For some time, I've become increasingly concerned and frustrated with difficulties that my patients are experiencing with getting their mental health care paid for. 

In the field of psychiatry, patients could generally get appropriate treatment until around 1991, when, increasingly, insurance plans and "managed care reviewers" began essentially decreeing who could and who could not be hospitalized, and how much would be paid to the physician - now called a "provider" - for care. 

The reason for this change is that, in truth, abuses had occurred in the system and ongoing use of care at those levels would eventually have bankrupted the system.  Mildly depressed or maladjusted people were being kept in psychiatric units for several months; medications were tried on a somewhat leisurely basis; psychotherapy was being used in a somewhat unfocused, long, drawn-out fashion.  With spiraling health costs, these sorts of abuses of the system could not continue. 

However, in the years which have followed, increasing corruption and micromanagement has occurred.  The previous medical/economic model was this: 
 

That was in the "good 'ole days".....now welcome to the world of "mangled care"... 
 

You get sick (or depressed).  You look at your mental health care (or medical) benefits list to see what "provider" you can go to - a provider who is "covered" or "in network."  If you choose somebody else, you will pay anywhere from 20% to 100% of the bill yourself.  [Typically, you don't get the BEST doctors.  The BEST doctors do not have to subject themselves to the mind-numbing bureaucracy and poor reimbursement rates of managed care plans.] 

You go to see someone "in your network" or an "approved provider."  Maybe you get better, maybe you don't.  You'll be limited to a certain number of visits - sometimes as few as one or two.  Sometimes you are offered the "privilege" of "trading" inpatient days of treatment that you don't think you'll need for more outpatient visits.  If you guess wrong, and ultimately require hospitalization later....... too bad!  You lose! 

If you have to be hospitalized, the entire amount of your benefits may be only $2,000 - $3,000 for care in a hospital: just about enough for 2 - 3 days, tops (and patients sick enough to require being hospitalized are almost NEVER ready to be discharged in 2 - 3 days).   If you stay longer, you'll pay the difference out of your own pocket.  Your "insurance plan" won't pay a dime more that it says it will in your contract, no matter how loud you scream. 

Or, you might go to an emergency room if you are hallucinating, or teetering on suicidal actions.  You'll be seen by someone who will "evaluate you", and then your admission will have to be "pre-approved"; if it's not, you'll be paying the entire cost of your hospital stay - something which used to be paid without question if a doctor said you needed it - out of your own pocket, and at $1,000 per day, on average.  Your "plan" may have a "reviewer" - for whom no particular credentials are required by law - say that you "don't meet admission criteria".  This, translated, means, you're not going to be admitted to a hospital no matter how sick you are. 

[Thus, a high school education and being a "reviewer" trumps what a physician has to say about whether or not you need care.  And, until recently, the "reviewers" and managed care plans couldn't be sued for "malpractice" even though, in many people's opinion, determining whether or not someone is sick enough to need to be admitted to the hospital is the province of a trained medical professional and not a high school graduate.  Frequently, people who were denied care by managed care plans actually went out and killed themselves.  Lawsuits have arisen because of it, and the exact nature of managed care plans' liability for these outrageous actions is currently being determined by active case law.] 

How bad does this get?  Sometimes plan reviewers are so tight-fisted with benefits that it you're not ACTIVELY SUICIDAL at the time you're in the emergency room, you won't get admitted.  In a U.S. News and World Report story in 1997, the tale is told o one unfortunate woman who was hallucinating, could not get admitted to the hospital for treatment, and later learned that every time she needed admittance to the hospital she had to say the magic words, "I'm suicidal" in order to get admitted - whether she was or not.... and just to get the help she needed! 

After being care for in the hospital, you'll be discharged "quicker and sicker."  The managed care plans have gotten so nauseating and mean spirited that legislatures have had to pass laws against the so called "drive through deliveries" which some plans were mandating: give birth, go home the same day.  Other laws have had to be passed banning "drive through mastectomies" - where women, facing one of the most horrifying operations of their lives, are kicked out of the hospital with surgical drains still in place and a bottle of pain pills thrust into their hands. 

