GOING CRAZY Paying for mental health
Alice, Mary & Houghton, William
GOING CRAZY Managed care & mental health Mary Alice & William Houghton In 1990, mental health cost 9 percent of the medical dollar. In 2000, it was 3 percent. Managed care had trimmed an average...
...Also lost under managed care are the traditional transparency, immediacy, and confidentiality of the relationship between therapist and patient...
...We favor a single-payer system (if it isn't micromanaged to death) but are not holding our breath...
...Discussing money can be stressful, confusing, and labor-intensive...
...Is it any wonder that surveys show increasing patient dissatisfaction with mental-health care...
...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...
...Most treatment plans take time to compose, and are tedious...
...Given the time required to argue with an unsympathetic manager, some therapists do not pursue appeals...
...Meanwhile, as employers struggle to control health-care costs and managers eliminate sicker patients, the number of uninsured in the United States approaches 43 million...
...We offer a 30 percent discount on our usual charge for those who wish to pay for themselves...
...Managed-care methods are spreading to public insurance contracts (Medicaid and Medicare) and to public hospitals, clinics, and medical schools...
...The best we can do today in our practice is to negotiate a fair and transparent agreement one patient at a time...
...Many of the sickest patients will be dropping out of psychiatric treatment as a result...
...In order to draw on insurance benefits, patients are now required to call their Managed Care Organization Mary Alice Houghton is president of the Wisconsin Psychiatric Association...
...The old law still exempts insurance companies from liability for their decisions...
...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...
...These can take twenty minutes, are apt to inhibit less assertive therapists, and most troubling, are conducted out of the patient's earshot...
...And we discuss money: how the patient's health plan works, and how we will operate under that plan as long as it permits effective treatment...
...She and her husband William practice psychiatry in Milwaukee, Wisconsin...
...Patients are expected to follow "the plan" as told to them (or drop out when anxious about it...
...Our approach is simple, though it takes time and labor...
...This is a term with no agreed-upon definition...
...But speak of it we must...
...Or they will be dropped...
...Patients saw the bill, questioned it, filled out their own insurance forms, clipped the bill to it, and mailed it to their insurance carrier...
...Our goals are informed consent and an increase of patient autonomy within the boundaries of the current system...
...We are fairly sure that patients' rights and parity legislation will be compromised by the insurance lobby...
...If they are concerned that a growing number of people will be included in the discussion of their case and the ensuing documentation, they sometimes decide it is easier to stop treatment...
...Mental-health care is not an ordinary commercial transaction...
...If the patient's request for service is denied, the patient and therapist can make an appeal...
...The Surgeon General's 1999 Report on Mental Health opposed this trend...
...In the first few sessions with a new patient, we discuss diagnosis, treatment options, and what information will go to the manager...
...Patients too are often intimidated by the process...
...Managed care had trimmed an average of 8 percent from all other medical costs but 54 percent from our specialty, mental health...
...This puts the therapist in the awkward position of mediating between two parties who have no direct contact...
...The country will not return to the old insurance system...
...There are more actors in the process, and more decisions about treatment made at a distance from the patient...
...But it clarifies the patient-therapist relationship, and paves the way for candid talk therapy...
...Some managers want phone reviews...
...A twenty-minute phone conversation can cover a lot of territory, and whatever is transmitted may be kept in the manager's data bank...
...Appeals aside, an alert patient can sniff out the process that is reshaping the schedule and goals of treatment...
...And we hope that the value of plain dealing and straight talk between individuals will outlast managed care.last managed care...
...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 the methods of managed care work against patient confidence and control...
...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...
...It takes as much as a quarter of the time in the first sessions...
...Patients knew what information went to the insurance company and could trust the setup because all the working parts were visible...
...A new wariness has entered the relationship between therapist and patient...
...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...
...and, if patients are eventually allowed to sue HMOs, the court system is apt to be slow...
...There are horror stories of records found on second-hand computers, and rumors that some companies pool information...
...Each senses the shadow of a third party, but is uncertain how to speak of it...
...MCO), ask for a list of approved therapists, be pre-autho-rized, and then call someone who can help them...
...The force of fear and anxiety of people under stress must be recognized and ameliorated...
...But cost cutting is not the only effect of managed care...
...Then there is the matter of appeals...
...Some therapists have said no to MCOs and treat indemnity-insurance patients only...
...But this locks out middle- and working-class patients...
...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...
...We think informing patients about the structure in which they are being cared for is an important part of reducing their anxiety...
...Things will have to get a lot worse before Congress reduces its reliance on the insurance industry...
...The changes in mental health treatment are not primarily a question of therapists' earning less, but about the loss of patient security and confidence...
...Meanwhile, insurers and some members of Congress are pushing for a national medical data bank...
...From our work outside private practice, we know many therapists who do not devote this effort to disclosure and security...
...And some therapists hesitate for fear they will lose company referrals...
Vol. 129 • February 2002 • No. 4
