Managed Care Managed Care By Debbie Barbaroussis-Goot Regis University Dr.
Ron Shaver April 16, 2001 To decide on whether or not an issue is considered ethical or moral we need the hard cold facts. Facts expose or explain what is to be decided upon – not what the outcome should be. Decisions regarding health care and mental health issues represent a major portion of ethical and moral choices. As individuals we are not always able to understand the justice, or fairness, behind the decisions supposedly based on hard cold facts.
Once upon a time being a therapist was considered a calling. The images of a counselor sitting back in their comfy cushioned chairs listening to hours and hours of patient’s dilemmas, heartaches and mental health issues have been replaced with the hard cold facts that therapists today are fighting over customers while behaving according to appropriately mandated practices. HMOs (health maintenance organizations) and PPOs (preferred provider organizations) are the therapeutic callings today – managed care.
As therapists and patients it may be difficult to grasp the concept of “managed care” as this system becomes prevalent in the mental health areas. Managed care is any health care delivery system in which strategies are employed to optimize the value of provided services by controlling their cost, promoting their quality, and measuring performance to ensure cost-effectiveness. Managed care now dominates health care in the United States.A managed care system actively manages both the medical and financial aspects of a patient’s care(Corcoran,1996). Three concepts are at the origin of argument with managed care: control of the treatment plan, cost effectiveness, and quality of treatment. Current quality of care measurements focus on limited and tangible evidence. How do we measure evidence of mental health improvements? Who should make the decisions regarding mental health issues, the physician or the Chief Financial Officer? Health is an issue which needs be left to the physician while dollars and cents can remain with the financial officer.
Managed care theoretically may seem appealing, but most view managed care practices as emphasizing cost control over quality. The ethical arguments of managed care are dependent on the goals of the physician and the provider.If the primary goal is always doing the best for the patient within the limits of available resources and less interest for the bottom line then subjecting patients to unnecessary risks is minimal.
However, if the patient is regarded as a secondary issue the physician and providers are ethically wrong. “It is the position of the National Academies of Practice that is unethical to compromise a patient’s needs and quality care concerns to satisfy financial objectives” (Pope, K. S. & Vasquez, M.J.
T., (1998) pg. 322). The APA Ethical Principals of Psychologists and Code of Conduct (Section 4.09c) states, “Prior to termination for whatever reason, except where precluded by the patient’s or client’s conduct, the psychologist discusses the patient’s or client’s views and needs, provides appropriate predetermination counseling, suggest alternative service providers as appropriate and takes other reasonable steps to facilitate transfer of responsibility to another provider if the patient or client need ones immediately” (American Psychological Association, 1992, pp.
1597-1611). As a result of managed care policy limitations, referrals may become necessary.Managed care assumes the ability to predict how long it will take to heal mental health issues, and may not include or recognize certain diagnosis. Managed care places a therapist in a precarious position.
Therapists will now need to make the “appropriate” diagnosis to cover therapy while acting also for the managed care organization. This practice called double agentry is one of the challenges facing managed care. Other challenges are fidelity; which entails loyalty to the profession’s basic ethical principles (the patient in need,) confidentiality; a supreme ethical principle which may be compromised for variations in policies, supervisions, billing or collection reasons, managed care now has the right to invade a patient’ file–failing to protect the patient, and informed consent; which denies individual freedom of choice forced upon the individual with limitations in policy coverage. Two other challenges are honesty; which within the system may produce exaggerated or false claims to ensure payment, also allowing dishonest physicians to make arrangements with the managed care providers, and finally, vulnerability; which creates the potential for lowering various quality of care standards that managed care claims to protect (Sabin, 1996).
Managed care goes against the Hippocratic oath, which in essence states physicians will do what is a benefit for the patients abstaining from whatever is deleterious or mischievous. The duty of the therapist is to inform and advise, maintain confidentiality, and reinforce a patient’s sense of responsibility releasing them with the confidence that they are healed. The assessment of human and emotional costs can not be compared with other medical conditions. However, advocates for managed care argue that there have been improvements in the managed care organizations such as recognizing professional counselors as viable mental health care providers. What were they recognized as before? Some counselors also state that working with managed care has helped make their practice more time and cost effective.
Who is the winner here? The therapist or the patient? Where the patient is concerned, the amount of paperwork a therapist completes should be the last consideration. Time management is important, but has little effect on the patient’s outcome and mental stability. Even in our supervision sessions at Community Counseling we are advised to place the least invasive diagnosis on an individual’s chart for fear of “labeling stigmas” in the future. Will this jeopardize their chance for insurance coverage? With some companies it may – is this ethical? To whom are my loyalties and obligations? Hopefully I can say with conviction–the patient. With regards to the cost effectiveness of managed care, we need to consider the results found in a study by Winegar who showed that in the year 1991 mental health costs rose from $4.25 million to $4.8 million.These figures hardly demonstrate an increase in savings.
Empirical research on managed care also fails to show an improvement in the quality of care and decrease in cost (Dudley, R.A., Miller, R.H., Korenbrot, T.
Y., Luft, H.S. 1998). Although managed care is here to stay, it requires revision.
Professionals are entitled to salaries commensurate with their education and scope of knowledge. Denying patients the right to choose someone based on whether or not they are on a certain list is almost as bad as censoring freedom of speech – everyone should be able to pick their medical or mental health provider.It would not be fair to ignore the fact that some physicians or therapist have milked the system. If a policy included a 28-day stay for inpatient treatment, then they stayed 28 days whether is was warranted or not. Managed care has eliminated this practice and made a difference in inpatient costs. The old “fee for service” system also encouraged too many sessions. However, a dishonest or conniving therapist will find a loophole in any system. Therapists must advocate for what is best for their patients.
This is an ethical and moral obligation of the profession. Failure to provide services to a patient of a recognized standard of care is unethical and clearly violates trust. In conclusion I view managed care as accepting the lowest competitive bid for services rendered. Does this mean that the services will be inadequate or flawed? Not necessarily.
Nevertheless, when patients fall ill or seek mental health care, therapists and physicians fall under organizational scrutiny of treatment plans, visit limitations and protocol for medication prescriptions.Managed care appears to focus purely on cost reduction and bottom line financials. Hospitals and training centers have downsized, even the amount of psychologists or mental health counselors have changed careers and to what cost? The cost of the patient. References American Psychological Association, (1992). Ethical principles of psychologist and code of conduct. American Psychologist, 47, 1597-1611. Corcoran, Kevin, (1996).
Maneuvering the maze of managed care: skills for mental health practitioners.New York: Simon & Schuster. Pope, K.
S., & Vasquez, M. J. T., (1998).Ethics in psychotherapy and counseling: A practical guide. San Francisco: Jossey-Bass.
Sabin, J.E., (1996). Is Managed Care Ethical Care? Controversies in Managed Care Mental Health Care edited by Lazarus, A. Washington D.
C.: American Psychiatric Press, pp.115-126. Winegar, N., (1992).
The clinician’s guide to managed mental health care.Binghamton, New York: Hayworth Press. Psychology.