Michael E. Holtby, LCSW, BCD
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
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
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.
THE FALSE PROMISE
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
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
THE CONSUMER RIPOFF
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
WHAT I PLAN TO DO
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!
FOR A RELATED SHRINK RAP ARTICLE ON MANAGED HEALTH CARE:
OTHER SIGHTS ON MANAGED HEALTH CARE
Read Ivan Miller's article: "Eleven Unethical managed Care Practices Every Patient Should Know About":
Last messed with November 15, 2001
Copyright(c) 2001 Michael E. Holtby, LCSW. All rights reserved.