The
Elephant in the Room:
How Therapists
View Managed Care’s Effect on the Practice of Psychotherapy
Senior Thesis
Julie Cohen
Psychology Department and Public Policy Concentration
Swarthmore College
2002
Examiners:
Professor Jane Gillham, Advisor
Professor Jeanne Marecek, Advisor
Professor Robinson Hollister, Advisor
Abstract
The rise of managed care has redrawn the health care map over the last two decades. This thesis is an exploration of how these dramatic changes have affected the mental health profession. Sixteen therapists were interviewed in a qualitative research study. Using grounded theory analysis, several themes emerged, including widespread impacts on the way that therapists view their profession, changes in the way that clients understand and seek treatment, and limitations on the type and amount of mental health care that the insured may now receive. This research, in addition to contributing to the body of work that has already been done in this area, may inform policy changes that would enhance client care as well as improve the relationship between therapists and managed care companies.
Acknowledgments
First and foremost, I would like to thank
my advisors on this project: Professors Jane Gillham, Jeanne Marecek, Robinson
Hollister, and David Smith. Jane’s guidance, support and steadiness were
invaluable at every step of the process, from the conceptualization stage to
the interviews to the myriad draft revisions as the deadline approached.
Jeanne’s expertise in qualitative research and willingness to be involved
greatly enhanced the project. Rob and David were both a terrific resource when
it came to helping me strengthen the policy component of the thesis. Second,
thank you to all of the therapists who participated in the study. It was
wonderful getting to meet so many people committed to their profession and
doing such great work. Thank you to Matt Oransky for being my thesis
cheerleader/commiserater. Finally, a million thanks to my family and friends
for their support throughout this project.
Table of Contents
Abstract
Acknowledgements
The Recent History of Mental Health Care in the United States
The Value of Mental Health Care: Parity/Comparisons with Physical Health Care
Managed Care Policy Considerations
Psychotherapy Defined
The Psychologists as Lone Ranger: Autonomy, Judgment and Decision-Making
Therapeutic Orientation and Satisfaction with Managed Care
How Managed Care Changes Therapy
Changes in Therapists’ Behavior Because of Managed Care
Study Methodologies
How Therapists View the Impact of Managed Care on their Practice
Therapists’ Perceptions of their Clients’ Experiences with Managed Care
How Interactions with Managed Care Representatives Affects Therapists’
Identities and Sense of Professionalism
Positive Aspects of Managed Care
Practical Strategies for Dealing with Managed Care
Implications of the Research in the Context of Past Studies
Limitations of the Research Method and Future Directions
References
An article in the
February 1998 edition of Family Therapy Networker magazine showed a
cartoon of a large, obtrusive elephant with his derrière parked right in
between a therapist and her client. The elephant was meant to represent managed
care, an unwanted third-party that has entered the therapist’s office and
fundamentally altered the way mental health care is delivered in this country.
In an ideal world, therapists could work
with their clients without regard to the cost of the care they were delivering.
People could seek out psychotherapy without wondering if their insurance will
cover it and/or their pocketbook can handle the strain. There would be no
stigma attached to seeking professional help for psychological issues, and
mental health would be valued (and funded) on par with physical medical care.
But the world does not look like this; many real-world constraints exist that
limit the amount of funding for health care. Though there has generally been a
willingness to pay large amounts of money for health care in the United States,
the costs have risen at such high rates that it became increasingly necessary
to find a way to slow that growth. In the 1980s and 1990s, it was not uncommon
for health care expenditures to rise 15 to 20 percent per year (Zelman &
Berenson, 1998). In 1990, health care spending represented 12.7% of U.S. gross
domestic product. As costs mushroomed, managed care emerged as a solution to
the ballooning costs of both physical and mental health care. In 1988, 25% of
people with employer-based insurance were enrolled in a managed care plan. By
1997, that figure had risen to 80%.
Clearly, this industry is pervasive; we are only just beginning to
understand how widespread its effects are on present-day health care delivery.
The Recent History of Mental Health Care in the United States
Before
delving into managed care’s history, it is understand to define the term.
Basically, managed care is an insurance system in which an appropriate level of
care is designated by an insurance company and then, to contain costs, certain
types and amounts of treatment are authorized while other kinds of care are
denied. Shoe-horned within the term “managed
care,” there are health maintenance organizations (HMOs), preferred provider
organizations (PPOs) and Independent Practice Associations (IPAs). HMOs are
capitated systems in which primary care providers are allotted a certain amount
of money per person whose care they are responsible for. This system is meant
to create an incentive for doctors to be frugal in what services they
recommend, because they are basically getting the same amount of money per
person regardless of whether the person has 10 procedures or two. PPOs allow more choice for health care
consumers because they can see a far wider network of health professionals. The
care provider typically accepts reduced fees in order to participate in the
network, and they usually accept some outside review of their work as well. An
IPA is when a group of providers form their own network of care and can then contract
with managed care companies for capitated contracts (Kent & Herson, 2000).
The rapid rise of managed care is mainly
a phenomenon of the last two decades, during which time millions of people
became members. In 1973, Congress passed the HMO Act in reaction to rising
health care costs. This legislation provided the funding and impetus for the
development of the managed care industry (Kent & Herson, 2000). By the
mid-1980s, many HMO insurers, still frustrated with the cost of mental health
services, contracted them out to specialized “carve out” mental health managed
care companies. The companies were often able to make large profits by managing
the type and amount of care participating therapists could offer their
patients. Accountability became a major theme. Therapeutic treatment that was
not considered effective by the standards of the managed care companies was
simply no longer funded.
The Value of Mental Health Care: Parity/Comparisons
with Physical Health Care
The managed care system, by its design,
suggests that mental health treatment, while worthy of being funded, can be
successfully rationed with few ramifications in terms of employee productivity
or overall wellness. Indeed, the implication is that many people were getting
more care than they needed and that this care could be cut without negative
consequences. This has happened in a way that is far more dramatic than the
changes in physical health care, where there is still a much stronger ethic
that people deserve treatment for their maladies. In fact, the question of
whether or not mental illnesses really constitute maladies (and therefore are
worthy of treatment) is often raised. Certain psychological interventions, such
as treatment for personality disorders, are not considered worthy of being
funded, even though they may be effective treatments. For other disorders,
treatment may not be funded because the technique is not extensively researched
yet. While it is true that the medical model is
not always a good fit for psychological disorders, there’s still quite a bit of
evidence that shows that mental illnesses rank among the most pervasive of all
health care woes.
Several
studies assessing the impact of mental illness have shown that mental health
issues have a major impact on mortality, productivity, and other indices of
morbidity, like effects on one’s family. The Global Burden of Disease (GBD)
study, published in 1997, puts unipolar major depression as the fourth highest
cause of global disability-adjusted life years (DALYs). Depression is sometimes
called the “common cold of mental illness” because of its prevalence,
especially in industrialized countries. In the GBD study, the only problems
with greater impact worldwide were lower respiratory infections, diarrhoeal
disease, and perinatal disorders (Murray & Lopez, 1997). Also on the list
of the 30 leading causes of DALYs are alcohol use, which is 20th,
bipolar disorder (22), and schizophrenia (26). Even schizophrenia, which is
relatively low on the list, is ranked higher than Human Immunodeficiency Virus
(HIV), which was 28th (although it seems probable that HIV’s DALY
has risen in the last five years as the disease has continued to spread).
Furthermore, the GBD study finds that these four neuropsychiatric conditions
(depression, alcohol use, bipolar disorder, and schizophrenia) caused 0.3% of
deaths and 10-15% of the burden of disease and injury worldwide in 1990 (Murray
& Lopez, 1997). This data makes it clear that psychological problems are
serious and substantial in the same way that medical problems are.
Because of
its prevalence and symptoms, depression has a devastating impact. The economic
and social burden of depression has been gauged for the United States, and the
sum is staggering—$43.7 billion in 1990, according to one group of researchers
(Greenberg et al., 1993). They calculated the sum using a prevalence approach
to cost-of-illness analysis, which measures the costs attributable to all
individuals suffering from the physical or mental health condition accumulated
over a particular year of analysis, in this case 1990. (The other option is an
incidence approach, in which one only calculates those diagnosed with an
illness during a particular year). To calculate those costs, the study authors
used the human capital approach, which considers the productive contributions a
person makes to society, which, they argue, is best captured by measuring the
market wage a person earns (Greenberg et al., 1993).
Of the $43.7
billion sum, $12.4 billion, or 28%, were direct costs. These include
professional medical and psychiatric services, rehabilitation, counseling, and
medication. Mortality costs of $7.5 billion, or 17%, were calculated based on
the number of people who committed suicide because of their depression.
Finally, the largest chunk, $23.8 billion (55%), was due to morbidity costs.
The morbidity category includes the reductions in work-related productivity
that occurred because of workers who were depressed. We can see from these
numbers that treating depression accounts for only 28% of the costs of the
disorder. Nearly three-quarters of costs are externalities, including suicides
and reductions in work-related productivity, caused
by those still suffering from depression.
Besides these direct and indirect costs
to an individual’s work-related productivity, those suffering from depression
also experience a general decline in their quality of life (Greenberg et al.,
1993). There is also a significant impact on the person’s family and friends.
Within the family, adverse effects can include marital strife, increased
likelihood of divorce, and the disruption of the family’s other social roles,
including the transmission of culture, rearing of children, and support to
other family members in trouble (Sartorius, 2001). Disturbingly, children of
depressed mothers are at a five to six times greater risk for depression
themselves (Downey & Coyne, 1990). In addition, at least 20% of patients
with chronic conditions like diabetes or heart disease also suffer from a
depressive disorder, so there is a definite link between physical and mental
illness (Sartorius, 2001). Depression is just one example of mental health
issues that are too important to be ignored by insurers and employers.
Managed Care Policy Considerations
Once we have established the importance
of mental health care, it then becomes important to consider how best to decide
which services will or will not be funded in a managed care system. Policy
analysis can be broadly defined as client-oriented advice that is relevant to
public decisions and informed by social values (Weimer & Vining, 1999).
When making health policy decisions, three are major considerations: containing
rising health care costs, ensuring access to health care for millions who are
without it, and providing health care that is appropriate for those who receive
it. Theoretically, containing costs drives the price of health insurance down
and thereby would hopefully increase the number of people who could afford to
access health care. But what effect might this have on the quality of the care
provided? The incentive for managed care companies is to keep costs low, which
is good for the employers, who will not have to pay as much to offer health
care to their employees. It is also good for managed care companies, because it
means that they generate profits (assuming they have set the price for
insurance coverage appropriately). At the same time, if the care allotted in a
managed care structure is substandard, one would hope that employers would not
purchase such a plan for their workers. So this would serve as a counterweight
to the incentive for managed care companies to offer very low-priced, very low
quality care. But a problem arises that is particularly acute in the area of
mental health: how well do employers—and laypeople in general—understand the
importance and value of mental health? Most people are utterly unaware of the
studies showing the pervasiveness of depression, the effectiveness of
treatments for it, or the overall incidence and impact of mental illness worldwide,
so how can they make good decisions about the level of mental health care that
they should purchase? The first step is to understand what psychotherapy is,
who practices it, and what approaches there are to treatment.
Psychotherapy Defined
The field of mental health is a wide net
within which practitioners, researchers, and
scholars all play a part. Within the term “practitioner,” there are several
different types of mental health professionals. They include clinical and
counseling psychologists, who obtain PsyDs or PhDs in their respective field;
clinical social workers, who earn a masters of social work; psychiatrists, who
attend medical school and then specialize in psychiatry (which gives them the
ability, unlike other mental health practitioners, to use psychopharmacology in
addition to talk therapy); and psychoanalysts, who may be in any one of the
proceeding categories but have also undergone additional training in order to
practice psychoanalysis (Rosenhan & Seligman, 1995). These practitioners
work in a wide range of settings, including inpatient psychiatric hospitals,
residential treatment centers, community mental health centers, and private
practices.
Therapists subscribe to a wide range of
different therapeutic orientations, anything from psychoanalysis to behavioral
modification. Nevertheless, there are a few common, and critical, element1s to
therapy. These include empathy, warmth, and genuineness. Therapists of most
orientations also value forming a therapeutic alliance with clients, which is a
joint sense of the goals of therapy and how they can best be achieved. Client
expectations of what therapy is about, as well as how well those expectations
match the therapist’s style, are also a key element of effective therapy
(Rosenhan & Seligman, 1995).
