| Ernie R. Downs, Ph.D. | Managed Care Aggression Syndrome - Etiology, Symptomatology, and Resolution
Psychology has reacted aggressively to the financial and narcissistic injury of managed care, entrusting its fate to a legal profession thriving on interminable discord rather than honorable solution. Predictably, we are now in a state of conflict, rather than dialogue, with the insurance industry. Therapists have the skills and temperament to resolve such matters, and should themselves engage the insurance industry in negotiations for a just, wise, and affordable system for psychotherapy payment. This article offers an alternative to managed care. My personal history and character are not too far from the mainstream for psychologists. I declared myself a conscientious objector against the war in Vietnam, but do not doubt that I would have gone willingly into World War II. I believe in charity and forgiveness, but also believe that violent criminals should be dealt with in a manner reflective of a society unafraid to delineate where treatment ends and punishment begins. I like to keep my doors unlocked and my “welcome” mat out, but there are people I would prefer not to take the latter literally. And even though I am as concerned as the next clinician about managed care, I fail to see the wisdom, maturity, or future in our jihad against the insurance industry. We have failed to respond to the threat of managed care in a manner consonant with our training and natures as healers, facilitators, and scholars. As war is supposed to be the last recourse in diplomacy, legal action should be reserved for only those civil and commercial matters in which all other approaches have been attempted and have failed. Legislative and courtroom belligerency seems to be the only game in town, however, and the litigation arms merchants have us all talking trash and loaded for bear. Remember those giddy days of the spring of 1998, when “We’ll nuke them on The Hill” was our battle cry? Well, of course nothing or the sort occurred (although now we are being told that 1999 could be the year of the big summer offensive). Lawyers get paid by the hour just as we do, and although we may feel in mortal combat against ultrabrief therapy for our clients, we all had better gird for ten more years of depth treatment from our attorneys — three sessions a week flat on the couch with our pockets wide open. The APA Professional Practice Directorate (APA, 1999) writes practitioners to “offer you the opportunity” to contribute “$50, $100, $250, or more” to its Legal Action Fund. Unnecessarily reminding us that “litigation is a very costly endeavor” the Directorate proudly informs us that the three current APA test cases against HMO’s are the culmination of a ten year strategy, but far from an end to things (“Rather, our national strategy calls for persistent hammering away at managed care on all fronts”). Just keep pouring it into those war chests, and try not to even think about when you may next see Tipperary. This belligerency is from a profession predicated on the amelioration of severe distress through respectful and empathic discourse? Amazing! And this is from a discipline on the cutting edge of conflict resolution? Incredible! And this is from a professional organization that has a Division of Peace Psychology? Absurd! Where do we imagine that the war is? Four changes are needed for psychology to emerge from this state of perpetual and unproductive warfare. First, we must accept that the brief period in which therapists charged insurance companies as much as they chose for seeing clients as long as they chose was an (inevitably closed) loophole, and not simply our due. As long as the latter remains our belief, or at least our collective public expression, we will remain fair game for any demagogue offering to lead a crusade to avenge our desecrated honor and recapture our mythical lost provinces. Such campaigns are usually long and bloody ordeals; ones from which arms merchants inevitably, officers frequently, but foot-soldiers rarely prosper. Our war against the insurance industry bears no prospect of reward for those in the trenches. The dream of a glorious victory over Big Insurance is a delusion the likes of which we would find clinically significant in our clients. Kosovars and Serbs can revel in the fantasy of a world without the other, but we providers need insurance companies as much as they need us. Why would one even try to annihilate someone on whom one is dependent? (We possibly need to remind ourselves that consideration of this very question forms the core of many a challenging clinical case.) Secondly, and most critically, we must severely alter the manner in which we talk about, and perhaps even think about, the healthcare insurance industry. From the jingoistic campaigns proclaimed by APA and state psychological associations to the managed care conferences proliferating nationwide, we are a people striving to convince ourselves of the moral degeneracy and atrocity of the enemy. We beat the drums and shout in unison, and learn to forget that most of the insurance people we know actually seem rather nice. Thirdly, we need to establish diplomatic relations. How many