Professional Practice: Licensing Board

A group called the Patient Advocacy Coalition in Colorado called all 34 Psychiatrists on Magellan’s referral list in Denver and Boulder last August. Twenty-three were either no longer in Magellan’s network or not available. Four had moved or disconnected their phones. Two didn’t return messages. One turned out to be a kidney specialist. “Only four were taking Magellan plan Members,” says the group’s head, Heidi Frey.

In a previous article, this author began the study of phantom services offered to subscribers of large, health benefit plans (Holstein, 2004). This article continues the investigation, this time looking at phantom networks in HMO’s and PPO’s.

The issue of phantom networks has also been highlighted in an APA law suit, Virginia Academy of Clinical Psychologists v. Care First, et al (Holloway, 2003). In this lawsuit, the alleged phantom panel (network) resulted from a sudden reduction in reimbursement to mental health professionals that led to many resignations from the provider panel. The basis of the Virginia Managed Care lawsuit was that the network continued to advertise that the psychologists who resigned were in their network. Consequently, many of those on the advertised panel were “phantoms.” This author and others are concerned that these examples are reflective of a phenomenon that has now come to exist widely in managed mental health.

Another concern driving this study is that, for a host of reasons, the insurance companies and managed mental health care carve-out networks have begun to implode. It is this author’s hypothesis that many of these networks provide inadequate psychiatric services and that psychological services are beginning to decline as a result of the failure to maintain the professional networks to serve covered lives. This concern comes in part from the people who call this author and express frustration over their inability to access an in-network psychologist or psychiatrist. This has happened with greater frequency over time. This study attempts to know more about the experience a would-be patient who has a managed care plan has in finding a treating professional.

Research Design

During the mid-summer to mid-fall of 2003, ten large networks serving residents of Monmouth and Ocean Counties, New Jersey, were identified. These two counties have population of 615,301 and 510,396 respectively and area of 472 and 638 square miles respectively. These are largely suburban counties with small urban and rural populations, as well. They cover a large area with traveling distances from point to point of up to 1 hours or more. These counties make up the north Jersey Shore and run most of the way across the State east to west. From south to north they run about 60 miles, about one third of the length of the State. Because there are population centers, it is usually not necessary for a patient to travel more than thirty minutes to see a mental health practitioner when access is not restricted by managed care.

Using Internet resources, the networks of nine of the ten plans were accessed to obtain the names of all the psychiatrists and psychologists providing services in the two-county area. The tenth, Value Options, supplied a faxed listing of their psychiatrist and psychologist network in the two counties.

Utilizing the aforementioned information, the names of every practitioner listed as in-network, their phone numbers and the names of any and all of the ten plans in which they participated were placed in a database during the mid fall, 2003. Commencing in mid December 2003 and continuing to late January 2004, a total of 285 providers participating in one or more of the ten plans were contacted. Data was received on all but four of the 285 providers from either the professional or the professional’s ancillary staff.

There were three psychiatrists who were employed by a clinic where the network information accessed online was not confirmed nor denied, at first because of “HIPPA concerns.” All other questions regarding these practitioners were answered. Subsequent efforts to get around this problem led to the decision that they did not want to provide data to the study. For the sake of the study, it was presumed that the networks that alleged their participation were accurate.

A template was used to introduce the survey to the respondents, either to the professional or to their ancillary staff/administrative assistant as follows:

My name is Dr. Russell Holstein and I am doing a survey in Monmouth and Ocean counties under the auspices of the American Psychological Association, Divisions 39/42 Interdivisional Task Force on Managed Care and Health Care Policy. We want to know about the access that patients seeking treatment within managed care networks have to mental health services. The results of this survey will be of benefit not only to patients to professionals as well.

The information that I seek is limited and the survey will only take a brief period of time. Your (the professional’s) name will be anonymous. We are interested only in aggregate data.

At that point, the survey questions began.

“You (Dr. )are (is) noted as participating in the ( ) network(s).”

Each network was specified. After each network is stated, the question was asked, “Is this true?”

The next question was “Are you (Is the professional) taking new patients from these networks?”

If the answer was “Yes,” they were asked for the earliest, available appointment that could be offered to an individual with the network benefit, who would be seeking an appointment at that moment. The time frame entered in the database was according to the number of weeks. (Anything within one week was noted as one week, etc.)

The final question was, “Do you (Does the professional) see young children, adults or both?”

