Impacts of Managed Care on Therapy

Even though health care is a hot topic, people often lack awareness of how policies directly affect them. “Behavioral health” (a.k.a. mental health insurance) is no exception. Rather than being put off guard by unexpected impacts, the following is an overview of some main issues that surface when an insurance company becomes part of your therapy. Armed with information, you can then make an educated decision about utilizing insurance benefits or paying out of pocket.

Background

The relationship between managed care and therapy has changed over the last thirty years. Back in the 1980s, therapy was seen in a positive light where people could address concerns when life threw a curve ball and generally provide enhancement that would lead to greater overall satisfaction. Once managed care became involved, this focus shifted to a medical model of necessity. Clinicians now needed to find a diagnosis for the “problem” and demonstrate how this was to be addressed.

Impacts

With this new approach, many facets of therapy have changed, not just how services are paid for:

Confidentiality

Insurance companies require a therapist to provide personal information for reimbursement. This includes a diagnosis, services rendered, and the duration of treatment. Because they also have case management to determine medical necessity, they may also request access to case files for specifics about the treatment plan and other sensitive information. For ethical therapists, there are concerns about the impacts on clients:

1. Providers are unable to control how the private information is handled once it is in the hands of the insurance company. It is unknown what kind of information is accessible and to whom, what policies are in place that protect client rights, etc.

2.It is common for managed care entities to allow outside parties access to information. For example, if the insurance company is contracted through an employer, the human resource department might receive information about services rendered. Certain government entities may be allowed access as well as contracted companies for running statistical analysis. The use of this information is beyond the control of both the therapist and the client.

Utilization of therapy

Managed care requires there to be something wrong (pathology model) to justify the expenditure. Many people have come to believe that the need for counseling suggests they must be mentally unstable or weak to need help. Therapy is a place for privacy, but it should never be something to be ashamed of. Many times, individuals come into counseling for support, to increase skills to deal with difficult situations, or to address issues before they become unmanageable. These instances do not suggest mental illness; rather, it highlights that there are times when help is needed to face the complicated challenges life brings in a healthy way.

Stigma that may have long term impacts.

Some of the above mentioned fear is not without merit. Our society continues to have detrimental assumptions about mental health, and these have wider impacts than just self-esteem. There are documented cases of individuals being denied insurance (home owner’s, life/term) due to participation in counseling. I am aware of one person who was overlooked for a government promotion requiring security clearance and another person who was almost denied entrance into medical school because background checks revealed utilization of mental health services. There is also the problem of pre-existing conditions which impacts the accessibility of not only services but also medications. The new health care law will hopefully address this last point.

Limiting Access to Providers

Part of the cost-containment strategy is to contract with individuals willing to take a reduction in their fees and comply with the insurance companies policies. There is no guarantee, however, that they will have someone on the panel that has the necessary expertise to address a client’s needs. A colleague of mine highlighted that you may by a pair of shoes on sale but they are little good to you if they leave you with blisters. The therapeutic relationship is similar; it is important to find the right fit so the money is invested wisely.

Determination of treatment

For those who are in-network, they may not always be able to practice in the way they feel best suits the client. Dr. Miller (1998) expresses concern that utilization reviewers often lack the expertise to challenge a course of treatment. He writes, they “often have merely a bachelor’s degree or a master’s degree with limited experience. These reviewers routinely overrule and change the treatment decisions of greatly experienced specialists with a master’s or doctorate degree.” In addition, without any knowledge of the client’s context or the dynamics that surface in therapy, they are lacking vital information that significantly impacts treatment decisions.

Fewer benefits than regular health insurance

In many cases, the financial benefits do not outweigh the risks. Some insurers do not offer any mental health coverage; others have high deductibles that must be met before the benefits take effect or have co-pays that are little reduction in the cost. There is also a common practice of limiting the number of allotted session, regardless of need. This means that services are based on fiscal impact rather than what is best for the client.

At this time, there are five major insurances and a few smaller entities providing coverage for the five million plus individuals in Colorado.[i] Each policy has different coverage so it is impossible for a provider to know any specifics without talking directly to the insurance company about the individual plan. If you want to go through your insurance, know that some policies offer coverage only for providers they are contracted with, while others provide coverage for both in-network and out-of-network. Most agencies have a customer service number on the back of the insurance card or a website where the benefit plan can be made explicit.

Utilizing insurance is a highly-individualized decision. Be an informed consumer! Know your rights, determine the cost-benefit ratio, and ask questions. That way, you can make a choice that right for you. Once determined, you can then focus on your needs rather than on whether to use your insurance plan.

For more information about the author, go to www.sbscounseling.com