In terms of the different orientations,
one can think of a continuum that runs from psychoanalytic/psychodynamic/global
therapies at one end to cognitive-behavioral/specific therapies at the other. A
central tenet of psychoanalytic theory is that repressed unconscious impulses
and drives sap our energy and create psychological issues. By unearthing these
conflicts through psychoanalysis, the impulses can be acknowledged and coped
with more adaptively, leading to psychological health. Unlike psychoanalysis,
which classically lasts up to five times per week for several years,
psychodynamic therapy is much briefer and is more focused on the present than
on events from one’s childhood and distant past. Instead, psychodynamic
therapy, also known as dynamic psychotherapy, emphasizes current social
relationships while still retaining the idea that unconscious impulses and
conflicts are at the root of the anxiety, depression or other presenting
problem that a person enters therapy with.
Cognitive-behavioral therapists, on the
other hand, practice a much more specific type of therapy. At the heart of
cognitive therapy is the notion that clients need to undergo a process of
cognitive restructuring in order to rid themselves of irrational thoughts like
“I need to be loved and respected by every member of my community.” Behavioral
therapy is premised on the idea that psychological distress stems from learned
behaviors, which can be unlearned and replaced by more constructive ways of
coping and adapting (Rosenhan & Seligman, 1995). Cognitive and behavioral
therapies are typically short-term therapies. Because they focus specifically
on behaviors and/or irrational thoughts, once those issues are addressed, the
therapy need no longer continue. This is in contrast to the more global
approach of a psychodynamic practitioner. Though
cognitive-behavioral and psychodynamic therapies are the orientations practiced
by the bulk of therapists, dozens of other therapies are in practice today. In
addition, many therapists actually identify themselves as eclectic or
integrationist, which means that they employ a range of theories and techniques
in their practice.
The Psychologist as Lone Ranger: Autonomy, Judgment and Decision-Making
When in private practice, therapists
often work alone, with one or two officemates, or even out of their own home.
Relatively isolated from peers, free from a hierarchical structure and without
a supervisor, they have a high degree of autonomy and very frequently make
independent decisions about how to provide care. Indeed, regardless of whether
one is in a private or group practice, the profession of psychotherapy is one
marked by the freedom to use one’s highly developed clinical judgment to make
decisions. Managed care has changed that. Although therapists do still provide
the care independently, they must then discuss their clinical work with a
managed care representative in a process called utilization review. The purpose
of this practice, from managed care companies’ perspective, is to inject more
accountability into the process and thereby cut costs. Cost-cutting is the main
reason that managed care has become such a widespread form of mental health
care coverage. While to some extent the utilization process has had this
effect, it has also raised a number of issues for therapists about the way they
do their work and the way that their clients view the process of psychotherapy.
Largely
because it is such a hot-button, pressing issue in the field of mental health,
several groups of researchers have gauged how mental health professionals feel
about managed care and its impact on their practice. In a mail-in survey of
over 15,000 psychologists from all over the United States, 79% of respondents
said the effect of managed care was negative. Ten percent said it was positive,
while 11% said that managed care had no effect on their professional work
(Phelps, Eisman & Kohout, 1998).
In a mail-in
survey of 108 mental health counselors from four states—Connecticut, Florida,
Ohio and Nebraska—about 90% of participants said that managed care has affected
their practice in some way, characterizing the impact of managed care as
“somewhat positive” (11.1%), “neutral” (17.6%), or “in some way negative” (60%)
(Danzinger & Welfel, 2001). In a main-in survey of independent
practitioners from nine geographic areas in the United States, just 2% reported
a positive impact from managed care, whereas 88% reported no positive impact.
In a separate question, 47% of respondents said there had been a negative
impact on the quality of care they provided, while 30% indicated that there had
been little negative impact (Murphy, DeBernardo & Shoemaker, 1998).
Several factors,
including professional work setting and level of training, mediated how mental
health professionals rated their experience with managed care. In the
country-wide survey by Phelps et al., the researchers found that independent
practitioners and psychologists in medical settings were more negative about
their experience with managed care than colleagues in academic or government
settings. This can in part be explained by the fact that those in academic or
government settings were more apt to say that managed care had no impact on
their practice than those in medical settings. Still, the majority of
psychologists in every setting rated the impact as negative (Phelps et al,
1998).
In
terms of differences across professionals with different degrees, a survey of
139 psychologists and social workers found that Ph.D. providers considered the
utilization process to be significantly more unhelpful and time-consuming than
providers with MA, MS, or MSW training. Perhaps this was in part because they
reported experiencing denial by utilization reviewers more often than
professionals with MA, MS or MSW did. PhDs also indicated greater adverse
effects to patient care because of utilization reviews, including the
possibility of utilization reviews compromising their client’s confidentiality
(Chambliss, Pinto & McGuigan, 1997).
Therapeutic Orientation and Satisfaction with Managed
Care
Because their approach emphasizes long-term, insight-oriented treatment, one might expect psychoanalytically-oriented therapists to chafe most at managed care dictates, but one study found mixed results. Chambliss et al. report no significant difference between mean scores of dissatisfaction for psychoanalytically-oriented therapists and their colleagues who employ solution-focused, cognitive behavioral or eclectic strategies. Psychoanalytic therapists were, however, significantly less convinced that short-term treatment is effective (Chambliss et al, 1997).
Therapists who
take managed care referrals tend to be more likely to say that they employ a
cognitive-behavioral approach. In a study of 142 Florida psychologists comparing
managed care (MC) versus non-managed care (NMC) therapists, many more MC
therapists (46%) identified themselves as cognitive-behavioral in approach than
did NMC therapists (16%). Just 11% of MC therapists and 14% of NMC therapists
identified themselves as Psychodynamic-Psychoanalytic, while 40% of MC
therapists and 59% of NMC therapists identified themselves as eclectic (Gold
& Shapiro, 1995).
An ethnographic study was conducted at
Wayside, a large Northeastern urban community mental health center that accepts
about eight managed care plans. The group of clinicians who work there, as part
of their philosophy, strive to enhance wellness rather than cure illness. The
therapists at Wayside embodied a meaning-driven, relational, “person-centered”
vision of their clients regardless of the therapists’ orientation, be it
psychodynamic, family systems, developmental or narrative. This conceptual view
of clients, and therapists’ conception of what constitutes good care, was found
to be in conflict with the managed care approach to therapy. In part, this was
because they felt strongly that anyone, regardless of income, should have
access to psychodynamic psychotherapy, but managed care made it very difficult
for them to maintain this equal access. They also resented being forced to
label clients with diagnoses, as well as the push towards conceptualizing
clients’ difficulties only in terms of symptoms—and then pursuing symptom
reduction as the primary course of treatment (Ware, Lachicotte, Kirschner,
Cortes & Good, 2000).
How Managed Care Changes Therapy
Several studies document reported changes
in the length of treatment, or number of sessions, that therapists spent with
their clients. In the Florida study of managed care and non-managed care
psychologists, MC psychologists reported seeing the majority of their clients
for significantly fewer sessions than NMC therapists. Among the managed care
therapists, 70% saw the majority of their clients for less than 21 sessions,
compared to 44% of the NMC therapists. Twenty-two percent of the MC therapists
saw the majority of their clients for 21 to 50 sessions per year, whereas 40%
of NMC did so. Finally, just 7% of MC therapists saw the majority of their
clients for more than 50 sessions per year, compared with 16% of NMC clinicians
(Gold & Shapiro, 1995).
In Murphy et al.’s study of 442
independent practitioners from nine geographic regions, 86% said that their
treatment interventions had been affected by managed care. Most respondents
also indicated that managed care has led to inappropriate treatment,
insufficient treatment, or both. Respondents
were also asked to indicate which of a set of circumstances they had
encountered (and to check all that applied). The most common responses, listed
in order of their frequency of being sighted, were: sessions had been reduced,
decreased flexibility and room for clinical judgment, premature termination,
decreased amount of assessment time, restrictions on patients served, increased
referrals for medication, increased use of protocols for treatment, and use of
treatments outside primary orientation (Murphy, DeBernardo & Shoemaker,
1998). Several of these responses, including the most frequently cited response
(“sessions had been reduced)”), have to do with not having enough time to pursue
treatment in the manner in which therapists wish to do their work. Indeed, in Ware et al.’s ethnographic study
of a Northeastern community mental health center, the shift to managed mental
health meant that the rationing of time was a central aspect of the therapy. An
element of time-consciousness had been injected into the “person-centered”
approach that therapists there generally practiced. Time became a product to be
managed in order to contain the cost of treatment (Ware et al., 2000).
In one of
the New Jersey studies, therapists who felt they had changed the way they
practice because of managed care often attributed this to an
emphasis on brevity in the treatment room. In response to a “yes” or “no”
question, 48% of therapists said that managed care had changed their approach
to therapy. Of those who said “yes,” 96% further commented on their answer.
Sixty-two percent of the comments fell into a category labeled “Excessive
emphasis on brief treatment.” (Rothstein, Haller & Bernstein, 2000).
Chambliss et
al’s study, “Reactions to managed care among psychologists and social workers,”
asked therapists to respond to several questions using a 4-point scale
(1=never, 2=rarely, 3=frequently, 4=always). The mean response to the question
“Have patients discontinued treatment prematurely?” due to managed care
limitations, was 3.0, or frequently (SD=1.0). Danzinger and Welfel conducted a
study with mental health counselors and obtained similar results. Sixty percent
of respondents said they had changed or would change their treatment plans
based on managed care limitations. In addition, 46% said that they had
terminated or would terminate with clients before they were ready because of
these limits, a surprisingly high figure. In order to receive reimbursement for
additional sessions, 46% of the mental health counselors in the study said they
had changed or would change a client’s diagnosis. Perhaps it is not surprising
that two-thirds of the sample reported some level of negative impact on the
counselor-client relationship (Danzinger & Welfel, 2001).
The review
process, in which therapists provide oral or written documentation about a
client in order to obtain authorization for more services, tends to be a
significant source of frustration for practitioners. Chambliss and colleagues
report that clinicians find the process unnecessarily time-consuming and
burdensome (Chambliss et al., 1997). Third-party reimbursement is a thorny
issue for the private practitioners in Strom-Gottfried’s study of 56 social
workers from the East and Midwest. In open-ended responses to a questionnaire
administered at a 1993 educational program on third-party reimbursement and
clinical practice, participants were
asked to identify their two greatest sources of satisfaction with private practice.
The category “independence—making my own clinical and business decisions” was
indicated by 40.4% of participants. When asked about sources of dissatisfaction
in private practice, 35% of respondents indicated “managed care/third party
demands/expectations,” 28% cited the “business aspects of practice and
paperwork,” and 14% said they disliked “difficulties getting treatment
authorization-payment-reimbursement” (Strom-Gottfried, 1997). Of course, one
must question the validity of the sample in this case since those in attendance
were there specifically to talk about managed care issues.
At Wayside,
the community mental health center in the Northeast where the ethnographic
study was carried out, the whole utilization review process is problematic for
the therapists, particularly the need to cast clients’ issues in terms of DSM
criteria for disorders and the focus on only alleviating the presenting
problem. The researchers report that it was very difficult for the clinicians
at Wayside to square their sense that good psychotherapy is preventative
treatment with the managed care dictum that one must show “medical necessity”
in order to authorize care (Kirschner & Lachicotte, 2001). When
psychologists in the Chambliss et al. study (1997) were asked “Are the utilization
reviewers qualified?” the mean response was 2.0 (on a 1-to-4 Likert-type
scale), or rarely.
Autonomy is
a major theme in the managed care debate. Many therapists dislike having their
work judged by a third-party completely external to the therapist-client
relationship. Discussion of
dissatisfaction with the review process brings up a more specific issue for
therapists: clinician’s loss of control over treatment. In Murphy et al.’s
study of independent practitioners, 84% of the sample reported that managed
care companies have control over aspects of patient care and treatment that
clinicians should be controlling. Only five percent of clinicians said they did
not experience this intrusion. The length of treatment authorized, which came
up as an issue in several other studies, also affected the therapists in this sample. Eighty percent
said caps on the number of sessions interfered with treatment. About 51% said
it was a very frequent occurrence while 16% said it occurred infrequently
(Murphy, 1998).
In
Strom-Gottfried’s survey of social workers, 22.8% said the desire for autonomy
was the most significant motivator in their decision to enter private practice.
Others in the mental health field feel similarly. Seventy percent of New Jersey
psychologists in the Rothstein et al. study indicated “yes” to the statement
“my morale and professional identity have been changed” by managed care. Of
those who said “yes,” 47% elaborated with comments that reflected a concern
about loss of control over decision-making (Rothstein, Haller & Bernstein,
2000). At the Wayside clinic, therapists reported that they needed to shift their style of practice in
order to accommodate managed care. Particularly difficult was the intrusion
therapists felt when non-professionals entered the process of deciding who gets
and treatment and how much they deserve. Even though therapists at Wayside
regularly met to discuss their cases and receive guidance from one another,
they also dealt on a regular basis with the third-party reviewers who were
analyzing their work, and they disliked that they had to suddenly submit their
particulars of their work to this third-party. They worried that frequent
interaction with representatives of the solution-focused “fixing” mentality of
managed care would eventually promote that type of mindset among themselves and
their fellow clinicians at the clinic (Kirschner & Lachicotte, 2001).
