Tommy had been playing video games with friends when he decided to kill himself. Without saying a word, he stood up, walked to his car, and drove into a tree at 55 miles per hour.
I met him the next morning, on day three of my psychiatry rotation at a large Boston hospital. Wearing a neck brace, with a cartoon black eye and a huge cast on one leg, he told me he still wished he was dead. Over the next week, his orthopedics team worked to fix his multiple fractures and attend to his physical health. Our job was to stabilize his mental health before transferring him to a specialized psychiatric facility for further care.
But which facility?
From the moment Tommy arrived in the emergency department, his father was fixated on where his son would be transferred. As a cop, he'd interacted with people in mental health crises for years, and knew the ugly truth about the mental health care system in the United States.
Even in Boston, which has been called a “medical mecca,” psychiatric care is in such short supply that whether a patient ends up at a renowned teaching hospital — or a place where no psychiatrist would send a loved one — depends on chance.
A nonprofit organization called the Boston Emergency Services Team (BEST) matches people like Tommy with beds at local psychiatric facilities. Though several Boston hospitals have their own psychiatric units, none has enough beds to take everyone who comes in through its emergency department. Because of low reimbursement for mental health care, hospitals lose money on psychiatric services. As a result, they tend to have fewer psychiatric beds than medical and surgical beds.
Standalone psychiatric hospitals have sprung up to fill the void. Many are operated by for-profit corporations like Universal Health Services, which runs more than 300 mental health facilities in 37 states and Puerto Rico. But if teaching hospitals can’t operate psychiatric units sustainably, how do these companies do it? The psychiatrists I worked with believe that the way that these facilities maintain profitability is by cutting costs to an extreme level, and official documents support their view.
In 2014, a UHS facility in Shreveport, La., was cited for inadequate staffing levels that led to multiple instances of sexual misconduct among patients. The state of Illinois cited another UHS hospital for “woefully inadequate” staffing. Indeed, dozens of UHS facilities in Massachusetts and across the country have faced investigations for neglect, assaults, and multiple patient deaths. In January, UHS agreed to pay $127 million to resolve a federal Department of Justice probe into its facilities.
I couldn't blame Tommy's parents for being worried. Their son was lucky to be alive, but perhaps wouldn't be fortunate enough to end up at a decent psychiatric hospital. For someone with a serious mental illness, how much luck should it take to stay alive in the wealthiest country on earth?
Unlike so many problems in health policy, solving this one is simple, though not easy to achieve: To increase our supply of psychiatric hospitals, we need to pay more for mental health care. Unless we want to devote even more of our economy to health care, this will mean paying less for other health care services.
For generations, procedural specialties like cardiology and dermatology have received more generous reimbursements from Medicare, commercial insurers, and other payers than purely cognitive specialties like psychiatry. The result of this disparity is that it's easy to get your knee replaced but a lot harder to manage your depression.
In an era defined by mental health challenges, from the startling rise in teen suicides to the devastation of opioid use disorder, it is absurd that payment policy prevents many leading hospitals from operating a psychiatric unit. Governor Charlie Baker’s legislation that would force hospitals and insurers to devote a larger share of their resources to mental health care is a good start.
At the same time, to avoid sending more money to low-quality, understaffed facilities, the government should increase accreditation standards for staffing and pursue more robust reporting of outcomes for psychiatric wards.
The last time I saw Tommy he was sitting up in bed, laughing with a friend who had come to visit. In just a week, he had started on a new medication and no longer wanted to die. Yet he remained fragile — the greatest risk factor for attempting suicide is a previous suicide attempt.
When Tommy’s dad told me that he’d gotten a bed at a reputable teaching hospital’s psychiatric ward, I felt immense relief: He had gotten lucky again.
After saying goodbye to Tommy and his family, I walked back to the psychiatry office in the emergency department. His name had already been erased from the whiteboard, replaced by that of a 23-year-old who had attempted suicide by Tylenol overdose. The BEST team had started searching for a psychiatric unit for her. Would she, too, be one of the lucky ones?
Garret Johnson is a dual-degree student at Harvard Medical School and the Harvard Kennedy School of Government.