MYTHS OF MANAGED CARE

This page is organized in the following manner (please scroll down):

MYTH 1: CONSUMERS ARE HAPPY WITH THEIR MANAGED CARE (MC) PLANS

Although some surveys show that the majority of people are satisfied with their plans, most of these people are healthy, and use heir health insurance for minor problems and preventative care. Surveys conducted by the companies themselves, of course, show favorable results. But when the research is done independently, for example by the Robert Wood Johnson Foundation, CareData, or Public Citizen, consumers are more likely to indicate dissatisfaction with MC. Reports describes problems such as limited access to care, long waits in getting appointments, and restrictions on type and duration of care.

MYTH 2: MANAGED MENTAL HEALTH CARE COMPANIES RESPECT CLIENTS' FREEDOM TO SELECT A THERAPIST

Although research consistently demonstrates that the client-therapist relationship is a key element in successful therapy, consumers' choice of therapist is often limited to those on the company's list. A prospective client may have to call a referral line where s/he is given the names of only one or two therapists. Sometimes MC companies will pay an "out-of-network" therapist,but this option may require a lengthy petitioning process and a higher premium and co-payment for the client.

MYTH 3: THE MANAGED MENTAL HEALTH CARE INDUSTRY SAFEGUARDS CONFIDENTIAL CLIENT INFORMATION

Under MC, there are many intrusions into patients' privacy. MC organizations may require frequent reports about patients' symptoms, histories, and progress from therapists seeking authorization for continued treatment. Some companies demand to inspect and keep copies of clients' records, including the therapist's notes. Increased computerized record-keeping and electronic transmission of data make it difficult to protect the confidentiality of client information. Clients who use their insurance benefits, managed or not, may have their information transmitted to medical data banks, which can make it available to prospective insurers, employers, researchers and government agencies.

MYTH 4: SHORT-TERM PSYCHOTHERAPY IS THE MOST EFFECTIVE PSYCHOTHERAPY FOR MOST PROBLEMS

While short-term therapy is appropriate for some problems, it does not work for others. Clients with conditions that don't respond quickly are often labeled "chronic" and denies any further treatment. Very brief therapy is now the only type authorized by many MC organizations, simply on the basis of cost. Consumer Reports found longer-term psychotherapy more helpful than short-term psychotherapy for many problems (11/95).

MYTH 5: THE MANAGED MENTAL HEALTH CARE INDUSTRY REDUCES WASTE WHILE MAKING NECESSARY TREATMENT SERVICES MORE AVAILABLE

Under MC, enrollees may have access to insurance, but access to care is limited. The trend is for ever more drastic reductions in mental health services. These include restrictions on the number of outpatient visits per year, the total outpatient expenditure allowed per years, and number of days or dollars spent on inpatient treatment for substance abuse and serious mental disorders.
 
No matter what the benefits package says it offers, plans can deny or cut coverage by declaring that treatment is "not medically necessary." MC plans are withholding mental health care from enrollees who need it. (The Wall Street Journal, 7/13/95; Newsweek, 5/20/96).

MYTH 6: THE MANAGED MENTAL HEALTH CARE INDUSTRY IS ONLY TRYING TO CONTROL SOARING COSTS

It is inaccurate to blame the cost of soaring health insurance premiums on mental health care. The cost of outpatient mental health treatment, in particular, has shown no evidence of runaway cost increases. What MC companies don't tell the public is that their administrative costs for "managing" care are high, ranging from 17% to 30% of insurance premiums. (Public Citizen's Health Research Project).
 
Health care companies have reported record profits, but these are seldom passed on to consumers as lower premiums or better care. The executives of health care companies are among the highest paid corporate officers in the U.S., with annual salaries of $1.3 to $5.9 million (Los Angeles Times, 12/3/95).

MYTH 7: MERGERS ARE JUSTIFIABLE BECAUSE THEY STIMULATE COMPETITION, WHICH LEADS TO IMPROVED QUALITY OF SERVICES

There is no evidence that health care company mergers have improved the quality of health care. Instead, they have resulted in increased bonuses paid to CEOs and increased value per share of stock. MC companies have accumulated huge sums of money from premiums that are being used primarily to purchase smaller competing companies. (The Wall Street Journal, 12/2/94).

MYTH 8: THE MANAGED MENTAL HEALTH CARE INDUSTRY UTILITIES THE MOST EFFECTIVE TREATMENT APPROACHES

Managed care companies promote the treatments that cost the least, not necessarily those that are most effective. They tend to discourage the use of any psychotherapy longer than a few visits, and to require medication instead of psychotherapy. They may deny inpatient treatment because of the cost. Some MC organizations even require doctors to prescribe less expensive, older medications, instead of the newer drugs that usually give patients better results with fewer side effects.

MYTH 9: MANAGED MENTAL HEALTH CARE COMPANIES REFER CLIENTS TO THE MOST QUALIFIED THERAPISTS

MC companies often limit coverage for psychotherapy while paying psychiatrists for medication visits only. (The Wall Street Journal, 12/1/95). Yet much of the research shows that depressed clients treated with medication alone relapse at a greater rate than those receiving only psychotherapy, or therapy combined with medication. For some patients, medication is simply not effective, or must be discontinued because of intolerable side effects.

MYTH 10: THE MANAGED MENTAL HEALTH CARE INDUSTRY ENCOURAGES THERAPISTS TO UPHOLD THE HIGHEST ETHICAL STANDARDS

Even though all professional codes of ethics require that the client's needs and welfare be the primary concern in decision-making, some plans offer financial rewards for restricting care. Therapists who do not comply may be dropped from the referral list. Many companies prohibit practitioners from discussing treatment alternatives and payment options with patient using "gag rules' in their contracts.(U.S. News and World Report, 1/15/96).