Another
major area of discomfort for therapists is concerns about ethical issues like confidentiality and
deception. In Danzinger and Welfel’s (2001) mail-in survey of mental health
counselors, about 75% viewed managed care as presenting ethical challenges to
some extent. Specifically, 52.8% reported that they experienced ethical
dilemmas occasionally, 12.1% reported that the dilemmas were more than
occasional, and 6.6% said that the dilemmas occurred often. On the other hand,
28.5% of respondents reported no ethical dilemmas associated with managed care
(2001).
In Murphy et
al.’s study of independent practitioners, 25% reported persistent ethical
dilemmas associated with managed care and 45% said they experience more
concerns than they would generally in their practice. Other practitioners saw
no difficulty, with 21% reporting that the ethical dilemmas they encountered were
consistent with general practice and 9% indicating no ethical dilemmas (Murphy
et. al, 1998).
Confidentiality
is an oft-cited aspect of ethical dilemmas. In the Murphy et al. study, a full
75% of respondents agreed with the statement that “contact with managed care
and utilization review compromises patient confidentiality.” Furthermore, 53%
strongly disagreed with the statement that “the vast majority of managed care
organizations keep clinical information confidential” (Murphy et al, 1998). In
Chambliss et al.’s study, there was a mean response of 3.5 (between
3=frequently and 4=always) to the question “How often is patient
confidentiality compromised?” (1997). Developing the therapeutic relationship
and getting the client to open up can hinge critically on the kept promise of
confidentiality. These results indicate that practitioners perceive managed
care as fundamentally inhibiting the success of this process.
Changes in Therapists’
Behavior Because of Managed Care
Therapists
admitted to employing deception in order to get more treatment authorized for
their clients. In Chambliss et al.’s study, 65% of therapists reported
exaggerating patients’ symptoms in order to obtain authorization for additional
sessions (1997). Danzinger and Welfel found that mental health counselors
“upped” clients’ diagnoses to more severe disorders (2001). At Wayside
community mental health center, the researchers noted that clinicians have a
whole battery of strategies for resisting managed care dictates, including, at
times, choosing the diagnosis with the assistance and consent of the client (“I
want all the sessions I can get. Go ahead and put down PTSD [post-traumatic
stress disorder]”) (Ware et. al, 2000).
Therapists worry about their clients’
confidentiality, they worry about how many session clients will be able to see
them for, and they worry about their wellness. Therapists often take on a big
burden in their ethic of care; they are dedicated to helping the people they
treat. At times, the managed care review process is an unwelcome intrusion into
this process, because therapists are held accountable for improving the mental
health of their clients at the same time that they are faced with mandates from
the managed care companies about how to provide care. This is especially
difficult and frustrating for psychologists when, as is the often the case, the
managed care representatives who are doing the utilization review have less
training and clinical experience than the clients’ therapist. In the discussion
section of their study, Rothstein et al. openly wondered how an insurance
company’s representative, who is not in the room with the patient at the time
the mental health care is given, and who has lesser credentials than the
psychologist, can safeguard the patient’s welfare (which is one of reasons
managed care companies give for the utilization review process). During
utilization review, the reviewer consults with the therapist about the course
of care, but few, if any, therapists find this intrusion helpful, instead feeling
like it is an affront to their professional integrity (Rothstein, Haller &
Bernstein, 2000).
Perhaps what scares therapists the most
is the possibility that managed care is permanently changing mental health care
in this country, that its ideas and methods have found their way into the
treatment room and the graduate school classroom. Gold & Shapiro, who
surveyed Florida psychologists, suggest that financial incentives to conform
may be “subverting their previously held convictions about what constitutes
effective clinical practice” (1995). As therapists learn patterns of
treatment that are received more favorably during utilization review, they may
be selecting a less painless treatment (in terms of reimbursement) in lieu of
the most effective.
Study Methodologies
With the exception of Ware et al. and
Kirschner et al.’s ethnographic work, all of the other studies cited were
mail-in surveys. While this method of sampling is convenient and allows
researchers to gather information from large numbers of participants, it is
plagued with shortcomings. Response rates are generally poor, hovering between
30 and 50 percent. In addition, responses to questions tend to be circling
numbers on Likert-type scales, answering “yes” or “no,” or writing short
answers in sentence fragments. Researchers and psychological organizations,
such as the American Psychological Association (APA), have been involved during
the past decade in surveying psychologists about their experiences with and
perspectives on managed care, usually
via mail-in survey. Researchers at the American Psychological Association
(Phelps, Eisman & Kohout, 1998) conducted a survey via mail to all 47,119
licensed psychologists in the APA database (15,918, or 34%, responded). In
another attempt to survey a cross-section of American psychologists about the
effect of managed care on their practices, a different set of researchers
(Murphy, DeBernardo, Caren, & Shoemaker, 1998) surveyed independent
practitioners in nine geographic areas throughout the country. In that case,
442 of the 1000 psychologists asked to participate actually responded to the
questionnaire. As with the other mail-in surveys, we must wonder whether
certain types of therapists are more likely to take the time to respond to a
mail-in survey. Are those who respond the therapists most upset with managed
care, or the most satisfied? Are they those who have just a smattering of
managed care patients, or those who derive the bulk of their income from these
clients? We cannot be sure, especially when such a low percentage of those
randomly selected to participate elect to do so.
Still more mail-in surveys have been conducted, some with twists on the generic model of mailing it out, getting it back, and then immediately analyzing the data. The study of psychologists in Iowa used a pretest-posttest measure to assess participants’ reactions to Medicaid managed care at both six and eighteen months after the implementation of a managed care system (Russell, de la Mora, Trudeau, Scott, Norman, & Schmitz, 2001). Of 334 psychologists invited to participate in the study, 153 (46%) completed the questionnaire at Time 1 (6 months) and 107, or 70% of those individuals, also completed the questionnaire at Time 2. In yet another mail-in survey, New Jersey psychologists were the participants in a study which examined demographics, work setting, income, and the effects of managed care on three factors: morals, approach to therapy, and professional identity and ethics (Rothbaum, Bernstein, Haller, Phelps, & Kohout, 1998). In this study, 812 of the 1,647 people asked to participate actually did so (for a 49% response rate).
Though these studies are impressive in
their number of participants, the richness of psychologists’ experience is
never captured. Therapists, who use talk with their clients to heal trauma and
explore the self, are themselves not fully heard. In these mail-in surveys,
they never get to express themselves with the richness of their voices. In
contrast, the two ethnographic studies eloquently capture the working lives of
the therapists at Wayside Clinic with detailed observations by a whole group of
observers. Of course, the downside of this approach is that the researchers only hear the experiences of a handful of
therapists at one clinical site.
This research project endeavors to capture the best elements of both methodologies. By doing face-to-face (and sometimes over-the-phone) interviews with 16 therapists, this project contains a large enough sample to hear from therapists who work in different localities, who adhere to various training models, and who have worked with dozens of different managed care organizations. At the same time, by doing qualitative interviews, which were often an hour or longer, it afforded therapists the proper time to really articulate their feelings and perceptions of the ways in which managed care affected their practice.
Sixteen
therapists participated in this study, with a mean of 17 years in practice
(range = 2 to 44 years). There were six men and 10 women in the sample. When
asked about how they would clarify their orientation, 37.5% of participants
reported that they adhered primarily to a psychodynamic orientation, 12.5% said
that they were psychoanalytic, 12.5% identified themselves as cognitive-behavioral,
and the remaining 37.5% had an eclectic orientation/other (see Table 1). Of
those in the study, 87.5% were Caucasian, 6.25% were Asian-American, and 6.25%
were African-American.
Eleven of
the study’s participants were found through a snowball technique. It began with
therapists who were initially identified as possible participants because they
were acquaintances of the researcher’s advisors. Those participants then
suggested additional therapists to contact. An effort was also made to select
random therapists from the telephone Yellow Pages. Of approximately two dozen
who were called, five therapists, all of whom were listed in a phone book
serving suburban Philadelphia, agreed to participate. Most of the therapists in
the sample are from the Philadelphia area, although one is from New England and
another practices on the West Coast.
All
participants needed to have current or very recent experience working with
managed care in order to participate in the study. An attempt was made to
select a fairly diverse sample, and as a result there are with therapists from
different training backgrounds and clinical orientations as well as with
different levels of involvement with managed care.
Table 1. Characteristics of study participants.
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An inquiry letter was sent to therapists asking them to consider participation in the study (see Appendix A). Then, in a follow-up phone call to set up interviews, therapists were asked if they currently or have recently seen managed care patients. If they met this criterion, then participants were interviewed either in person or over the telephone by the researcher. The face-to-face interviews took place either at the therapists’ office or, in a few cases, in the person’s home. Participants reviewed and signed a consent form before the interview began. This was mailed ahead of time to those participants who did phone interviews and given immediately before the interview to those whose interview was in-person (see Appendix B for a copy of the consent form). The entire conversation was tape-recorded and lasted anywhere from 40 to 90 minutes. The phone interviews were also tape-recorded. During the interview, participants were asked a standardized set of questions about their perceptions of managed care. Therapists were given the opportunity to read the questions before the interview if they requested, and about five participants did this. The remaining therapists heard them for the first time when they were asked the questions orally by the experimenter during the interview. Either scenario was acceptable for the study because the questions were not meant to surprise the therapists or even to gauge their immediate response. In fact, the more reflective and thoughtful the therapists were about the questions, the richer and more realistic their responses.
The questions are
divided by category. There are four main sections of the interview: general
information about one’s practice, overall experience as a therapist, strategies
for interacting with managed care companies, and recommendations for policy
change (see Table 2).
INFORMATION ABOUT YOUR PRACTICE
1. How long have you been practicing as a therapist?
2. How would you classify your orientation? What model were you trained under?
3. What is your usual caseload? What kind of patients do you see? What percent
are adults? What percent are children?
4. What percent of your patients come to you through managed care?
5. How many plans do you work under? Is each one similar, or are procedures and
paperwork for each quite different?
6. Do people have to get a referral from a primary care doctor in order to be
referred to you?
OVERALL EXPERIENCE AS A THERAPIST
1. In general, what has your experience been like as a therapist? Have you
felt satisfied with your career choice? Do you feel like you’ve been able to
really help your clients over the years?
2. (If you can remember), when did managed care begin to affect your practice?
3. Do you feel like your orientation fits with a managed care perspective?
4a. How, if in any way, has it changed what you do in your practice? Has it
ever impinged on your judgment about how to provide quality care?
4b. Does managed care ever affect the approach you take right in the moment
when you are in a session with a client?
4c. Do you start therapy differently with a managed care patient than with
other clients?
4d. In what ways, if any, has it impacted outcomes for clients?
4e. How has it impacted termination of therapy with clients?
5. Is there anything about managed care that has changed the way you do therapy
in a positive way?
6. Do you feel managed care has made you more accessible as a therapist?
STRATEGIES FOR DEALING WITH MANAGED CARE ORGANIZATIONS
1. Do you usually work with the same person each time you call for
authorization, or do you deal with all different people? Did you actively forge
that link, or is that company policy? Does this vary across the managed care
agencies you work with?
2. Are the representatives who you speak with psychologists? If not, what
training do they have? [Then: How much does this vary from company to
company? In this respect, do you prefer some to others?]
3. Could you describe the managed care person with whom you have had the most
productive relationship? Why was that? What qualities did the person (or the
relationship) possess?
4. Do you feel like, in general, your professional judgment is respected by
those representatives and by the MCO in general? Tell me more about that. Do
any examples come to mind?
5. In situations in which a managed care company disagrees with your
recommendations, what happens? What do you do? Have you developed any
strategies for dealing with these kinds of disagreements/differences? How have
they worked?
6. Has there ever been a time when you really ended at an impasse? What did you
do then?
POLICY RECOMMENDATIONS
1. Think about some of your best experiences with managed care. Is there a
managed care company that stands out in your mind as particularly good? What
about them do you like?
2. What changes, if any, would you like to see to managed care organizations?
[Please be as specific as possible.]
3. Do you know of therapists who have strategies of resistance for getting
around the rules? What are they?
4. What changes might most dramatically or fundamentally improve your situation
or that of your colleagues? [Any type of response is appropriate here, anything
from intra-office policies to nationwide reform].
