JUL 1997


Therapists Talk 
Shrink Rap 


    Michael E. Holtby, LCSW, BCD


Mismanaged Mental Health

First published in Colorado's AIDS Newsletter, Resolute!

Not to be reproduced without the permission of the author

What follows is the testimony given on June 20th to the Health Committee of the Governor's Council for People With Disabilities, which asked this writer and others to testify about their experience with managed health care.

In a 1983 meeting which actually occurred here in Denver, the National PWA Coalition was formed, and the term "PWA" or "Person with AIDS" was used to replace "AIDS patient" or "AIDS victim" as a way to assert one's personhood, and get away from being viewed as only a helpless and passive host of the virus. The following basic rights were spelled out:

"PWA's have the right to full explanations of all medical procedures and risks, to choose or refuse their treatment modalities, and to make informed decisions about their lives while maintaining their privacy and the confidentiality of their medical records... and most importantly, to be treated with human respect."

One of the consequences of the AIDS epidemic has been an understanding that long term survivors of not only AIDS, but cancer as well, are people with a collaborative relationship with their health care providers. AIDS treatment is such a quickly changing field that even the best infectious disease physicians cannot keep up with the developments. Patients have learned that they need to do their own homework, and be assertive with providers to insure they receive the best care. In fact, one study of long term survivors showed the majority had fired at least one doctor.

We have also drawn a definite link between the mind and body as it applies to maintaining our immune systems in an emerging field called "psychoneuroimmunology". We have found, for instance, that depression makes a PWA 1.67x more susceptible to disease progression. In another example from the general population, we have known for a long time that 60% of all office visits to a medical doctor are for problems with a psychological basis.

Given these awarenesses of the need for a self-empowering form of health care, and one which places a high value on their mental health, it is with particular irony that we are increasingly moving away from such an approach. Health insurance is a benefit provided by employers, and they in turn, have negotiated policies with insurance companies. The end result has been that patient care is now cost-centered according to employer and insurer needs and goals, rather than patient-centered according to health care needs and goals. As Alan Savitz, MD formerly of Human Affairs International, a managed mental health care company has stated, "The patient is no longer the customer. The customer is the payer (and the payer is the employer)." The end result has been that patients have lost their rights to choice, privacy and decision-making with regard to their health care -- the very things research has found to maximize their immune systems.

With the increased bureaucracy and the philosophy of the need to control externally has come the notion of rigid protocols to determine care. Individualizing treatment has become increasingly contested by case managers. Patients and their providers are told what the treatment will be. This includes the requirement of medication, most typically antidepressants. If clients have their own ideas of what they want, and resist medication or other protocol specifications they are labeled as "noncompliant" and can and often do have their authorization for treatment terminated.

The conflict between self-determination and empowerment versus the juggernaut of managed health care occurs at all levels. When a subscriber calls to get a referral for therapy he or she calls a 1-800 number and talks with someone in a cubicle somewhere out of Colorado. They assign on the basis of zip code, presumably providing a therapist who is conveniently located. However, for instance if one of my clients wants a male therapist who is an HIV specialist, knowledgeable about the gay culture and not homophobic, the intake worker cannot make such a match. This is despite the fact that the technology to do this is available, and preferred providers fill out application forms sometimes two dozen pages in length that provides all this information. The intake workers don't know the providers, as their local physician might. To the person in the cubicle its just a name on a screen. Subscribers can specifically ask for me, but I am no longer on the preferred provider lists.... lists that the managed health care companies sometimes refuse to publish. And in doing so, hamper the subscriber's ability to get the help of local professionals to make an informed choice. One intake worker was quoted as saying, "Listen, if you're sick, it doesn't matter who you see. And if you don't take the names I give you, I can't help you anymore."

To add insult to injury, a subscriber cannot just get a referral. They have to provide some detail as to what the problem is before they are given the necessary pre-authorization. When you consider my caseload of stigmatized PWA's and homosexuals, you can see the inherent dilemma. They have very legitimate concerns with what will happen to this information once it is revealed. I am aware of one instance in which a married man devastated with the end of an affair couldn't bring himself to tell his managed health company's intake worker that his problem was that he was a family man with young children, but in love with and jilted by another man. He didn't pursue therapy as a result, and consequently killed himself. In another instance, a woman gave identifying information about her husband, the insured party, but when pressed as to the problem insisted on a referral without revealing the nature of her pain. She was refused a referral and authorization. What she didn't want to tell them was that her husband was sexually molesting her daughter.