After you get out of the hospital, you'll be back into the same limited care scenario with your physician - or therapist.  Many insurance plans simply won't pay for a Ph.D. psychologist or M.D. psychiatrist to do your psychotherapy, so you'll be seeing a social worker level therapist that can be "bought cheap" by insurance companies. [NOTE: this does NOT impugn the integrity or the outstanding abilities of many social worker level therapists.  I know many, refer my patients to some of them, and am privileged to call many of them my colleagues.  All things being equal, however, if I were in the patient's role, I would want available to me ALL my options, and not to have the demarcation line of my treatment options drawn right before getting to the doctoral level of training - be it psychologist or psychiatrist.] 

Additionally, if your plan actually DOES pay for a psychiatrist to see you, it will most likely be with an emphasis on using medications.  I have nothing against medications, and prescribe them frequently!  BUT.... the focus on the "pill cure" sometimes forces patients to have to make the choice of "trying the pills" first because the plan won't pay for a course of psychotherapy without some "effort" being made with drug therapy first.... or will pay so little for care that any physician in a managed care plan with any sense of ethics (not to mention common sense) will realize that he or she had BETTER try the patient on medication because, if they don't, the benefits will run out before the patient is better; the patient will then be beyond the therapeutic reach of the psychiatrist and, even if pill therapy should be instituted at that time, after a trial course of therapy, there will no money left in the plans' benefits to pay for it! 

Your "plan" may not cover some medications your physician or psychiatrist wants to use.  If you require them, you may have to pay them out of pocket.  You may frequently experience the sense that you are being run through the office of your "therapist" like a widget on an assembly line, in a somewhat impersonal fashion.  This is because the therapist or psychiatrist is getting paid so little for your care that he or she is frequently not all that interested in you, and because multiple, 15 minute appointments must be conducted, one right after the other, so that the physician or psychiatrist can make enough money to pay all the bills, fund their malpractice insurance, etc.  [NOTE: the "filthy rich doctors" that the public fantasizes about do not exist except in some of the surgical specialties or interventional cardiology - where the risks are high, the training long, and the stress is extreme.  Most make between $100,000 to $150,000 for 60 to 80 hour work weeks, or about $50,000 to $75,000 per year if they worked a conventional 40 hour week - which hardly any of us do]. 

You may not like Dr. Jerko.  Unfortunately, you don't have much else to choose from.  Physicians who have sold out to managed care plans are not going to be the most customer friendly ones out there.  You tell all your friends about Dr. Jerko.  "Don't go to him," you say; "he never listens to me, just scribbles on a pad when I'm there and then hands me a prescription at the end of my 10 - 15 minute appointment."  Unfortunately, your friends (if they're in the same health care plan you are) are not going to have any better choices.  If they are in a different health care plan with "managed benefits", etc., they'll have the same crummy options. 

Only if you choose to go outside of the "system", put your faith in the American system of capitalism and free enterprise, and go see someone that has to deliver the goods or they won't stay in business for very long - in other words, a physician in private practice who contracts directly with the patient for service - you're going to stay on the same managed care "run-around" carousel. 

There are other costs which also occur in the "mangled care" scenario: 
- inefficient, poorly focused care from mediocre practitioners keeps you sicker longer; 
- you miss more work; 
- you have to drive back and forth to more doctors appointments because: 
     (a) you have to see the psychiatrist/therapist more because they're so poor they can't get you 
           better efficiently; 
     (b) they're making you come back every month so they can "see how you're doing" just so they 
           can make the cash register go "ka-ching" and rack up another paltry payment for a 10 - 15 
           minute visit so that they can make up in quantity what they can't do in quality - charging, 
           and receiving, a fair price for excellent service and results. 