The
qualitative data collected by taping the interviews were transcribed and then
analyzed using an approach called grounded theory. It is a data-driven type of
analysis in which the text is extensively analyzed and coded following several
systematic steps, eventually generating theoretical constructs (Silverstein,
Auerbach, Greico & Dunkel, 1999). First I read and marked all of the text
that was relevant to my particular research concern. Then I grouped all
instances of similar ideas (called “repeating ideas” by grounded theorists)
that occurred in the transcripts. These groups of repeating ideas yielded
themes, which were given names closely resembling the respondents’ own words.
In the next stage, these themes were grouped together to form more abstract
constructs. By doing this analysis, I thus was able to systematically locate
the issues that emerged as shared areas of concern for therapists. As we will
see below, these areas included perceived distortions in the conduct of
therapy, unwelcome shifts in therapists’ role and professionalism, and changes
in clients’ access to and understanding of therapy.
Results
Though the sample included a diverse range of therapists—some who no longer take any managed care clients and others who see virtually all of their clients via managed care referrals—all held the view that managed care has had a significant impact on their practice of therapy. The impacts they described were widespread, cutting across several domains, including how clients view therapy, the type of and amount of services that clients receive, the way that therapists conduct their practice, and the way that they view their profession.
Table 3. Outline of Major Themes.
b) The underlying philosophy of managed care is
not the right one.
c) Managed care regards clinical care as just a
business.
d) Managed care creates ethical dilemmas,
especially with confidentiality issues.
a) With managed care, therapists cannot use the interventions they prefer.
b) Managed care determines what problems therapists can work on with their clients and when termination is initiated.
c) Therapists are pressured to medicate or consider medication.
d) Conflicts related to confidentiality put therapists in an ethical bind that threatens to compromise their alliance with clients.
e) Therapists believe that managed care has instituted procedures designed to block clients' utilization.
f)
Managed care
will not authorize treatment for certain diagnoses.
g) Clients are relying too much on their
insurance in their understanding of therapy.
d) Therapists find the reporting requirements tedious and burdensome.
e) The reimbursement process is haphazard and
troublesome.
f)
Low reimbursement can mean working more hours to make a decent income.
g) Anger at being mistrusted, disgust at being forced to lie.
h) If therapists can afford it, they often stop accepting mc referrals.
4) Positive Aspects of Managed Care
a) A solid referral base.
b) Therapists are now pushed to be more efficient and accountable.
c) Clients who were previously unable to afford therapy now have access to it.
d) Clients who might not have
considered therapy before (for reasons other than
money) may come now.
5)
Practical Strategies for Dealing with Managed Care
a) Using
their language and emphasizing the negative.
b) Fudging
diagnoses.
c) Finding the most amenable managed
care people.
d)
Preparation is important to successful negotiations.
e) Seek help
from experienced therapists.
f ) Pay someone to handle the financial hassles.
[I have] some really serious cases with people who are really dangerous to themselves and where I’ve been told flat-out by a managed care company, “Treat as many symptoms as you can in a handful of sessions and that’s it” (subject 2).
It can impact in some of these cases where you only have five or 10 sessions at a time. How much do you really open up in that time in terms of personality issues creating some of the problems if, after 10 sessions, they give you five more and that may be the end of it? I guess maybe the analogy would be when you’re in brain surgery and then, before you’re done, you’ve got to close it up (subject 3).
Managed care has sort of tried to pressure therapists to make things short-term and shape things in relationship to the patient in a way that makes it much more like, “I have this many visits. What can you do for me?” . . . It’s something else. It’s crisis management, symptom-reduction something. It’s not psychotherapy (subject 5).
Those questionnaires [on authorization forms] are often based on symptoms, when in fact what I was trying to do was talk about what led to the symptoms or what was her experience” (subject 13).
What they wanted was to make the person conform to society, and my belief as a therapist is that my job is to bring the best out of the person” (subject 4).
Many managed care companies want you to know what the goals of treatment are, and yet, in a more open-ended therapy, the person comes in with an issue but it may not even be the central issue that they want to talk about. They may open up new issues as they become more open to their own inner life, and so what may have started out as the issue in the start of the therapy may really change and deepen and grow (subject 13).
I guess for me the process is a little bit slower and it’s much more sort of organic in terms of looking at the person kind of holistically and their whole life experience as opposed to very symptom focused or sort of remedial in that sense, like fixing the immediate. I guess it’s sort of like a healing process versus a band-aid. I know that’s a trashy metaphor, but managed care seems to want the band-aid (subject 8).
One of the problems I have with insurance in general, not just managed care, is that it’s run on the medical model, and most mental health doesn’t fit the medical model, so I think there’s this sort of whistling in the dark. . . To base feelings of anxiety on the same model that you do the flu, that’s not the same thing. It’s not going to have a 10 or 20 day course and that’s it (subject 4).
I think managed care psychotherapy is an oxymoron. I also think maybe psychotherapy has been hurt in America by being covered by insurance at all. That we sold our soul to the good money that insurance brought in and we over-medicalized our understanding of psychotherapy (subject 5).
How you define psychotherapy becomes the question. You know, is it something that is a problem-fixer, or does it deal with the deeper issues that people bring to various parts of their lives that create dysfunction? I think most managed care companies seem to think it’s more problem-focused. That’s it’s kind of a quick-fix. I think their philosophy is, well, if problems crop up again, they can come back and have a problem-focused experience again. But I think what that does is it shifts responsibility simply because insurance plans shift as people change jobs or as employers change insurance companies. And, in addition to shifting responsibility, I think it can be discouraging to the patient (subject 3).
Not every therapist found managed care’s philosophy incompatible with his or her own. Those who are more comfortable with cognitive-behavioral approaches generally experienced less tension because of ideological differences. Subject 15 is a psychoanalytically trained therapist who now often employs cognitive-behavioral techniques. Half of her clients are managed care referrals.
I don’t have a problem working short term. I see some
benefits to short term. I don’t resent short term as much as some people to do.
Sometimes I do, but in general I can see it working (subject 15).
Managed care regards clinical care as just a business. For therapists, therapy is not merely a business, but the managed care turns them into business people and to interact with “employers” who are also business people. Many said that this is in opposition to the reason that they became therapists, which was so that they could do clinical work.
I mean, I know allegedly we’re all working for the person’s health and well-being, but it is the whole financial sort of incentive/disincentive that they’re doing good things for their company if they reduce the amount of services given, and within limits I believe that I’m doing the client service if I get them more sessions . . . They are not going to say, “Well, gee, this person really should only get 10 sessions, but you made such a compelling case, hey, let’s give him 20” (subject 8).
Clinical kinds of decisions need to be made by clinical people. If the issue is whether or not someone who is depressed is continuing therapy, it should not be made by a business person. It should be made by a psychiatrist or social worker, somebody who knows something (subject 4).
I don’t think it’s a very good model at all, because there’s an inherent conflict of interest in the concept that if somebody needs treatment, it’s not in their economic interest to provide it. It’s a conflict of interest (subject 3).
By managed care taking the position that they’re managing, you know, the care, they’re really not. What they’re actually doing, in my opinion, is very much managing the finances. And insurance companies over the last few years have made a fortune, have literally made, I mean, ridiculous amounts of money (subject 11).
Managed care creates ethical dilemmas, especially with
confidentiality issues.
Not only does managed care make the work too business-like, but it is also
continually thrusts therapists into ethical dilemmas they would not otherwise
have to make. Confidentiality problems, in particular, occur all the time.
Some managed care wants more information than others, and that, for me, is like an ethical dilemma. Because I know that all this information goes into a computer, and computers are not sacrosanct. So I tell my clients up front, “I cannot guarantee 100 percent confidentiality”. . . Then they think about it and most do it anyway. Most can’t afford not to use managed care (subject 4).
I had left my answering machine on with the volume up, and they called me and left an extensive message naming her name and all her problems and asking some question. . .But I was aware that her all this personal information was sort of floating from one answering machine to another, and who knows about the safeguards (subject 13).
With managed care,
[loss of confidentiality] is going to be a prerequisite for getting the
services, because I can’t control the information they’re going to want and I
don’t want to be a block from the person getting the care, so we have to talk
from the very beginning about what’s confidential and what isn’t (subject 8).
They said, “Give a diagnosis.” Who wants to slap a diagnosis on a toddler? I have an ethical dilemma. They won’t reimburse unless there’s a diagnosis. Usually people use adjustment disorder. To me it’s not ethical. It’s not moral. Even for an evaluation they won’t say “rule out” is okay. It has to be a firm diagnosis (subject 7).
I happened to have supervised a student
a few years back. . .who was in a master’s program and doing an internship. She
had worked for an insurance company, and she told me the gossip that goes on
about cases in these companies is horrendous (subject 3).
Gestalt therapy is one of the no-nos, so I can’t tell them I’m using Gestalt. I can’t remember where I read it, but I read that’s one of the approaches they think aren’t acceptable. . .So, I tell them I’m doing cognitive-behavioral, reality therapy, journaling, book-reading—and none of that’s a lie. I just don’t say that in addition I do Gestalt. . .I don’t like lying, but you’re sort of forced into it if you want to stay in managed care (subject 4).
I mean, managed care programs don’t even want to hear, you know, psychoanalytic or psychoanalysis or analytical orientation or psychodynamic. I mean, they want to hear cognitive and behavioral, symptom-related, boom boom, that’s it. So, it doesn’t mesh at all [with his orientation, which is analytic] (subject 11).
With managed care, therapists cannot use the interventions they prefer. All of these contradictions between managed care ideology and procedures and the way that therapists would optimally like to run their private practice have an effect on the services that clients receive. When a therapist feels forced to use a different style of therapy with their managed care clients than they do with those who are private pay, it may mean providing them with inferior care (because the therapist isn’t employing his/her greatest strength, which is the therapeutic modality he/she has training in).
Partly because of the demands of managed care, I have learned about and utilized more short-term approaches than I probably would have otherwise. So I was in workshops, read a fair amount about short-term, solution-oriented therapy and different variations of that, and about cognitive therapy. Frankly, I regard a lot of those things as pretty superficial and unsatisfactory, but I also find uses for them. They’re useful tools (subject 14).
I can remember sort of trying to be a little more behavioral in my approach. I’m not a behaviorist so that didn’t really fly. I just found myself feeling, No, I can’t do this; I’m just going to have to do what I do. If it can work out in the short term, that’s great, and if not, the client’s had a good experience, one hopes, and may go on to find longer-term help. I just didn’t have a good feeling about rushing an agenda. Sometimes it just doesn’t work well, particularly depending on how long it may take you to join with certain clients. You can’t start to rush into a sort of behavioral focus (subject 6).
Does my orientation fit with a managed care perspective? Absolutely not, underlined, bold. It does not. . . and most of my training has been psychodynamic, but I think out of practical reasons, and I think for some good reasons also, for therapeutic reasons, I have had to become more savvy to more cognitive behavioral strategies and to be able to talk more behaviorally (subject 9).
In psychoanalytic psychotherapy, the idea of every 5 or 10 sessions saying, “What are our goals and how far have we met them?” would be just nutty, just completely destroy the process. I’m not saying that there isn’t a process of reflection, there is. But it’s done much more subtly than that (subject 5).
Managed care determines what problems therapists can work on with their clients and when termination is initiated. Even for those therapists who stated that they never let managed care affect their practice, other parts of their interview revealed ways in which they adapted their practices to managed care requirements. For example, the decision about when to terminate therapy is no longer one made exclusively between therapist and client. Now, a third-party, the managed care company, has a very strong input.
Termination is by the numbers instead of by the outcome. I keep my eye on the number of sessions and as the number of sessions begins to run out, then I start to introduce termination. When we have three sessions left, let’s talk about how we’re going to focus work in the next three sessions. When I work with a private-pay client, often I don’t suggest termination at all—I wait until the client suggests it (subject 2).
If I know that I’m restricted to a certain number of sessions. . .I’ll just tell the person, “This is what we can do in the time allotted,” but I often feel that they should probably come longer. Psychotherapy takes time, and I really don’t believe in the 10-session cure. It seems to me that managed care, calling it behavioral health, is just that. They want us to normalize the person’s behavior and get them back in the workplace so the employer will be satisfied with the contract. That’s all they care about. They don’t care if these people go home every night depressed or don’t have a social life or aren’t happy in their marriage. Just so they’re functioning. You know, it’s kind of like battlefield first-aid. Give them a bandage and a shot and send them back (subject 14).
I think the example is that a lot of people don’t finish what they start. They feel better, but they don’t get well. . . I have a patient [whose insurance] happens to pay for unlimited visits with no co-payments. She going to work at things until it’s done, as opposed to somebody else who knows that five months down the line, they may have to stop therapy and come back seven months later. That’s going to impact the outcome (subject 3).
