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. 

Are these people for real?

This is from the actual Remarks section of an actual Explanation Obfuscation of Benefits received in the mail today:

Remarks
D214 -- We have reviewed your previously denied claim. We have found you to be eligible and are overturning your denial for that reason. Your claim has been reconsidered and has been denied. . .

The basics

I am reading Jane Hall on Deepening the Treatment. It's a book for beginners (she teaches technique at an analytic institute). I didn't realize it was for beginners when I bought it, otherwise I would not have.

Liv Ullman wrote in her memoirs that the book you need comes into your hands when you need it. I picked this one up the other day because every time I walked past my bookshelf it called out to me.

So far, and I'm a couple of chapters in, I haven't read anything I didn't already know. But I'm hanging on every word, nevertheless, partly because Hall says what she says so well, but mainly because she is reminding me why I became a therapist in the first place.

Managed care and training as a psychologist exert a powerful pull. Hall reminds us all of our roots.

Managed Care is Killing Me

The economy is going into free-fall. The cost of consumer goods is up 5.6% this year, the worst it's been in 17 years. Tax collections in our state are down by more than 6%. Population growth has slowed in the 10-county Metro area. Home values are plummeting in the midst of rising foreclosures. Our state's jobless rate is at a 15-year high and expected to get worse. Everywhere you look there's more bad news.

In the meantime, what insurance will pay for our services has remained stagnant--or declined. Psychologists are probably the only professional group that has lost ground in the last few decades. Managed care is killing us.

One way in which it is doing so is by adding significantly to the paperwork/case management burden that we face. Just one small example is this fax memo I received from one company:

Wellness Assessments are to be completed in your office at the time of the initial evaluation and faxed to [insurance company]

A second Wellness Assessment is to be completed in your office during the 3rd, 4th, or 5th session and faxed to [insurance company]

A set of algorithms are applied to all Wellness Assessments designed to identify potential clinical risk

• Some potential risks yield a letter that requires you to determine whether the identified concern has been fully assessed and, if applicable, addressed in the treatment plan. It is strongly recommended that you file the letter and document that the risk is being addressed in treatment or has been ruled out in the course of assessment/treatment
• Potential risks that yield a Care Advocate outreach call require you to complete a brief clinical review

For members who have seen you in the past and return to treatment, representing a new episode of care, the Wellness Assessment should be completed even if the member completed Wellness Assessments during a previous treatment episode.

During the first two quarters of this new initiative, you have seen between one and five new referrals. In all or most cases, a Wellness Assessment was not sent. Please review these requirements to support your implementation of this process.

This is a level of supervision which I have not received since I was in grad school. Let me just say that I don't need an insurance company computer to tell me when a client is at risk or a Care Advocate to tell me--after the fact--what to do about it!

A Wellness Assessment, by the way, asks some very intrusive questions of the client:

• In the past month have you felt you ought to cut down on your drinking/drug use?
• In the past month have you felt annoyed by people criticizing your drinking/drug use?
• In the past month have you felt bad or guilty about your drinking/drug use?
• In the past week, approximately how many drinks of alcohol did you have?
  

This is protected information that is now going to be faxed to... who? A clerk? I certainly don't know. And besides running algorithms on it, what will they do with this information? It's not anonymous: It asks for complete identifying information at the top.

These are actually useful questions, as are the others on this sheet, but they are also questions that competent therapists routinely ask. Why we should have to ask them twice and fax them in for someone to second-guess us (we are, after all, fully licensed to practice psychology independently) is beyond me. Besides which, all this c**p takes time I could be spending with the patient! Actually helping them with these problems!!