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.

APA vs. APA

MANAGED CARE SHOCKER!   Imagine my surprise when I opened my mail and found a letter to me from AmeriChoice by UnitedHealthcare managed care insurance company telling me that psychiatrists were not referring enough of their depressed patients for psychotherapy (presumably to psychologists and social workers.  Nothing was said about psychiatrists doing the therapy themselves).

The letter went on to say that "evidenced-based medicine" has shown that the combination of antidepressants and psychotherapy is more effective than either alone.  This letter was almost as bizarre as another letter I had received not long ago from another managed care company telling me that Abilify or any other atypical antipsychotic medication is not the first choice in augmentation medicine for patients with major depression who do not respond to an antidepressant alone.  No sh*t, Sherlock!

The letter about psychotherapy, as well as the one about about misuse of certain brand-named drugs, is a sick joke coming from managed care, which joined forces with the pharmaceutical companies in the late nineties to try to destroy psychotherapy as we know it.  As I describe in my new book, managed care companies routinely paid psychiatrists a lot more for doing med checks than for doing psychotherapy. In response, psychiatrists stopped doing therapy for the most part, and they began to see medication as a cure all for everything and appropriate for everybody.

Then, mangled care companies started lying to their subscribers about how much psychotherapy was covered under their insurance plan.  In their reading materials, the companies might say that 20 sessions per year were covered, but then they would only certify 4 or 5 sessions as "medically necessary" and refuse to cover any more.  Therapists would then have to spend hours on the phone arguing with clerks about what treatments were medically necessary.  The clerks would try to intimidate the therapists.  Why, the therapist must not be very competent if he or she could not cure the patient in four or five sessions!

For the record, 20 sessions in most mainstream psychotherapy models is itself considered brief therapy, which is most appropriate for patients who are relatively high functioning, have at least some good relationships, and have a single, very well-circumscribed conflict to manage. Diagnositically, they would have only one disorder (no co-morbidity).  This type of case is today rather unusual because patients with anxiety or depression generally have behavioral and relationship issues as well.

In other words, brief psychotherapy works best for the so-called "YAVIS."  YAVIS means young, attractive, verbal, intelligent, and successful.  One might ask why such an individual would even need therapy in the first place.  And, of course, they tend to get better no matter what the therapist does.  For patients who are the most in need of psychotherapy - such as those with serious personality disorders, alcohol and drug abuse, and/or long term repetitive self destructive behavior - brief therapy accomplishes very litle.

After a while, mangled care insurance companies found out that it was not cost effective to hire clerks to argue with therapists, and they were also getting a bad name with employers who are the primary ones purchasing insurance.  I recall a managed care group losing a contract with Matel Toymakers in Southern California because they did not certify as medically necessary psychotherapy for patients who were referred for treatment by the company's own Employee Assistance Program (EAP)! 

So insurance companies quit that strategy and merely racheted down fees for ALL psychotherapists. 

This practice, they found, had a side effect that was just perfect for their ultimate bottom line. Suddenly, psychologists who never before had the slightest interest in prescribing psychiatric medication wanted prescribing privileges.  It was all an issue of money, and little else really. 

(The problem with psychologist prescribers, from this psychiatrist's point of view, is that psychiatric medications not only affect the brain, but may interact with all other organ systems, diseases, and non-psychiatric medications.  If you want to do it, IMO you should go to medical school.  Of four psychologists first trained in psychopharm by the Armed Services, two of them decided to do just that).

Instead of banding together to fight for their patients' needed access to psychotherapy, as well as for their own need to all get paid at rates comparable to other highly trained professionals, the American Psychiatric Association and the American Psychiatric Association got into a turf war over prescribing privileges.  I have come to believe that mangled care has devised a strategy to divide and conquer.  If they did, they were successful beyond their wildest dreams. 
                                                                                                                        

And now they have the audacity to complain about psychiatrists and psychologists not working together, because it would actually save them money? This may seem self-serving coming from a physician, but it is true: Your friendly neighborhood health insurance carrier does not give a good God damn about their patients' mental health.