JONATHAN M. METZL, M.D.*
Much of the dispute over the value of long-term psychotherapy in a managed-care system has focused on issues of time and money. This paper reviews the arguments put forth by defenders of psychotherapy and by managed-care organizations, and then moves to reconceptualize the issue through the perspective of narrative literary theory.
What do they do? They dialogue.
Faster than almost anyone expected, managed care has become the de facto national health policy.
Why are managed-care companies so reluctant to deal with psychotherapy? As the implications of health-care reform sweep across America, why have insurance plans in every state offered only minimal coverage for mental illness, refused to admit many psychiatrists and psychologists into their treatment "networks," and severely restricted access to outpatient psychotherapy? And why do many psychotherapists, subsequently, harbor deepseated reservations about managed care? In an age where the business model is supplanting the out-of-control medical model, these developments do not seem to make sense for one simple reason: mental illness is big business. In a system presumably fueled by demand and, if enough demand, supply, there is an unending supply of demand. In any given year nearly 30 percent of the (non-institutionalized) American population between the ages of 15 and 54 will meet the criteria for a mental illness.3 Of these, only 15 percent will seek treatment with a health-care professional. Over the course of a lifetime it has been estimated that 50 percent of the population will suffer from a psychiatric disorder as defined in the Diagnostic and Statistical Manual, of which fewer than 40 percent will receive any type of treatment.4 Moreover, recent surveys have suggested that up to 97 percent of the (surveyed) American public support insurance for mental illness, of which 87 percent feel this coverage should be at the same level as for medical illnesses5 This presents, it would seem, a great opportunity Unlimited demand. Limited supply. Popular support. Many, many potential customers.
And yet, managed-care companies across the country have treated mental-health coverage as if it were a treatment to be avoided at all costs. Claims are frequently denied. Access to care is often heavily restricted. When benefits are provided, they are at a level that many mental-health providers find perilously inadequate. Constant and often intrusive assessments regulate the treatment when it begins, and often dictate when it should end. Not enough support, many contend, in the face of severe, debilitating, and long-standing afflictions such as major depression, posttraumatic stress disorder, or many personality disorders, to name just a few; and clearly unequal funding compared to that offered for many other treatments available in the health-care system.
TIME AND MONEY
Why such limited investment? Why such limited coverage? Why such regulation? There is, of course, the much-discussed issue of finance. In 1960, according to the Federal Bureau of the Census, 5.1 percent of the gross national product was spent on health care. By 1995 this had risen to 13.7 percent.6 It has been estimated that this number will reach 15 percent by the year 2000. Meanwhile, though many managed-care companies began as nonprofit organizations devoted to the equitable delivery of health care, most have become large, complex, and highly profitable organizations. In 1996, there were over 200 managed-care companies in the United States, most owned by large insurance companies.7 These exist in the form of organizational models, such as health maintenance organizations (HMOs) and preferred-provider organizations (PPOs). Currently, managed-care networks cover approximately half the population of the United States. It is anticipated that within the next ten years, almost the entire insured population will be enrolled in one of these networks. …