How psychiatrists are failing the patients who need them most

April 10, 2015 at 06:45 AM

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(Bloomberg Business) — The profession of psychiatry didn't have a place for a patient like Derek Ward in the months before he brutally murdered his mother and then killed himself.

Voices had crowded the 35-year-old's head. The once-successful personal trainer now spoke of drones spying on him and the CIA infiltrating his Long Island, N.Y., apartment.

For months, his mother Pat Ward, a well-respected English professor, had been franticly trying to get him an appointment with a psychiatrist. Yet dozens of doctors said they either didn't take his insurance or wouldn't see patients with Derek's complex condition.

Many simply never returned her calls. At one Long Island hospital, four doctors to whom she was referred told Pat their next appointment was three months away — an all-too-typical wait time, according to Ward's brother, Robert Lubrano, a Catholic priest who helped her in her quest.

In the $100 billion mental health industry made up of doctors, clinics and hospitals, the hard cases — patients with government-funded insurance, psychosis or a history of drug addiction — are sometimes finding it nearly impossible to get help. Instead, a growing number of psychiatrists, hit with cuts from insurers, are focused on cash-paying patients with easier-to-treat conditions. The government-funded community clinics, meant to serve as the safety net, are at capacity after funding cuts during the recession.

"I think it is one of the greatest public health crises we are facing today," says Ron Honberg, the national director for policy at the National Alliance on Mental Illness who sees "tragic situations" all around the country.

So while Pat Ward, 66, waded frantically through a labyrinth of rejection — a maze negotiated by untold thousands every year — Derek drifted toward the abyss. Finally, she landed that elusive appointment for Oct. 31, but it would come too late. The last threads holding Derek to reality were about to snap.

"My sister is dead because she couldn't get Derek an appointment with a doctor."

Three days before the scheduled visit and four days after his medication ran out he killed Pat with a kitchen knife, decapitating her and dragging her body and severed head into the street outside their home in Farmingdale, New York. It was a crime so gruesome that a passerby thought it was a Halloween prank. Derek then walked to nearby railroad tracks and threw himself in front of a commuter train.

No doubt Derek's psychosis killed him and his mother that day. Yet even in such an extreme case, the Wards' family and friends also blame a mental-health system in which fewer doctors are willing to care for those who need help the most.

"My sister is dead because she couldn't get Derek an appointment with a doctor," says Lubrano, who talked to Pat almost daily about her struggles.

An increasing number of doctors have been dropping insurance as demand grows from easier to treat, high-dollar cash clients — the anxious Wall Street bankers, worried soccer moms or depressed college graduates, who don't usually phone them in the middle of the night or pose a safety threat.

Since 2005, the number of psychiatrists taking private insurance or Medicare has dropped almost 20 percent, to 55 percent, as of 2010, according to a study in the Journal of the American Medical Association. That compares with other specialties where 93 percent take private insurance and 86 percent take Medicare.

The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and the Patient Protection and Affordable Care Act (PPACA) — Obamacare — were supposed to help level the playing field by requiring individual and small-employer insurance plans to include mental health benefits. Yet because of the low reimbursement rate paid by many of those plans, few doctors will take them, and those who do have long waits.

Central Nassau Guidance & Counseling Services, a publicly funded mental-health clinic near where the Wards lived, doesn't take any of the plans sold on the PPACA exchange, which reimburse doctors 40 percent less than other insurance, says Jeffrey Friedman, the clinic's chief executive officer. It already loses an average of $20 a visit for a privately insured patient, he says.

In Maryland, only 14 percent of the 1,154 psychiatrists listed in-network for plans sold in 2014 on the PPACA insurance exchange had an appointment available within 45 days, according to a recent study by the Mental Health Association of Maryland.

Meanwhile, states had cut mental-health funding by $4.35 billion following the recession, including money that helps support community clinics, according to the National Alliance on Mental Illness. While that trend began to reverse itself in 2013 as the economy healed, mental-health spending is still below pre-2009 levels.

Insurance companies have followed the downward trend as they try to control rising medical costs. While many doctors have been squeezed, psychiatrists say it is especially bad for them. Florida Blue, a Blue Cross & Blue Shield company, paid $72 for a standard office visit with a psychiatrist while a primary-care doctor got $134 for a visit requiring a similar amount of time, according to 2014 billing documents obtained by the American Psychiatric Association.

