2 psychiatrists battle to lead charge against insurers

March 19, 1995|By John Fairhall | John Fairhall,Sun Staff Writer

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.

Divided opinion

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."

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