Thursday, August 15, 2013

Manage Care Insurance Declares War on Psychotherapy

Beware: Managed care can be hazardous to your health

The old joke is that “managed care” insurance should be more accurately termed “mangled care” insurance.

At the annual meeting of the American Psychiatric Association in May in San Franciso, Susan Lazar, M.D, a psychiatrist in private practice, discussed the cost effectiveness of psychotherapy. While new federal laws and the upcoming Affordable Care Act mandate equal treatment of mental and physical health problems, access to psychotherapy in particular is under attack from insurance companies. 

“For the past three years, many insurance companies, including Cigna, UnitedHealthCare, and Kaiser Permanente, began severe restrictions on mental health care, particularly psychotherapy,” Dr. Lazar said. She added that patients most in need of more prolonged and intensive psychotherapy are typically the patients whose treatment and services are threatened.

Long term psychotherapy is often the first line treatment for a number of psychiatric conditions, including personality disorders and chronic severe anxiety mixed with depression.  Medication certainly can augment treatment in cases like those, but it is literally just a band aid. In children and adolescents, family psychotherapy is particularly important, and it is disappearing at an alarming rate as kids are plied with potentially toxic central nervous system depressants and stimulants to shut them up and keep their parents’ anxiety and guilt under control.

Psychotherapy has also been shown to be extremely cost effective according to many studies, yielding savings not only in overall health care costs and utilization, but in disability, destructive or antisocial behavior, and other societal costs. That does not, of course, mean than it is cheap.

Large multi-site and meta-analytic studies have demonstrated that psychotherapy reduces disability, morbidity and mortality; improves work functioning, and decreases psychiatric hospitalizations. Psychotherapy teaches patients life skills that last beyond the course of treatment. The results of psychotherapy tend to last longer than psychopharmacological treatments and rarely produce harmful side effects.

The American Psychological Association tried to send out warnings in a 2010 paper titled, Where Has all the Psychotherapy Gone? According to the author of that paper, 30 percent fewer patients received psychological interventions in 2008 than they did eleven years earlier; since the 1990s, managed care has increasingly limited visits and reimbursements for talk therapy but not for drug treatment; and in 2005 alone, pharmaceutical companies spent $4.2 billion on direct-to-consumer advertising and $7.2 billion on promotion to physicians, nearly twice what they spent on research and development.

While the percentage (3.37) of Americans who received outpatient mental health care in 2007 was very similar to the proportion of those (3.18 percent) receiving such treatment in 1998, the pattern of that care changed. Overall there was a decrease in the use of psychotherapy only, a decrease in the use of psychotherapy in conjunction with medication, and a big increase in the use of medication only.

In 2008, 57.4 percent of patients received medication only, indicating that compared with treatment patterns in 1997, approximately 30 percent fewer patients received psychological interventions. This trend was noted particularly among those with anxiety, depression and childhood-onset disorders – the very conditions that respond best to longer term psychotherapy.

For children being treated, 58.1 percent received medication alone and no other interventions. This despite the lack of research supporting the safety and usefulness of many of these medications.

The burgeoning managed care industry has developed strategies to reduce the costs associated with the mental health and substance abuse benefits portion of both public and private health insurance plans. Over time, management of these benefits has resulted in controlling provider fees, strict limitations on episodes of inpatient care, and a reduction in the average number of outpatient visits per patient treated.

Interestingly, prescription drugs are not typically part of the costs managed by these carve-out plans. By 2006, the costs of psychotropic drugs accounted for 51 percent of mental health care spending. Per capita expenditure for psychotropic medications tripled from 1996 to 2006.

If patients and potential patients do not complain to their employers as well as to their politicians, this situation will only get worse as the insurance companies develop even more ways to get around mental health parity mandates. And even if you don’t need help, do you really want to live in a society in which you might often find yourself surrounded by unstable individuals who can’t get help?

It’s getting dangerous out there.


  1. Not to mention that many therapists refuse to accept insurance as a form of payment because they find the bureaucracy maddening and the patient could be permanently saddled with a pre-existing condition.

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