This paternalistic approach to treatment is continued with case reviewers overseeing the work of the therapist. The case managers' level of experience and education is usually less than that of the provider, and their primary goal is to see that the case is wrapped up as soon as possible. A great deal of pressure is put on providers by a lot of talk about a "brief model" of therapy, and about "symptom relief" as the only goal. This is not the treatment of human beings, it is a paint by the numbers protocol which alienates my self-empowered, long-term AIDS survivors.

Providers are treated with the same level of authoritarianism as patients: they are given "report cards", and rated on how quickly they end therapy; they are blackballed if they are viewed as "difficult". They are required to sign lengthy contracts which are not negotiable and include "gag" and "non-contestable" clauses. Texas is trying to outlaw the "hold harmless" clauses which make the provider liable for the companies' refusal of treatment. In capitated plans or through bonuses providers are even given financial incentives to not provide services. One managed health care administrator in a recruitment effort said, "We are looking for providers who see their role as preserving the benefit plan." I'm sorry but I see my role as preserving the patients' life and mental health.

The ultimate decision as to the continuation of treatment is up to the case manager, another person in a cubicle in another state who has never met the patient. The key here is the refusal of therapy as not "medically necessary". Yet this has never been objectively defined, so it can be used as any point the case manager decides therapy has gone on long enough. I am also aware there is tremendous pressure on these case managers to keep their authorization numbers down. Their jobs depend it. In a Colorado survey of 223 psychologists 64% reported instances of treatment being discontinued when it was still indicated.

Even if you are given your full authorization of 20 to 30 sessions, it can be woefully inadequate. If the client needs to see a psychiatrist for medication, and even if it is for twenty minutes it counts as a session. The minimum course of an antidepressant is one year, so even without side effects and other complications, half of the designated sessions are eaten up by this alone. Some case managers dismiss such concerns by saying, "We don't cover chronic conditions."

The irony is that withholding outpatient psychotherapy costs more than providing it. An estimate from the Alcohol, Drug Abuse and Mental Health Administration was 3x more in costs to society in such areas as domestic violence, child abuse, poor school and work performance, substance abuse and crime. Outpatient psychotherapy keeps people out of far more expensive inpatient therapy, and in addition reduces medical visits and hospital use. It seems a penny-wise, pound foolish policy.

The double irony is that outpatient mental health under the old system was actually less expensive for insurance companies due to deductibles and 50% copays. What is happening here is not a cost savings or the real management of health care but corporate greed and a redistribution of the Country's health care dollar. With the per session costs higher when micro-managed the only way to show a savings is to restrict services. I would like managed health care to stop hiding behind slick brochures promising 20-30 sessions, when the reality is 10-20% of that. Therapy has become comparable to fast food. Where is the beef?

In an effort to accommodate my clients' needs for affordable therapy I joined thirty preferred provider panels. I resigned, however, on May 1st of last year from all of them. I cannot support a system I view as dishonest, unethical and antithetical to the health and well-being of my clients.

The fact that I continue to practice, as do the others testifying before you today, is the ultimate comment on the unacceptable quality of care provided by the managed health companies. Our clients would rather pay us full fee out of pocket than get the therapy offered by their managed health care company at the cost of a $10 copay. We need to move more towards an emphasis upon subscriber rights versus employer savings, and towards patient empowerment rather than corporate enrichment. We need to get back to consumers as our clients, with self-determination, fully-informed choice and privacy for their lives -- those things we already know keep us all healthy.

For my personal response to managed health care read:

"I Quit!"

"My Recovery from Managed Health Care"


"A Word About Managed Care," Jules & Catherine Ohrin-Greipp

National Coalition of Mental Health Professionals and Consumers



Last messed with November 15, 2001

Copyright(c) 2001 Michael E. Holtby, LCSW. All rights reserved.