You don't need Freud to interpret the bronze statue of Don Quixote in Dr. Harold I. Eist's book-lined office. Hero to some and fool to others, the tough-talking Bethesda psychiatrist is crusading to rescue his profession -- and the public -- from what he sees as the evils of insurance companies.
"Greed-driven, they are like sharks in a feeding frenzy," charges Dr. Eist, who has been likened to a Ninja Turtle in his fierce campaign for the presidency of the 38,000-member American Psychiatric Association.
The all-Marylander race between the impassioned Dr. Eist and the even-tempered Dr. Steven S. Sharfstein, president and chief executive of Sheppard and Enoch Pratt Hospital in Towson, has become an emotion-charged referendum on the future of psychiatry.
Both men say that insurance-driven "managed-care" programs have provoked unprecedented turmoil by eroding the autonomy of psychiatrists, squeezing their incomes and forcing them into new roles.
Both say that patients are being short-changed as managed-care programs cut the number of days patients spend in psychiatric hospitals and the number of therapy visits they make to psychiatrists' offices.
But their apparent common ground is crumbling under a volcanic clash of personalities and perspectives as they accuse each other of being unfit to lead. A psychiatrist who practices alone in a basement office in his home, Dr. Eist, 57, wears a sweater to work and is a self-styled outsider railing against the Washington leadership of the APA, of which Dr. Sharfstein is the national secretary.
Dr. Sharfstein's private practice has dwindled to six patients, and as CEO of Sheppard, the 52-year-old former New Yorker greets a visitor in a suit. There is a poster on neurotransmitters of the brain in his office, but no Don Quixote.
The underdog in the contest, less well-known Dr. Eist has attacked Dr. Sharfstein like a shark chasing dinner, accusing him of engaging in managed-care practices at Sheppard Pratt that "will contribute to the destruction of psychiatric care."
Fed up with the criticism, Dr. Sharfstein lashed out at an antagonistic questioner at a recent candidates' debate in Columbia, one of many held around the country in advance of tomorrow's deadline for members to mail their ballots for president-elect of the APA.
"I think this kind of innuendo, this kind of smearing, is something that is just extraordinary to happen in a professional association election," he said angrily.
It's not surprising that managed care is fueling their conflict. Psychiatry is a troubled field, and the bad news has reached medical schools, where fewer and fewer graduates are choosing this specialty. The laugh-a-minute life of the fictional psychiatrist in the TV comedy "Frasier" is a far cry from the real marketplace.
The days when patients picked their own therapists and insurers paid the bills without question are over. More than 50 percent of all insured Americans are enrolled in plans that manage mental health services.
Psychiatric hospitals have been hit hard. Venerable Sheppard Pratt -- 103 years old and the largest source of mental health services in Maryland -- has transformed its hilltop hospital to meet insurers' demands. There's a steady stream of traffic past the hospital's stone gatehouse on North Charles Street as patients arrive for treatment and leave the same day -- a big change from the past.
Since 1992 the hospital has reduced its beds from 320 to 200, cut the average hospitalization period from 50 to 14 days and expanded nonresidential treatment programs on and off the picturesque 100-acre campus near Greater Baltimore Medical Center. "We're trying to cope and survive," says Dr. Sharfstein, noting that Sheppard Pratt now calls itself a "health system."
Although many psychiatrists charge that managed care programs undermine care, insurers assert that good management improves quality while restraining costs, making mental health treatment more affordable for more people.
As alarmed as many psychiatrists are, they are divided over what to do. Quoting General George S. Patton, Winston Churchill and Virgil, Dr. Eist urges war against the enemy.
"Greed is a special form of violence which is literally killing Americans and destroying the best medical establishment in the world," says Dr. Eist, whose oratorical skills would serve him well as a trial lawyer. "I do not believe we can change a bad system by becoming part of it."
But Dr. Sharfstein, while casting himself as a critic of managed care, says that to survive, psychiatrists must learn to live with and lead the changes under way -- or risk becoming a "historical footnote."
"What's happening now is a shakeout of the whole medical market with the consolidations and mergers that are taking place, the closure of hospital beds, not just psychiatric hospital beds, [and] the downsizing of specialties," Dr. Sharfstein says. "That's a movement which will not be reversed. We will not go back to the old days. I think my opponent in this election has his head in the sand if he thinks it can be reversed."
