Psychoanalysis, Psychotherapy & Managed Care
What are the effects and implications of managed care on the mental health care professionals ("providers" in managed care parlance) and their patients ("consumers", again, in managed care terms)?
It is important to remember that the concept of managed health care was created by the business community to contain the cost of health care spending. Healthcare costs were rising at a rapid rate, and if health care services were being used unnecessarily, then controlling those services would be useful.
The downside of this approach is the possibility that treatments deemed necessary by the mental health professional, would be judged as unnecessary by the case managers of a managed health care organization in an effort to cut cost.
The goals of the mental health care professional and managed care business person are fundamentally different, if not opposed. The mental health care professional's goal, using his or her years of training, experience, and expertise, is to help the patient. The mental health professional's monetary needs are secondary to this. The managed care business person's goal is to decrease cost and increase profits for his or her company. These are two profoundly different philosophies and interest. It is for this reason that a former president of the American Psychiatric Association, Harold Eist, M.D. has declared the term "managed care" a misnomer--It should be "managed funding."
The public is becoming aware, of late, of the real effects on them as patients ("consumers") in a managed care environment. What have been the effects of managed care on mental health professionals and their patients in psychoanalytically informed psychotherapy?
A typical example may be helpful. It would be unfair to claim that what follows is representative of all managed health care firms but it is far from uncommon. A person sees, that as part of their benefits, they have fifty-two weeks per year of psychotherapy (extremely generous). They think: "Wonderful, if I have problems, I can consult a mental health professional!" The person comes to feel anxious or depressed, is suffering, and decides to see a professional for consultation.
The professional evaluates the patient and decides that the patient could be most assisted with psychoanalytically-informed psychotherapy. The patient, upon hearing the whys and wherefores, agrees. The professional then calls the managed health care company and receives a form to fill out requesting authorization for psychotherapy. The form asks some reasonable questions (diagnosis, presenting problems, etc.) as well as the most confidential and intimate details about the patient, and a few questions only a god could answer (exactly, how long will this take?--i.e. the exact number of sessions?). The professional answers these questions to the best of his or her ability, including his not being able to know exactly how long therapy will last. The professional has, of course, received the patient's permission to inform the managed health care company of the most intimate details of their life. All of this information will end up in a managed care databank.
The professional receives (maybe) authorization for six sessions based on the conclusions of a managed care case manager who has never seen nor examined the patient. The case manager's conclusions are generally based on guidelines written by the managed care company. The manager will likely not have the experience, training, and expertise of the evaluating professional. Along with the authorization comes another form, to be filled out and resubmitted at the end of the six sessions. Again, the form is submitted, except this time two sessions are authorized, or worse yet, the treatment is deemed "medically unnecessary". Endless time is spent appealing this decision, with results unknowable. A horror story? Yes. Uncommon? No.
The managed care environment interferes with, if not obstructs, the effective delivery of psychoanalytically informed psychotherapy.
As a result of these practices, the majority of the members of the Dallas Psychoanalytic Center have decided not to involve themselves with managed care organizations.
These practitioners remain private, independent, fee-for-service mental health professionals. Most facilitate the patient's efforts to claim traditional insurance benefits.
What are the advantages to their patients?
1. Autonomy in the choice of one's own therapist.
2. Complete confidentiality. The intimate details of one's personal life has no chance of being divulged to an outside party. In fact, many analysts keep no process notes of what transpires during sessions. This results in an atmosphere of trust, where one is free to discuss anything.
3. Freedom from third party intrusion and control. The patient and the psychoanalyst, together, determine the treatment and length of time necessary.