Correspondence
Managed Care and Mental Health
N Engl J Med 1996; 335:56-58July 4, 1996
- Article
To the Editor:
In his Health Policy Report on managed care and mental health (Jan. 11 issue),1 Iglehart inaccurately characterized my campaign for the presidency of the American Psychiatric Association. It was based on timehonored clinical and scientific values central to ethical medical practice, which place the sanctity of life before the sanctity of the dollar. I insisted that physicians have moral, ethical, and legal responsibilities to advocate, in the political and social spheres, for both the best patient care and excellent systems of care. My opponent, Steven Sharfstein, and I did not differ on these essentials. We differed on how best to advance and maintain health care for the chronically underserved mentally ill of America in the current mean-spirited, bottom-line climate.
I challenged the belief that managed care could be changed from within. My view has been vindicated both by Sharfstein, who acknowledges that the market has driven the seriously mentally ill from hospitals to shelters, and by the “good” managed-care companies that are being forced by the “bottom feeders” to cut services to survive in the shark-infested waters of unfettered capitalism. Those of us who treat patients every day painfully witness the tyranny of the bottom line, giving rise to the “tyranny of the healthy over the sick.”2-4
Physicians have a sworn duty to attend to the health care of our citizens. It is paradoxical that those who profess concern about limited fiscal resources are not attacking profiteers leeching a system in which fewer than one in five mentally ill persons receives treatment. It is a national travesty.
4 ReferencesHarold I. Eist, M.D.
American Psychiatric Association, Washington, DC 200051
Iglehart JK . Managed care and mental health. N Engl J Med 1996;334:131-135
Full Text | Web of Science | Medline2
Austad CS ,Hoyt MF . The managed care movement and the future of psychotherapy. Psychotherapy 1992;29:109-118
CrossRef | Web of Science3
Ackley DC . Managed care and self-esteem. Independent Practitioner 1993;13:226-2294
Annas GJ . Magic, miracle and the market: do we need a new medical ethics for managed care? Alumnae Rep1995;18-27
To the Editor:
Any responsible review of managed care should address the issue of secrecy and the implications of a system under which interpretive guidelines and other conditions of treatment are withheld from patients and psychiatrists. In the present atmosphere of secrecy and the gagging of psychiatrists, patients cannot be assured that their psychiatrists will do all that is needed to alleviate their pain and improve their functioning. In their Sounding Board article (Jan. 11 issue),1 Shore and Beigel understate the potential effect of this environment on the physician–patient relationship. Calling for “clinical ingenuity” is not sufficient.
The authors point out that under the insurance system “patients could be transferred to the public sector.” The naive reader might conclude they mean that health maintenance organizations (HMOs) do not do the same. No evidence suggests that HMOs are more reluctant to dump patients onto public programs than were the systems they replaced.
Finally, the authors do not address the numbers of psychiatrically ill patients who feel they have to pay for care and treatment from their own funds. Because of discrimination and stigma, psychiatry has traditionally had a larger proportion of patients who pay for their own care and treatment than any other non-cosmetic medical specialty. As managed care imposes the values of the business world onto medicine, more will be driven to pay for psychiatric treatment from personal funds, being too desperate to take their chances on “ingenuity.”
1 ReferencesRoger Peele, M.D.
, Washington, DC 200161
Shore MF ,Beigel A . The challenges posed by managed behavioral health care. N Engl J Med 1996;334:116-118
Full Text | Web of Science | Medline
To the Editor:
Both articles dealing with managed behavioral health care miss a scandal. The HMOs and managed behavioral care companies are deceitful. They promise patients comprehensive mental health and substance-abuse care. Brochures cite the benefits of 20 sessions of outpatient care per year and 30 to 60 days of inpatient care. Only in the fine print does it say that all care is based on “medical necessity.” Since the definition of “medical necessity” is determined by the company and contracts for behavioral health care services go to the lowest bidder, services are diminishing.
The true figure that payers and patients should look at is the percentage of each medical dollar that is spent on behavioral health care services. Iglehart cites figures of 3 to 5 percent in HMOs, as compared with 10 percent in other arrangements. Even lower percentages will no doubt prevail as we move into capitation.
