Testimony to U. S. House of Representatives

Managed care Consumer Protection Forum

 July 24, 1996

Karen Shore, Ph.D., President

 National Coalition of Mental Health Professionals and Consumers

I am Dr. Karen Shore, a clinical psychologist and President of the National Coalition of Mental Health Professionals and Consumers. The National Coalition is a national grass-roots organization whose members are clinicians from all mental health disciplines, consumers of mental health care, and consumer advocates. Three and one-half years old, the National Coalition now has 18 affiliated state/regional coalitions. Our sole issue is the damage we believe is being done to mental health care, and to our health care system in general, by the implementation of the concepts of managed care and managed competition. We believe that managed care, whether it is run by corporations or by government, is damaging to patients, to quality care, to the quality of the professions, and to society in general. We believe it must not only be regulated, but it MUST be replaced by a more pro-consumer model of insurance and/or health care delivery. We ask Congress not to under-estimate how many citizens, Democrats and Republicans alike, oppose managed care and want it replaced.

In this testimony, I will present:

I. Problems with managed care and managed competition

 II. Regulations needed now

 III. Why managed care must be replaced by a more pro-patient insurance system

 IV. Alternatives to managed care

 V. Clinical vignettes from our files demonstrating managed care treatment problems

I) Problems with managed care and managed competition. A) In Medical and Mental Health Care:

1. The operating principle of managed care is that neither patients nor clinicians are trusted to make cost-effective decisions; all are controlled, "managed." 
2. Insurers and managed care companies (managed care company's) almost completely control, the flow of patient referrals and money,
• making patients' health dependent on the managed care company's decisions, leading to refusals of access to appropriate care or clinicians, increased stress as ill patients or family members may need to fight for proper care, under-treatment, tremendous out-of-pocket expenses for refused treatment, tremendous inconvenience and expense to family when nearby hospitals are not "network" hospitals, prolonged waits for treatment, leading to patient harm, death, and even suicide.

 

• and making clinicians economically dependent on the managed care company, giving managed care company's the power to control, intimidate, threaten, punish, and eliminate clinicians from the job market, strongly influencing decision-making. Many clinicians have found themselves breaking personal and professional ethical and/or moral codes, and many who refuse to under-treat patients or neglect patients' needs for privacy find themselves out of work.
3. Eliminates three basic consumer rights:
• choice: providers chosen for them based to a large extent on "economic profiles," i.e., how much money a clinician "costs" or "earns for" the insurer/managed care company,

 

• decision-making: managed care companys decide what is "medically necessary" for whom, based on changeable standards often idiosyncratic to the insurer, and
• privacy: insurers/managed care companys demand detailed information to make decisions; the information may reach employers or others; may happen more if mandatory reporting to data banks.
4. Competition has led to: favoring cost over quality; corporate profits, executive incomes, and stockholders over care; premiums and capitation rates that are inadequate to support appropriate care; denial of payment for patients who don't "follow the rules" in an emergency; favoring of lesser-trained, compliant, "cheap" clinicians over highly qualified professionals who refuse to under-treat; employers seek "cheapest" plans, not necessarily best plans.
5. Clinicians face unemployment if they do not sign managed care contracts. Contracts may: force clinicians to take legal responsibility for insurer's decisions (hold-harmless clauses); prohibit clinicians from telling patients about proper care or when the insurer wants to under-treat (gag clauses); impede clinicians ability to make best referrals; provide incentives for under-treatment; drop clinicians who do not under-treat or who advocate for patients. Fear and intimidation often drives treatment decisions.
6. This is NOT a "free market solution" to health care. The "free market" now exists only for insurers (sellers) and employers (buyers), not for patients or clinicians, and the managed care companys control both supply and demand.

 

7. Has seriously reduced hospital stays, sometimes putting patients at risk.

 

8. Hospital care has become dangerous as large percentages of nurses are replaced by minimally trained personnel.

 

9. Managed care plus decreasing public funds are leading to the destruction of our teaching and research hospitals.

 

10. Managed care company's are replacing highly-trained clinicians with the "cheapest," preventing access to more highly trained clinicians, especially for patients who cannot afford treatment without their insurance. In mental health, especially in the field of psychotherapy, this now means that bright people must not get advanced training if they want to work "hands-on" with patients.