When a call did not reach a suitable respondent a message was left asking for a return call. If no call was returned, a second call was placed two weeks after the initial attempt. If the second call was not returned, a third message was left. Anyone not responding by the time the data was analyzed was retained in the survey as a non-respondent

Results

The data are summarized in Table 1 and 2. Table 1 reflects the data gathered from Monmouth County practitioners, Table 2 from those in Ocean County.. Each of the ten plans surveyed are listed at the top of each box. The figures in the first row are the number of psychiatrists and psychologists alleged in network from the information gathered from the names on the websitesor the faxed list. The second row shows the number who, upon contact, confirmed their network status. The third row lists the number of professionals who were not taking new patients. Data in the next four rows indicate the number of professionals available by time frames. For example there were two Monmouth County psychologists with first available appointments in three to four weeks in the QualCare (first box) network. The next row indicates the number of professionals with available appointments who treat children. Because there were a number of practitioners with offices in both counties, the numbers are slightly inflated.
The question as to whether or not a practitioner was taking new patients involved a certain degree of judgment. For example, the “not taking patients” category included a number of situations. These included those who, in fact, did not work in either county, had moved away, were deceased, not actually psychiatrists or psychologists (i.e. one listed psychiatrist was a social worker/administrator and another was a dentist), were not working in an outpatient setting, were on medical leave, or said directly that they were not taking new patients. If a professional indicated they could not provide an appointment time but instead would place the patient on a waiting list, they were listed as not taking patients. There were several psychiatrists in one mental health clinic that would not accept referrals except from clinicians who also worked at the clinic. They were listed as not taking patients.

Tables 1 and 2 indicate that, given the demographics of the two counties, psychiatric services are largely inadequate. Mental health services in Ocean County are in worse shape than in Monmouth County. Services in Monmouth are hardly in good shape.

Discussion

It would be extremely useful to have covered lives data from the ten plans studied. Efforts to obtain this data for both counties were unsuccessful except from the Blue Cross/Blue Shield plans, despite the fact that this data is supposed to be available. One of the findings of this study is that insurance companies and State agencies are non-cooperative or unable to help.

The plans varied greatly in terms of the percentage of reported in-network providers who were both in-network and able to take new patients. Table 3 summarizes this data.

Table 3 clearly reveals that the accuracy of the practitioner database varies considerably. One plan, GHI Behavioral Management Program, which is a subsidiary of Value Options, clearly has an exceptionally inaccurate data base and that the situation for GHI in this two county area is poor. Only one psychiatrist in both counties (this one was at the northern end of Monmouth County) was taking adult patients. Even those plans with higher accuracy percentage rates such as United and Cigna, pose serious access problems as the actual number of professionals in the two counties is very low. These are fairly large plans with very limited networks.

Feedback from professional colleagues suggests that there are several factors accounting for the relative adequacy/inadequacy of the networks. The first is the amount of contracted payment. The less adequate the reimbursement, the less adequate is the network. Second is the hassle factor. The more paperwork in amount and frequency, the less adequate is the network. Also a problem in this category is difficulty in getting paid. A third factor is the size. As the size of the plan increases, more professionals are needed to cover the beneficiaries. This gives the impression that access is greater because there are more clinicians. So the first two factors notwithstanding, this factor may make certain plans appear more adequate. Thus, the two Magellan plans have more professionals even though it is reported that the reimbursements are less and hassles can be many. They are large plans with many beneficiaries and the appearance of greater adequacy is more apparent than real. This will be spelled out below. Finally, there are the plan’s efforts to create and maintain networks. Table 3 suggests that, whatever these efforts are, most networks fall short here.

Reviewing the tables above suggests that for their size, a number of plans limited the number of participating professionals, such that finding a psychiatrist is often exceptionally difficult. In addition, despite what may be perceived as an ample number of psychologists, the distributions of both professionals may place a number of potential patients at an unacceptable distance from a suitable psychologists or psychiatrists. The exceptional size of the area studied and the decrease in numbers of clinicians due to those claiming out of network status and those not taking patients makes this likely.
As mentioned above, Horizon Blue Cross/Blue Shield provided some data as to covered lives. Their Magellan managed care plans in the two counties have in excess of 146,865 covered lives. *

Magellan’s 24 psychiatrists and 44 psychologists serving the managed care plans are not a lot of resources when dealing with perhaps considerably over150,000 covered lives.
Consider that, of this number of professionals, virtually all are serving other managed care and fee for service patients from the general population. This results in there being only a few slots available to the Magellan patients. The conclusion is that these insured people now have become an underserved population.

Other Difficulties with Access

First, in this study, an in-network practitioner providing services supplied his or her “first available appointment.” The fact that they had a first available appointment (e.g. within one week) wrongly suggests that any patient seeking services could be seen at that appointment time. This is often not the case. Many patients need special consideration due to work, childcare and in the case of children, conflict with school hours. A few professionals pointed this out when they described their availability, in that the first appointment times available were those that patients were least likely to accept (e.g. mid-morning or early afternoon, weekdays).

Second, the availability of a psychologist or psychiatrist for services does not necessarily mean that they are the right professionals for the job. For example an individual seeking treatment for an eating disorder (anorexia or bulimia), may find it difficult to find a specialist in their disorder from the list of professionals, as there is a relatively small number of professionals offering such services in this two county area. Anyone seeking services for other than the most common DSM IV diagnoses would be in great difficulty attempting to pick the appropriate provider from the short list of in-network professionals who are actually available. The idea that one professional fits all is clearly not accurate.

