MAY 1996


Therapists Talk 
Shrink Rap 


    Michael E. Holtby, LCSW, BCD

"I Quit!"

Originally published in Colorado's AIDS Newsletter, Resolute!, May 1996

Do not reproduce without permission of the author

Until this month I was a preferred provider for over thirty managed health organizations -- but I quit! I am going to gamble my career as a psychotherapist of twenty-five years on this move. Some say it will mean forced early retirement. Some say managed health care (MHC) is the health cost containment wave of the future. I am betting that patients are becoming so disgusted with the disparity between what they get and what they were promised, that they will be willing to see me -- even though it will cost more.


In good faith I tried to play by the rules. I signed up for all the provider panels I could, thinking this was the best way to serve my clients. However, as a result over the past three years I have seen my income plummet, my caseload increase, and my hours at the office soar.

Managed behavioral health care organizations contract with therapists for the privilege of being one of their preferred providers. However, their contracts are not negotiable, but rather a take-it-or-leave-it offer. Contracts can run two dozen pages, and include such clauses as a gag rule which prohibits any criticism of them, and a noncontestable clause. They tell us they will pay us a fraction of our normal fee, sometimes as low as half. Then they add various fees like an extra charge if we don't use the right claim form, a fee for annual re-credentialing, and a fee for extra liability insurance.

Then they erode us even further by requiring a lot of extra time which, by our contract, is not billable time. Rather, it is frustrating bureaucratic time: waiting on hold to talk with them, utilization reviews by phone and by report (in some cases 4-6 pages in length). If we don't pre-authorize sessions in advance we aren't paid. If we don't submit our claims within a certain time frame we aren't paid. Even if we do everything by the book they don't pay us for at least two months, and some like to hang onto our money for up to six months!

I had to hire an office manager to help with all the extra requirements. And even at that I have been working fifty to seventy hours a week. I have often preached to clients that work is not all there is in life. It is now a cliche that those on their deathbed never say they should've worked more. I no longer am willing to be a corporate slave, to some company that is basically trying to reduce access to treatment by multiple obstacles to both providers and patients.


Managed health care is the insurance industry's answer to rising health care costs. They portray providers as out of control, and making hundreds of thousands of dollars at the expense of society and their patients. This has never been the case in outpatient mental health.

The old indemnity insurance benefits for mental health involved a year maximum of around $1,000 and the client had a 50% copay. The high copays helped restrain excessive expenditures. And the $1,000 limit is less than the cost of one MRI.

Now an additional pig is at the trough and he is hungry! An audit found one managed behavioral health company allocating two-thirds of its premiums to administration and profit. To look attractive and competitive most MHC benefit packages have a very low copay. But that and the extra layer of bureaucracy has meant a 41% reduction in benefits to break even and compensate for the increased expenses.

This system is not about saving money. It is about redistributing the money to corporations. And those at the top are now making sinful amounts of money.


Most clients come to me and say they have thirty sessions in their plan per year that they are entitled to. Yet the industry is touting "short-term, problem-focused, goal-oriented" therapy. This means six to eight sessions are authorized. In capitated plans the provider begins losing money if he sees you any longer. In others the case manager will refuse further sessions as not "medically necessary". There is so much pressure on providers that some companies give us a report card, based on our average number of sessions. If you are over that of your peers you run the risk of being no longer used for referrals, or dropped altogether.

Managed Health Care companies talk about combating the Woody Allen Syndrome of excessively long and unproductive therapy. They point to studies on the effectiveness of short-term therapy. Yet fail to point out that short-term therapy is defined as thirty sessions or less -- not six. There is plenty of evidence that the longer the therapy, the greater the benefit - most notable to the reader is the study done by Consumer Report (November 1995).

This drive for brief therapy is money driven. MHC cannot pay the bills without it. As Ivan Miller, Ph.D. of Boulder has pointed out, "the bottom line economics require a drastic reduction in the quantity of services provided."


Not only do you get less sessions, you get less quality. In order to use your benefits you have to call an 800 number, wait on hold, and then tell some anonymous person in another state what your problem is. Then they will give you a name -- often selected by zip code rather than specialty, or expertise or experience. The intake worker rarely knows the provider. There is no accounting for continuity or therapeutic relationship or rapport. If you have seen me before, you can't count on being approved to see me again.

Further, your therapy cannot be individualized. It has to follow a protocol for your particular diagnosis -- which may involve medication. If you don't like this cookie cutter approach you can be labeled "noncompliant" and denied benefits. And this is typically decided by a case manager with far less education, and experience than your therapist.

But the worst is yet to come: your confidentiality is at serious risk. As a provider I must do a detailed report, either in writing or in a phone review to a case manager to get you more than the initial session. This must include a diagnosis, and details of your situation -- including your sexuality and HIV status. If you are having "problems in daily living", such as a relationship breakup or the adjustments of living with HIV, you cannot get benefits without a diagnosis to prove "medical necessity". Most providers use a diagnosis called an "adjustment disorder" in cases like this. However, I have come to believe this is an overdiagnosis of a relatively healthy person. And you are at risk -- even with such an innocuous diagnosis -- of being denied disability, life and health insurance in the future.

There are serious concerns with the data base which has been developed on you by such detailed and personal reports. The managed health care companies are merging, and buying each other out as these large corporations gobble each other up. There is no telling where your information will end up. It is pretty likely one place will be the Medical Information Bureau (M.I.B.) which is a national data base that insurance companies can tap into when considering you for a new policy.


As of May 1st, I am reducing my fees by almost 25%. The hitch is I want to be paid in full at the time of service. I will help you submit insurance claims, but as an out-of-network provider you will receive less reimbursement. In some instances I won't be covered at all. And I will strongly advise you just to pay out-of-pocket and not risk your confidentiality to a corporate data base.

On the other hand, there won't be a conflict of interest. You will be my only employer, and I won't also be employed by a company whose mission is to limit your health benefits. You can select me because of my long-time specialization with gay men and HIV. You will have treatment that is tailored to your individual needs, and directed by you. And you will determine how long you see me, not some case manager who has never met you.

A factor in my decision has been my HIV clients talking about trying to get away from fear-based decisions which keep us all from taking risks, and also keep us from growing, lulling us into complacency, and a false sense of security. I too, want to walk the walk, not just talk the talk. So I am terminating all my managed health care contracts, confident that you will try that route and end up at my doorstep!


"Mismanaged Mental Health"


Read Ivan Miller's article: "Eleven Unethical managed Care Practices Every Patient Should Know About":

National Coalition of Mental Health Professionals & Consumers, Inc.

"Why Managed Health Care Hurts You," by John Grohol, Psy.D.

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



Last messed with November 15, 2001

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