more severe mental illness.

And there's a tendency to look at this as a responsibility of individuals, underplaying the reality of the biological and the genetic factors that are associated with these illnesses.

So big, broad-brush question here: What can be done about all this?

It's a great question and I'm not sure that there's a simple answer. I think in the short term, I think there needs to be an understanding that the hospital system is at increasing risk. So there needs to be great care in looking at further cuts or the reimbursement for these services.

Longer term, we need a system of reimbursement that's a little bit more fairly structured.

OK, that might be the desire or the goal, but let's talk about the likelihood of any or all of that happening. Do you think that psychiatric services will ever pay for themselves?

I think that they will be more challenged than most other services to pay for themselves. I think, however, if you step back and you look at the broad impact of psychiatric illness, there's many, many medical illnesses that can cause psychiatric symptoms, and there's tremendous co-morbidity between substance abuse, medical illness and psychiatric illness.

So as we look at health care reform, there are tremendous opportunities on both the cost side and on the quality side, as well as on the reimbursement side, to handle the way psychiatric care is delivered in a more integrated and thoughtful way.

Dr. Summergrad, thank you very much for coming in, good to meet you.

Thank you very much for having me.