Florida Blue takes a number of factors into account when determining reimbursement rates, says spokesman Paul C. Kluding. These include the number of providers available in the same medical field, the geographic area of particular providers, the insurance products that the providers participate in and the type of medical services provided to its members, he says.

"When providers choose not to participate in network, there's no protection for patients against balance billing or exorbitant chargers."

The insurance industry's job is to get the best value for its customers and the rates insurers pay are based on negotiations with doctors, says Clare Krusing, a spokeswoman for America's Health Insurance Plans (AHIP).

"Health plans negotiate with providers to ensure patients get the best value for their health-care dollars," says Krusing. "When providers choose not to participate in network, there's no protection for patients against balance billing or exorbitant chargers."

Money isn't the only issue. Many psychiatrists, particularly those in private practice, won't take appointments with more complex patients like Derek Ward, who often have histories of drug dependency, multiple hospitalizations and deep psychosis. They say those types of patients are too time consuming, especially after hours, according to interviews with more than a dozen doctors and patient advocacy groups. One doctor says he also worries they could a pose greater risk of physical violence.

"In solo practice, they might not have the infrastructure for dealing with the needs of patients with multiple concerns — social problems, income instability or housing issues," says Harold Pincus, vice chairman of psychiatry at Columbia University.

Into this sea change came the Wards.

Derek had his struggles, but Pat and her friends believed he could rise above them, and they say that until the year before his death, he never showed signs of serious mental illness, according to interviews with six of Pat's friends and relatives.

There's a high-school prom picture of Derek — handsome, athletic, smiling. He's in a crisp tux with his arm around the waist of an attractive young woman in a silvered evening gown.

Derek never had problems making friends, recalls his grandmother, Josephine Lubrano.

Still, Derek suffered on and off from depression after the divorce of his parents and death of his brother, who died of a heroin overdose when Derek was 17. At one point, Derek was making good money as a personal trainer until a hand injury derailed that career path. Following the injury, he developed a pain-killer addiction. He'd also had a prior arrest for procession of a controlled substance and a firearm.

He had a close relationship with his mom, whom he lived with on and off for most of his adult life. In a letter to Derek found among Pat's belongings by Lubrano, she wrote about how much she enjoyed the time the two would spend watching movies, exercising and taking walks together.

"I really do appreciate our relationship, even though I might not always say it or show it," Pat wrote in the letter.

"I'm also very proud of your accomplishments. You've achieved so much and in the process you have become a beautiful person. I'm very proud of you and I know your brother is too."

Whatever optimism Pat Ward had that Derek might ultimately regain his footing began to fade on a hot August day in 2013 when Derek's grandfather, Carl Lubrano, died suddenly at 90 years old. As a child of divorce, Derek viewed his grandfather more like a father. Making his grief worse, the wake was held in the same room of the funeral home where Derek's brother had lain 17 years before. After being there just a few minutes, Derek snapped and ran seven miles home.

Soon, the voices came, along with his paranoid fantasies about the CIA and drone spies. After months of privately suffering, he finally asked his mother to take him to the emergency room. Pat was relieved. He was admitted to Zucker Hillside Hospital in Glen Oaks, N.Y., for almost a month.

The stay provided no firm diagnosis, but doctors suspected Derek was suffering from post-traumatic stress disorder related to the loss of his grandfather and to memories of his brother's death all those years before, Pat's friends say she told them. Derek was accepted to an outpatient program at South Oaks Hospital in nearby Amityville. There, he was getting regular care from a psychiatrist he liked, but because of his previous pain-pill addiction, Derek was required to go to a substance-abuse support group twice a week.

He hated the meetings. By summer's end, he made a fateful decision: He stopped going. Under South Oaks' rules, that meant he could no longer see his doctor and would have to find another physician to prescribe his medication.

Citing patient privacy laws, North Shore-LIJ Health System, which owns South Oaks and Zucker Hillside, can't comment on Derek's case, says Terry Lynam, spokesman. Bruce Goldman, who heads Zucker Hillside's substance abuse program, says hospitals try hard to keep patients like Derek in treatment. "But if there is no imminent danger, people have the right to refuse care," says Goldman. "It is frustrating for us. It is often frustrating for the families. It feels like there is no help, but often it is the patient who is refusing the help."