Third, between 20 and 25 of the 90 listed psychiatrists listed on the web sites and a few psychologists who were in network and taking new patients did so as part of their work at mental health facilities that also work with the medically indigent (e.g. Medicaid) and the poor uninsured. Outside of these facilities, all of which receive government funding, the patients with Medicaid (or Medicare/Medicaid combined) or poor and uninsured have virtually no place to go. Professionals at these facilities were those with the longest waiting times (many were 7 or 20 weeks and one was 39 weeks).

Managed care’s use of these facilities interferes with and impairs outpatient treatment for the most under-served group of patients. It is unlikely that they would be able to receive weekly individual psychotherapy where appropriate. This is a typically unseen serious problem. As these clinic services have been increasingly curtailed by diminishing public funding, the problem becomes much worse as these clinic facilities, for monetary reasons, prefer insured patients than those who are indigent or have Medicaid that pays little.

Fourth, in some cases, there is an adequate number of psychologists and a serious shortage of psychiatrists providing services to children. This raises questions about whether managed care is taking its commitment to a full range of services seriously. Given the shortage of child specialists, it is hard to justify managed care restricting access at all.

The general conclusion that results from reviewing this data, is that the managed care companies are not doing an adequate job providing a network that is comprehensive enough and large enough to provide services to its covered lives, especially children.

Implications for Psychiatrists: You Don’t Need Managed Care

There is clearly an inadequacy in the number of available psychiatrists. Psychiatric services are frequently needed on an as soon as possible basis. Psychiatrists have also learned that, if they are competent, their practices thrive even when they move out of managed care. This raises concern about the quality of a psychiatrist who is still working for managed care and has openings. According to Moran (2004) 52% of psychiatrists have been able to opt out of managed care.

Implication for non-psychiatrist mental health professionals: if you take managed care patients, you may be taking unacceptable risks

The results of this survey document that finding the right psychiatrist for a patient who needs psychiatric services is difficult and that many of the psychiatrists who might be appropriate to offer an appointment and who are in network, have a long waiting list. This not only places the patient in grave jeopardy but the treating provider has full responsibility to make the appropriate referral but. As Holstein (2002) indicates, the likely liability in the case of a patient who commits suicide or causes harm to him or herself or others while waiting to be seen by an in-network psychiatrist will fall on the non-psychiatrist professional who is currently treating the patient and not the psychiatrist whose waiting time is long or the managed care company. This is even more true if the patient’s health plan is self-insured. The implication is that it is a good risk management idea to avoid new patients from inadequate managed care plans with phantom networks where there are few psychiatrists.

Summary

A survey of ten mental health networks providing services in Monmouth and Ocean Counties, New Jersey, documented that even, at best, the availability of psychologist and psychiatrist providers is considerably less than that which is claimed. Taking into account inaccurate listings, retirements, deaths and those not accepting new patients, etc., the number of professionals is often inadequate. The number of psychiatrists is far more inadequate than the number of psychologists and this particular situation poses special risk management concerns for psychologists and other providers who may find that a new patient needs psychiatric care.

The results of this study have broad and obvious implications for public policy, which tilts in the direction of the ever-increasing necessity to reform our health care system.

These results also have broad implications for remedies to the intentional or unintentional invisible rationing (Miller, 1996) that is made evident by this study.

There are two approaches to forcing a reform of health care that these findings feed into. First, these results raise concerns about accessibility that are exceptionally newsworthy and will become even more newsworthy if further studies document a pattern similar to those found here. This information can raise public and media interest in health care reform.

A second approach to remedying our impaired health care system is a legal one. The American Psychological Association has documented the value of suing healthcare plans that provide a phantom network. This data and additional data that will be collected will document to lawyers who use the legal remedies to our health care problems such as class-action lawsuits, the value and vitality of potential legal action. Numerous patients, unable to get appropriate timely, in network mental health care could represent one such class.

Bibliography

Geyelin, Milo, (2001). Managed-Care Firms Handling Mental Health Trigger Complaints: The Wall Street Journal 238 (90) p. 1

Holloway, Jennifer Daw, (2003). Virginia Managed-Care Finally Heads to Trial: Monitor on Psychology 34 (4) p. 24.

Holstein, Russell, (2002) Managed Care Contracted Professionals: Are You Practicing Dangerously?: New Jersey Psychologist 52 (4) pp 14-15.

Holstein, Russell, (2004) Triage as Treatment: Phantom Mental Health Services at Kaiser-Permanente: Independent Practitioner, The Independent Practitioner, 24 (2) pp

Miller, Ivan, (1996) Ethical and liability issues concerning invisible rationing. Professional Psychology: Research and Practice, 27 (6) pp 583-587.

Moran, Mark, (2004) Psychiatrists Outside of Managed Care Value Autonomy in Treatment Decisions. Psychiatric News, 39 (6) p. 13.

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