First in a series of occasional articles on how money affects patients and their care. To read more, click here.
CAMDEN, Maine — In elegant rooms with sparkling views of Penobscot Bay, some of Harvard’s most skilled psychiatrists treat patients from across the United States — football players referred by the NFL, lawyers sent by their firms, a school janitor with a wealthy brother.
What they have in common is the means to pay $2,150 a day for a minimum of 30 days of treatment at Borden Cottage, a remote outpost of McLean Hospital, perhaps the country’s best-known psychiatric facility. Credit cards are welcome. Health insurance is not.
In return, patients have access to a heated outdoor pool, a movie theater with reclining leather seats, a vintage bowling alley, and, most importantly, gold-standard residential addiction and psychiatric treatment for as long as they need it — and can afford to pay the bill.
McLean’s steady expansion into the realm of private-pay care, which now accounts for 40 percent of its residential beds and several outpatient programs, exposes a tension in mental health care: Options for the upper middle class and wealthy are growing at a time when many other patients say they can’t get their insurers to pay for adequate treatment.
The phenomenon threatens to create a two-tier system “where high-quality care is only accessible to those with enough resources to afford care out of their own pocket,’’ said Brian Rosman, policy director at Health Care for All, a Boston-based patient advocacy group. Rosman blamed in part “unreasonable’’ restrictions by health insurers for the problem.
But Dr. Scott Rauch, president of McLean, said its growing array of private-pay programs — not all of them luxurious like Borden Cottage, but all providing highly specialized care — serve an important purpose that helps all patients. They subsidize the hospital’s money-losing insurance-based residential programs and allow them to expand.
“Hopefully it’s understandable to all why that’s a good thing,’’ he said.
Insurers will typically cover three to seven days of inpatient care for many psychiatric patients in crisis — long enough to stabilize a patient with medication.
While many patients then go on to outpatient therapy, others need residential treatment, which insurers are not required to cover under Massachusetts law — and often do not.
“Some insurance companies won’t pay without a fight, and most won’t pay without considerable work to document need,’’ said Danna Mauch, president of the Massachusetts Association for Mental Health, an advocacy organization.
Those who win the battle can typically expect coverage for a couple of weeks of treatment. And while private-pay programs such as Borden provide one-on-one therapy to patients daily, most insurance-based programs rely on group therapy, which requires fewer staff.
Patients such as Shellye Echeverria need more.
A week into her sophomore year at Boston University in 2012, Echeverria reached a breaking point after years of struggling with anxiety and depression. When she revealed her suicidal feelings to her parents in a text, her mother drove from their home in the New York area, and they headed for McLean. Echeverria was admitted to an inpatient unit and diagnosed with borderline personality disorder, a complex condition characterized by intense, overwhelming emotions and unstable relationships.
Fortunately, McLean had a specialized program, 3East, for teen girls and young women with just this diagnosis. The 10-year-old unit is considered one of the best in the world. It is also private-pay. It is not at all plush like Borden, but it’s still pricey — $1,435 a day for intensive specialized care. McLean opened a self-pay unit for teenage boys and young men at the same price last year.
“The only thing we had to do was figure out how to pay for all this,’’ said Henry Echeverria, her father.
She spent six weeks in the program, learning to calm “hot” emotions by chewing ice or dunking her head in cold water — part of a proven approach called dialectical behavior therapy. It aims to build coping skills such as mindfulness and emotion regulation to help patients get through crises without harming themselves. Cold water automatically slows heart rate and respiration, which reduces feelings of distress.
A relative paid for Shellye Echeverria’s first month there. Her parents dug into retirement funds and relied on credit cards to pay the rest —a decision her father said saved Echeverria’s life. Other families he met on the unit were either wealthy or took out second mortgages and home equity loans to cover the cost, he said.
After Echeverria was discharged from McLean’s 3East, Henry Echeverria, who works as an insurance consultant, sought to persuade his health insurer to reimburse him for her care. He mailed off the necessary paperwork to Cigna, but the company refused, he said. A representative told him McLean did not include the proper diagnosis and treatment codes in the medical record, he said. A Cigna spokesman said he could not comment on her situation because of patient privacy laws.
Still, Henry Echeverria has no doubt the cost was worth it. “I am a completely different person,’’ agreed Shellye Echeverria, 25, who recently completed college and is now working as a nanny.
