xxAACP Newsletter, Volume 14, Number 4, Fall 2000
GUEST EDITORIAL
The Tin Hospital
Across from the main entrance of Boston’s Beth Israel Deaconess Medical Center (BIDMC), where I work as chief resident of the 25-bed inpatient psychiatry unit known affectionately as "Deac 4," crouches the skeletal remains of a brick building, a victim of "phase I" of BIDMC’s "turnaround plan." Who would have thought a structure made of the very material the Big Bad Wolf could not blow down could be demolished in a few short weeks? These days, as I watch the wrecking ball pound the gutted remains, I think of the department of psychiatry at BIDMC which is under an attack by the board of the hospital and its parent corporation, CareGroup. Last week the board announced that psychiatry, save a small consult service, is to be eliminated. Just a few weeks ago one of our three inpatient units was closed, reducing inpatient psychiatry beds from 60 to 43 only six weeks after the news of the first "reduction." Now, after a weekend retreat worthy of Edward Scissorhands, the board of CareGroup has agreed to the recommendations of it’s CEO, James Reinertsen, that "inpatient psychiatry will be discontinued, and there will be no outpatient psychiatry department."
This impulsive edict is grossly immoral. My friends in psychiatry, nursing, occupational therapy and other services will lose their jobs. My residency– Harvard-Longwood, a combined program of BIDMC, Brigham and Women’s Hospital and the Massachusetts Mental Health Center, which has provided residents with a nationally recognized combination of excellent medical, psychodynamic and community psychiatry is faced with amputation of major service and educational opportunities. Worst of all, our patients, who get exceptional care at our hospital will lose out. My unit, Deac 4, contracts with the state department of mental health to treat those chronically and severely mentally ill patients eligible for public sector services. BIDMC’s other remaining unit, Six North, specializes in treating medically ill and geriatric patients and also college students. Neither unit will be replaced according to current scenarios.
Despite this awful news– this devaluation of the entire psychiatric community–the citizens of Boston are apparently to be reassured by the full-page advertisement from the pen of Dr. Reinertsen run in the Boston Globe not once, but twice this past weekend. It reads, in part: "our patients always have and always will come first." The psychiatric patients, who currently may wait over 24 hours in emergency rooms for psychiatry beds or board on medical units with no psychiatric treatment, are apparently not included in the category "our patients." Dr. Reinertsen has informed the BIDMC community by e-mail that decisions about which services to cut (or, in the cases of obstetrics, dermatology, and orthopedics, "trim") were made not on the basis of which departments were "lucrative," but rather based on "space." But the fact of the matter is that psychiatry, while it reduces costs to hospitals by treating the many somatically-focused patients who would otherwise use a greater proportion of medical services and by decreasing length of stays of patients with medical and psychiatric comorbidity, loses money. According to the system of accounting wherein psychiatry shoulders the same amount of overhead per square foot as does the intensive care units, we operate in the red. Hospitalized patients have gotten sicker and reimbursement has not followed.
Medicare and the HMOs, which dominate the insurance landscape in Massachusetts, don’t pay for the full services their patients receive. Our patients have a high rate of recidivism; our medications are expensive and require monitoring. And most damaging to the bottom line, there is often no place for our patients to go after discharge. We continue to treat on inpatient units those severely ill patients who could be discharged to drug rehabilitation programs, half-way houses, day hospitals or psychiatric shelters– if only those places had beds. There is simply no room at the inn.
While the public sector managed to treat severely mentally ill patients for eighty years, the private sector, which has failed the commitments it made only eight years ago, has decided to send those patients with brain illnesses, our psychiatric patients, to the street. The profit-based hospital system is kicking us out and the question that arises is this: Can public-sector care be managed under a system of capitalism which dedicates fewer and fewer resources to social services (unless, of course you wish to count the "correctional" system)? Investment bankers make bundles of cash by skimming a bit of lucre off the top of the deals they broker; even union organizers can fund their operations on the sweat equity of their workers by the system of monthly dues. But you just can’t squeeze dollars from the homeless or from the addict or from the schizophrenic. A system of competition which causes the best and cheapest doo-dad in America to gain ascendancy, does not work when there is no product and therefore no profit.
How then to treat these capital-less patients? It seems to me that the how is in the why. We treat them because we should treat them: it is our responsibility, the responsibility of our community, and of our nation. The richest country in the world in the middle of a decade-long boom economy has both a moral and a practical imperative to treat it’s most beleaguered citizens. As William Black wrote: "A dog starved at his master’s gate/ Predicts the ruin of the State." The people must elect a government with a ethos based on decent treatment of all citizens which funds hospitals which treat all patients. As community psychiatrists know, without a little socialism mixed in with our capitalism, the United States, like the Beth Israel Deaconess Medical Center, is like a tin man without a heart.
Bristol Myers Squibb Fellow
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