MYTH 11: THE GOVERNMENT MONITORS THE MANAGED CARE INDUSTRY TO INSURE PROTECTION OF HEALTH CARE CONSUMERS

In California, health maintenance organizations (HMOs) are regulated by the Department of Corporations (DOC). Many believe the DOC is a weak overseer. For example, it relies on figures submitted by the HMOs, without verifying their accuracy. (Center for Health Care Rights, 1/31/96).
 
The DOC is supposed to provide comparative information about HMOs to people selecting a health plan, but it has been slow to do so.
 
Regulation at the federal level is minimal. The Employee Retirement Income Security Act (ERISA) exempts most health insurance companies, including MC companies, from any state regulation.

MYTH 12: MANAGED CARE IS HERE TO STAY

Managed care is here, but it does not have to stay this way forever. It's up to all of us. If you would like to know what you can do, contact California Coalition for Ethical Mental Health Care (CCEMHC).

Copyright, [COPYRIGHT]1966, CCEMHC (California Coalition for Ethical Mental Health Care)

DEFINITIONS

Managed Care (MC) -- systems designed to contain health care costs by monitoring treatment and establishing financial incentives to limit car.
 
Out-of-Network Provider -- a psychotherapist who is not under contract with the managed care company.
 
Short-term psychotherapy -- in the context of MC, usually extremely brief treatment for the stabilization and crisis intervention. The exact length varies with each company, and may be as brief as one visit.
 
Long-term psychotherapy -- in the context of MC, tends to refer to treatment that is longer than short-term psychotherapy.
 
Outpatient -- a person who receives health care without staying overnight at a care facility.
 
Inpatient -- a patient admitted to a hospital for at least 24 hours.
 
Gag rules -- rules that prohibit contracted professionals from talking to patients about their treatment needs and health plan.
 
For more information, click here.

A Word About Managed Care

by

Jules Ohrin-Greipp, Ed.M., NCSP

Catherine Ohrin-Greipp, M.S.W., B.C.D.

This page will attempt to convince you, as the purchaser of psychotherapy services, that purchasing these services out of your own pocket is not only more beneficial to you; but it is also safer, and will keep your work in therapy far from the prying eyes of the insurance company.

We will also make an issue of managed care, and try to show that it is neither "managed" nor "care." As the consumer, patient, client, the decision to use your insurance through managed care is up to you. We just want you to be aware of the possible pitfalls and difficulties that might arise in the future, should you choose to use this option.

Even though the example we use may apply to the medical end of the spectrum, we will concentrate most of my comments on the mental health aspect of managed care.

In the past, you would visit your doctor, who examined you, took blood samples, and sent you for lab tests if he or she felt something was wrong. You sent your bill to the insurance company, who usually paid. Now, it is necessary to ask permission for these tests or procedures. Not only that, but a huge layer of people now stands between you and the services you need. Guess who pays for them, and for the multi-million dollar C.E.O.s who run these companies...YOU DO!!!

The same procedures are followed on the mental health end of the spectrum. Except, every 10 or so visits, the therapist (or you) have to request permission to continue treatment. This means explaining why treatment is still necessary.

THIS MEANS DETAILS OF YOUR PROGRESS AND THE REASON YOU ARE THERE IN THE FIRST PLACE.

And, do you believe that this information is going to a mental health professional to decide?...Guess again! In many cases, it goes to a clerk who usually does not know much about treatment issues. YOU HAVE NO PRIVACY!!

And you thought that Roe v. Wade reasserted your right to privacy.

The greatest obstacle is that you, as the purchaser of psychotherapy services, own the right of confidentiality - not the therapist. So if you sign on the dotted line to allow the insurance company and managed care provider the right to pry and probe, the therapist can do little, except to caution you about the consequences.

If you have a history of psychotherapy, even for something like anxiety after a divorce, or for stress on the job, you could have difficulty getting certain jobs, or be denied life insurance, or even have a "snitch" at the insurance company spread the word if you run for public office. In the next section, there is a WORD FOR WORD copy from a release that a client was asked to sign. Look at it carefully, and consider how your life would be different if ANY one of the people mentioned was notified of your therapy.

The following is quoted directly from a release from an insurance company (emphasis added).

"TO: All hospitals and other medical care institutions, physicians and other medical professionals, insurance institutions, employers, group policyholders, contractholders, benefit plan administrators, independent claim administrators, and insurance support organizations.

"I authorize you to furnish New York Life Insurance Company, its agents, affiliates and subsidiaries, or benefit plan administrators, independent claim administrators, and insurance support organizations with copies of records you may have concerning examinations, treatment, including drug, alcohol or psychiatric treatments, if any, history, diagnoses, prescriptions, other medical information, information relating to medical expenses and any personal or employment related information which may relate to this claim.

"I understand that such information and records will be used by New York Life for the purpose of evaluating and administering claims for benefits. New York Life may release it for those purposes, or for the purpose of coordinating benefit payments under any Non-Duplication of Benefit Provision, to any of its affiliates and subsidiaries, to its representatives performing business or legal functions, to insurance support organizations, to benefit plan administrators, to independent claim administrators, to my employer, group policyholder or contractholder and their representatives, and to all other insurance institutions.

"This authorization shall be valid for the duration of this claim.

"I know that I have the right to ask for and receive a copy of this authorization. I agree that a reproduced copy of this authorization will be as valid as the original."

Think carefully about using your insurance. Even without the managed care side of the issue, there is less and less privacy between you and the world. You risk much.

As a last comment, I have found that those who pay for their own treatment actually have a tendency to improve faster. They have made an investment in their own lives and seem to work harder than if treatment is paid for by a third party.

There are other sources of on-line information about managed care. Please check them out; this issue is very important for you as consumers of mental health care.

For more information, click here.