"That was her biggest fear, having lost one son and thinking about losing a second son."

Now Pat Ward found herself in an increasingly anxious effort to find a replacement psychiatrist before Derek's medications ran out. Having lost one son, Pat was all the more determined to get help for Derek. "That was her biggest fear, having lost one son and thinking about losing a second son," says Karen Coutrier, who worked with Pat for more than 20 years at Farmingdale State College.

But what seemed like a basic task was proving impossible. Lubrano and several of Pat's friends joined her efforts. Dozens of queries produced only dead ends. Coutrier remembers calling through a list of names Pat gave her and doing research online, all to no avail. Coutrier knew the system. She'd worked as a nurse practitioner in Manhattan.

Pat tried Central Nassau Counseling & Guidance and was told they had a wait list, says Lubrano. Friedman says his center is at capacity and has been getting inundated with calls after several mental health clinics on Long Island recently went out of business.

Meanwhile, Derek was becoming more disconnected, say Pat's friends. He began compulsively smoking cigarettes, going through an entire pack in 30 minutes, Lubrano says. Other behavior was downright creepy. In the deep of the night, Derek would sneak into his mother's room and blow cigarette smoke in her face. As her search continued, Pat twice more took him to the emergency room to get him more pills. Both times, doctors gave him five-day prescriptions and referrals to more psychiatrists — none of whom could see him, says Lubrano.

In late October, Pat finally found a doctor who would see Derek. The appointment was set for Oct. 31. But it was problematic. He would be out of meds for at least a week before the visit. Pat called her 90-year-old mother, crying on the phone, deeply worried about what might happen.

Derek was no longer willing to go to the emergency room, so Lubrano and Coutrier suggested she call 911 in hopes the paramedics or police could get him to the hospital. Pat declined. His paranoia, she said, might cause him to react violently to the police and they would injure or kill him.

The next day, Oct. 28, Pat sensed something was terribly wrong. When she returned to her apartment from a hair appointment, Derek was nowhere to be found. She phoned her brother, her voice anxious. "I'm afraid," she told him.

"Stay put," he replied. He had a wake to attend in a nearby town, but he'd be over after. It was about 7 p.m. At 7:55 p.m., police received a 911 call about a body lying in the street directly in front of Pat's apartment building. After leaving Pat's corpse on the asphalt and her head on the opposite side of the street, Derek walked about 300 yards to the Long Island Railroad tracks. When a speeding train was less than 25 feet away, he threw himself, hands raised, in its path.

Lubrano drove up to this scene, blinded by swirling police lights. As he tried to get to the apartment, a detective stopped him and told him what had happened.

Some mental health professionals are pushing for changes that will help to insure that future Derek Wards don't get lost in the system.

The American Psychiatric Association has been appealing to patients to complain to their insurer or employer if they feel insurers are requiring excessive preauthorizations for treatment or if they can't find an in-network provider.

State regulators have been taking action against insurers they say aren't providing proper access to mental health services. In New York, Attorney General Eric Schneiderman has reached settlements with three companies over allegations they were more likely to deny claims related to mental health and substance abuse than for other medical issues.

Mental health-care providers are also trying to do more with the limited resources they have. At Carolinas Healthcare System, in Charlotte, N.C., psychiatrists are starting to use telemedicine to use their time more efficiently, says Roger Ray, Carolinas' chief physician executive. At 18 of their primary care sites and emergency rooms, patients can be connected immediately with a psychiatrist or behavioral health worker via video conference.

Carolinas recently opened a new psychiatric hospital that it estimates will lose $5 million to $7 million a year. Still, it hopes those losses will be offset elsewhere as insurers start paying a lump sum for managing a patient's overall health rather than a fee for each service they provide, says Ray.

All of which is perhaps faint solace for the Wards' family and friends. A week after Pat's and Derek's deaths, mourners packed St. Kilian Roman Catholic Church around the corner from where Pat and Derek died. The attendees included two Catholic Church bishops, many of Derek's old classmates and prom dates, and Pat's students and co-workers.

The mourners all had the same question, expressed by Coutrier. Surely better care for Derek could've prevented this tragedy?

"How many more deaths do we have to have before we are going to say, enough is enough?"

—With assistance from Anita Kumar and Michael Weiss in Princeton.

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