Night Shift
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“Hmmm,” I said, half snorting, half sighing as I scanned my email in-box. “It looks like now every insurance policy is going to have to cover psych admissions.”

“Are you sure you want to read the New York Times before going to bed this morning?” my wife asked, tilting her head. I looked at her, then at the dog, who had tilted her head in the same questioning way. “You always get yourself so worked up you either can’t sleep, have nightmares, or talk in your sleep all day long and wake up exhausted. You’ll be half psychotic yourself by the time you wake up to go back to work. I guess, at least now maybe our insurance will cover it.” She chuckled at her own joke which caused the dog to wag her tail in excitement.

“This isn’t about psychotics,” I said spoiling their fun. “They say it will ‘help prevent gun violence’,” I said using my newscaster voice.

“Why not? It seems like it might help.”

“All those wackos who end up shooting up a McDonalds are seldom on the loose because they lacked the insurance to be admitted to a psych hospital. ‘Oh, I know you’re a potential mass murderer, but I can’t admit you to the hospital because your insurance won’t cover it. I hope you’re not mad at me or anything’.”

“I think you’re getting psychotic already,” she said with a shrug. The dog slinked under the kitchen island.

“They’re out on the street because nobody knows they are that sick. Haven’t you watched the news? ‘He was such a nice boy,’” I said in my granny voice. “Well, until he set fire to the police station. Even the ones that you really aren’t comfortable with seldom give you enough to take them off the street for any appreciable time. It’s a civil rights thing. Admitting someone to a psych facility against their will is almost as difficult as incarcerating them. Maybe even harder. You have to show that they are a real danger to themselves or someone else. And that’s really difficult.”

“Aren’t you always telling me about people who come in saying that they’re going to kill themselves?”

“Those people virtually never intend to kill themselves or anyone else. Most of them are drunk or high and have nowhere to go on a cold night. It’s three hots and a cot, baby!”

My wife and dog just looked at me blankly.

“They just want a meal and a place to sleep for the night,” I explained. “Just like you, Bodie,” I said, turning to the dog. Her ears went from perky, as if she was hanging on every word, to drooped, as though she were suddenly embarrassed. “It’s OK, Girl. You’re a dog. You’re supposed to be taken care of. People are supposed to take care of themselves.”

“I think you’re losing it.”

“I just find it frustrating that the federal government, which can’t pay the bill for what they’ve already bought, seems to go looking for more worthless things to borrow money to buy.”

“It can’t be that big of a deal, can it?”

“Actually, I already knew about this. There was a notice from the White House Drug Policy Director posted in the call room at the hospital. It just didn’t seem as official until the Times discussed it. The White House actually had a little different take on it than the Times, though. I think they were a little more honest about it’s intent. While the Times suggested that this new rule would prevent gun violence – which is baloney – the White House said this was all about requiring insurance to cover drug treatment. The notice said that a 2012 survey concluded that there were 23 million Americans in need of drug treatment and currently only 1 in 10 of those actually received treatment. And that’s where it becomes a big ticket item. If someone’s a little nutty and talking about suicide, we can admit them for three days max to figure out if they’re serious about it. But if someone is high or drunk and says they want to get off the sauce, now their insurance will be forced to pay for that coverage. And most of those programs can be 30 days of in-patient treatment.”

“But aren’t you always complaining that you had to hold some drunk all night while you looked all over for some place to take him? It doesn’t sound like you’re being consistent.” The dog looked at me with one ear up and one down as if to emphasize the question.

“Oh, I know it sounds like it could make things go smoother in the ER. Who knows, maybe I’ll even make some money off these patients now. I just hate to see everyone forced to pay a fortune for something that probably doesn’t do a lot of good. I just don’t see these programs graduating many sober, straight people. If they subjected psychiatric treatment to the same outcome requirements that we have to show in medical therapies, I would suspect that most of the treatment facilities would close.”

“That’s a pretty cynical view of psychiatric care.”

“I wish it weren’t so. But it seems to me that there are a small few that truly require and benefit from psychiatric care. And then there is this huge group that either knowingly or passively milk the system.”

“Isn’t that true of many other areas of medicine as well,” she said tilting her head again with a look of motherly correction. Taking her cue, Bodie cocked her head at precisely the same angle. “Haven’t you told me that many of the people you see at night don’t need to be there?”

“Oh, that’s true,” I replied with some resignation. “But here’s the funny part – well, not funny, just hypocritical. The rule doesn’t apply to the government programs, Medicare and Medicaid. They still don’t have to cover drug treatment if they don’t want to.”

“Is this all a part of your government conspiracy paranoia? Do you think the government is trying to bankrupt the private system so we will all turn to a single payer government system to save us?”

“It’s not paranoia if it’s true,” I said.

“Isn’t the bottom line, though, that this will make it easier for you to get all those people out of the ER quicker into psych units? I hear you complain all the time about babysitting some drunk all night while you called all over creation to find an in-patient bed. Won’t it improve that situation?”

“You know, I’m not sure it will. First is the principle of ‘build it and they will come’. I’ve told you the numbers. I think that we could fill every psych bed that anyone could fill. And now, since private patients will be insured, the units will preferentially take them over the low paying Medicaid and Medicare patients that make up the bulk of these patients. I think, in the end, it could soak up all the available beds, actually making the problem worse,” I noted with an air of depression.

“Cheer up,” my wife encouraged. “I know they intended well.”

“Yeah,” I said defeatedly, “and you know what they say about good intentions.”

Mark Plaster, MD is Founder and Executive Editor of Emergency Physicians Monthly

 

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