One of the things that’s really difficult about managed care is that clients are told you have thirty sessions in a year. They don’t mean it! They do not want you to use all thirty. So I have clients saying to me, “Well, what do you meant that they were hesitant to authorize sessions 15-20?” Well, because they are. And so what I say to clients is, unless you are willing to let me emphasize the negative parts of our work—that’s how you get the most sessions—but they don’t like that. I mean, the companies don’t like it and the clients don’t like it because they feel, “Then why does it say that?” I say, “You can take that up with HR. I’m just telling you the reality” (subject 15).
Well, my ethics bind me to say that I practice the same and that I don’t capitulate to managed care and I do what the patient needs, and so on. But you change your view of what the patient needs with managed care patients, because sometimes you’re doing your best compromise between getting for them what they need given the constraints that they are under (subject 5).
Therapists
are pressured to medicate or consider medication.
.
I think therapists want to believe that they haven’t given up the right to make certain critical decisions. When I’ve had people [from the managed care company] ask me, ‘Did you refer the client for medication?’, I feel I have a right to say I don’t think it’s wise to go there right now, even though it may be the bottom line with managed care that every client who’s depressed is supposed to go immediately on medication (subject 6).
If I know ahead of time that a person’s coverage allows for, say, 10 visits or 20 visits, that it’s, it’s not a negotiable thing, then depending on what their problems are, there might be things I get into and other things I just do not get into whatsoever because there’s no time to really get in and really properly work on them. Then, I might very much focus almost totally on reduction of their symptoms or modifications of their behavior, something of this nature—without what I would consider really working through the stuff that is behind it. Just trying to get them to function better, you know, feel better. And sometimes that includes medication, a referral for medicine or something (subject 11).
Conflicts related to confidentiality put therapists in an ethical bind that threatens to compromise their alliance with clients. Clients are very much aware that their personal emotional life is in a computer file somewhere and is being discussed by employees of their insurance company. Clients will sometimes ask therapists to refrain from mentioning certain aspects of their history, which often puts the therapist in an ethical bind in which he/she must choose to side with the client, and conceal information, or tell the insurance in order to maximize the amount of treatment the person might receive.
[She] really did not want her history of incest in her family revealed on that questionnaire and her father’s physically abusive behavior with her mother, and yet they [the managed care representatives] were saying, “Why is she having trouble building a relationship with a man?’ and so forth. ‘Why is this situation so intractable?” (subject 13).
I’m seeing a 19-year-old, and I didn’t really want to tell the insurance company that he was smoking marijuana. That really gets murky in terms of your liability and what you have to report. It’s hard to get somebody’s confidence when they feel like you’re going to be ratting on them. So it just adds something else into the mix when you’re already dealing with a difficult situation (subject 1).
Certainly one area is in terms of lesbian women. Even though there are ethics of managed care, there’s also a huge rumor mill out there, and a lot of people have heard horror stories, whether they’re valid or not, of all their managed care information going to their personnel department or this or that or the other thing. So a lot of times people will say, “Well, can I see you and just pay out of pocket and not use my insurance, because I don’t want to risk certain things (subject 8).
Concerns about confidentiality sometimes factor into a client’s decision to leave therapy.
I think it was a factor, not the only factor, with her withdrawing from the therapy, because the managed care company was getting more and more intrusive, and she didn’t want to reveal the serious history that she was coming into therapy with (subject 13).
Therapists believe that managed care has instituted procedures designed to block clients' utilization. By virtue of the way it is set up, many therapists reported, managed care presents roadblocks for people as they attempt to begin therapy. Therapists said that clients frequently told them how difficult it was to get through the phone system and/or to get the name of a therapist in their area who had availability. This situation was particularly difficult for those who feel hopeless or may be suffering from depression.
To call and actually get a referral can be incredibly intimidating. Most people, when they pick up the phone and make the call, are at a low point. Then they get these menus that they’ve go to work their way through and they’re placed on hold for 15 minutes. And then they have to talk to someone over the telephone that they’ve never seen before and give them the most intimate information about themselves (subject 13).
I have come to very strongly believe that one of the ways that managed care companies are saving money is by making the system so difficult that many people give up and don’t even try. They say, “Look, fewer people are using our services, we must be doing something right. We’re saving money.” But I hear from clients that they’ve called six and eight times trying to find a therapist. I have people who’ve come to me private pay because they got so fed up trying to find a therapist through the managed care company that they just gave up. The managed care company saves money by that. And this isn’t an isolated problem. That’s a common problem. And with the biggest insurance companies in this area, I’m hearing it from almost every client (subject 2).
It’s obviously a very personal, very sensitive process for people. I had one client who said, “It took me a month before I could even not hang up the phone with the secretaries to make an appointment.” It’s a scary thing for a lot of people (subject 16).
Managed care will not authorize treatment for certain diagnoses. One’s diagnoses will also have a huge effect in another area: whether or not the therapist can get authorization to see a patient. Couples and family therapy and personality disorders are areas that therapists said almost never get funded. To get around this, therapists say that they often do things like label personality disorders as something that does garner authorization, such as depression or anxiety. In order to conduct couples therapy, therapists label one member of the couple as the client.
I think there are times that people fudge diagnosis guides. Try not to do it too blatantly, but there’s some subjectiveness to that. Unfortunately it often works against the client. Somebody’s really coming in about a marital problem, but that’s not covered by insurance. Then you have to diagnose a disorder in order to come to see me under your insurance… that becomes a label that’s attached to that person (subject 2).
Like the V codes [Family Issues]. I used to use them all the time. . .The insurance companies rejected all the V codes, so no one used them anymore. Then there’s one insurance company that sent around a list of insurance codes they will not accept, which is a problem. You know, like some of the diagnoses that are commonly used are on the list. So I discussed with a psychiatrist, you know, what are we going to do on this case? They have ADD, but ADD is not acceptable. What do we say? You know, I guess we came up with a Not Otherwise Specified diagnosis (subject 12).
Here’s an issue: with young children, especially toddlers and preschoolers, you can see problems developing before a child can actually receive a diagnosis. And the DSM [Diagnostic and Statistical Manual] is really not made for kids that young. So it doesn’t really capture the issues that are going on at that stage of life very well. Often you’ll see stuff in a relationship between a parent and a baby or toddler. If you let it go for a couple of years, maybe a child will get oppositional defiance. You won’t see it yet (subject 7).
I know my own therapist gave me an adjustment disorder because you have to have a disorder and said, “This is going to be covered for a certain number of sessions, and if you want more sessions, you have to have another disorder.” I said, “I don’t want that. Major depression? Forget it.” Up the diagnosis, that’s his strategy (subject 7).
I know that they don’t want to hear personality disorders. Like, forget it. Say, if you have somebody who has severe anxiety, an eating disorder and a personality disorder. I mean, the idea of bringing up a personality disorder as justifying treatment is just like, is like, that’s ridiculous. They don’t want to hear that, they don’t want to pay for that, so it’s like, don’t even bring that up, because that’s gonna make them less likely to approve (subject 11).
I work with a lot of children who have developmental disabilities and pervasive developmental disorders, and once you give that diagnosis to managed health care, they’re not going to cover anything, because it’s not considered a psychiatry, you know, a social/emotionally/behavioral disorder, it’s developmental delay, there’s no treatment for that, that’s sort of the stance (subject 9).
It has changed the attitude of therapy to make it—people sometimes approach therapy the way they approach their dentist. People come who know nothing. “I’ve been given your name. You’re my therapist”. . . I think it’s made people more passive in their approach and that’s changed their relationship to the process and their relationship when it’s over. It’s made it a very medicalized, short-term thing in their minds and I think it goes against the grain of what therapy ought to be. . . I just think therapy is different now. I’m even fussy for the person who cuts my hair, you know? People are being sent to The Hair Cuttery now (subject 5).
I try to alert them that this is a responsibility that they’re taking on. I think too much of what has happened, and this is not simply managed care, but insurance in general, is that it has created an unconscious mindset that, “We’re going to get what the insurance pays for. If it doesn’t pay for it, we’re not going to do it.” I try to alter that (subject 3).
Before, people seemed to have pretty much, they had more traditional insurances. So they were either going to pay out of pocket or they were going to use their insurance. So they could go wherever they wanted and use their insurance. So it was about that time [the mid 1990s] that people sort of started having less of a sense of I’ll decide where I go based on reputation or word of mouth or even the yellow pages versus I’ll go to this list of people that people tell me to go to (subject 8).
There’s sort of a
sense of, well, gee, my company sent me here for three sessions, and yeah,
okay, there are my three sessions. Now are we done? Versus sort of the more. .
.I guess it’s more like they’re coming for a procedure rather than a process
(subject 8).
The worst managed care plans are the ones where people don’t have to pay a buck. I don’t like those. It doesn’t feel like I have as much success than with one where people are paying 10 or 20 dollars [as a co-payment]. . .Some people, we can’t work together because they’re so not invested in doing their homework and showing up when they’re supposed to because there’s absolutely no cost to them. There’s lots of cost to me: sometimes it’s financial, sometimes it’s you wasted a spot (subject 15).
You have to do all these goals and objectives and I hate it. I always do these goddamn treatment charts. I mean, I think treatment plans are great, but the kinds of things they force you to do, where everything has to be allegedly measurable, it drives most therapists absolutely crazy. I used to just hate doing those because I felt really sort of fraudulent . . . .You’d see a problem that was of long standing and you’d have to think of this goddamn short term measurable goal, so sometimes it felt like a very itchy jacket, or maybe a straightjacket (subject 6).
Here’s this intimidation factor too. If you ask for too many sessions, are they going to send you fewer people? There are all these very cloudy ethical areas that this system introduces into the practice of therapy (subject 3).
I don’t like lying, but you’re sort of forced into it if you want to stay in managed care (subject 4).
I know that there’s a lot of fudging diagnosing going on, and I think that’s pretty uniform throughout. A therapist knows that if you diagnose somebody with borderline personality disorder, they might not give you anything but actually baloney. . . there’s a lot of fudging going on with the diagnosing because the system is not respectful of the truth. It’s like a parent who says, when their teenager says, “I’m having trouble and people are foisting drugs on me,” “I don’t want to hear it. I don’t want to hear the truth. Don’t come to me with that” (subject 6).
Therapists also have to deal with frequently having their judgment questioned, often by people with far less training—and far more power in the situation—than they themselves have.
There’s an assumption that I don’t know what I’m doing. If they question me about substance abuse issues, they were probably in diapers when I started doing work with substance abuse. So I think that a higher level of confidence and trust in my judgment [is something that would improve the situation] (subject 3).
So I’m on the phone with them, and they have a list of questions they’re asking me, and it’s like this routine list of questions they’re supposed to ask, and I was like, “In case you’re interested, I’ve diagnosed him with bipolar disorder.” They didn’t even ask about manic episodes in this list. The person who was reading the questions didn’t know what she was doing. So, I guess that’s one of the things that is so frustrating. It’s one thing if they hold you accountable. It’s another thing if they don’t know what they’re doing and they hold you accountable (subject 1).
From the questions they asked, it never sounded like they actually did practice or were currently practicing, because the questions seemed so out of sync with what I would ask. I don’t know how to describe it, but if somebody who’s not a cardiologist asks you questions about your heart condition, you sort of know the difference between somebody that’s asking as a cardiologist and somebody who’s asking as a lawyer (subject 8).
So they’ll say, “Did you ask them this?” And you know as a therapist, why ask them this? You’re going to send them into a tailspin or they may become psychotic or they may become suicidal. So then you’re having to explain yourself to this idiot, and it’s just a waste of time. It’s very frustrating as a clinician to be questioned like that (subject 16).
I don’t think that they’re really able to appreciate a clinician’s judgment. They have no idea what they’re doing. They just go by some sort of outline on paper. They probably have some kind of decision tree—from their home office in Milwaukee (subject 7).
At the end, I didn’t feel like they cared what my judgment was. They weren’t against it, but they didn’t know enough to be able to judge if I was an idiot or not. They just didn’t know anything. It was talking to someone who was in a completely different domain of discourse (subject 6).
I prefer having the same person, because he or she and I can get to create a rapport, a relationship, get to know each other, and we both know the client. So that would be my preference. I don’t know why managed care goes the other way. Maybe it’s a money thing. Mostly they do the rolling thing. Whoever you get first is the one you get. . . They need to be knowledgeable about the different diagnoses and the different attributes of that diagnoses. They have to be willing to listen to me and my clinical information. They also have to be willing to offer support, ideas. If I’m having trouble phrasing something the way the managed care wants it, a really good case manager is going to give me those words. . . Generally speaking, I think a good case manager is someone who’s sympathetic to the fact that these people aren’t crazy but they need support and they deserve it (subject 4).
