Endangered Species: Endangered Species

By Wylie, Mary Sykes | Family Therapy Networker, March/April 1994 | Go to article overview

Endangered Species: Endangered Species


Wylie, Mary Sykes, Family Therapy Networker


Challenging cases are the least of many therapists' worries these days. The Golden Age of Private Practice is coming to an end and no one is-quite sure what the new, corporatized mental-health system will look like or how it will shape the future of the therapy profession. REVOLUTION

ELINOR ADAMS, A MINNEAPOLIS MARRIAGE AND FAMILY THERAPIST for more than 20 years, has earned the high regard of her colleagues, a solid professional reputation in her community and the right to expect a dependably full caseload in her private practice. Under normal circumstances or at least what used to be considered normal in private practice she would have no reason to doubt that her collegial network and pool of satisfied clients would continue to provide referrals unto perpetuity, or until she retired, whichever came first. But these are no longer normal times, and Adams says she is "anxious, afraid, uncertain" about the future. At this stage in her career, when she ought to be enjoying the professional independence and financial security that are the fruits of success, she spends all of her free time going to meetings informational meetings, brainstorming meetings, professional policy meetings, political strategy meetings, mutual commiseration and self-help meetings with other colleagues who are just as worried as she is, at least those colleagues, she comments, "who don't still defiantly have their heads, in the sand."

What do all these nervous people have in common, these established, mature, settled private practitioners who now fly from one meeting to another like flocks of edgy birds? These mid- and senior-level clinicians, many just as established as Elinor Adams, feel they have about as much job security right now as the engineers on the Super Collider project that Congress recently abolished. The entire health-care delivery establishment in Minnesota is, likewise, about to be "abolished" at least in its current form.

In its place, a statewide system of government-regulated managed competition, called MinnesotaCare, is scheduled to go into effect by mid-summer, fundamentally altering private practice in Minnesota, if not ending it entirely. According to unverified but widely disseminated estimates, MinnesotaCare may push 30 to 70 percent of independent therapists out of business.

As goes Minnesota, so goes, it is feared, the rest of the country. Minnesota may be at the far edge of the curve it always has been a progressive state in matters of public policy (Public Broadcasting radio personality and famous native son Garrison Keillor says that the antismoking forces have made such an impact on state law that if you want to have a cigarette in Minnesota, you have to go to North Dakota) but what's happening there is commonly perceived as a bellwether for the rest of the nation. There is little doubt that some form of government-regulated managed competition will play a central role in national health-care reform it is the linchpin of the Clinton proposals. Already, managed care is a conduit to mental health services for a surprisingly large number of Americans. According to a market survey conducted by Open Minds Newsletter, which analyzes trends in the behavioral managed care industry, nearly half of the 178 million Americans with health insurance are enrolled in some kind of managed care company specializing in mental health.

In its broadest sense, managed care usually refers to a corporate, privately run (though often government-regulated) system of health care that coordinates and delivers an entire range of medical and, sometimes, mental health services to a "prepaid" population, while also managing the costs of providing that care. By both selling the "product" and paying the overhead of producing it, the managed care company theoretically operates under the same incentives as a wholesaler or producer, who stays in business by controlling expenses while still maintaining high enough quality to attract customers to buy what the company is selling. …

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