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.
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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