Commentary: Whose Side Are We On?

Nonprofit health maintenance organizations (HMOs) state that their goal is to serve the public, whereas the main goal of for-profit HMOs is profit generation. One might assume, therefore, that the operating procedures of these two types of HMOs would be different from one another. A recent experience of mine, however, suggests otherwise.

I routinely take calls at one of the psychiatric hospitals in the area. Although I am not a child psychiatrist, I am occasionally called to the child psychiatric unit to admit a new patient or in the case of emergencies.

I had just arrived at the hospital on a Friday evening when I was called to the child psych unit. A child who'd been admitted to the unit five days earlier had been told that he was going to be discharged and was "balking."

When I arrived on the unit I found out that "balking," in fact, meant screaming at the top of his lungs, crying, banging his head on the wall and swearing that he was going to jump out of the car on the way home and try to kill himself. He also screamed that even if he did make it home in one piece, he'd burn down his apartment and kill his whole family in the process.

"We can't discharge this kid like this," I said. "That would be crazy. I've admitted many kids to this unit who look better than this when they're admitted."

The nurse in charge looked relieved. "Thank you," she said. "That's exactly how I feel."

Since discharging anyone from a psychiatric unit late on Friday is generally a bad idea, I asked how it was that this discharge had been planned.

I was told that the discharge had not been planned, but that the well-established nonprofit HMO's psychiatrist who would be responsible for this child's outpatient care-and had not yet seen this child-called and told the psychiatrist in charge of the unit (who had already gone home for the day) to discharge the boy. The unit psychiatrist then called the unit and told the nursing staff to discharge him per the nonprofit HMO's request.

As I discussed the situation with the nursing staff on the unit, they told me that the same thing had happened with this boy one week earlier. They said that as he was being dragged out of the unit the previous Friday, he had vowed that he'd be back within three days because of multiple suicidal threats. When he managed to jump out of a moving car two days later, suffering minor injuries, his promise was fulfilled.

I was incredulous. We called the boy's mother to tell her that we would not discharge her son this weekend.

"But the [HMO] psychiatrist just told me that I'd have to pay $1,000 a day to keep my son in the hospital over the weekend, and I don't have that kind of money," she said. "I need to come get him."

"I'll take responsibility for this decision," I said.

"I can't take the chance that they'll charge me for the weekend. I'm coming to get him," she said.

She called a half hour later, crying, and told us that her car had broken down on the way to the hospital. In desperation she had spoken with the HMO psychiatrist who again told her she'd be responsible for the bill over the weekend if her son weren't discharged. What about the broken car? The patient's mother said she'd been told to have her son sent home in a cab.

"A cab?" I was stunned. A kid who had jumped out of a car five days earlier and who was swearing that he'd jump out of a car on the way home? A kid who was going to burn down his house? Discharge him at all-much less in a cab? I felt like I'd entered a fun house.

I told the mother, the patient and the nursing staff that no matter what the HMO said, this boy was not going to be discharged while I was on duty. I asked the mother who the HMO psychiatrist was and told her I'd speak with him myself. When she told me his name, my heart sank. It was a psychiatrist I knew, who most people found caring and competent, a devoted father to his own children.

I called this psychiatrist at home, told him what I'd heard, what I'd seen, and said that the boy was going to stay in the hospital. Without accusing him directly, I simply said that I expected that his mother would not be threatened with having to pay her son's hospital bill.

In his defense, this psychiatrist said that he feared this boy was becoming institutionalized. An institutionalized patient is managed care's biggest fear because an HMO depends on healthy patients, who do not utilize the services it (theoretically) offers, to remain financially solvent. Institutionalized patients are costly "utilizers."

"This boy may be becoming institutionalized, but wishing otherwise isn't going to change how he is right now," I said.

As I hung up the phone, I wondered, "Whose side are we on?" As psychiatrists, we actually work against the health of our patients when we succumb to the pressures our institutions place on us-when we start believing that working for the financial health of our institutions is our primary goal.

Whether "for-profit" or "nonprofit," HMO bureaucrats and administrators be damned, let us focus on caring for our patients and working toward their health. Doing anything else jeopardizes us all.