 This is also particularly apparent in nursing. There is no better way to destroy quality and our system than to make advanced training a "liability" and by forcing highly-trained clinicians out of direct care.

B) Problems with Managed care Particular to Mental Health Care:

 

1. Eliminated true psychotherapy; replacing it with superficial brief treatment, crisis intervention, and self-help (which can be excellent, though not a substitute for treatment). Forced focus on symptoms, prohibiting treatment of the causes of symptoms. Some companies state they do not cover chronic or ongoing problems or serious/complicated diagnoses.
2. Reduced psychiatric hospital days causing increased re-hospitalization, patient injuries, deaths.

 

3. Intrusion into privacy through utilization review (case management) leads many patients, out of fear or humiliation, to forego their benefits or to avoid needed treatment altogether.
4. May force children and adults to use medication they may not want or need to provide a quick and less expensive, albeit superficial, "fix." May require medication and prohibit psychotherapy, despite studies showing benefits of psychotherapy. Often force patients to try two or three of the older, less expensive anti-depressants, despite more serious side-effects, before doctor is allowed to prescribe a newer, easier to tolerate, but more expensive one, like Prozac or Zoloft.
5. Controls which clinicians a patient may use or require patients to change clinicians as health plan or employment changes, despite overwhelming research showing that patients consider the patient-therapist relationship to be the most important contributor to healing.
6. Advanced training is a liability. Many managed care companys will not allow psychotherapy patients to see clinicians with Ph.D.'s or M.D.'s, or other doctoral degrees. Even master's level therapists are now beginning to be replaced by bachelor's level "counselors" (unlicensed, no professional training).

C) The false "rising costs" problem in outpatient mental health Studies show that the "rising cost" problem in mental health was due to abuse of insurance plans largely in inpatient substance abuse and inpatient adolescent treatment. The managed care company's have come to earn great profits by managing outpatient psychotherapy when it WAS NOT part of the rising costs problem.

 Outpatient psychotherapy costs did not rise above the C.P.I, and utilization had remained stable for 15 years. Reasonable co-pays have regulated over-use of psychotherapy, and the willingness of clinicians to give discounts to those in financial need allowed more access to more comprehensive treatment before managed care than with it. The industry enjoys invoking "the "Woody Allen" image, using the phrase "worried well" and implies that great many people languish in prolonged psychotherapies due to the greed of the clinician and the desire on the part of the patient for a hired "friend."

 These false images are deliberately invoked to make legislators and employers think that outpatient therapy needs to be "managed," that it is an open, endless pit. Here is the truth, based on consistent research findings:

Without external "management," and even with very generous benefits, there was NO crisis of "rising costs" in outpatient psychotherapy before managed care:

• people end psychotherapy when they feel better, even if more sessions would be covered

• 85% of psychotherapy patients end treatment before the 26th session, and the 15% who remain in treatment have more serious problems to begin with

• Costs for outpatient psychotherapy were NOT rising above the CPI and utilization rates had remained steady for the past 15 years 

For patients with personality disorders, and those with histories of abuse, neglect, and trauma, short-term therapy is inadequate; many personality disordered patients do not begin to show improvement until at least 6 to 12 months into therapy. These are generally the 15% who do not leave therapy before the 26th session.

Employer's considerations:

• About 65-80% of discharged workers are dismissed due to personal problems, rather than for incompetency or technical inadequacies

• 80-90% of industrial accidents are likely related to personal problems and the employees' difficulty handling stress 
• About 60% of employee absences are thought to be due to psychological problems 

Experts in short-term treatment for anxiety find that at least 11 sessions are required when there are no major stressors, such as marital discord. Where there are life stressors, at least 20 sessions are required, and often 40 sessions is considered "short-term" work by these experts. Managed care often limits treatment to 3-8 sessions, regardless of the problems. Patients consistently state that the patient-therapist relationship is a major factor in effective psychotherapy, indicating that choice of therapist is essential to outcome. Co-payments are effective means of controlling utilization Liberal outpatient benefits lower overall mental health costs by preventing costly hospitalizations. They also reduce costs for medical care, as about 60% of medical visits are found to be sought for conditions with a psychological base, often without any physical findings.

