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Perspectives - Vol. 1, No. 5 - Meeting The Challenges Of Managed Mental Health Care - Page 2 of 2


Catherine Chambliss, Ph.D., Ursinus College, Collegeville, PA, USA: Fri, Nov 1st 1996

Continued from Page 1

The "Mild Problem" Default

Managed care assumes that most clients' problems will remit after brief treatment, proffered by masters' level practitioners, sometimes in group format. This is the least expensive means of delivering mental health care, and it sufficiently addresses most easy problems clients bring to treatment. Rather than assume a serious, longstanding diagnosis, the system's default is that most clients have mild problems, largely amenable to brief counseling.

The system currently assumes that if a severe disorder is inadvertently overlooked early on, and the standard brief treatment model is shown to be insufficient to meet the client's needs, either the utilization reviewer will authorize a treatment extension or an appeal can be submitted (and most providers surveyed have found the appeals process at least somewhat efficient). There is a crack in this system that an undetected severe disorder client might fall through. It occurs because so many managed care therapists are not highly trained diagnosticians. When their brief treatment fails (assuming they can always recognize its failure...clients who stop coming may be misread as success cases), these clinicians may not appropriately attribute this to the existence of a more serious underlying pathology. In such cases, the client would be terminated without appropriate treatment, to needlessly experience additional suffering that his mental healthcare benefit was supposed to address.

Specialists Overdiagnose & Overtreat

Those who are quick to defend managed care would say this rare risk is worth taking. Using the cheapest professionals, so long as they are usually capable of handling their task, allows costs to be contained. Doctoral level specialists are like other specialists; their training can make them overly sensitive to the possibility of extreme pathology, and leave them less optimistic about clients' strengths and capacity to improve with minimal intervention. Knowing the dangers of a missed diagnosis, these professionals are suspected of holding on to therapy clients longer than is required, overattributing pathos, and misconstruing normal phenomena in symptomatic terms. Through the psychiatric diagnostician's lens, much that is arguably normal may look disturbingly deviant. Once this pathological meaning has been attached to a client's experience, the client's own interpretation of their circumstance may shift in the direction of despair. This shift may be wrongfully taken as evidence validating the clinician's erroneous judgment.

Psychiatrists and Psychologists Diagnose More Conservatively

The doctoral level folks' rejoinder to this is that their training helps to protect against this type of overdiagnosis. Having seen and worked with those with the severest forms of mental illness, they argue that they are better equipped to enjoy the normal when they see it. They are also in a position to offer more credible reassurance to the worried well that while their lives may not be perfect, they have plenty of company and need not be plagued by fears of a massive breakdown lurking right around the corner.

Less highly trained therapists seem to be more likely to use more extreme diagnostic categories, while most psychiatrists and clinical psychologists prefer to use these labels conservatively (being well aware of the psychological risks associated with diagnosis) and to follow DSM-IV inclusion criteria strictly.

The only exception seems to occur when these clinicians are placed in the conflictual situation created by third party payees that demand a clinical diagnosis for reimbursement of treatment. Generally, the evidence suggests that most physicians (61%) will bend the diagnostic system somewhat to meet their clients' needs for care; similarly, the majority of the managed care psychologists and psychiatrists recently surveyed (Scholl et al, 1996) admitted to enhancing diagnoses in order to justify what they saw as needed treatment.

Without such factors distorting the diagnostic enterprise, trained clinicians feel they adhere to stringent diagnostic criteria. They are trained in empirical science, and the value of research comparing the relative efficacy of different treatments in managing a given disorder is a function of the accuracy of the client's diagnosis. This tradition makes them highly critical of those who dilute homogeneous clinical categories with inappropriate cases that have been incorrectly diagnosed.

These clinicians believe in using empirically validated treatments specifically designed for particular problems. Applying the standard of care appropriately requires a correct diagnosis. To treat clients who could benefit (and sometimes benefit quickly) from such proven help in other ways is increasingly viewed as negligent. Doctoral training is designed to enable clinicans to process and synthesize ideas from various studies, in order to assure provision of cutting-edge care.

Optimal Responding: What the heck to do? Accountability is here to stay

Although many people are currently predicting the demise of managed care in a few years, no one is seriously predicting a return of the former indemnity plan/fee-for-service system. Most accept that the shift to greater accountability and insistence on high-quality, efficient service is here to stay. While the present incarnation of managing behavioral healthcare costs is not going to last forever, its cost-consciousness is likely to be permanent. The autonomy previously enjoyed by psychotherapists receiving third party reimbursement is a relic of the past.

Since the sands keep shifting, it might be tempting to just stand back and wait it out, rather than invest a lot of energy trying to develop the skills that today's managed care companies are looking for. The problem is that change will continue; if you're set on waiting for the next permanent, timeless program, get comfortable...it could be a while.

Instead, it's probably more constructive to learn how to manage the new demands of managed care. The new goals of mental health providers include: (1) Becoming adept in delivering appropriate, empirically validated, brief treatments (state-of-the-art technical eclecticism), (2) using group service delivery methods wherever appropriate, (3) striving to develop new ways to help more people, more lastingly, with fewer resources, and (4) communicating more effectively with utilization reviewers. Even though all of your clients will not be managed care subscribers, the expectations of all clients will reflect the profession's growing systematicism being compelled by managed care.

