Do physicians have a professional responsibility to participate in the managed health care plans through which the vast majority of Americans receive medical care? By choosing not to participate in managed care panels, a physician is by definition limiting his or her services to only those who can pay.

"A lot of doctors who have stayed in managed care have done so because as physicians they feel they have an obligation to serve a wide range of patients," said Lawrence Lurie, M.D., chair of APA’s Committee on Managed Care.

Lurie, who is now retired from practice, said that he saw in his own practice how managed care had expanded access to people who had not previously been treated in the mental health system.

A December 2002 report by the Center for the Health Professions on practice patterns in California found that "the problem of lack of availability of physicians in many regions of the state is largely due to physicians not accepting patients with certain types of health insurance (or without health insurance altogether) rather than due to an absolute shortage of physicians. . . ."

But Lurie and others interviewed by Psychiatric News said that the math is not so simple, and that the finger can be pointed in the opposite direction—at the system itself. "If an insurance plan sets up a system that doesn’t provide adequate reimbursement," said Burlington, Vt., psychiatrist Robert Emmons, M.D., "it’s the insurance plan that is limiting access."

Managed care, especially the sort that provides financial incentives for meeting capitated budgets, has its own professional conundrums.

"I am very concerned about the conflict of interest that is inherent in managed care," Emmons said. "The work is hard enough that I don’t like to add more complications. Of course, it’s not a perfect world, but if there is a financial conflict of interest that can be avoided, I would prefer to do so." Emmons said that he treats patients with a wide range of incomes and circumstances, including some patients eligible for Medicaid and Medicare. But he acknowledges his practice is not for everyone. He practices psychoanalytically oriented psychotherapy and noted that patients with complex serious mental illness are liable to be better off in a clinic setting.

Ed O’Neil, Ph.D., director of the Center for Health Professions, which published the report on California practice patterns, added that the autonomy of the physician is an accepted tradition.

"Medicine has historically acted this way and made individual adjustments in fees as well as providing charity care for free," he said. "The broader issue of health care finance for everyone is something that I think all doctors should work on, but if the financing system fails, it is not the ethical fault of physicians. They should not be held responsible for the financing system."

Lisa Mellman, M.D., said physicians choosing to practice independently have options for providing care to those who cannot afford to pay under a fee-for-service model.

"Everyone deals with it in his or her own way," she said. "A psychiatrist may work part time in a clinic system and feel comfortable that he or she is providing care for the underserved and those who cannot pay."

She added, "There are better and worse managed care systems, and each individual physician has to make a decision at each juncture in his or her career and development. One may make a decision to opt out or in at one point in a career and make another decision at another point."

Lurie believes that opting out is a form of protest that may register change in the system. "Some of the companies are realizing that they have to deliver a better product and to be more psychiatrist friendly," he said.