 "Management" of mental health benefits often costs almost as much as the cost of the treatment itself. This is now leading to a system of capitation, whereby clinicians are only given enough money to provide an average of about 3 sessions/patient - a completely inadequate sum.

 QUESTIONS

 Is it cost-effective to "manage" outpatient psychotherapy when - most patients leave before the 26th session

• patients naturally end treatment when they feel better 

• the 15% of patients who stay in treatment longer than 26 sessions are those that are shown to require more than brief therapy 

• co-payments effectively "manage" psychotherapy? Is it a good idea to limit freedom of choice when patients feel that the patient-therapist relationship is one of the most important factors in successful outcome?

Does it pay to severely limit access to adequate psychotherapy when inadequate treatment increases absenteeism, accidents, lowered productivity, and hospital admissions?

II. Federal Regulations Needed Now

1. Guarantee coverage and portability regardless of employment or medical status; eliminate pre-existing condition waiting periods on all policies.

 

2. Guarantee the right of all citizens to purchase any approved form of insurance, including fee-for-service plans, managed care plans, Medical Savings Accounts, and any other form of insurance yet to be devised and introduced into the marketplace.
3. Allow all citizens to purchase their own insurance and to deduct 100% of the premiums, giving them the same benefits now given to employers.

 

4. Phase out employer involvement in health care; allow employers to return premium money to employees in the form of income so that citizens may purchase their own insurance. Consumers have lost control over health care; this would help them regain control.
5. Require all managed care plans to offer a reasonable "Point-of-Service Option"

 

6. Protect the citizen's right to "contract privately" so that consumers can purchase any treatment they deem necessary, even if their insurer has declared it "not medically necessary" or denies treatment or payment, or if the consumer desires not to file a claim for particular services for reasons of choice, privacy, or self-determination. All SES classes need this freedom.

 

7. Do not impede the States' rights to regulate managed care. Correct the ERISA exemptions from State regulations for health plans rather than extending ERISA to all health plans.

 

8. Encourage the development of pro-consumer alternatives to managed care that preserve freedom while providing incentives for citizens to be responsible, cost-conscious, educated consumers (e.g., Medical Savings Accounts, "Managed Cooperation," or other ideas).

 

9. No mandatory reporting of patient information to data banks; consumers must be able to protect their privacy.
10. Prohibit "gag clauses" in provider contracts (clauses prohibiting clinicians from telling patients when the insurer is denying appropriate care, impeding proper referrals, or providing inadequate information to patients).
11. Prohibit arbitrary limits on mental health benefits that are not applied to medical benefits. (Violence, homelessness, crime, teen pregnancy, troubled adults raising troubled children, child abuse, drug and alcohol abuse, etc. are, to a large extent, mental health problems that may require intensive, sustained treatment, as do serious mental illnesses. The cost of NOT treating mental health problems is three times the cost of treatment.)

III. Why Managed care Must Be Replaced by a more pro-patient system

The National Coalition believes that regulation of managed care will never be adequate to protect consumers and quality care. The only solution is to build more pro-consumer models of cost-containment. Consider:

1. Powerlessness of consumers and clinicians: The basic tenets of Managed care are that managed care companys must control patient and clinician behavior in order to contain costs. Managed care cost-containment mechanisms require a relatively powerless patient and powerless clinician. The values are at best paternalistic, with the assumption that the "managers," in the form of gatekeepers, case managers, and utilization reviewers, know best. This seriously interferes with the consumer's right to make decisions and gives absolute power to the Managed care companys to allow or deny treatment and reimbursement.

 Capitated premium arrangements then provide incentives for health plans and clinicians to under-treat. Further, because clinicians have become dependent on managed care companys for referrals and income, decision-making is too often guided by fear and intimidation, sacrificing the primacy of the patient, ethics, morals, and quality and sound clinical judgment. Managed care and consumer freedom are inimical to each other.

