IN DEFENSE OF MANAGED CARE

IN DEFENSE OF MANAGED BEHAVIORAL HEALTHCARE
by
Janeen Weiss, JD, LCSW, CEAP

As a mental health care manager for an international managed care company and a private practitioner, I am in a unique position to assess the value of managed care. If you believe the media, the only thing that comes across is that life would be perfect if there was no managed care. Many private practitioners would agree with that. But, would the life of the patient be better? That is the main question.

Everyday, in my work, I get requests for authorizations for sessions from doctors and therapists. Everyday, I get to see first hand what these providers are doing to supposedly help the patients. Many practitioners are excellent, but way too many, I’m sorry to say, are not. They see patients endlessly, regardless of the need for the patient to get care.

APA standards and guidelines, though by no means exact, suggest that certain diagnoses can be handled, or should be remedied in a certain period of time. For example, adjustment disorder is expected by the very nature of the disorder, to be handled within about 16 sessions.

Often, providers ask for 60 sessions a year– some have even requested a total of over 150 sessions. The diagnosis is immaterial. And, what of the practitioner who knows that the client has only 20 sessions a year and schedules them all up front, knowing full well that the patient will not be able to have any covered sessions later in the year if needed. A private practitioner who really wants their patient to get better will also work towards managing those 20 visits so the patient does not end up using those sessions in the first quarter of the year and have nothing for the remainder of the year and be forced to pay out of pocket.

This is NOT for the patient’s benefit. It is for the financial gain of the provider. If after 12 sessions there is no improvement, the provider should ask themselves, what is it I need to do to help this client. Not, how many more sessions can I get out of the insurance company to prolong this care.

With a few exceptions, therapy need not be interminable. When we discuss treatment plans and protocol with providers when sessions seem excessive, it is astounding how many therapists not only get angry at this, but actually do not even know what a treatment plan is. They do not have a treatment plan laid out for the patient. There are no goals, no collaborative process that has been done with the client. This is not only harmful to the patient, it is just plain poor therapy.

Of course, these providers, the ones that have poor skills, keep patients coming needlessly and endlessly, are the ones that get the angriest when questioned.
“I’m the therapist. I know what’s best for the client. How dare you question me.”

Well, if that is the tone you take with your clients, how do you expect them to get better? How are you helping them? How do they acquire the skills and self worth to handle life without becoming dependent upon the therapist? And, how many practitioners spend half of their 50 minutes with their patients complaining about managed care. Way too many.

Do not blame managed care for your inability to treat. Good care is good care, whether you get paid or not.

As for pay, most managed care companies pay a minimum of $60 for 50 minutes. That is a minimum, with prices going much higher, especially for MDs, who spend 10 minutes with a client and charge $120. How many people in the United States get paid $60/hr for their work? Few if any. That is good pay by any standards. If you are having trouble making your own ends meet, please do not blame Managed Care if your practice is not full. And, a practitioner is never forced to get on an insurance panel. You can always forget about taking insurance and charge what you want without answering to anyone.

So, what is the role of Managed Care (MC). One of the main reasons for the birth of managed care was due to out of control costs by providers. For example, 6 months hospital stays for the “worried well”. That cost was all billed to an insurance company, who blindly paid for it.

The public and companies cried out at the cost of healthcare (they are still crying out). . Insurance companies responded by only covering ‘medically necessary care’. That was the birth of the medical necessity criteria (MNC), which became the basis for receiving insurance benefits. This definitely hurt the practitioner who had unchecked and unlimited access to all health insurance benefits, regardless of necessity.

The ethical practitioner, unfortunately, got caught in this onslaught due to the rampant abuse by many unethical providers.

Managed behavioral care (MBC) companies are a business, just like therapy practice is a business. Reviews are done by licensed practitioners. Many of these reviewers (like myself) are also private practitioners. When we refer clients to providers in our network, we assess the client’s needs as well. Then we defer to the practitioner to work appropriately with the client and set goals and an agenda for treatment. The provider then requests additional authorizations for care from the managed care company after an initial set of authorizations are given. If the MBC Company receives a request for additional sessions that appears to be excessive and inappropriate for the diagnosis, we contact the provider to discuss their treatment protocol and their plans for the patient’s recovery. That way, the client’s needs are being addressed. We attempt to work collaboratively with the practitioner. We often get a lot of ‘ego’ instead.