It was somebody I was working with around a client who had an eating disorder and a lot of medical complications related to it. And it’s interesting because it’s like a parallel process, her relationship with me sort of felt like my relationship with the client in the sense that she made me feel like she was an ally rather than an adversary. She seemed to remember the client (subject 8).
[I prefer it] if they leave me alone and let me do my job. Like I said, there’s never been anything that’s been helpful from the managed care company, so it’s just a matter of the ones that don’t stand in my way too much (subject 2).
Therapists find the reporting requirements tedious and burdensome. There is also burdensome paperwork and/or the types of phone interactions that some therapists mentioned above.
I think it can be very satisfying in the sense of being able to feel that you’ve truly done something to help some people or some families. That part has remained the same. Over the years, though, because of insurance and their involvement and more paperwork. . .it’s become much more tedious, much more of a pain, which inevitably then detracts enjoyment from it. It’s very much work now, whereas before it was not. It was like, uh, a profession. It was something I was fortunate to be in, but now. . . [dealing with insurance companies] really detracts from this whole experience (subject 11).
If I were doing full-time practice, I sort of wonder or worry if I would get resentful of some of the managed care clients. For every hour I see this person, I have to do 20 minutes of paperwork and get half of my regular fee, versus somebody else where I get my full fee and I have to do five minutes of paperwork. I would really worry about whether a particular client, where I get sort of resentful or whether that would impact on the therapy. I would certainly hope to work that through, but it’s a worry I would have. . .I think people also get really burned out on the paperwork, and so it’s almost like the focus changes from getting my paperwork done versus really sort of ruminating more and thinking more sort of clinically, and so that’s another sort of pressure point that’s not a good one, from my perspective (subject 8).
The reimbursement process is haphazard and troublesome. Actually getting paid can at times be an arduous process, and just about every therapist mentioned this issue spontaneously despite the fact that there were no questions in the interview that specifically addressed payment issues. Some felt like the managed care companies were playing games with them in order to avoid paying. Others just felt like there was lots of “bungling idiots” managing the payment system at the managed care companies.
I think they need to make the payment process a whole lot quicker. . .They’ll use anything not to pay. A client you’re seeing over and over again. You forget to put in a diagnosis. They send it back. You send two in: one you forget the diagnoses, one it’s on. They send it back. I mean, let’s get real. That’s ridiculous. But they’ll use anything. That pisses me off (subject 4).
I have a very big beef with the insurance companies about the payment system. They play games so as not to pay, and I am just so disgusted that I’m almost ready to write a book on it, I’m so fed up. . .You know, it’s horrendous what they do, it’s just so uncalled for. . .Or you’ll get an authorization [for treatment], and in it’ll say, “Even though you have this authorization, payment is not guaranteed” (subject 12).
I didn’t get paid for a really long time on a couples of cases, and that was dreadful. . .it was horrible. You’d spend hours on the phone trying to track things. One of my clients had left for New York, had terminated because he moved to New York, and three months after that I still hadn’t been paid, and I’d spent about four hours on the phone on and off in trying to find out what happened to the payment because they had screwed up. No, it wasn’t withholding anything, it was just bungling (subject 6).
Low reimbursement can mean working more hours to make a decent income.
Many psychologists are making 30-40% less in fees, as an average fee, than they did 7 or 8 years ago. And I think the way that affects the quality of care is that many therapists probably see more clients than they would otherwise, simply to be able to make a professional income. You go to school for years and years, make lots of sacrifices, jump through all kinds of hoops. . . and I think there might be some times when you’re not as up to your game. If you’re seeing 28 people per week rather than 22, it’s probably going to affect something. It’s hard to quantify. I’m not saying that there’s any negligence or malpractice, but certainly it will impact on your ability to perform (subject 3).
Anger at being mistrusted, disgust at being forced to lie. Though technically therapists are not employed by managed care companies, many report feeling like they have five or 10 part-time jobs, and so there sometimes is a sense that they are employees of the managed care companies. Part of this relationship is a basic inequity in which the therapists are not trusted to do their work well without constant supervision.
Sometimes I wonder if I’m self-employed or whether I have 12 different part-time jobs (subject 3).
It’s like being employed. You suddenly realize you’ve got this boss over you, and then the boss is with you all the time, in every relationship (subject 10).
And why all the freaking paperwork? It’s like we’re not trusted to do what we’re supposed to do. It’s like they think that we’re going to try to keep people in therapy forever and just try to dig into deep pockets. They haven’t a clue. Most therapists don’t want to keep people around because it’s too draining (subject 4)
I think now that therapists have learned about accountability…I think we deserve more respect as professionals, we should be given a little more leeway to make decisions about the treatments necessary. They should audit us, spot-check us, talk to us, get to know us, learn to trust us, but not micromanage every case. I think it could be less paperwork for them as well as for us. I think their system is so micromanaged, such nitpicking rigidity, that they’re eroding their own purpose, which is economy of operation. And they’ve become unwieldy, and they don’t end up saving money. It doesn’t make sense (subject 14).
Therapists feel that they have to
fudge diagnoses and stretch the truth in other ways, and having to lie to one’s
“bosses” contributes to low morale for these clinicians
They do respond to certain behavioral problems or panic attacks or other things, or if they’re on medicine, you can always say, “Well, with the SSRIs we’re going to need at least six weeks to see if they’re working,” and they’ll say, “Well, that’s true.” You just understand to say what is applicable but also you know what they want to hear. And it’s a shame. You know, it’s almost a verbal game. You’re going back and forth and trying to justify what you’re doing rather than just being able to treat patients (subject 11).
But yet we have to write those things or they don’t approve those visits. So it’s always playing with the edge of reality. We get the visits and then we do what we really should be doing (subject 14).
Indeed, their whole professional sense of self is jeopardized by these transgressions. Therapists feel like are not being treated with respect; they are not being given the autonomy to do what they are highly trained to do without having to constantly justify their decisions every step of the way.
I think there’s a whole language and a whole procedure that they follow and it’s not about really hearing that individual case and what the circumstances are. It’s about do you meet the criteria, and if you do, if you meet one particular criteria, you have these many sessions. If you fall under another diagnostic criteria, then, you know what I mean, it sounds on the phone when you speak with them very much like they’re following a flow chart, and it does not feel like my particular clinical judgment and clinical impressions for this particular child, despite what the diagnosis says, is really considered (subject 9).
Managed care takes the position that therapists need somebody to manage them, to tell them what to do and what not to do. In some of my past jobs, it was fairly regular, where I’d get some, pardon my French, idiot on the phone who didn’t have a degree, wasn’t a therapist, didn’t know what the hell they were talking about, pardon my French. And that’s one of the things I think you’ll hear commonly from psychiatrist or whoever that you’re treating somebody and you get on the phone with this managed care person who doesn’t even have a degree or experience or whatever questioning them. Well, did you do this? Did you do this? What about that? What about that? What about that? They’re seeing the client as an “it.” As an object, not a person (subject 16).
If therapists can afford it, they often stop
accepting mc referrals. The
clinicians in the sample whose experience has been mainly with private pay
clients in private practice are much less positive about managed care
interactions than their peers who garner the majority of their clients through
managed care referrals (though it is impossible to unpack whether therapists
who liked managed care less got less involved with it or those who are less
involved are able to be more critical because of their relative distance from
it).
You know, the managed cares, a lot of them pay less.
A lot less than what I would charge. They’d be asking me to see someone for
almost, like, half the cost. Which I would say, you know, I’m pretty
established. I don’t see a need to do that now. And then all the procedures,
you know, you have to sign up and get credentialed by the groups, which is
sometimes an unbelievable process. And it just goes on and on. . . My practice
is such here that I have people that have managed care coverage or U.S.
Healthcare or something and I explain the situation, they know what it is, and
they say, well, they want to see me, so they’ll pay me and not use their
insurance. I’m fortunate in that respect. So, in combination with me being
established around here and having a fairly good reputation or flow of
referrals, and not financially needing to sign up with them, and not like them
at all. Put them all together and that is kind of why I stay away from them
(subject 11).
Subject 6 now has no managed care clients,
but they used to represent 50% of her caseload. She recounted an experience in
which she asked a managed care representative to authorize more sessions with
one of her clients. This interaction was so unsettling for her that afterwards
she stopped accepting managed care referrals.
I just had this experience, I was so naïve, here I’d been doing managed care for a number of years, and I was so naïve that I didn’t realize that she had this series of questions in front of her on the computer, this series of little slots she had to fill in. I was really talking about the case and I just felt like a complete fool. At a certain point I stopped myself and said, “You don’t want to hear any of this stuff, do you?” And she really didn’t, but she couldn’t say and then she was only going to give me five sessions anyway. I said to her, “Why are we even talking about this? You know it’s on your screen that for this problem, given the length of time I’ve been working with this person, you’re only going to give me five sessions, isn’t that right?” And it was. I got really pissed. I got more sessions out of them, though. I did but I hated them. I didn’t work with them after that case” (subject 6).
It wasn’t the only reason I decided to [stop accepting managed care clients], but the most practical reason of how managed care impacts your work is time. It eats up your time, and that adds to the workload (subject 9).
When I went into it, it felt more like when you became a therapist, you do therapy, and now it feels like when you get to do therapy, that’s kind of a luxury. I don’t mean to sound too cynical, but. . .that’s what I mean in terms of recommending it to people. That it’s really hard to do therapy as sort of the actual primary thing you do (subject 8).
I’ve only stayed on this panel because I’ve never not been able to get the amount of treatment I’ve asked for, though I’ve had to fight for it. I’ve never compromised length of care for the panel, ever—and the moment I do, I will never take another patient from them (subject 5).
Positive
Aspects of Managed Care
Despite
its frustrating aspects, the therapists in the sample identified a few positive
changes that have come about because of their involvement with managed care.
A solid referral base. For those therapists who rely on managed care for referrals, it means that they no longer have to go out and promote themselves as aggressively in order to have a solid client base.
So it has freed me somewhat from that [worrying about referrals]. But if I had to depend on that, I think for a young person, it’s not a great profession (subject 10)
The only thing I can say that might be considered positive [about managed care] in terms of me running my practice is that I don’t have to do any dog and pony shows. Ten or 15 years ago, the way that clients became hooked up with a therapist was through a referral from a previous client, from a recommendation from a professional organization, recommendation from another therapist, recommendations from their family physician, or from attending some kind of presentation that was given by a therapist on a specific topic. . .I would say I don’t hurt for clients. Like I said, I kind of have 10 or 12 part-time jobs, because somebody calls XYZ company and they say, “Well, in your area there’s [him] and [the other psychologist who practices in the same office.] They call one of us, and if one of us is on vacation or something, they call the other one of us (subject 3).
Therapists are
now pushed to be more efficient and accountable.
Well, I don’t think it hurts to think of how you can help people in a quicker way. So that’s a good thing because that pushes you to be the most efficient in terms of treating. I don’t think there’s anything wrong with holding psychologists accountable for what they do (subject 1).
I think it does force people to be efficient and more focused, more structured, and to think about the goals. You learn in grad school that you’re supposed to set goals and agree to what you work on. I don’t know that people would have the goal in mind as much as they do without managed care—and I think that’s a good outcome. I do think that there are effective short-term therapies; I’ve seen it. So I know it’s possible to be very structured and effective and see someone for a short term and get results (subject 7).
I think certainly it’s easy for a therapist to get lazy and, especially with a client you like or whatever, you’re just like, oh, this is nice, we’re doing good work and they can learn more and they can have more self-actualization. And just sort of keep it going indefinitely. So, I mean, I think if there’s a plus that would be it, that it keeps you sort of constantly saying, “Are we on track here?” (subject 8).
Clients who were
previously unable to afford therapy now have access to it.
The plus of managed care is that many of these people have access to therapists that they wouldn’t know about or be able to find or whatever . . .It has also let me see people who don’t make very much money. And I really don’t do things much differently. So they’re getting the same therapy that they would be getting if they were paying $100 (subject 15).
I really like the variety of clients that managed care brought. There’s much more diversity in terms of ethnic and racial diversity, diversity of problems, often economic diversity (subject 6).
Clients who might not have considered
therapy before (for reasons other than money) may come now.
And I can see it getting some people into therapy who, with an open
ended long-term contract, couldn’t handle it. But when you say, oh, we’ll meet
5 times, we’ll see what happens, we’ll hopefully get things improved, they can
get on board for that (subject 15).
Most of the therapists in the sample developed strategies to maximize the number of sessions they could get authorized for their clients. Their strategies included finding different ways of presenting clients’ situation, finding the right managed care people with whom to talk, and generally being prepared for those interactions. The suggestions that follow are more often ideas that were expressed by one or a few therapists rather than ideas representative of the views of all the study participants.
