The Psychotherapists’ Guide to Managed Care in the 21st Century

Why should a book on practicing psychotherapy be reviewed in The American Journal of Psychiatry? Psychiatrists are constantly being pressured not to do psychotherapy by managed care organizations and by publicly financed local mental health centers because it is too expensive. Within the field of psychiatry there is a biological revolution occurring—we have more understanding of the brain, and we have treatments that were unavailable just a few years ago. All this pushes psychiatrists to become diagnosticians who provide biological treatment and refer patients out for psychotherapy for “problems of living.” Fortunately, most training programs in psychiatry include or even stress learning the skills of psychotherapy so that psychiatrists can better relate to patients, can understand them better, and can have the option of treating patients psychotherapeutically. Additionally, psychiatrists are the only physicians who formally use this skill in their medical practice. This book would be very helpful to readers who enjoy practicing psychotherapy and want to include it as a meaningful part of their practice.

The book developed as the authors began writing a guide for helping psychotherapists work with managed care organizations. The built-in conflict between the business approach (making money) of the managed care organizations and the practitioner’s goal of “healing people in an ethical and responsible manner” is discussed in a well-balanced but thorough manner.

There are three distinct sections in the book. The first, Meet Big Brother, presents the historical development of managed care organizations, their effect on the practice of medicine, the many pitfalls that are often unexpectedly encountered, the current problems of confidentiality, and the role of politics and law in all of this. This section comes across as a diatribe about managed care organizations and reflects much of the discussion I have heard and participated in on rounds, in hospital halls, and at committee meetings with my colleagues. The book describes several twists to the way managed care organizations deal with practitioners and patients that I had (fortunately) not yet encountered, all clearly focused on making money and not on the patient. This section is helpful in the sense that it organizes and reviews the realistic frustrations that result because of the incursion of managed care organizations into psychiatric practice.

The second section provides information that will help psychiatrists make the decision to work with or to practice outside of managed care organizations. The authors discuss the new terminology used in managed care, such as “medical necessity” and “risk assessment.” They also discuss the use of the Global Assessment of Functioning score, pointing out that managed care organizations consider a score less than 55 as too pathological for use of psychotherapy and a score more than 70 as too healthy for psychotherapy. Managed care organizations often use these numbers to make decisions about payment for treatments. The goal of “therapeutic stabilization” by means of brief outpatient therapy is emphasized by managed care organizations “to keep costs down.”

The authors discuss day-to-day practice needs under managed care organizations, including the need to learn new terminology (the language of impairment), how to complete an outpatient treatment plan, and how to get paid. Several examples of outpatient treatment plans along with case scenarios are presented and are most helpful. The completion of the HCFA-1500 (12/90) form block by block was an eye opener to me. Readers who do not know what this form is will definitely benefit from this book.

There is an excellent chapter on “Computerizing Your Practice” with good discussions of cost, tradeoffs, and a list of programs available for office practice. The last chapter in this section, “Time-Limited Psychotherapy,” is a good, brief discussion with references.

The third section focuses on options and approaches that will be helpful in maintaining a successful psychotherapy practice within the context of current medical practice and the constraints of managed care organizations. The discussion ranges from now to the future and includes the concept of practicing without managed care contracts in a group or other structure. The authors describe what they call “coordinate solutions,” where “the interests and abilities of the psychotherapist meet the requirements of most MCOs.” These include developing special skills in working with patients with alcohol and substance abuse problems, patients in need of disease management, older adults, children, adolescents, HIV/AIDS patients, and patients with depression. They also discuss the development of special techniques such as hypnosis, neurolinguistic programming, eye movement desensitization and reprocessing, group therapy, and being trained in the practice of psychopharmacotherapy through the Department of Defense. (The authors acknowledge that psychiatrists generally disagree with the concept of nonphysicians being granted prescription-writing privileges for psychotropic agents.) This section closes with a discussion of options of flight (practicing outside of health maintenance organizations altogether) or fighting back against managed care; they provide a list of organizations that already exist for this purpose.

The book has a good list of references and appendixes that include specific forms, addresses for all sorts of useful resources, and a “managed care glossary.” These are very helpful and thorough.

I think that this book is well written and contains a great deal of practical information and ideas that would be helpful to any practitioner of psychotherapy in the care of patients. It clearly reflects the authors’ hands-on experience and approach.