Theresa Nguyen, vice president of policy and programs at Mental Health America, a nonprofit organization based in Virginia, said the family’s experience is typical. “Only in America do we have insurance [that] doesn’t cover what we need and then we pay extra,’’ she said.
Some insurance companies, however, have started paying for the sickest teens to stay on 3East on a case-by-case basis, said Dr. Joseph Gold, McLean’s chief medical officer. McLean runs two insurance-based programs for teens that include some dialectical behavior therapy, which is sufficient for most adolescents, he said.
But insurers said residential care is usually not medically necessary, except for a few exceptions, like those for eating disorders and obsessive compulsive disorder. In these cases, an overnight program is necessary because staff need to monitor binge eating and excessive handwashing around-the-clock.
“A lot of these therapies can be done in the community on an outpatient basis,’’ said Lora Pellegrini, president of the Massachusetts Association of Health Plans. “There is no evidence that these residential programs are producing better outcomes for patients.’’
Psychiatric hospitals with private-pay patients, including McLean, the Menninger Clinic in Houston, and Sheppard Pratt Health System in Baltimore, acknowledge that they have not studied whether patients in these programs achieve better results than those in insurance-based programs. Comparisons are difficult, in part because the industry does not agree on what to measure, or even what constitutes success.
But some differences are obvious. At 3East, when Echeverria became severely anxious at night, a doctorate-level clinician coached her through the episode. She was able to practice the skills repeatedly for weeks under supervision, and staff carefully planned her long-term therapy.
“There is no way to pull that off’’ with programs covered by insurance, said Bonnie Katz, senior vice president of strategy and business development at Sheppard Pratt, which has also expanded its self-pay program.
There also may be more subtle advantages to these expensive self-pay programs. Susan Fendell, an attorney with the Boston-based nonprofit Mental Health Legal Advisors, said “patients are treated as guests and clients. This is less stigmatizing to patients, and that could improve outcomes.’’
Cheri Andes, executive director of the National Alliance on Mental Illness in Massachusetts, said this type of gold-standard care should be available to everyone.
“Think about how a cancer patient is greeted at the door of Dana-Farber [Cancer Institute]. How they are wrapped in concern and enveloped in reassurance and how they are shepherded through their illness,’’ Andes said. “That is what we want for everybody. We want the Dana-Farber experience.’’
More than half of all the patients at McLean, once a refuge for the wealthy and elite, are now covered by private insurance. It has a far lower percentage of poor patients than most other Massachusetts psychiatric hospitals.
About 17 percent of its patients are on Medicaid, compared with a 48 percent average statewide, according to data from the Center for Health Information and Analysis in Boston. This is in part because many patients are referred directly by psychiatrists or by colleges, leaving less space for those waiting in hospital emergency rooms.
But while McLean said it loses about $4 million a year on insurance-based residential programs, its overall profit is about 2 percent.
Its most profitable programs are those for which patients must reach into their wallets. There’s Fernside in Princeton, Mass., at $1,985 a day for addiction and psychiatric treatment; Appleton in Belmont at $700 a day for chronic mental illness; and the Pavilion in Belmont — $55,300 for 14 days of treatment for anxiety, depression, and psychosis.
And there’s Borden, hidden at the end of a winding tree-lined driveway. Camden residents initially opposed Borden when it opened in 2015 but have since embraced it. In June, town voters approved an expansion from eight beds to 12.
The 14-acre property was originally owned as a private retreat by businessman Charles Cawley, a founder of the bank MBNA. Cawley built many of the amenities McLean patients now use. They have limited time for recreation, however; they are scheduled for individual and group therapy from 8 a.m. to 8 p.m.
During a July tour, staff members were careful to keep a reporter away from patients. They have included executives, lawyers, doctors, and a man who had traveled from abroad and who had been so addicted to alcohol and sedatives that he was unable to get out of bed.
On this particular morning, the eight men and women were said to be gathered in a cognitive behavioral therapy group in a large living room and then were scheduled for a trainer-led fitness group in the gym. They meet one-on-one with a psychiatrist or therapist two to three times a day, often in plush chairs overlooking the island-studded bay.
Clinicians said they are treating patients who may not get help otherwise, either because they would not tolerate conditions in a standard facility or because they require absolute privacy.
“Some folks are their brand, and if folks knew they were struggling, it would affect a lot of people who work for them,’’ said Catherine Milliken, program director for Borden. “We don’t have paparazzi in the bushes.’’