Why I Hate Managed Care in General, and the Medical Model in Particular

Image via Wikipedia

So this arrogant psychiatrist in another state, who has never met nor spoken to my patient, decides in less than 10 minutes on the phone* to deny coverage for depression and ADD because she's made only minor progress in 12 weeks of outpatient psychotherapy ("three months!" quoth he, obviously horrified).

Oh, yeah, and because she's not getting "standard" (read: "cheaper") treatment, to wit, psychotropics.

He actually asked me why I was asking for more sessions! Um, because she's still depressed? still has family issues? Still doesn't know what she wants to do with her life? After all, he says, it's not working, is it?

Yes, it is. It may be slow, but it is working. Her problems have been years in the making and we're not going to turn them around in three months. He seemed astounded by this concept.

He implied more than once that my treatment of her was substandard. She wants a non-drug solution and I'm not forcing the issue, partly because her depression is moderate, therefore not an emergency, and partly because most of it is environmental in origin, not endogenous. As for the ADD, well, it is definitely holding her back, but it's not going to kill her, and I see the decision whether to medicate or try adaptations and accommodations as a personal one. I respect patients' ability to make decisions like that for themselves, and support their right to do so.

And by the way, the standards of care are written by--wait for it--the American Psychiatric Association.

Not to mention, success with medication is hardly guaranteed. I have had dozens of patients who have not responded to medication after medication after medication. Do insurance companies then want to stop paying for any more drugs? No. This is about money, pure and simple, and it pisses me off. This, people, is why we need national health care.

So if your insurance company doesn't want to pay for ongoing psychotherapy, fine. If it doesn't fit within their definition of "medically necessary," fine. I get that, and I have no problem with it. But don't imply that my work is substandard, dude. Do not go there.

*actually, he'd clearly already made up his mind before he even picked up the phone, based on a one-page request form I'd faxed in. I suppose I should have claimed "moderate" progress on the form. Her role functioning has improved because she's learning to structure herself better ("yes, but is her concentration better?" the insurance company care manager wanted to know) and she's made one of the major life decisions she came here to make. But I really feel we're just getting started. "Moderate" to me implies that we're about halfway through. "Major" progress would be close to the end, right?

While I was writing this the care manager called to see if I wanted to appeal. You betcha! And she pointed out that this all happened because I didn't return their calls quickly enough to suit them. I got passed on for this "peer review" thingy (Do you really think he's my peer? Do you think he's got a doctoral degree in psychology and 30 years experience providing psychotherapy?) partly to punish me.

Anyways, if I had, she went on to say, she "might" have given me two more sessions!! to get the client to agree to a med consult.

Makes me want to set my head on fire. 

Suicide

'Cause suicide is painless,

It brings on many changes,

And I can take or leave it if I please

-The theme from M*A*S*H,

by Johnny Mandel & Mike Altman

I've never tried it myself, but I really doubt that suicide is painless. Yes, I know--it's just a song. But there are lots of songs out there that imply the same thing, and the sentiment corresponds with what more than a few of my suicidal clients have as much as said. The truth of course is somewhat different.

The time leading up to the decision is certainly emotionally painful, and of course sometimes the person is motivated by chronic physical pain to consider suicide in the first place. And finally, suicide is ugly, so that no matter how you do it, it is going to be traumatic for whoever finds you.

It's not at all romantic

Suicidal people are in a world of pain. They do not feel loved, or even lovable. Waldowski, the suicidal dentist in M*A*S*H, couldn't get a girlfriend, and that was his central motivation for wishing to die. But most suicidal people (I would except folks like Hitler in his bunker) are loved. If you are depressed enough to kill yourself, you can't feel the love, but it's there. Both fictional scenarios, M*A*S*H and Tom Sawyer, are accurate in that regard. People will go to great lengths to keep you alive if you give them the chance (witness the ritual the whole M*A*S*H unit puts on to help Waldowski get laid), and they will certainly grieve you if you don't.

People die because they have given up hope. It is one of life's greatest tragedies that a laughing baby, a beloved toddler in his new white Stride-Rites, a snaggle-toothed teeny-bopper with her braces and pigtails, and a grinning teenage boy can grow up to be so hopelessly miserable that they end up blowing their brains out under a tree in the park one night, swallowing pills and putting bags over their heads in lonely motel rooms, or swerving their cars into oncoming traffic. Or like my friend back in '85, stuffing towels under the garage door and sitting in her car with its engine running, her favorite music on the radio, and a Moosehead in her hand, waiting for the Reaper.

Seasons don't fear the reaper
Nor do the sun, the wind, or the rain
We can be like they are...

We'll be able to fly...
Redefine happiness...
We can be like they are

-Don't Fear the Reaper
Blue Oyster Cult

No, you can't: You can't be like the elements, you can't fly. (The last verse of the song makes suicide sound like the Darling children following Peter Pan out the nursery window.) You'll be dead. Suicide doesn't redefine happiness, or bring on many other changes, either, other than that you are now dead. I once heard a workshop presenter liken people's fantasies of suicide to the scene in which Huck and Tom watch from their hiding place as the townsfolk drag the Mississippi for their bodies, grieving the boys' presumed deaths and regretting every wrong or injury done them, however slight. I'm not sure suicidal people really understand that they will not be here somehow to see that their loved ones or the bosses or whoever "will be sorry." That relationship can't change after you are gone. The people you leave behind may well wish they could have a do-over, but will be too late for that. If you want things to be different, you have to be here for it.

Some folks, like teenagers, or persons with Borderline Personality Disorder, tend to give up hope when the problem situation is clearly (at least to the dispassionate outside observer) a temporary one. This was, of course, the case with Romeo thinking Juliet had really died. But they over-react, they believe that they way they feel now is forever, always has been, and always will be. They cannot remember that they actually have felt better recently, and most likely will again soon. They see no solution to their situations. Such folks are particularly prone to impulsive, lethal attempts. This is perhaps life's greatest tragedy, because such people do not have to die. Many, if not most, suicides don't, but these people really don't. Unfortunately this is a decision that, once made, cannot be un-made: As the old line goes, it's a permanent solution to a temporary situation.

I'm not sure what I'm trying to say with this rambling missive. Perhaps I just want you, if you are feeling this way, not to give up hope. I want you to believe that the love is out there, even if you can't feel it right now. I want you to believe that you can find happiness again, or maybe for the first time, but you can find it.