times in the past five years have you read something like “APA representatives will meet with mental health insurance officials to discuss their current issues and future vision?” Odd, but I do not recall anything like that either. This is like the bad old days between Israel and her neighbors. Do we have to wait for Jimmy Carter to invite us all to Camp David? Finally, we need to come up with our own solutions to the psychotherapy payment issue. It is time to stop chortling over managed care’s inability to operationally define “medically necessary” and come up with something better ourselves. A listing of principles would probably be helpful at this juncture. The three most basic to the matter under consideration are the value of psychotherapy, the fairness and desirability of therapy being covered by health insurance, and the need for some form of regulation of the apportionment of mental health benefits. I do not anticipate extensive argument to my first two contentions from Independent Practitioner readers. Those in doubt as to the third might meditate on the fact that health care expenditures have increased from 4.1% of GDP in 1965 to 8.9% in 1980 to 13.6% in 1995 (U.S. Bureau of the Census, 1980, 1997). For those still unconvinced, extrapolating for the next 30 years (factoring in the effect of Boomer graying is recommended only for the stout and sound of heart) ought to do it. Principles more specific to the current managed care situation are needed for a progression to proposals. My own proposal and list is simple, brief, and to the point. 1. DSM, ICD, or any other categorization of mental states is inadequate in itself to describe the severity of a clinical condition, to determine the course in which treatment should proceed, or to establish the amount of care that is appropriate. 2. Managed care case managers rarely have the foggiest notion from a phone interview or reauthorization form whether or not treatment is progressing satisfactorily, or more treatment would be helpful (let alone medically necessary). This is true even when the case manager happens to read beyond the diagnosis and number of previously authorized sessions (which I know from personal experience is not universal practice). I have penned a few of my managed care reauthorization requests so poorly that I have not been at all certain myself what I have written. Not a problem. To my experience, illegibility has no relationship to success in procuring additional client visits. Micro management of outpatient psychotherapy is a hoax. We know it, managed care officials know it, and, as I am aware from having had the privilege of a candid conversation with a managed care case manager on the topic, those who decide on psychotherapy reauthorization requests know it best of all. The cost containment function is legitimate, but the process is a total sham. Managed care will remain the dominant form of general medical coverage until something is devised to better allot treatment on a cost-effective basis. Like psychotherapy itself, managed care is in great demand. Even the private practice psychologists whom I know, who rarely support managed care with their voices, invariably vote for it with their wallets and purses. If we desire to move out of managed care’s surveillance, it is incumbent upon us to improve it. How might we proceed wisely and equitably in the allocation of outpatient therapy without the hovering gatekeeper? What should replace “medical necessity,” “biologically based,” and the rest of the binary foolishness we all despise? The answer has to be “something very different.” If we were to try to sneak in our own pseudoprofessional nomenclature - criteria intended to appear scientific but be delineated legally - we would be back to playing with double-edged swords and feeding the arms merchants. We need to initiate a dialogue amongst ourselves - at all levels and in all our clinical publications - on our vision of the wise and fair funding of psychotherapy without managed care. When a consensus is reached, we should assertively and honorably engage the insurance industry in the quest for a solution. I do mean “we.” Although legal sorts will probably eventually be necessary for codification of agreements, we are the experts in the calm pursuit of the equitable solution. We do not need to hire an agent or invent a persona to negotiate constructively with the insurance industry; we need only to be ourselves. My own solution is for a standard individual allotment for outpatient psychotherapy. I propose that APA promote a solution whereby all policyholders would be entitled to ten sessions per year, with no more than a modest co-payment. After that, clients would be able to receive a maximum of one session per week, with the insurance company and the client splitting the cost. It is imperfect, but has some clear advantages over the current situation, or anything I have seen on the horizon. Therapist Advantages 1. Increased ability to plan therapy. The duration and foci of treatment could be collaboratively planned with the client at any time. 2. No more closed panels. In fact, there would be no more panels. As we all know, the whole paneling process has nothing to do with clinician competence and everything to do with screening out clinicians who might not be “managed care compatible.” With uniform coverage, this would no longer be an issue. (As evidence of the above assertion, I am on a number of managed care panels in my group practice, which I somehow do not qualify for, in my solo practice. The managed care mentality is that group practices are managed care referral dependent, and therefore easily persuaded to play the reauthorization game by insurance company standards 3. No more reauthorizations! 