More on Managed Care

I read the Residents’ Forum each month even though I am 18 years out of residency. Usually I find something touching and hopeful. So it has been with Dr. Sandra Dejong’s articles, but I was dismayed by the column in the March 16 issue titled “Managed Care and Psychiatric Training.”

I had barely started practice when managed care hit like gangbusters. For years, I tried to play the game until I was involved in several tragic experiences when care was cut, transferred to other “providers,” or denied entirely. These experiences convinced me that the insurance industry does not know and does not care about either the welfare or the treatment of the mentally ill.

Gradually, as I could afford it, I went off panels and now take only out-of-network insurance. My income did drop somewhat but so did my anxiety and depression at colluding with an unjust system. I had to do it—it was that or leave medicine. And what I have found, despite my initial belief that I would be driven out of business, is that I am actually doing real psychotherapy again, as opposed to the truncated nonsense that managed care peddles, which doesn’t help anyone. Well, I take that back. It helps managed care’s profit.

With the advent of discussions about the possibility of repeal of ERISA legislation, I have begun to receive some charming and amusing letters from insurance companies aimed at enticing me back on their panels. They often earnestly admonish me to practice ethically and to provide adequate and effective treatment—as though they knew anything about that.

The irony is that effective treatment is efficient and cost-effective. This is so even when treatment is a long-term psychotherapy, psychoanalysis, residential treatment, or supportive treatment with medication. Effective treatment keeps people from running to internists, abusing their spouses and children, and misusing substances. When, some years ago, I attempted to engage an insurance company executive in this discussion, he shrugged and said that he couldn’t care about that because the expenses of those tragedies didn’t come out of his cost center.

The current system is immoral and cruel and must change. The ERISA legislation has to be repealed so that insurance companies are held liable for the medical decisions they do in fact make. When that happens, the notion of insurance company ethics will not be such an oxymoron; these companies will have to underwrite effective and ethical care because cash will be coming out of their hides when they make a mistake—just like it comes out of the hides of doctors when we are negligent or make a bad decision. And won’t that be a glorious day!