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
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
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
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:
OTHER SIGHTS ON MANAGED HEALTH CARE
Last messed with November 15, 2001
Copyright(c) 2001 Michael E. Holtby, LCSW. All rights reserved.