4. No more war. For anything from a lively afternoon tussle to a lifetime of righteous indignation, we would need to return to abortion, affirmative action, nature-nurture, Monicagate, or any of the other old standbys. Client Advantages 1. Increased ability to plan therapy. A related benefit would be the ability to decide how much financial commitment to make to treatment. Back when most therapy was paid for out-of-pocket, client investment and sacrifice were acknowledged to be important elements in the curative process. If we can get beyond the role of client financial advocate, I believe that this again will be apparent. 2. No confidentiality worries. Clinicians are concerned about what happens, and what might happen, to the information we pass on to managed care about our clients. Many of our clients also are worried, and the rest of them should be. Insurance Company Advantage The advantage for insurance companies is the bottom line. I believe that insurance companies would pay less for psychotherapy under my system than they do at present. In New Hampshire, the state in which I practice, an initial outpatient psychotherapy authorization for eight sessions is universal practice. After that, an additional authorization of five or six sessions is almost automatic if the clinician fills out the paperwork. The total number of sessions funded is usually 13-20 per episode for clients who choose to stay in treatment. For the same insurance company expenditure on clinician fees, clients could receive approximately 15-27 sessions under the above-proposed system. My guess is that insurance company payments to providers would not change significantly under my proposed formula. The very substantial change that would occur would be in the elimination of insurance company payments for managed care personnel, and for legal planning and litigation. I would be in favor of a bargaining position by APA whereby all such insurance company windfalls would be apportioned equally amongst increased insurance company profits, increased provider pay rates, and increased policyholder therapy allotments. The peace dividend should be shared by all parties. An argument against any system of uniform benefits is that no clients should receive less funding for psychotherapy under any proposed system than they could receive under the current one. The argument posits that there should be special provisions or formulas to insure at least parity, and without parity no new system should be considered. Such a stipulation would combine the nearly impossible (a radical change in apportionment criteria, with many receiving more but none receiving less) with the totally unknowable (what an individual’s total psychotherapy benefit would be from a managed care system no longer in existence). Such a provision would inevitably lead to a combination of the most effective inertia agents of regulatory bureaucracy (studies, codes, laws, and bean counters galore) and academia (articles, responses to articles, and arguments over statistics and methodology). Most depressingly, such a stipulation resounds with the echo of attorneys goose-stepping up courthouse steps, brandishing briefcases full of state-of-the-art legal weaponry; and this is precisely where we and the insurance industry stand today. To end the state of perpetual warfare, any solution must be sufficiently brief, simple, and fair to avoid the definitions, standards, exceptions, contingencies, and protocols which, through their manipulation, promise inevitably irresistible first strike spoils to whichever side can rally the most public or political support, or hire the shrewdest attorneys. Such a wise and fair solution would entail almost mutant deviations, both from psychology’s and insurance’s recent history of bitter conflict with each other, and from the dominant societal patterns of codification, bureaucratization, and litigation. Yet it is the sort of outcome which we must collectively pursue–if we are to have peace. References American Psychological Association Practice Directorate. (June 16, 1999). Mailing to practitioner membership. U.S. Department of Commerce (1980). Statistical abstract of the United States. Washington, DC: U. S. Government Printing Office. U.S. Department of Commerce (1997). Statistical abstract of the United States. Washington, DC: U. S. Government Printing office.
Ernie R. Downs, Ph.D., is an adult, adolescent, and marital therapist in private practice in New Hampshire. He welcomes opinions on the article addressed to himself or letters to the editor. His address is: 47 Moharimet Dr., Madbury, NH 03820, (603) 743-1565. |
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