The debate over managed care and mental health mirrors the one concerning physical health problems. Like psychiatrists, many specialists -- from cardiologists to radiologists -- complain about losing independence and income at the hands of health maintenance organizations.
But managed care has shaken up psychiatry more than any other specialty. "It's pushing people out of business," charges Dr. Paul A. McClelland, president-elect of the Maryland Psychiatric Society. "And it's threatening to put more people out business."
The major reason is that psychiatrists are deemed replaceable. Why pay a psychiatrist $90 an hour to provide outpatient therapy to someone who is not seriously ill when a social worker or psychologist can do it for $45 to $60? insurers ask.
Psychiatrists insist they're better qualified because they're physicians who spend four years in medical school and four more years in residency programs specializing in psychiatry. But their argument has been weakened by licensing laws in Maryland and other states that recognize psychologists, social workers and others as legitimate sources of mental health services.
As a result, psychiatrists find themselves under pressure to lower their fees and to accept new roles. Managed care companies often assign psychiatrists to do an initial assessment of patients, prescribe medication if needed and treat the most seriously ill. But the majority of cases probably will be sent to a social worker or psychologist.
Making matters worse for many psychiatrists, they're being subjected to close scrutiny and asked to provide detailed information about their patients, raising privacy concerns. That's big change for solo practitioners whose only relationship with an insurance company has been to mail a bill and receive a check.
"Now they're being asked to send in treatment plan forms, to explain what's going on," says Dr. Henry D. Harbin, a psychiatrist and president of Green Spring Health Services Inc., a Columbia company that specializes in managing mental health services on behalf of insurance companies. The company's clients include the HMO subscribers of Blue Cross and Blue Shield of Maryland.
Oversight improves care, according to Dr. Harbin. "It is not just managing costs," he says. "One advantage of managed care -- when it's done well -- is to do a better job of identifying who are the high quality medical providers in the network and refer more patients to them."
Care vs. profits
But psychiatrists, social workers and psychologists say managed care companies sometimes put profits ahead of care. Groups representing these professions have protested against pressure that Maryland's largest HMO company, Mid Atlantic Medical Services Inc., is putting on therapists to reduce the volume of services provided to patients.
The company has told therapists that it will withhold up to 40 percent of their fees if they provide more than "medically necessary" care, a phrase that's subject to widely different interpretations.
"The question is what is the line between needed and unneeded," observes Jonathan P. Weiner, professor of health policy and management at the Johns Hopkins School of Public Health. "The line is more clear for physical health care than it is for mental health care."
Sheppard Pratt, as part of its efforts to adapt to the changing market, has entered into a managed care contract with the Kaiser Permanente HMO, agreeing to provide subscribers' services under a fixed budget. Although Dr. Sharfstein says this represents only a small part of the hospital's business, Dr. Eist has seized upon the arrangement as proof that his opponent is selling out to managed care.
But the distinction Dr. Eist would like to draw makes even some of his supporters uncomfortable.
Psychiatrists are increasingly entering into contracts with managed care companies to ensure a continuing source of patients, albeit under agreements that limit the psychiatrists' roles.
"The jobs now are in the managed care and HMO business in large part," says Dr. John A. Talbott, chairman of the department of psychiatry at the University of Maryland School of Medicine.
Dr. Sharfstein argues that psychiatrists are better off organizing programs like the one he has with Kaiser; it leaves medical experts rather than insurance companies in charge. But Dr. Eist says he'd lead psychiatry into battle, fighting for state and federal legislation to curtail insurers' actions.
The lines are drawn, the campaign all but done. The election results will be announced next Sunday or Monday. The winner becomes president for a year beginning in May 1996.
"People have charged me with being Don Quixote," Dr. Eist says, but he believes he has tapped into the anti-managed care emotions of most psychiatrists.
Dr. Sharfstein says if his colleagues vote with their heads he'll win.
"If people vote from the point of their frustration and their fear, they will vote for Harold Eist," he says. "If they vote from the perspective of concern but also from a perspective of coping and rising to the challenge, they'll vote for me."