When a patient has a behavioral health issues that is served by going to therapy, they are in a vulnerable place, relying on the therapist to guide and help them. When the therapist automatically says at the end of a session, “Well, we have a lot to discuss. See you next week at the same time”, the client agrees even if they don’t want to continue with this provider; even when they don’t like the provider. The client is often in a weakened state and is waiting, hopefully, for something positive to show up. When the provider says, ‘Well, that will take a long time. We’ll see.’ What does the patient do but believe them and think it has to take a long, long time for improvement.

This is not true. Solution focused therapy, cognitive behavioral therapy, NLP, hypnosis, and more have shown that improvements can come much faster than traditional talk (psychoanalytic) therapy where the provider typically shakes her head in agreement without ever creating a plan or getting feedback from the client. A recent article in The Psychotherapy Networker discussed the fact that the providers who got the best results and had the most success were the ones that asked for and received feedback from the clients. If the feedback was not positive nor in the patient’s favor, the course of treatment was changed.

Too many therapists have one way of doing things and are inflexible in their treatment process. I once had a provider hang up the phone on me when I asked what his treatment plan for a very young child was. He refused to answer. Turned out, he never had one. He just wanted to keep seeing the client and watching her on a regular basis without actually doing any treatment. When that happens, who does oversight. And, on top of that, these providers triangulate the family into the picture and everyone gets overwrought and blames everything on insurance. That is NOT good therapy. This does not help the patient.

Managed Care companies are the ones that have been assigned the task to do the oversight. Someone has to. Psychiatrists over or under or improperly medicate on a far too frequent basis. Hospitals (and I could name so many names) treat mental health patients in an abominable manner. And, don’t get me started on how they treat teenagers and their families – it’s shameful and harmful.

When patients are crying out for help for serious problems, there must be some controls. Most providers are sole practitioners with no supervision or oversight. There is no one around to say, ‘you are harming this patient’ or ‘if you changed your approach, you could really assist this patient in getting better’, or even to say, ‘good job.’ The only entity around is the managed care company. You may not like it, but if you would work with managed care, you might find they are a practitioner’s strongest ally.

We are not here to dictate treatment, or to treat other practitioners like children. We are here to assist in getting the best care for the patient. At least, that is true for me and my colleagues. If your mission in life, as a therapist, is to help people get over life’s hurdles whatever they may be, and you have access to several other professionals who can assist you in your quest, why wouldn’t you utilize that gift? Saying no to that assistance makes no sense unless your bruised ego is more important than the quest to help that patient

The care manager can assist you in developing a treatment plan and suggesting alternatives to assist the client. The idea that you have to keep a client in treatment for 5 or more years has gone out with straight Freudian concepts. Remember, these care managers are also licensed practitioners with many years of experience. They do want to help the patient. It is good for the client and smart for the company.

As for psychiatrists, insurance companies have Medical directors who do oversight. If what the doctor is doing is appropriate and meets standards, there are few, if any arguments. But, where does the patient or the patient’s family go when the doctor is doing something potentially harmful, does not listen to the patient’s needs or even diagnose correctly. The patient turns to his insurance company for help. And, we do help. We have review committees, quality control committees and more to assure good patient care. And, Managed Care companies are heavily monitored and regulated by the State. MC must answer to some very strict laws or pay a heavy fine.

Yes, managed care could be improved. Yes, the needs of many Americans, especially those with mental illness and substance abuse issues, are not being fully met due to lack of insurance. To me this is inhumane, but it is due, mainly, to a company’s refusal to contract with the MCC for additional coverage. The MCC would be glad to cover it if the company would buy it. But, the costs are getting higher and higher.

So, until there is Universal Health Care (which I favor in spite of my job) or everyone in this country has access to affordable and good mental and physical care without being drained financially, managed care has its place in our society and can work in everyone’s favor.

Note: The use of the word provider is not meant to insult any practitioner. It is an all encompassing word that includes facilities as well as therapists and psychiatrists.


Janeen Weiss, JD, LCSW, CEAP, SAP has been in private practice for 10 years. She has also worked in managed behavioral care for 6 years, was an adjunct professor at University of Southern California and is the president elect of the Los Angeles chapter of the Employee Assistance Professionals Association.