Psychiatry suffers under managed care Patients, not costs, must come first, and stigma must end

February 04, 1996|By Steven S. Sharfstein

AN EPIC STRUGGLE is occurring over the control of health care and the doctor/patient relationship. Although this is occurring throughout the new medical marketplace, nowhere has it been felt more than in the diagnosis and treatment of mental disorders.

Today, more than 100 million Americans have their mental health and substance abuse benefits managed by for-profit behavioral health subcontractors known as "carve out" companies. This is a growing and dominant presence in the daily lives of psychiatrists and their patients.

Managed "care" companies achieve their financial goals by limiting freedom of choice for patients, curtailing the use of expensive services, and "selecting out" high-risk patients and high-cost physicians. This process of use management and cost shifting can be characterized as "managed cost and mangled care."

Real managed care

Genuine managed care, in contrast, could and should lead to more opportunities for care and treatment by providing support for effective outpatient interventions for more people with mental illness and substance abuse disorders who are not now receiving them. When this expansion of treatment occurs, we can say we are managing care in the interest of the patient and society.

Throughout the modern era, psychiatric care has been misunderstood and stigmatized. The public still believes that individuals suffering with mental illness are violent, crazy, and act like Brad Pitt in the current film "12 Monkeys." Insurance companies traditionally discriminate against treatment for mental illness by limiting the dollars for care, and payers vacillate between extreme views: that the mentally ill are hopelessly disabled or, in the opposite stereotype, among the "worried well;" that is, not seriously ill and therefore undeserving of support for treatment dollars.

Psychiatry is a part of medicine and with the increasing effectiveness of treatment, the traditional distinctions between "mental" and general medical conditions are no longer valid. Patients with general medical conditions such as diabetes or heart disease who also have depression, severe anxiety or substance abuse are among the highest users of hospital and medical care. The timely provision of psychiatric care can dramatically reduce the use and costs of medical care for these patients. Yet despite its demonstrated effectiveness, cost containment driven by managed care threatens access to care, leading to widespread demoralization among practitioners, and a reluctance on the part of medical students to pick psychiatry for a career.

Two case examples illustrate how "managed cost" in its present form can be destructive for patients, or how "managed care" can improve opportunities for treatment and expand services to patients in need.

A 35-year-old lawyer faces financial ruin due to a serious mental illness. Her health maintenance organization covers only "acute care and short-term therapy" and has a $25,000 lifetime maximum. This contrasts with coverage for all other general medical conditions with limits on length of stay, or office visits based on a generous definition of medical necessity and a $1 million lifetime maximum. She suffers from severe depression, alternating mania, which has been successfully stabilized over the years through a variety of medication strategies and psychotherapy. Unfortunately, she occasionally relapses, requiring short-term hospitalization. With her fourth episode requiring inpatient care, the family faces treatment costs approaching $20,000 per month and financial devastation.

This scenario demonstrates a real problem with a significant population of individuals who suffer from severe and persistent mental illness. All too often these individuals will run out of money in the face of managed care denials and low lifetime limits. Without effective treatment, many patients, like this lawyer, wind up homeless on the street or in the judicial and penal system. Eventually tax dollars end up footing the bill for this person's care, either by subsidizing mental health services from local governments or by paying for incarceration by a society that does not know how to care for individuals with severe mental illness. This kind of dehumanizing treatment should not happen here in the United States today. This social policy moves us back to what was more common in the 19th century.

Where managed care worked

A 47-year-old married man with two teen-age children became severely depressed after losing his job as an advertising executive. He began drinking alcohol heavily and ended up being pulled over by the police for speeding, and in the process received a DWI. The court system sentenced him to a substance abuse rehabilitation program, which eventually referred him to a psychiatric facility for evaluation after a suicide attempt.

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