Trends in Office-Based Practice Under Managed Care

To the Editor: I read with great interest the article by Mark Olfson, M.D., M.P.H., and colleagues (1). Although the study was well conducted, there is an alternative way of interpreting its results. Dr. Olfson and colleagues concluded, “In the decade between 1985 and 1995, office-based psychiatrists tended to spend less time with each patient, provided psychotherapy in a smaller proportion of visits, and prescribed psychotropic medications in a larger proportion of visits” (p. 455).

The decline in visit duration occurred only among privately insured patients and among those with health maintenance organization or prepaid health insurance, whereas among self-paying and publicly insured patients, the length of visits remained essentially unchanged. The one factor that distinguishes these two groups is the presence of managed care contracts in the group of patients that was seen for shorter visits and the absence of managed care contracts in the other groups, which prevented a shortening of visits for these groups.

This phenomenon raises significant questions of ethics. The first concern is that of discriminating among patients for the type of treatment provided on the basis of the expected source of payment. Second, the results of this study raise the question of whether managed care contracts breed unethical behavior among psychiatrists by pressuring them to provide less treatment because of economical constraints.

The authors concluded that “Changing financial arrangements and new pharmacologic treatments may have contributed to these changes in practice style” (p. 451). I suggest that practice style changed only toward the patients who were under managed care contracts, given that there was no change among patients in the other groups.