2. There is a serious conflict of interest when insurers make treatment decisions and keep whatever money is not used for treatment. Though early HMO's may have been driven by quality, the field has been overrun by entrepreneurs seeking profits and control over the market. Due to the increased competition, demands for lower costs by employers, and the powerlessness of consumers and clinicians under Managed care , premiums and capitation rates may already be too low to provide appropriate care.
3. There will never be parity for mental health under managed care, even if laws mandate that there can be no discrimination in benefits, for Managed care plans consider mental health treatment a good place to cut costs, and proper treatment can easily be declared "not medically necessary."
4. Consumers Lose Three Basic Rights Under Managed care. Managed care cost-containment mechanisms require that consumers lose three basic rights: choice, privacy, and the right to make one's own treatment decisions.
5. Consumers may need to fight the insurer for needed treatment or benefits during a time of medical or psychological illness. People have died or suicided after needed treatment has been delayed or denied by Managed care companys. Others, supposedly insured, are paying large out-of-pocket sums for needed surgeries and other care because a case reviewer, under pressure from the managed care company, has declared it "not medically necessary."
6. Steering of patients only to "cooperative, managed-care friendly" clinicians. Providers who don't agree with the insurer's "treatment philosophy" or who advocate too strongly for patients risk being ejected from networks or denied referrals. Many are being driven out of work. Many are choosing to have nothing to do with managed care, thus losing their ability to work, while many others feel "indentured" into service by an entity they feel is damaging to patient care, patients, clinicians, and the professions.
7. Managed care has the potential to destroy quality care and the professions. What will happen to our professions when it is better to be the least trained you can be; when no independent thinking is allowed or professional judgment tolerated; when all clinicians are completely dependent on insurers for their livelihood and dare not "disobey" them? Demoralization is already high. But this is only because most of today's clinicians were trained before managed care. Established medical residency programs and mental health internship sites are reporting that they must "re-educate" clinicians for managed care. HMO's are taking over responsibility for internships and residencies from the professions so that new clinicians will be trained by the managed care companys, reducing opposition. I predict that within a few years, managed care companys will begin buying medical and graduate schools. Students will be educated in "managed care techniques" during training, eliminating the need for insurers to "re-educate" them later. Mental health graduate students will be taught that no patient requires intensive therapy, and none will be trained to provide it.
8. Intimidation of consumers. Even patients report being afraid to argue too much with their Managed care company for fear of being denied treatment for other problems. One mental health consumer told us she was literally threatened with discontinuance of approval for further therapy if she continued to complain about their decisions.
9. This is NOT a "free market" solution. A free market depends upon the ability of the users of goods and services to decide upon a product's usefulness and value. Under managed care and managed competition, insurers are the "sellers" of a "product" called a health plan, and employers are the "buyers." Neither the patient nor the clinician is part of this "marketplace." The free market exists only for insurers and employers. Secondly, a true free market relies upon supply and demand. However, managed care companys control supply by deciding how much of what treatments will be available and who will provide them, and they control demand by deciding who needs how much of what treatment. Managed competition is actually bringing about the elimination of competition. Soon, there will be no body of clinicians outside of Managed care . Once managed care is the only choice and there are few independent practitioners, patients will not find true "second opinions" on anything. Further, there will be no competition for Managed care itself, which will bode poorly for quality and for patients. In addition, as the larger and wealthier managed care companys continue to buy out the smaller ones, that one-seventh of our G. D. P. that represents our health care budget will be controlled by three or four corporations. Some are now seeking markets abroad as well. This industry is gaining unprecedented power, both in the health care fields and elsewhere, and make it impossible to regulate them.
10. It will become impossible to adequately regulate this industry

Insurers rightly argue that regulatory legislation will impede their cost-containment methods. The more they contain costs, the less consumer freedom there is; the more consumer freedom, the less they can contain costs by their mechanisms. Some managed care companys have already shown that they would rather ignore regulations and simply pay fines when they are caught. Consumers and clinicians will forever feel the need to fight for freedom and quality, and the managed care companys will forever fight against regulation. This is an irresolvable problem inherent in the managed care system that demands that we find alternative cost-containment methods. Consumer freedom and managed care are inimical to each other.

IV. We Must Find Alternatives to Managed care

 The answer for a democratic society is not to remove everyone's right to determine his/her own health care, but to design benefit plans, be they government plans or private plans, that make treatment affordable to all, yet make patients cost- and utilization-conscious. Congress and citizens of the United States must realize that consumer freedom can only be protected by a measure of consumer responsibility. Further, to have a fair system, this responsibility must be to an affordable extent (meaning affordable even for the poor.

Medical Savings Accounts, though they definitely have major problems associated with them at this point, have already shown that costs can be reduced when people are given incentives to make responsible, cost-conscious health care decisions. There is no reason we could not alter the MSA design to make them affordable, fair, and reasonable to all citizens, regardless of health or economic status.

