THE VIRGINIAN-PILOT
Copyright (c) 1994, Landmark Communications, Inc.
DATE: Thursday, December 1, 1994 TAG: 9412010481
SECTION: LOCAL PAGE: B1 EDITION: FINAL
SOURCE: BY MARIE JOYCE, STAFF WRITER
LENGTH: Long : 116 lines
Until recently, psychologist Jeffrey S. Katz decided when his patients were healed.
Now, an insurance company often makes the call.
Katz roots through a pile of paperwork on the desk in his Virginia Beach office. ``Here's one,'' he says, seizing a letter from an insurance company and reading aloud: ``Authorized units were exceeded,'' He picks up another. ``We're unable to certify this treatment.''
Katz is dealing with managed mental health care, under which each patient's progress is scrutinized by an insurance company.
Patients are spending less time in treatment under managed care. In the future, some may be getting medicine instead of lying on the therapist's couch.
Insurance companies say patients receive good care for less time and money. But some doctors say people may not get the help they need.
Insurance companies say they have a simple reason for clamping down - they were getting bilked.
``There was real misuse of mental health benefits,'' says Nancy Eleuterius, president of Sentara Mental Health Management. Sentara is one of many local and national companies that covers Hampton Roads residents.
For instance, a woman who went to see a psychiatrist might be referred to another doctor for testing, then sent to a family counselor, who would bring in the woman's children for testing. ``She'd see three people in the practice,'' says Eleuterius.
Some people went through years of therapy to achieve ``self-actualization,'' rather than to treat a mental health problem, says Beverly Outlaw, vice president of operations for Sentara Mental Health.
It's like the difference between getting surgery for a tummy tuck and getting surgery to treat a disease, she says.
But therapists deny that abuse was rampant.
``I think the insurance companies have had bad experiences. . . with a few unethical psychiatrists and hospitals, and therefore they have decided to make the whole class stay after school,'' says psychiatrist Jerome Blackman.
Therapy is a painful process, doctors say. Patients endure it because they have serious problems that need help.
``I have never, ever had somebody walk in and say they're interested in self-fulfillment and self-discovery,'' says Katz. ``I've never had anyone come in for the hell of it.''
Therapists have a strong incentive to finish treatment quickly, says Michael S. Weissman, a Chesapeake psychologist who has studied the issue for a state psychologists' association. Most treatment ends in fewer than 15 sessions without any managed care, he says.
``Like any business, if you take advantage, if you exploit the market, you're out of business,'' says Weissman. ``If you want to get referrals. . . you want to get results.''
In a typical situation, a managed care company agrees to pay for a certain number of sessions, usually about eight, when a patient begins treatment. If doctor and patient feel that more treatment is needed, the therapist must file a report about the patient's progress and get permission from an insurance company's case manager.
This restriction makes it hard to decide how to treat patients, therapists say, because they don't know how much time they'll get. Some will do well in eight sessions; others may need years.
Think how a surgeon might feel, says Blackman. ``They don't want to say, `I'll operate on you, but your insurance company only pays for 20 minutes.' ''
Therapists complain that many insurance company case managers have less training than the doctors, and they make decisions without knowing the patient.
``Oftentimes, I'm talking to a nurse or licensed professional counselor. Those people are hired by insurance companies to cut costs. I don't know that they have the best interests of the patient in mind,'' says Katz.
At Sentara, the case workers are psychiatric nurses with at least a master's degree, says Eleuterius, and they consult with staff therapists before deciding to cut off treatment.
Therapists say they're fighting an uphill battle, partly because it's very difficult to measure why and how psychotherapy works.
Also, the average insurance customer doesn't expect to need treatment, so they don't demand more mental health benefits.
``Most adults are used to taking care of themselves,'' says Blackman. ``They don't think they'll ever be faced with an emotional problem they cannot handle.''
Not all insurance plans operate this way, but managed care makes up a significant portion of the market. Katz says about 80 percent of his patients are on some type of managed plan; for Weissman, it's about half.
As much as therapists dislike this system, they say it's even worse when they can't do business with the companies at all.
Managed care typically requires patients to use a doctor on a list approved by the insurance company.
Several of Weissman's patients have had to switch to other doctors in the past year because their employers changed to insurance plans that don't have Weissman on the list. Another 20 or so have called about starting therapy and been turned away.
The business is changing, says Sentara's Outlaw. In the future, some patients may not see a psychologist or psychiatrist at all.
A woman feeling depressed after the death of her husband might turn to her family doctor for prescription antidepressants, says Outlaw. A hyperactive boy might be treated by his pediatrician with medicine for attention deficit disorder.
If the medications don't help, then the patient would be referred for counseling.
``That's what's happening now if you look at rural communities,'' says Outlaw. The family doctor treats less serious mental problems. ``The real dilemma is to decide where that cut-off is.''
Or a patient might see a less expensive clinical social worker instead of a doctor, says Eleuterius.
For instance, a man feeling depressed or anxious because of money problems might need a financial counselor more than a therapist.
``The patient is getting the right care at the right level,'' says Eleuterius, ``but not more than they need.'' by CNB