Should our society determine that it does not wish to pay for most outpatient mental health treatment, the deceit should stop. In my opinion it would be far better if companies were to state the truth to patients: “We do not want to pay for your misery and mental suffering, even though it is treatable, because we operate in a highly competitive environment and you (like everyone else in a managed-care plan) have meager mental health coverage. If you are hurting, please pay for it on your own.”
Jay M. Pomerantz, M.D.
123 Dwight Rd., Longmeadow, MA 01106Author/Editor Response
The authors reply:
To the Editor: The views of Drs. Eist and Pomerantz underscore the strong feelings and concern about the quality of care felt by many in the face of market-driven forces. But it also is important to emphasize what gave birth to the rapid growth of companies that provide managed behavioral health care. These companies emerged in the mid-to-late 1980s, during a period of explosive growth of private, for-profit psychiatric hospitals. They prospered because private employers viewed their services as providing greater value than they had previously obtained from mental health providers who practiced traditional fee-for-service medicine. As a consequence, the vast majority of companies that insure their own employees now contract with these specialized companies for behavioral health care coverage. Private payers have been well satisfied with the results — lower and more predictable costs.
On average, the managed behavioral health care companies are arranging through contracts with providers to spend about twice as much for mental health services (as a percentage of the insurance premium dollar) as do most HMOs. The rapid emergence of these companies has compelled some of the largest HMOs to improve their capacity and commitment to provide mental health services. For example, I reported on the decisions made by the northern and southern California regions of the Kaiser Permanente Medical Care Program to upgrade their mental health services substantially.
There is no question that the success of these companies has disrupted the professional lives of providers and altered the patterns of patient care, but to characterize them as evil empires, as Eist and Pomerantz essentially do, is not warranted. America does, after all, spend more money on personal health services than any other country, and Congress is moving in the direction of insisting that health insurers cover mental and physical afflictions on a more equal basis.
John K. Iglehart
Author/Editor Response
Drs. Peele and Pomerantz bring up a number of important points about managed behavioral health care.
Managed behavioral health care has by no means corrected all the flaws in the mental health care delivery system. For years it was accepted without question that the fiscal well-being of and quality of care in the private sector would be guaranteed by having the underfunded public sector treat patients who had exhausted their insurance coverage or were too difficult to treat. As Dr. Peele points out, that discriminatory situation continues to the extent that employers who contract with HMOs and managed behavioral health care companies refuse to cover patients with more difficult or expensive illnesses.
There has been genuine controversy in the field of psychiatry, predating the advent of managed behavioral health care, about the extent to which insurance should cover all forms of psychiatric treatment, particularly the psychotherapies. Twenty years ago Astrachan et al.1 suggested that insurance coverage of the “humanistic tasks” of psychiatry — those that foster development and growth — should be carefully defined to avoid inappropriate medicalization of this important psychiatric function and the attendant inflation of costs. Dr. Peele may well be correct that if the definition of medical necessity is left to companies providing managed behavioral health care, more patients will be forced to pay for their own care. Mental health professionals must define crisply and convincingly what kinds of psychotherapy, for what conditions, should be covered by insurance as medically necessary and what should be paid for out of pocket as a vital human growth experience.
Gag clauses are highly offensive to clinicians and patients — so offensive that they are being outlawed in some states. Managed behavioral health care companies, a group of highly competitive, entrepreneurial enterprises, are just beginning to understand that managing the behavioral health care of 111 million people makes them, in effect, a public utility, accountable to the public for the way they do business, beyond cost containment, value to the shareholder, and the invisible hand of the marketplace. Gag clauses are only the most obvious manifestation of a broader, unresolved clash of cultures between the competitive business environment and professional practice that must be settled for the sake of patient care in an era of constrained resources.
1 ReferencesMiles F. Shore, M.D.
John F. Kennedy School of Government, Cambridge, MA 02138Allan Beigel, M.D.
University of Arizona, Tucson, AZ 857211
Astrachan BM ,Levinson DJ ,Adler DA . The impact of national health insurance on the tasks and practice of psychiatry. Arch Gen Psychiatry 1976;33:785-794
Web of Science | Medline
