Magazine article Commonweal

GOING CRAZY : Managed Care & Mental Health

Magazine article Commonweal

GOING CRAZY : Managed Care & Mental Health

Article excerpt

In 1990, mental health cost 9 percent of the medical dollar. In 2000, it was 3 percent. Managed care had trimmed an average of 8 percent from all other medical costs but 54 percent from our specialty, mental health. The Surgeon General's 1999 Report on Mental Health opposed this trend. It ranked mental health second only to heart disease as a cause of disability, and it reported that only one-third of the 20 percent of Americans who need psychiatric treatment in any given year receive it.

But cost cutting is not the only effect of managed care. Also lost under managed care are the traditional transparency, immediacy, and confidentiality of the relationship between therapist and patient. The changes in mental health treatment are not primarily a question of therapists' earning less, but about the loss of patient security and confidence. The essence of traditional mental health care was informed consent of the patient, which depended on candor about treatment and about money. Private-practice psychiatrists like us used to write out our bills and hand them to the patient on the first of the month. Patients saw the bill, questioned it, filled out their own insurance forms, clipped the bill to it, and mailed it to their insurance carrier. Patients knew what information went to the insurance company and could trust the setup because all the working parts were visible.

But the methods of managed care work against patient confidence and control. There are more actors in the process, and more decisions about treatment made at a distance from the patient. In order to draw on insurance benefits, patients are now required to call their Managed Care Organization (MCO), ask for a list of approved therapists, be pre-authorized, and then call someone who can help them. After one or two meetings, the therapist must submit a treatment plan to an MCO manager (often a psychiatrist reaching retirement) that sets short-term goals and establishes "medical necessity." This is a term with no agreed-upon definition. Whether to deny or approve money for further appointments is the manager's decision, although insurance companies are eager to leave therapists legally responsible for continuing, or stopping, treatment. The old law still exempts insurance companies from liability for their decisions. Whether they should be held responsible was debated last fall as an addendum to the Mental Health Parity Bill, but Congress defeated that notion, for now.

Most treatment plans take time to compose, and are tedious. Some managers want phone reviews. These can take twenty minutes, are apt to inhibit less assertive therapists, and most troubling, are conducted out of the patient's earshot. A twenty-minute phone conversation can cover a lot of territory, and whatever is transmitted may be kept in the manager's data bank. There are horror stories of records found on second-hand computers, and rumors that some companies pool information. Meanwhile, insurers and some members of Congress are pushing for a national medical data bank. While most MCOs are trying to devise a system so that the details of an individual's symptoms and private life are excluded, concerns about leaks are legitimate.

Then there is the matter of appeals. If the patient's request for service is denied, the patient and therapist can make an appeal. This puts the therapist in the awkward position of mediating between two parties who have no direct contact. Given the time required to argue with an unsympathetic manager, some therapists do not pursue appeals. …

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