Provider Options

  1. Wait it out...ignore managed care. Continue business as usual.
  2. Scale Back...avoid managed care and reduce practice.
  3. Specialize in nonmanaged care...Develop services outside MC
  4. Selectively join MC panels...Distinguish quality companies
  5. Join a CMHC or large interdisciplinary group practice
  6. Join a Staff-Model HMO
  7. Administer a group practice where most services are provided by less expensive practitioners...develop extensive managed care connections, and arrange for masters' and bachelors' level providers to fulfill the contractual obligations of these numerous managed care contracts.

Empiricism

There are some therapists practicing therapy who have no interest in any empirical support for what they do. Managed care has confronted such practitioners with the perhaps intimidating demand to demonstrate the efficacy of their interventions. Practitioners need to be familiar with therapy outcome research. They must also be able and willing to change their behavior if the data so warrants.

The bottom line is that psychotherapy must demonstrate its effectiveness, at least as compared to no treatment. If not, then why do it? This is not to say that each therapist must follow a manualized approach or that each intervention must be successful with each client. However, one ought to be able to use statistics to demonstrate that significant positive change is associated with the treatment methods being used. Each mode of treatment must be able to operationalize its terms in order to permit empirical validation.

The scientific method entails the systematic pursuit of knowledge through the recognition and formulation of a problem, the collection of data through observation and experiment, and the formulation and testing of hypotheses. Clinicians must demonstrate their effectiveness through use of this scientific method.

How do you and the client know what has been accomplished and when this expensive process of therapy is complete? What is it the client wants to do or not do? How will the client and therapist know when this has been accomplished? How can this be measured reliably and objectively? Who else might have access to signs that the therapeutic objective has been achieved?

By approaching therapy in this manner, the therapist creates a simple experiment, in which the therapist and the client can assess if the therapy has been successful. Clients often say that they want to feel better. We need to help them translate their goal into a measurable form, so that the outcomes of the experiments we will conduct with them can be assessed. In therapy we need to help clients move from the abstract and global to the specific and well-defined. When, where, and with whom do they wish to feel differently? When do they not feel good? How do they assess that now? How do they know when they do feel good? In this way, clients can evaluate the impact of our help more meaningfully. Simultaneously, this process leaves clients better prepared to conduct future experiments in living on their own, once therapy proper has been concluded.

Survival Prerequisites

Surviving the managed behavioral healthcare revolution requires practitioners to make both attitudinal and behavioral changes. We need to shift away from regressive nostalgia for the freedom and autonomy we formerly enjoyed, and focus instead on the opportunities of the present and future. An understanding of the indictments leveled against some clinicians of the past who may have exploited the old third-party payment indemnity plan system may help us appreciate why radical change was needed.

Revising your therapeutic practice in light of the new accountability and efficiency imperatives involves becoming more outcomes-focused and streamlined in your work. Many traditional treatment models were premised on the idea that the best psychotherapy proceeds slowly and cautiously. This assumption that more therapy sessions produce more client improvement has increasingly been challenged from within the field. Research findings questioning the positive correlation between length and treatment and outcome have been slowly accumulating since the 1950's. We've been working to tailor and trim our clinical contacts with clients for decades.

In principle, our discipline's values have long paralleled those of the MCOs; we all have been looking for ways to help clients improve their lives as rapidly as is possible. Those who continue to insist on the general value of an exceedingly gradual therapeutic process are hard-pressed to substantiate their claims that more is better.

Considering the potential risks associated with long-term psychotherapy can help us view the pressure to speed up treatment in more benign terms. If lengthy treatment sometimes creates harms that can outweigh the advantages of such longer treatment, the MCO insistence on timely turnaround can seem more appropriate. If less therapy can create more benefits overall, then our goal of helping clients most effectively can be compatible with the managed care goal of helping clients rapidly.

Such rethinking can move us along to the next important steps: addressing the details of this shift in orientation. How can we systematically do more with less? What techniques allow us to make the best use of limited time with clients? How can we engineer homework assignments for maximum effect? At what point does "less" become a problem? With whom is cutting corners too costly? How can we offset the costs associated with the greater demands of these more taxing clients?

The Importance of EVTs

Staying current with the burgeoning clinical literature is more of a priority than it was in the past. As we seek to cut corners in treatment in order to effect cost savings, we will become increasingly dependent on empirical evaluations of the impact of these efficiencies on the quality of outcome for our clients. A rigorous experimental mindset is vital.

Various professional groups are responding to this increasing need for current information about empirically validated treatment methods (EVTs). For example, as was discussed previously, the American Psychological Association has developed one of the most sophisticated, nonproprietary summaries of EVTs, and plans to continue to update this information. Similarly, the American Psychiatric Association has developed detailed treatment protocols for many disorders.

Accessing the latest research findings is easier than ever, thanks to the evolving information highway. Learning how to subscribe to relevant e-mail lists and access Web sites containing state-of-the-art information pertaining to diagnosis and treatment can help clinicians make prudent decisions about how to pare treatment and thereby improve their effectiveness.

Improved communication between providers and MCOs can also facilitate collaboration. Exaggerated notions about the "evils" of MCO procedures and criteria can be tempered with accurate information about these rapidly changing businesses. As competition increases, MCOs are becoming more values-focused (Panzarino, 1995). They need the help of well-informed providers to forge better clinical answers. It is in their best interest to work as allies with providers. To facilitate this alliance, providers must keep their defensiveness in check, and stay focused on the mutual objectives that guide their work with MCOs.

Reference
Chambliss, Catherine (1996). Meeting the challenges of managed mental health care. [Online]. Perspectives. [1996, November 15].

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