Using their language and emphasizing the negative. The therapists in the sample suggested that clinicians learn the language of managed care. Clinicians need to know their buzzwords and talk about symptoms the client is experiencing rather than personality issues (even if these are what led to the symptoms, one should still emphasize the concrete stuff).
Basically telling them what they want to hear and the way they want to hear it. For them to say, “Okay, then, we’ll allow it.” I’m not saying misrepresenting information or lying or anything, but I just know what the buzzwords are, the things they want to hear and the things that they don’t want to hear. Okay, and if you understand that and can present your case that way, it increases tremendously the likelihood that you’ll get it approved (subject 11).
Learn the vernacular they want. Learn the vocabulary, and use it (subject 4).
Another suggestion was to use very objective measures to make one’s case.
Sometime when I called about someone who has problems with depression, I might cite information from something like the Beck Depression Inventory, or something like that. I’m using a lot more objective measures to make my case (subject 3).
One therapist suggested talking about ways therapy can save managed care money. The idea is to talk about prevention in a way that will appeal to their bottom line.
When I had clients who I knew were self-destructive, I always made a point of talking about how we were keeping them out of the hospital and what we were trying to do. It was true but it was important to state and to talk seriously or write seriously about self-destructive behavior and suicidality because I always knew they were looking at the bottom line and that was the question: Is this the cheaper way to go? (subject 6).
Another therapist’s recommendation was this: Clients are always in crisis. In other words, therapists should present the worst elements of a client’s case in order to create a sense of urgency and need for continuing therapy.
One of my favorites a colleague gave me. Everybody is
in crisis. . .In other words, the crisis may not have happened in the same time
frame I said. So let’s say I’ve had five sessions for you and during that time
somebody in your family got sick. Well, I might wait until I need more sessions
[and then say to the managed care person], “Oh, you know she called me and I
really need to schedule her. She just found out her mother got a diagnosis”. . . You don’t make up the crisis; you just
share it with them in a timely manner that works to help you (subject 15).
Fudging
diagnoses. One clinician said that her own therapist sometimes fudges the
diagnoses for people in order to get more sessions.
I know my own
therapist gave me an adjustment disorder because you have to have a disorder
and said, “This is going to be covered for a certain number of sessions, and if
you want more sessions, you have to have another disorder” . . . Up the
diagnosis, that’s his strategy (subject 7).
I prefer working with the same person because then they learn the case and they know my style and they give much fewer hassles (subject 15)
One therapist said that, when she calls the managed care company and happens to get on the phone a representative who she dislikes, she suggests telling them that one has another call, hanging up, and then calling back later and hopefully speaking with someone else.
“Oh, my other line is ringing. I’m so sorry . . . It’s okay, I’ll get the authorization later” (subject 15).
A few therapists said that, when it is possible to learn managed care representatives schedules, they avoid the days that those they dislike working with are on duty.
I wanted to stay out of his radar because I saw him as bad for patients, browbeating to minimize treatment, and someone who would blackmark me (subject 5).
One therapist said that when she is not sure what mood a therapist is in, she tries speaking with them about her less controversial cases first. These are the cases for which they will almost definitely authorize more sessions. If that goes well, she then moves on to some of the cases where it’s less clear that more sessions are necessary.
If they had a bad day, they ain’t going to authorize. They’re going to give a lot of grief about it or ask lots and lots of questions . . . One of the tricks is, when some people call me when I have a bunch to do, I start out with somebody mild. No big problems, going smoothly, see how they handle it. If they’re fine with that, then I can move on to some of the more difficult ones. But if they can’t handle a mild one, [then I say] “Oh, I only had that one. Thanks.” Oh yeah, that to me is one of the ways you can successfully negotiate (subject 15).
I document heavily when I talk to health
care plans . . . I ask their name, I ask what department they’re in, what
extension they’re at, you know, etc. (subject 9).
I was lucky enough to have some colleagues who were farther along in the process, they had been licensed for a while, they knew more about managed care, and they sort of mentored me to help me to choose which and where (subject 4).
Pay someone to handle the financial hassles. Dealing with managed care representatives became too much of a hassle for one therapist (but he still liked the solid referral base of working with insurance companies), so he decided to pay someone else to do his billing. The bill-payer earned about 10% of his fees, but it eliminated the hassles for him.
I fax it off to a fellow I pay to do billing. I always pay somebody to do billing. . . He finds out for me. Sometimes he’ll find out immediately and sometimes you don’t find out for a week or two. . . I just cannot sit there day after day and make call after call. And he does. He’ll sit there and work on it. But no, I don’t do it. I’m the laziest guy in the world. I don’t want to do secretarial work. If time is money at all, then why should I waste time sitting on the telephone? That’s not what I want to do with my free time (subject 10).
Discussion
Among the many difficulties for therapists discussed in the results, including shifts in identity and sense of professionalism, changes in clients’ conception of care, and alterations to the form and length of therapy, a few issues were particularly salient.
It is striking that therapists often feel they must lie to managed care representatives in order to have authorized the type and amount of treatment they wish to give. Not only do therapists feel like they must lie sometimes, but, for those therapists who are of orientations other than brief, solution-focused cognitive-behavioral, the managed care system also constantly reinforces the notion that what they spent years in graduate school learning is not a valid or effective modality to practice. Almost no one in the sample, even those who completed PhDs or PsyDs within the last 10 years, had courses in graduate school that addressed how managed care would affect their practice—much less about how to maintain a positive sense of self and of one’s orientation despite being rejected for what they do professionally and what they believe in.
Therapists want
information about how to be effective advocates for their clients in a managed
care world. That is one of the reasons they develop and seek advice from other
practitioners about tactics that work, although many of them strongly dislike
having to do this. On the one hand, they do use strategies of resistance, which
are ways to continue giving the care one believes is ethical while pretending
to bow to the managed care model. But, on the other hand, the results clearly
show that there is at least as much acquiescence as resistance. One such
example is the termination process, which has been changed from a decision that
the client makes with the therapist to a decision ultimately made by the
authorizing managed care representative and the client’s insurance benefit.
When a decision is made, there is usually fairly little that a therapist can do
to fight it.
There were countless cases cited of certain types of disorders never getting funding (personality disorders, family issues, etc.). Besides the simple fact that treatment would be denied if one tried to submit for authorization, another disturbing implication of this denial is that it gives managed care companies enormous power in terms of delegitimitizing certain diagnoses. If therapists stop using certain diagnoses entirely simply because managed care will not fund them, then it becomes a situation where managed care begins to have as much power in determining what is and is not mental illness as the DSM-IV or graduate training programs wield. Considering that the creators of the DSM-IV and the professors working in graduate programs have devoted their professional careers to advancing mental health research and treatment, whereas managed care companies have devoted their professional careers to capping costs (among other goals), it is very disturbing to realize that currently managed care may have equal or even greater pull in terms of shaping the field of psychotherapy.
The unpleasant side effects of working with managed care have meant that many clinicians have steered clear of it entirely or have left the system once they had a solid enough referral base not to have to rely on managed care companies for clients. What does this mean for people seeking therapy? It is not clear, but it probably means that the care they are getting is from less experienced, less established clinicians, because those who have been in the field longer are much more likely to have the independent referral base that allows them to avoid managed care. One of the selling points of managed care is that it increases people’s accessibility to therapy, because those who could never afford to pay out of pocket can now seek professional help for the cost of a small co-pay. But in reality their accessibility is only to the therapists who are tolerating working with managed care; they are denied access to everyone who has decided to stay out of the system. Furthermore, they are only allowed to choose between the few therapists in their area who are providers with that particular managed care company, narrowing a person’s choices even more. It then becomes a situation where people go to the therapist their insurance company recommends rather than the one whose style and therapeutic modality would be most beneficial for them. Indeed, if managed care has its way, the only type of care a person can receive on its dollar is brief therapy dealing only with the presenting problem.
It is impossible to make generalizations
that apply to all managed care companies since each company has different
policies and procedures. Some companies are already doing many of the things
recommended below; others may have offered these things in the past.
Nevertheless, if these changes were implemented, clients would have better
access to care and therapists would likely feel much more comfortable with
their role within the managed care system. The first recommendation concerns
training for mental health workers.
That is followed by several suggested changes to managed care companies.
The final recommendations are for national legislative changes.
Improvements to
graduate-level training programs. Teach about managed care—but don’t
internalize its standards. Many of the therapists in the study, but
particularly those who had finished graduate school within the last five years,
felt that they would have benefited from more discussion and advice in graduate
school on how to deal with managed care. Helpful topics might include teaching
the managed care philosophy of therapy (as well as a critique of it),
developing a treatment plan, diagnosis, documentation, details on the payment
system, ways to frame the therapy one does in the proper language necessary for
reimbursement, and what to do when you disagree with a managed care companies’
recommendations. Programs should also provide training in ethical issues that
may be unique or heightened when working with managed care, particular
confidentiality issues and use of diagnoses. It might also be helpful for
programs to bring in current practitioners, or even managed care
representatives, who can speak about their experiences.
At the same time, many other therapists were concerned that managed care policies would have too much influence on graduate education in terms of dictating what constitutes quality care and which disorders are worthy of treatment (that is paid for by insurance). Though it seems dangerous to propose taking time away from other topics during graduate school in order to address these issues, spending at least a little time on these topics is preferable to pretending that managed care does not exist and that one will be able to practice the same way one might have 30 years ago. In addition to the topics mentioned above, it would also be helpful to include some training on the public policy issues connected to therapy. Examples including the history of managed care, the pros/cons of managed care, and some of the broader issues, like how they system might be improved. With this background, students would have the knowledge and tools if they wanted to become active in trying to change policy. There really needs to be ample information given in graduate school coursework about the reality of managed care, and perhaps a bit more coursework on brief therapy as well. But, at the same time, professors would be cheating their students if they spent too much time “teaching to the test.” By doing that, they allow managed care even greater power in shaping the practice of therapy. There needs to be an adequate balance of information, critical reflection and resistance to managed care.
The
recommendations below are all suggested improvements to managed care
organizations.
Preventative
work. In general, there needs to be more of an emphasis on prevention.
Right now, the focus is on reducing the symptoms that people are experiencing
when they come in for treatment. Once a person’s pain has eased, he or she is
expected to leave therapy. But it’s possible that earlier intervention could
have prevented the crisis episode from ever occurring. Therapists can do so
much more with their clients than just help them deal with specific symptoms
and stressors. They can also help people learn how to manage their experiences
so that they won’t need to re-enter therapy repeatedly every time there is a
crisis. Through more in-depth work, they may be able to help the person
discover different ways of thinking about and dealing with similar situations
in the future.
It is very difficult to convince managed
care companies that this preventive work is worth funding for two major
reasons: the first is that there is not a lot of research yet in the prevention
of psychological problems. The second is that employers change their insurance
company (and people change jobs) all the time. This gives managed care
companies little incentive to invest in authorizing more therapy, because even
if it will lead to less need for treatment down the road (and thereby lower
costs), it’s quite possible that another insurance company will reap the
benefits of the preventative work the client did with a therapist while still
on the first insurance company’s watch. Another issue is that managed care
companies may not adopt preventive interventions because they are not cost
effective for the company (not just because people change insurance but because
the major costs of psychological problems are costs to family, work, and
society at large, rather than costs to the managed care company).
Despite this problem, it might be worthwhile for insurance companies to offer an alternative plan to employers, one that has an emphasis on preventive therapy. As noted in “The Economic Burden of Depression in 1990,” morbidity costs, which in this case are losses in work-related productivity, were a whopping $23.8 billion in 1990 (Greenberg et al., 1993). Employers who understood and were willing to think about the long-term mental health of their workers—and how it could be beneficial for their own bottom line by increasing productivity—might be persuaded to pay more for a plan with preventive services than for a “bare bones” plan that only emphasized solution-focused, symptom-managed therapy.
Offering
training. If companies want therapists to be on board with the managed care
program (and thereby help them maximize their profits), then they need to
provide opportunities for them to learn the managed care philosophy through
presentations and training sessions. Not only is this a good way to help
therapists feel more comfortable and knowledgeable about the system that they
are working in, but it also provides a wonderful opportunity for therapists to
meet their colleagues who are also mental health care providers in the network.
By getting to know the other therapists, then they can also use that knowledge
to make informed referrals for clients who need or wish to change therapists.
Managed care representatives with specialties. The therapists in the study who worked with children felt it was particularly important to have representatives who specialize in certain areas. This was because, in their experience, the people they talked to usually didn’t know much about the mental health issues of children. It would be tremendously more effective for a therapist who exclusively sees autistic children to speak with someone at the managed care company who had a background in autism and developmental disorders than to talk with someone who does not even know the diagnosis for it without relying on a checklist. Several of the therapists in the study wished for more knowledgeable managed care representatives. By splitting people up into specialties, it might be feasible for the managed care companies to hire employees who knew—or could learn—about certain topics (even if they did not have a tremendous amount of overall clinical experience).
