We all know that a hospital emergency room can't turn you away
if you're in need of care. That's been law since the Emergency
Medical Treatment and Active Labor Act was passed in 1986. But,
there is a case when an attending doctor might think twice before
deciding whether or not you need to be admitted: if you've passed
through those sliding doors with a mental health issue, and --
here's the kicker -- are privately insured.
A study published Tuesday in
has found prolonged wait times in Boston-area emergency rooms for
severely ill psychiatric patients. The study's 53 insured subjects
were each deemed in need of immediate hospitalization. So, why then
did a sample population whose primary reason for admission was
suicidal ideation -- with select cases exhibiting homicidal intent
-- spend on average 8.5 hours waiting in the ER?
Overburdened hospital staffs and restricted facilities for mental
health patients are a leading cause of this wait time. But, at
least part of the blame falls on prior authorization requirements
put in place by insurance companies.
"This is an issue psychiatrists know all too well," says J. Wesley
Boyd, MD, PhD, a staff psychiatrist at Cambridge Health Alliance
(one of Harvard Medical School's teaching hospital) and the
supervising author of the study. "Lots of other medical specialties
need to get authorization for drugs, and certainly for procedures.
But, prior insurer authorization for [emergency room] admission is
unique to psychiatry."
"Could you imagine if a pregnant woman came into an emergency room
in labor," says Boyd, "and they said, 'we have to hop on the phone
with your insurance company and get this prior authorized'?"
According to the study, psychiatrists spent an average of 38
minutes on the phone with insurers getting emergency patients
authorized for admission over a three-month period, with 10% taking
over an hour. In one case, a psychiatrist spent over five hours
obtaining authorization. But, with all this time spent chasing
insurance provider approval -- delaying care and taking away from
psychiatrists' duties -- only one of the 53 requests for
authorization was denied.
"Essentially, the forgone conclusion is if you jump through the
hoops, stay on the phone long enough, and answer all the questions,
your patient will ultimately be admitted," says Boyd.
Then why all the fuss?
People in Boyd's field call it "rationing health care by a hassle
factor." The idea is that when a doctor calls up a provider like
), the process will be so laborious, so time-consuming, he or she
will be deterred from seeking approval for patient admission in the
Health-care providers' reasoning behind this, Boyd explains, is
quite simple: "The less service [private health insurers] agree to
pay for, the more money they get to keep in their pockets."
Insurance companies certainly aren't inept at making money. The
top-10 US health insurers, which, along with the names above,
), and others, drove a 250% increase in profits last decade.
The approval process usually goes something like this.
A doctor will place a call to the insurance company and be put on
hold for an inordinate amount of time. Or, Boyd recalls from his
own experiences, he or she will be kicked around from department to
department until finally connecting with the appropriate
representative. Once a representative is reached, the process is
relatively straightforward: a list of questions confirming a
patient's condition is administered by someone who, Boyd says, is
almost never a doctor. (Very rarely, he says, will a claim be so
contentious that a call will get passed up high enough on an
insurance provider's hotline to become a doctor-to-doctor issue).
The approval process is less challenging than it is tedious.
Occasionally it will escalate to aggravating, like when, as Boyd
illustrates, a representative is struggling to pronounce a
medication name such as
while a doctor waits on the other end of the line, and more
importantly, a patient waits for desperately needed care.
Boyd also points out that because this is an emergency setting, the
doctors making these calls are more often than not overworked
psychiatry residents working on very little sleep.
"There's a constant flow of patients coming in through our
emergency rooms, and you can imagine if you are the on-call
psychiatrist, you're going to think twice before letting someone
in. Because once you make that decision, you know that you or one
of your colleagues is going to need to be on the phone."
And that's a problem. He continues:
"Colleagues of mine have pressed me to make sure its known that a
lot of psychiatrists will do what they can to not hospitalize
someone even if it's needed, especially if they are in a busy
practice, because 40 minutes to an hour is time they simply don't
(Boyd assures me that neither he nor the residents who participated
in this study ever let a patient leave who they determined needed
The study's lead author, Amy Funkenstein, MD, offers a broader
"Massachusetts is considered a model for health reform, yet we
found that seriously ill patients routinely spent hours stranded in
the ED [emergency department] due to insurance bureaucracy. The
hours psychiatrists spend obtaining those authorizations could be
far better spent treating our patients."
It might be easy to dismiss this as a niche issue. But when
26% of Americans are afflicted
by varying types of mental illness each year, inadequate mental
health care is clearly not an insignificant problem.
Projecting this small pilot sample across a population of 1.6
million psychiatric admissions among people with private insurance
in the United States annually, an average 38 minutes of phone time
to secure insurer approval equates to roughly 1 million hours of
"wasted psychiatric time."
Unfortunately, however, Boyd doesn't see a change coming anytime
"In order to stay afloat, hospitals have to play ball with the
insurance companies. I'm sure if a hospital wanted to take the lead
in the fight against this issue, they might end up being punished
by the insurance companies next time contracts were being
In addition, there isn't the same kind of public outcry for mental
health care infringement like there was, for example, when insurers
were pushing for rapid postpartum discharge in the early '90s.
Boyd recalls the very
against what were then dubbed "drive through deliveries," so
labeled for the 48-hour limit insurers put on paying for post-birth
hospital stays. The American Academy of Pediatrics, the American
College of Obstetrics and Gynecology, and the American Medical
Association all publicly denounced the practice. A number of
highly-publicized commentaries were published, one such titled:
"Early Discharge in the End: Maternal Abuse, Child Neglect, and
Physician Harassment." When the issue reached Congress the next
year, sentiment quickly shifted out of managed health care's favor,
and by 1997, national law mandated that 48 hours was the minimum
amount of postnatal care insurers were required to pay for.
"Because of the stigma surrounding mental health issues, you don't
have the same public reaction. People aren't willing to stand up
and say how dare you for not allowing me full access to what I need
immediately if I have depression, or am suicidal, or have
schizophrenia, or my loved one does."
With the nation's attention recently tuned to mental illness, and
the role it has played in mass shootings and other domestic acts of
aggression, it's hard not to find what appears to be an unnecessary
barrier to treatment difficult to stomach.
For now, we can only hope that the individuals who do require
emergency care are at least Medicare recipients -- Medicare
requires no prior authorization for emergency room visits -- or
have no insurance at all, because that's 40 minutes less they'll
have to wait to receive the much needed medical attention.