Much of the debate about health care has been carried out at such a height of statistical abstraction that the potholes and ankle-twisting wrenches for the patient in the street below are scarcely visible. Doctors in daily clinical work see distress in the face of an individual patient or in their sudden silence. What follows is only one vignette from psychiatry, but the power of money and the intrusion of managed care methods have similar disruptive effects throughout medicine.
"John" is a 40-year-old mid-level manager at a Milwaukee retailer with a wife and three daughters. At similar jobs in Seattle and Denver, he was downsized out despite excellent performance reviews. Trusting, buttoned-up and from a repressive background, he told himself it was the product of mergers and acquisitions, "reorgs," only business; but he could not completely escape his tyrannical superego (his stern, unreflecting self-criticism): he wondered if he did something wrong and minded his p's and q's more strictly thereafter.
A year ago John suffered an episode of major depressive disorder (DSM-IV Code No. 296.22), three months of exhaustion and anhedonia, during which he was racked by insomnia and a paralyzing fear of errors. Reluctantly he consulted a psychiatrist. With fluoxetine(Drug information on fluoxetine) (Prozac) he regained energy and in three exploratory therapy and medication monitoring sessions (CPT-4 code 90807, $130 each) decided to use weekly group therapy led by the psychiatrist to better understand his emotional restriction, his tendency to isolate and his inability to call on support. This therapy plan was deliberately chosen to combine the advantages of integrated treatment, continuity and low cost. In the next six months, John learned from group interaction, modulated his harsh superego somewhat by listening to his own and others' free associations, and expanded his tolerance of his own desires. He began to show definite signs of assertiveness and spontaneity. People at work and home said he was a different man and that he came across more clearly. He was intrigued to discover fantasy experiences of aggression, sexuality and grandeur; although he was not at all sure how much he wanted to express these outside of the therapy group. His monthly group therapy bill was $140, paid at first by his HMO.
He received a promotion and permitted himself to enjoy it guardedly. Without telling him or other employees, however, in the pursuit of cost reduction and greater efficiency -- as all businesses do -- his company switched health care benefits to a large national HMO, which has itself merged in the last year, gobbled networks, captured lives and grown in value on Wall Street. "Health Inc." has strict but unpublished "medical necessity requirements" and an efficient phone-tree review process.
In the first scheduled 20-minute phone consultation, the reviewer, "Bob," seemed happy to schmooze with the psychiatrist about John and his history -- giving the doctor some queasy moments, which he brushed aside in order to do everything possible for the patient -- but concluded that he did not think the case met their medical necessity criteria, saying Health Inc. does not authorize psychiatrists to conduct group therapy, approving only master's-level workers to do that (at about the same cost).
The psychiatrist asked to appeal and was scheduled for a review with the medical director, "Dr. Thompson" in Atlanta, two weeks later. He also informed the patient about the process, and John began to consider his options, his fear of exposure and jeopardy no doubt slowing his progress for a month or two.
In the eight-minute appeal consultation, Dr. Thompson briskly asked about sleep and job attendance and said the case did not meet medical necessity requirements because it was no longer acute. The psychiatrist presented his argument that the resolution of the last episode and the expansion of John's emotional alternatives to prevent future episodes require this low-cost form of therapy. But Dr. Thompson replied, "It doesn't meet medical necessity criteria for acuteness. We don't do ongoing therapy. It's in the contract his company signed, which he could look up if he wants to. Hey, we don't want to be mean, we're in the business of helping people. We'll give him another two sessions to finish up and three 15-minute med checks till August 15th. So I guess you're reasonably contented?" The psychiatrist said, "Not really, and I'm not sure John and his family will be," and hung up.
The American Psychiatric Association's Practice Guideline for Major Depressive Disorder in Adults (1997) divides treatment into acute and maintenance phases, and adds: "Psychological and interpersonal factors often play a substantive role in increasing the risk of recurrence, and psychotherapy may be very productive during the maintenance phase." Therein lies the gap between ideal principle and business reality.
The psychiatrist reported the appeal to the patient, who then phoned Dr. Thompson and had a carbon copy tense exchange. John considered going to the human resources department at his job, but ultimately he was not confident enough about his position -- or his dawning awareness of his tantalizing but questionable fantasies and his ability to keep them under his hat -- to do that. Instead he negotiated self-payment and continues group therapy, to which Health Inc. most likely has no objection. (Of course, they could have disclosed the criteria to John and his company earlier on, but then they would not have been able to advertise their caring image so much.)
My hunch is that most patients and doctors, when faced with an imposing letter of denial from Health Inc., will slink away quietly rather than appeal or consider alternatives. The risk of exposure of inner emotions and fantasy is simply too great. The patient sees things through dire, dark superego glasses, expecting disgrace. Does the managed care organization really need personal information to "determine medical necessity," or do they know that gathering it deters doctors and patients from making claims? What was so special and high-tech about the exchange and the criteria in this instance? In any event, most patients simply drop out of sight and are probably counted among the "satisfied" customers by the insurance company.
It should be clear that Dr. Thompson is not the scapegoat. I feel virtually certain he does not really enjoy his job but has to do it, just like his unseen and unknown soul mate John.
One question to consider about such a case is whether it is unusual or really quite typical. In what way is it different from what is likely to happen with the majority of managed care plans? I believe it is the nearly universal final common pathway of the managed care process. It is the average, the daily routine, almost prototypical, not at all a rare horror story.
The system itself, along with mob psychology, motivates good people to do bad things. As Health Inc. expands, Dr. Thompson and all its executives are driven by their needs for security and power. In the race to the bottom line, can they resist ever simpler formulas, if only to handle large populations efficiently? Certainly there are some ethical managed care companies, usually the smaller ones, but who in the United States aims to stay small?
Everyone has the best of intentions and can point to the highest of motives and principles. In this actual lived experience, however, given the nature of neurotic psychology and the corporate requirement for numbers and control, the outcome is the inevitable degrading of treatment that is private and continuous.