Streamlined procedures. Therapists in the study bemoaned talking on the phone with representatives who didn’t understand clinical care and who they sometimes found to be unpleasant. One remedy for this issue is to eliminate the need for these phone conversations. At least one therapist works with a company that allows her to submit authorization information online, and she reported that this is a great alternative to telephone conversations with managed care people (it is also less costly for the managed care companies, because they need fewer people to oversee the authorization process). Many companies also use mail-in or fax-in forms for reauthorization. Therapists liked these, but only if they were very simple to fill out and did not require a lot of their time. They want to be spending time doing quality work with clients, not doing paperwork and making phone calls.
More flexibility in terms of reimbursement. Several insurance plans have a benefit that allows for a certain number of sessions but no more than that under any circumstances. This lack of flexibility, while an effective cost-containment measure, is unrealistic if one of a company’s goals is providing quality care. One standard allotment definitely does not fit all. An alternative is to allow a different number of sessions depending on the client’s level of co-payment. So, for example, they might have to pay a 20% co-payment on their first 20 sessions per year and then a 40% co-payment thereafter. This provides an incentive structure in which the person will not continue to stay in therapy unless they really feel that they need the treatment. At the same time, a 40% co-payment still isn’t so prohibitive that a working person cannot afford it. One therapist recommended raising fees in general. This was because she felt that clients didn’t become as invested in their therapy as they might otherwise; her clients were paying more to park their cars when they came to see her than they were for their co-payment. Many therapists said that having to pay some amount of money for each session meant clients invested more in the therapeutic process. While not advocating that insurance companies make clients pay for their own therapy, it does seem that a $10 or $20 co-payment almost always makes sense. This money will help defray the cost of therapy and might even help fund some innovative programs.
Prompt payment. Many therapists spontaneously mentioned—without even being asked about it—how difficult it is for them to get paid for their services. When someone was working with a company that paid promptly and reliably, it was a very positive aspect of the company that they were sure to mention during the interview. If companies want to attract the finest clinicians to their panels (which they should be trying to do if they care about quality care for their members), they need to treat them decently. Therapists called for prompt payment and, more generally, better organized payment systems.
Soliciting feedback from therapists. A few of the managed care companies occasionally have provider panels. They bring together a panel of therapists who are providers in the network and ask them to discuss problems that they have encountered and make suggestions about company policies. Every managed care organization should do this; “employee” feedback is vital. The primary purpose of these feedback panels is to give the organizations ideas about how they might run more smoothly and efficiently. Second, and just as important, the process in itself improves the relationship between the two parties, because it gives therapists a forum in which they feel heard and it humanizes the company for them (perhaps it also humanizes the therapists for the company, which isn’t a bad thing either).
Openness to a
variety of orientations. Right now, short-term, solution-focused
cognitive-behavioral therapy is the type of treatment that managed care
companies prefer to authorize. The rationale is that it is believed by the
managed care companies to be the most effective and cost-effective. When
research has examined the effectiveness of psychodynamic and other types of
therapy, those modalities have been found to be as effective as
cognitive-behavioral approaches. A landmark National Institute of
Health-sponsored collaborative study on the treatment of depression showed that
interpersonal therapy, a psychodynamic approach, was at least as effective as
cognitive therapy (Elkin, Shea, Watkins, Imber, et al., 1989). It is also clear from this sample that
therapists with all kinds of orientations, from psychoanalytic to Gestalt, are
getting authorization to work with managed care clients. Yet, they often feel forced to lie about
their orientation and indicate cognitive-behavioral. Within reason, why not
open up the range of openly accepted modalities so that therapists no longer
have to lie?
Develop and
show trust in therapists. Many
therapists in this sample felt like the managed care companies distrusted them.
One therapist expressed the idea that therapists should be able to develop a
track record with the companies, so that, over time, they would not need to be
followed so closely in terms of authorization. Perhaps there could be a
probationary period that looks like the present level of utilization review.
Then, after a few years, therapists’ status could be changed so that they have
more freedom within the system. This could potentially save money for managed
care companies because they would not need to employ as many telephone
representatives to oversee authorization. At the same time, their concern might
be that, without that accountability, therapists would go right back to seeing
all their clients long-term. Hopefully if these were the therapists who had
developed a track record of accountability, this would not be an issue.
Besides, the therapists in this study who brought the topic up mentioned that
they don’t even want to keep people in therapy long-term because it is too
draining and they prefer the variety of seeing new clients.
Easier
access for clients. People typically call their insurance to arrange
therapy when they are distressed, discouraged, or depressed. When they are
unable to talk with a live person in those circumstances, and instead get
voicemail or put on hold for extended periods, it is enough of a disappointment
for some that they never even start therapy. This might result in a big cost
savings for the managed care company, but is a total failure in terms of
providing care, and it is bad customer service. If these companies really have
a commitment to helping people access quality care, that needs to start with
enabling them to make that first step as painlessly as possible. Indeed, the
entire process should be streamlined and simple for clients. Every person on
that insurance plan should receive some information, such as a brochure or Web
site with information on how to access one’s insurance benefits. Companies that
attract more customers because they are user-friendly often end up being more
profitable in the end.
National health care reform initiatives. When therapists were asked what changes they would like to see to managed care, several simply said, “Get rid of managed care.” Most did not have a ready answer for what system could replace it, although the idea of a national health care system was mentioned a few times. That does not seem feasible in the present political climate. However, if more of the problems of managed health care were exposed, perhaps it would begin to seem more possible.
Legal
accountability. There should be strong national legislation that holds
managed care companies responsible when clients receive sub-standard care
because their insurance will not cover certain services that they need. A
regulatory body that oversees managed care and mandates a certain standard of
care might also be beneficial.
Public
education. Therapists need to take
the lead in educating the public about mental health issues and managed care.
If consumer’s information does not come from therapists, it will come from
insurance companies. Many therapists in the study reported that, over the
years, consumer’s conception of therapy has shifted from a process that the
therapist and client are best able to determine the duration and necessity of
to one that is mainly determined by the stipulations of an insurance benefit.
It may also help to educate clients about the difference (at least in managed
care’s eyes) between psychiatric diagnoses and problems in living, things like
relationship difficulties, job difficulties, and stress associated with
transitions in life. Managed care is
willing to cover (some) costs of treatment for the former, but usually not
willing to cover much regarding the latter.
Still, therapy can be very helpful for dealing with problems of living,
and therapists have an obligation to let more consumers know that they can make
an active decision to seek out therapy for these kinds of issues.
Parity with physical health care. People deserve treatment for mental health
problems, just as they do for maladies that are exclusively an affliction of
the body. Worldwide, depression, alcohol use, bipolar disorder, and
schizophrenia are all among the leading 30 causes of disability-adjusted life
years, a measure of mortality and morbidity (Murray & Lopez, 1997). Suicide
is also a costly and devastating issue, with $12.4 billion in mortality costs
in the United States in 1990 directly attributable to depression-induced
suicides (Greenberg et al, 1993). Anorexia and substance dependence are also
huge national concerns. There’s no question that these are serious public
health issues. Far too much stigma currently exists, and it is impeding access
to treatment. Mental illness is real,
it’s much more common than many people realize, and it should be a national
health priority.
For the most part, the
findings in this study dovetail nicely with prior research. None of the
findings are shockingly discordant with studies that have been done before.
What this study does that most others could not was go far beyond reporting
that X number of therapists checked the “not satisfied” box on a mail-in
survey. The richness of the kind of data presented in this study is only available
either through observational work, like Ware et al.’s ethnographic study in a
community mental health center, or through first person interviews. This kind
of research gives us a sense of what therapists are thinking about when they
check the “not satisfied” box. Only
then can we understand that, for therapists, “sometimes it felt like a very
itchy jacket, or maybe a straightjacket” (subject 6). Only by asking them to
speak in depth can we hear a practitioner say, “Clinical kinds of decisions
need to be made by clinical people. If the issue is whether or not someone who
is depressed is continuing therapy, it should not be made by a business person”
(subject 4). This kind of qualitative work also builds on the survey work that
has been done. For example, if past studies have shown that a majority of
practitioners in a sample are upset by the loss of confidentiality that managed
care necessitates, a study like this tells us why they are upset and how
they and their clients have adjusted to this reality.
Because of the relatively small sample size (n=16), the snowball technique for finding participants, and the fact that all but two of the therapists in the sample practice in Pennsylvania, it is not possible to generalize these results to make assertions about all therapists practicing in the United States. But that really was not the point of this research; the purpose was to get a rich, in-depth sense of how the therapists in the sample feel about and react in response to managed care, to hear their stories and to learn from them.
Some say that elephants
never forget. We, too, must never forget: that clients deserve quality care,
that therapists deserve a degree of autonomy that recognizes their integrity,
and that the field of psychotherapy should be shaped by those who have devoted
their lives to advancing the profession, not by those who have devoted
themselves to cutting costs. No matter the political climate, despite the
financial constraints, we must always be striving to maintain the highest
standards for health care, including mental health, for all our country’s
citizens.
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APPENDIX A.
Psychology Department
Swarthmore College
500 College Avenue
Swarthmore, PA 19081
Dear :
I am writing this letter to ask for your participation in a
study I am conducting as part of my senior thesis, which is about the effect of
managed care on the practice of psychotherapy. I am a senior at Swarthmore
College majoring in psychology with a minor in public policy. Swarthmore
psychology professors Jane Gillham and Jeanne Marecek, who both specialize in
clinical psychology, are advising me on this yearlong project.
My research takes an interdisciplinary approach, one piece of which is public policy analysis. The other component is in-depth interviews with psychotherapists about their experiences conducting therapy—and the ways that managed care practices and procedures have changed that work, for better or worse.
I am interested in interviewing therapists about their experiences working with managed care companies. So long as you are someone who accepts reimbursement for treatment from managed care companies, I would very much like to interview you. Professor Gillham or Professor Marecek recommended that I contact you and suggested that you might be willing to participate in the study.
The interview itself will take roughly 45 minutes and will be conducted in person. In the next few weeks, I will be calling to see if you would be willing to take part in this study, and to verify that you are a psychologist who accepts managed care reimbursement (which is the key criterion for inclusion in the study). If you are interested and eligible to participate, I will make arrangements to meet you at a time and place that is most convenient for you.
I have included with this letter a consent form and a sheet with a few questions about your practice. To make best use of our limited time in the interview, it would be very helpful if you would think ahead of time about a few instances in which managed care affected the way you practice psychotherapy.
If you have any questions, please do not hesitate to call me at 610-690-3868 or email at jcohen1@swarthmore.edu. Jane Gillham can be reached at 610-690-5771 or jgillha1@swarthmore.edu. Jeanne Marecek can be reached at 610-328-8674 or jmarece1@swarthmore.edu.
Thank you very much for your willingness to consider participation in this study.
Sincerely,
Julie Cohen
Class of 2002
APPENDIX B.
Psychology Department, Swarthmore College, Swarthmore, PA 19081
Investigator:
Julie Cohen, Class of 2002
Phone:
(610) 690-3868 Email:
jcohen1@swarthmore.edu
Principal
Advisor: Professor Jane Gillham
Phone:
(610) 690-5771 Email: jgillha1@swarthmore.edu
Consulting
Advisor: Professor Jeanne Marecek
Phone: 610-328-8674 Email: jmarece1@swarthmore.edu
The Effect of Managed Care on the Practice of Psychotherapy
The major goal of the project is to understand how managed care has impacted the way that therapists think about their profession and pursue their work with clients. In addition, the study will examine strategies that therapists use in their interactions with representatives of managed care organizations.
You will be asked to respond to a series of questions about your work in a tape-recorded interview lasting approximately 45 minutes. Most questions are open-ended and exploratory.
The tape-recorded interviews will be transcribed verbatim. No names will be attached to the tapes or to the transcriptions, which will be used solely by the principal investigator and her advisors. The tapes will be destroyed in May 2002 after the thesis is completed.
No one will be identified by name in the thesis. Therapists will only be identified by clinical orientation, percentage of caseload that comes from managed care, type of practice, and how long one has been in practice.
Your participation in this study is strictly voluntary. You are free to decline to participate in the interview or to withdraw from it at any time. Also, you may decline to answer specific questions during the course of the interview.
If you have any questions about this research, please contact Julie Cohen, Jane Gillham or Jeanne Marecek using the contact information listed above.
I have read the above and give my consent to participate in the study.
____________________________ ___________________
Participant Signature Date
____________________________ ___________________
Investigator Signature Date