Our Coalition's "Managed Cooperation" (attached) plan also aims to engender a cost-consciousness in patients, while educating them about appropriate fees in their area and requiring clinicians to print their fee schedules.

There may be other ideas not yet known or devised that would provide excellent, affordable care without restricting consumer freedom or destroying the professions. We must allow experimentation with alternative plans.

Congress should not under-estimate how many Democrats and Republicans want alternatives to managed care.

V. Vignettes collected by the National Coalition

 Most of the following vignettes come from the hundreds of letters written to us.

1. A woman entered psychotherapy and reported chronic depression; childhood sexual abuse; repeated nightmares; phobic avoidance of movies, TV, jokes, or anything else that seemed sexual; and a phobic terror at work. A utilization review (UR) over the phone resulted in the reviewer telling the therapist that since the patient was not actively hallucinating, there was no "medical necessity" for psychotherapy.
2. A pre-adolescent girl was referred by one therapist to a colleague. The child had been molesting younger children. The managed care company assigned a therapist but would not allow the therapist to contact the family until they pre-approved the case. They asked the therapist to fill out a form and provide information he did not have, since he had not seen the child. It took over 15 days to get the consultation approved. In the meantime, the child's family could no longer tolerate the situation and managed to get her admitted for a 30-day stay in a psychiatric hospital. The interference in treatment resulted in a far more expensive treatment than was necessary and was a difficult experience for the child.
3. A woman was in therapy for 5 years, twice/week at a reduced fee. Then, her employer switched to a managed care company at a time when the patient's mother was dying, her husband suffered a psychotic break and attacked her physically, her step-brother was admitted for a psychiatric hospitalization, and her step-sister was getting married. The reviewer certified only one session every other week, insisted on a brief technique and medication. The therapist appealed the case, but the appeal was denied. The therapist then initiated a "level two" appeal. Within one week, he received a letter from the managed care company informing him that they were reviewing the credentials of the therapist and that they wanted him to send in his credentials for evaluation.

 When he called the company, he told the company that he felt intimidated (re-evaluation of credentials could result in his ejection from the network, jeopardizing his ability to earn a living). The person on the phone told him "off the record" that it was their intention to intimidate him.

4. A severely disturbed man who has had chronic personal, marital, family, and vocational problems for twenty years was doing fairly well after several years of weekly psychotherapy. When his insurance was changed to managed care and the company requested a case report, the lack of confidentiality and his sense of unpredictability about the continuation of his treatment caused him to become very upset and to impulsively terminate treatment. Some time later, hea gain contacted the therapist saying that he was now virtually unemployed, alienated from his child, in severe conflict with his wife, and he felt "depressed, distraught, and out of control." The therapist believes he would have continued to do fairly well had it not been for the intrusion into his privacy and his loss of control over his own treatment.

 

5. Ms. Z's 15 year-old son became depressed and suicidal. The managed care company (managed care company) forced her son to go to a hospital under contract the managed care company.

 He was discharged in less than 48 hours, only to become assaultive to his mother. He was readmitted to the same hospital, this time for 9 days. The managed care company disregarded the psychological testing reports which indicated that the boy was at high risk for self-harm and needed prolonged inpatient treatment.

 Soon after this 9-day hospitalization, Ms. Z's son attempted suicide. He was then admitted to a state mental hospital where the cost of care was shifted to the state and to Ms. Z.

 

6. A deaf adolescent girl made a suicide attempt and found treatment at a mental hospital with a special ward for the deaf. This was before the managed care company took over the insurance. Later on, the girl made a second suicide attempt. The mother requested that the managed care company allow her daughter to return to the hospital with facilities for the deaf, even though this was relatively far from home. The managed care company refused, saying that she had been there once before and if the service was any good, she would have been cured and not need help again. The managed care company would only allow an admission to a local hospital under contract with them that did not have a unit for the deaf.

