Jay M. Pomerantz, MD

[Drug Benefit Trends 11(12):5, 7, 1999. © 1999 Cliggott Publishing Co.,
Division of SCP/Cliggott Communications, Inc.]
 

A new patient calls me for an appointment. I am quite busy but might be willing to take on a new patient. This patient has been referred to me by a  national carveout managed behavioral health care company known for hassling providers. My answer is that I am too busy at the moment to take on the case.

Will I tell the patient about my self-serving behavior? Much as I like being straightforward, I keep my thoughts and feelings to myself. If I were to opt out of that particular network entirely, I could no longer receive payments for two long-standing patients unlucky enough to have that same company as their insurer.

Another new patient calls me for an appointment. He is a physician and has been referred to me by several mutual friends. I agree to see him quickly,  given the high level of distress he is currently feeling. As a physician, he is aware of potential managed care problems and has already called and
obtained permission to see me from, coincidentally, the same managed care company to which I alluded above.

When the paperwork arrives, however, it shows approval for only an initial evaluation session and requires a telephone call to a case reviewer for any subsequent treatment. When I finally make it beyond the various automated telephone menu options, assurances that my call is important to the company and may be monitored to ensure quality, and endless classical music while on hold, I finally get to leave a voice mail message. When some other patient's psychotherapy session is interrupted because the case reviewer calls during a time convenient for her, I find out that there will be no further authorizations for my doctor patient (whom I have already seen a second time because he is in a crisis situation) because I do not believe he requires medication.

No Second Visit

The case reviewer tells me that it is company policy (new to me!) that psychiatrists can conduct psychotherapy only if they are also prescribing medication for the patient. I could continue with this patient if I would prescribe a psychotropic medication (not quite stated is the case reviewer's
subtle encouragement to prescribe medicine, since it will save us both some hassle). Since I say that I do not think, even knowing company policy, that any medication is indicated, the case reviewer declares that the doctor must be referred to a social worker or psychologist for further treatment. She will not allow the payment for the second visit because it was not authorized in advance; nor is the patient liable for the cost, according to my contract with the company. The case reviewer reluctantly agrees to call the patient to tell him that company policy requires him to change providers. I also call the patient to tell him about my dealings with the managed behavioral carveout company.

The rest of this story consists of, if anything, more poker playing, although I am no longer a participant in the deal. The doctor patient -- fortunately, not incapacitated by his personal emotional turmoil and experienced with managed care -- involves his employer and insurance broker. The managed care company quickly backs down and sends me an authorization for eight additional
sessions of individual psychotherapy. I call the case manager to confirm the fact that the company is now willing to pay for this patient's treatment and to ask, casually and respectfully, about the reversal of policy. The case manager, as a good poker player would, tells me only that her supervisor made
the decision.

These particular scenarios and many more, often with much more at stake (eg, suicidal patients requiring hospitalization) occur over and over again. These games take their toll on professionals, patients, and managed care personnel. Poker playing is not what I learned in medical school, psychiatric residency, or the first 25 years of practice in both public and private sectors. Nor do
I think that the case manager (a psychiatric nurse by profession) particularly liked her role in the game. I am also aware that there is a cost rationale for the managed care company's position that it is cheaper and possibly no less effective for nonpsychiatrist professionals to treat all patients not requiring concurrent medication. What is problematic is making that decision after the case is referred to a psychiatrist and then disrupting treatment already begun, especially when the odds are (and they always are in managed care) that the treatment will be short-term. It is also particularly distasteful that the managed care company is not up front about its policy with patients, providers, or purchasers. Only in actual practice, after the insurance policy is purchased and accessed, does the truth emerge, and then it is only enforced when there is a vulnerable individual.

The latter story actually occurred before the first one that I cited and may account for my selective availability to patients, depending on their managed care insurer. In any event, closed poker is now in vogue throughout managed behavioral health, and much is being wagered on the outcome for patients, providers, companies, and society. Should we have to wonder who is being candid with us and be forced to keep all cards to ourselves even in accessing and providing health care?

Dr Pomerantz practices psychiatry in Longmeadow, Mass, and is a lecturer on
psychiatry at Harvard Medical School in Boston.