One year into my term as Editor it amazes me I have previously not opined about the biggest scam/problem our profession has faced since I became part of it near 20 years ago.

Managed care for outpatient psychotherapy is a farce. It is, and always has been, about depriving consumers of psychotherapy and cutting costs in a field where costs are relatively easily maintained. Although mental health in general accounts for only about 6% of the healthcare budget in this country, it turns out to be one of the easiest areas to ration by simply placing barriers to care and forcing patients and professionals to justify the need for services.

Some simple thoughts for those pundits who claimed “we needed to be roped in – we were abusing the system before managed care”.

The vast bulk of the spending on mental health care before we were “managed” came from inpatient services. In the heyday of the 60’s and 70’s some people did indeed spend many months in hospital settings. Some of those did not need that level of care, and would have managed well in outpatient settings. We corrected that problem when we set some limits on inpatient mental health days and asked for justification of longer stays. Of course, then the sharks realized they could save lots of corporate money by reducing inpatient stays to less than one week, essentially rendering hospitals nearly useless as anything other than temporary holding facilities. Think about it: It takes two weeks for any of the major anti-depressants or mood stabilizers to get to therapeutic level in patients. However, almost no-one now stays in that long. How much meaningful psychotherapy can one do in less than a week with any but the simplest adjustment disordered patients?

But now it was clear to some that “Hey, we can save some money by trying to divert people out of psychotherapy and discouraging people from wanting to use their full benefits as defined in their health plan”. Whole companies sprang up around this idea, at least one of them run by one of APA’s great heroes, a man who sold us down the river but has managed to come out looking like the great savior. Most of us know the story. We have slid gradually into a world where we write treatment plans to be read by some 24 year old with a Bachelor’s Degree (hopefully in Psychology) or perhaps a Master’s Level person who parses out psychotherapy sessions in thimble sized doses. Some few of us opted out early (mine was by simple bull-headedness, not any kind of wise long-term understanding), but most stayed and have adjusted their practices. Many have learned to “keep their session numbers down” so they will continue to get referrals from the companies that feed them patients (don’t get too high an average number of sessions or you’ll be blackballed!), or developed “warm” relationships with “care managers” (What a lousy euphemism that term is). There are even seminars to teach you how to get in better with managed care panels, to teach one how better to release the flow of precious manna (referrals) that allows one to sustain a livelihood. The fact is that most of us could not opt out of the system – we realize that others are waiting to take the place of those of us who leave, we understand there is a limited self-pay market, and that without staying on panels many patients would receive either no care or very sub-standard care. So most of us accommodated. It wasn’t a real choice.

But it was all a farce. Almost all the management of psychotherapy “benefits” was and is useless. Simply put, managing any benefits for psychotherapy before the 26th session is ludicrous (in perpetuity this will be true unless the basic function of how psychotherapy works changes). All we need is to review Howard, Kopta, Krause & Orlinsky (American Psychologist, Feb, ’86) who penned the “The Dose-Effect Relationship in Psychotherapy”. They show that 50% of patients improve measurably by the 8th session and by 26 sessions, 75% improve. And once they are “measurably improved” MOST PATIENTS LEAVE PSYCHOTHERAPY! They don’t hang around for thousands or even hundred of sessions. They have lives to live and can’t and don’t devote their time and energy to more therapy once they feel better. And yes, perhaps some unscrupulous or poorly trained or pathological psychologists/other therapists attempt to keep their patients longer. And yes, some of those patients are dependent or masochistic and so they stick around. But most DON’T. The data on that are clear.

So, if you want to limit psychotherapy, here is the simple solution. Give every consumer 26 sessions up front in a year. 75% of them will be better by the time they’ve used their benefits. THEN, if you want to consider rationing benefits because you are worried about people using too much of the overall benefit dollar for therapy, you can consider oversight of the care. But by then you have lost about 70 % or more of your patients. All that crappy rationing (“you may have 8 sessions” – the sickest game of “Mother May I” ever created) can go away. No treatment plans or OTR’s or other tripe until we reach at least a respectable point where we have some high confidence that the patient has improved.

Managing most psychotherapy is a farce. Please, don’t tell me managed care companies are “realizing” this now and starting to drop their overview requirements – as indeed some companies are lowering outpatient review requirements. They are only doing that because if makes business sense for them – they need to cut THEIR budgets because they haven’t managed to save their subscribers (the corporations and larger insurance companies that sub-contract for the mco’s business) enough money, and they make more on their dying corporate mission by spending less.

Bryant Welch knew all this years ago, when he wrote one of the seminal articles of our field that too few read. “Managed Care: The “Basic Fault” (psychoanalysts all got the inside reference to Balint and smiled at Bryant’s extension of the term – sadly many of them were the least likely to ever be part of the insurance system).

Overall, managed care is a scam. A 3rd party system that has never and will never help healthcare, but will only siphon money off to corporate interests. Let us never be fooled that it was started to benefit the consumer or improve health care. It was designed to save healthcare dollars, without overt rationing on the part of either the government or employers, neither of whom wanted to be the bad object. It has NOT saved healthcare dollars, but it has lessened care for some and made oodles of money for some smart entrepreneurs. We continue to have an enormous problem with our health-care system, and we are still going to have some day deal with either increasing costs to higher proportions of GNP OR we will have to ration care. And one day, we will look back on managed care as a failed “experiment”, but those who really knew will understand that it was never an experiment, but a great way for some people to get rich and lots of people to get poorer (care that is).

Finally, my gratitude to Ivan Miller, Peter Gumpert, Harry Lewis, Stan Moldawsky, Arthur Kovacs, Karen Shore, Joe Bak, Russ Holstein, Mary Kilburn, Stan Graham, Brian Sweeney and those mentioned above for helping me figure this out along the way and being brave enough to scream out that the system was corrupt from the start and couldn’t be fixed by negotiation, conciliation or adaptation.

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