When managed care meets mental health

November 11, 1996|By Lawrence I. Sank

BETHESDA -- The good news is that you could have greater access to mental-health care. The bad news is that your most sensitive secrets could be laid bare to unsympathetic strangers.

The new federal health-care legislation, welcomely, requires that the same benefits be provided for approved mental-health claims as for medical claims. Parity, however, has a distinct down side. The insurance industry and its managed-care minions will be unwilling to allow greater use of psychotherapy. Despite evidence that overall utilization of services is reduced when mental-health services are more widely available, the industry is likely to make access to this new level of benefits difficult.

Managed care has taken its toll on those requiring health services. Patients have suffered reductions in covered or allowed office visits, hospital stays, diagnostic tests and procedures as part of the strategy exercised by insurance companies to reduce health-care costs.

Nowhere is the result of this strategy of cost reduction more insidious than in mental health. The managed-care process, involving ongoing oversight of mental-health care, is intrinsically destructive to the patient, however much it is intrinsically useful to insurers intent upon reducing use of services. The most vulnerable patients are subject to psychological harassment that causes them to drop out of treatment prematurely or, perhaps, not pursue necessary treatment at all.

The unique qualities of psychotherapy -- the subject matter, the psychotherapeutic relationship, and the process of psychotherapy -- are inherently sensitive and require special protection. The Supreme Court acknowledged this point last June in Jaffee v. Redmond. Justice Stevens wrote that effective psychotherapy depends upon an atmosphere of confidence and trust in which the patient is willing to make a frank and complete disclosure of facts, emotions, memories and fears. The possibility of disclosure, therefore, might impede development of relationship needed for successful treatment.

Managed care, with its reviews of intimate personal history, disclosure of psychological symptoms, stigmatizing diagnoses and attention to implementation, goals and outcome, does not offer this protection. Obviously, great harm can be done if a review determines that the proposed or on-going treatment is ''not medically necessary'' and reimbursement is refused.

Third-party intrusion

Even care that is deemed medically necessary is damaged by the review process. Scrutiny, beyond the merely clerical (dates of service, diagnosis, mode of treatment), threatens the psychotherapeutic process. The review intrudes a third party into the consultation room. Each inquiry serves to weaken the special bond in therapy that depends upon absolute confidentiality.

As the patient signs the release-of-information form required by the insurance company to approve reimbursement, the patient and therapist become aware of another party's intrusion. No longer does the psychotherapist focus only on delivering the appropriate service consistent with sound professional judgment. He must now factor in whether the presenting problem and the corresponding treatment are consistent with the submitted treatment plan and whether any alteration will be approved for reimbursement.

The patient also is called upon to revise his internal calculus. Will I be allowed to continue in treatment? Dare I raise this problem only to have the treatment curtailed or terminated before it is adequately addressed?

Who will be learning about my most private thoughts and behaviors and what will become of this information? Will this be disclosed to my employer? Will it affect my future insurability? Do I forbid my psychotherapist from reporting completely about . . . my abortion, my rape, my substance abuse, my childhood trauma, my sexual proclivities, etc. . . . And if I choose not to disclose, can my continued care be authorized?

Too quick a disclosure

Conversely, there is the pressure on the patient to disclose too quickly -- faster than is clinically advisable or comfortable for the patient -- to justify a need for continued care. There is pressure on the therapist to disclose too much information or risk rejection of benefits. These various concerns strike at the very essence of the psychotherapeutic process and threaten its integrity and viability.

Thus the managed-care industry, having lost the legislative battle over parity between physical and mental-health reimbursement, can still win the cost-containment war. It need only become more intrusive -- more ''cost-conscious'' -- which will persuade the most vulnerable to flee from or avoid appropriate care.

Case review as a cost-savings device is unconscionable, and to the extent that it requires the involvement of mental-health professionals, it is also professionally unethical. While it falls to our legislatures to regulate the actions of corporations, it falls to professional ethics and licensing boards to address ethical transgressions. I have filed ethical complaints against licensed-care reviewers because their job-related activities have done harm to patients and to the psychotherapeutic process of which they made themselves a part.

Each of the mental-health disciplines (psychology, psychiatry, social work and nursing) have provisions in their ethical codes that rule out such behavior. I urge that the respective professional associations explicitly denounce such professional activity and impose sanctions with real teeth. I urge consumers to do the same.

Lawrence I. Sank, a clinical psychologist, is director of the Center for Cognitive Therapy.

Pub Date: 11/11/96

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