-Finally, there's the "cost" of giving up ALL OF YOUR CONFIDENTIALITY: your drug addiction, alcoholism, adultery, suicidal decompensations, overdose attempts, your teenagers drug habits.... everything becomes part of your record.  All of the gory details of you life or your kids' lives have to be "reviewed" by the "reviewer" to determine if the care that your physician is specifying is "appropriate" - translated as "will the insurance company pay for it or not?" 

So, if your idea of a good time is having all of your dirty laundry and the skeletons in your psychological closet rattling around in computer data banks with virtually instantaneous access, anywhere in the world, to "qualified" people who want to determine your "insurability", etc...... you'll just love the "brave new world" of zero confidentiality of managed care!

In truth, there actually is.  I'm pleased to say that several managed care companies I've worked in the past - at least then - really did seem to have the patient's best interest at heart. 

In the best of managed care plans, care still has to be reviewed - but not but once every several months.  Yes, the patient does give up some amount of confidentiality... but that's the price to be paid to insure that some unscrupulous practitioners don't just "game the system." 

And yes, some of the plans out there on the market, for that reason, really do save money, making health care affordable for more people, thus keeping it from being priced prohibitively out of reach so that employers can't afford to pay health insurance premiums or it would "break the budget." 

On the other hand, philosophically and logistically, even the BEST of most of these plans still are operating in a matter which drains some of the efficiency out of the system.  Any plan or scheme which renames doctors as "providers" and renames patients "health care recipients" or refers to them as "covered lives" is off to a bad start.  Any plan which has "checkers" and "checkers checking the checkers" to insure that care that a physician says is needed is considered "appropriate by the plan" begins to drive up the cost of health care - and your premiums - simply because more peoples' salaries have got to be paid to "protect" the system.  In this way, no matter whether or not these plans save money by nickel and diming you to death, they may still cost more in the long wrong because of bureaucratic bloat and inefficiency, as well as committing the "penny wise but a pound foolish" error of being cheap on care up front, only to have to pay out more later. 

As with any other organized field of human endeavor, the quality and the ethics of any of these plans ranges from excellent and moral to shoddy, soul-less, and corrupt.  My advice, therefore, to the neophyte "health care consumer" shopping for a health plan or HMO  is classic: "buyer beware."

Managed care plans - even the best of them, most likely  - consider every dime they pay out actually taking care of the people in their plans divided by the amount they take in, their "loss ratio."  Thus, dollars paid out for a patient's well-being and health care are considered a "loss" by your managed care plan.  Note: this isn't called a "service ratio", or a "patient care dollar" ratio, but a "loss ratio." 

The message is clear: any dime or dollar paid out by a managed care plan is considered a LOSS.  They make their money by taking more in with premium dollars paid up front than they do paying it out.  This is also how private practice doctors make their money as well, actually: taking more money in than they pay out - for light bills, malpractice insurance, health insurance, staff salaries, utilities, etc. 

But please examine the motivation.  In the managed care scenario, the economic pressure is to do less for the patient to cut that "loss ratio" down and make more money for the health care plan - as well as more "bonuses" for the physicians.  In the private care scenario, the economic temptation is for the physician to do more than what's needed.  All things being equal, and considering an ethical and competent physician in both scenarios, I'd rather take the one who might make a little more by taking that extra little bit better care of me than one who's afraid to order one more test because s(he) will get in trouble with his/her HMO for "wasteful care" - when that one little test...or even a really big, expensive test... might be the difference between catching something which would kill me while there's still time to do something about it rather than just letting it slide. 

The flip side, of course, is that managed care plans, just like insurance companies, must make some kind of a profit or they won't be around and in business long enough to offer YOU any kind of insurance protection.  Just make sure that they aren't making their profit by denying you care that you need and deserve!

Here are some of the most recent and interesting articles about what's really happening on the "damaged care" scene: (more links pending)