 

7. The X. family had 10 children. Mrs. X. was forced to go on welfare when her husband abandoned the family. Mrs. X became employed and was able to get off welfare, but she says that her family would have better mental health benefits if they had remained on welfare. In 1995, one of Mrs. X's daughters became increasingly disturbed, with symptoms of depression, eating disorder, suicidal ideation, self-mutilation, and running away from home. The managed care company's reviewers "grudgingly" allowed her 15 days of partial hospitalization (a day program), which her doctors felt would be inadequate. The daughter ran away again for 24 hours and was found disoriented the next day. The managed care company authorized a 2-week hospitalization, which her doctors again felt was inadequate. On discharge, the girl ran away again for 5 days. The managed care company's restrictive attitude changed after the mother's story "A Mother's Fight to Save her Girl" appeared in the Philadelphia Inquirer (October, 1995). Since then, Mrs. X's daughter has been receiving appropriate care.
8. A woman called the managed care company's 1-8-- number, as required for permission to begin therapy and for assignment to a therapist. When she called, the gatekeeper asked first for identifying data, including her husband's name, social security number, address, etc., since her husband was the policyholder. She was then asked to tell the person on the phone why she wanted therapy. The woman replied that she couldn't discuss it with someone over the phone and just wanted the name of a therapist. The gatekeeper said that in order to make an appropriate referral, the woman would have to reveal the nature of the problem. She again said she felt she couldn't and asked again for the name of a therapist. Again it was refused. The woman hung up feeling that because she had already told the gatekeeper her husband's name and other identifying data, she could not now reveal to the insurer that she just found out that her husband was sexually abusing their daughter. The woman was not able to get treatment for herself and her family for several more months, when she received the name of an out-of-network therapist from her primary care doctor (who probably was going against his managed care contract by referring out-of-network). The woman decided she could not use her insurance benefits because of the intrusion into privacy, and she has had to pay for the treatment completely out of pocket.
9. A woman with a diagnosis of borderline personality disorder was seriously depressed and anxious. She rarely left her home except to work due to anxiety attacks when out socially. She had an eating disorder and would binge and purge with laxatives. This became so severe that hemorrhoid surgery was necessary. Her fears of using public restrooms kept her more isolated and restricted her activities, which led to more depression, self-loathing, and binging. She self-medicated through substance abuse and promiscuity in the past, but no longer wanted to engage in these behaviors.

Instead, she focused on her body, seeking out unnecessary surgery for her chin and seeking surgery to reduce scarring she inflicted from compulsively picking acne. When she entered treatment, she had suicidal fantasies and was self-destructive in other ways. She was seen twice weekly for two years at a reduced rate. Her carrier changed to a managed care company during this time. The therapist was not a network provider, but the patient stayed in the treatment through non-network benefits. During the two years, the patient began to control her eating disorder and began to go out socially.

 However, she was still lonely and frightened of both isolation and intimacy. Her depression and anxiety had lessened somewhat, but was still present, as was her self-loathing and hatred of her body. She was still self-destructive. After two years of treatment, the managed care company stated that "treatment had gone on too long," that the condition was chronic, and that they had "no desire" to pay for it. The therapist appealed the denial of reimbursement, but the reviewer said that he did not believe that the patient could get better through treatment. When the therapist reiterated the progress the patient had made in two years, the reviewer stated that she must then no longer need treatment if she had made progress in that two year time span. Within one conversation, the reviewer deemed the patient first incurable, and then cured. This refusal of reimbursement was devastating to the patient and interfered with the patient/therapist relationship, which is often tenuous with such disturbed patients. Despite a reduced fee, the patient was unable to pay for treatment, and terminated prematurely.

 Sometime later, she recontracted the therapist and re-entered treatment. She reported that after leaving treatment, she became involved in a masochistic relationship with a bisexual male prostitute. She became so enmeshed with him, and the closeness was so important to her, that she was unable to ask him to wear a condom. At the time this complaint was written, the patient was awaiting the results of an HIV test. The therapist believes that if the patient had not been pushed out of treatment by the denial of reimbursement, she would not have become so self-destructive. Should she be HIV positive, it will not only destroy her life, but it will end up costing the insurer far more than it would have cost to pay for continuing psychotherapy.

We implore Congress to realize how damaging the system of managed care and managed competition is to quality care and to our citizens, our research and teaching hospitals, and our professions. Please regulate managed care now and allow for alternative benefit designs and plans so that we in the United States may continue to look for a better, more pro-patient system.

 Thank you.

Respectfully submitted,

 Karen Shore, Ph.D. 

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