THE RISKS OF MANAGED CARE
Where Your Help
The Risks of Managed Care: A Position Statement
by Granville Angell, EdS, LPC, NCC
(I wrote this article in
1997, but it is still relevant today, even though this information is now
more widely known.)
This part if my
web page is dedicated to warning persons who are considering counseling of the potential
risks involved in relying upon managed care resources and some health insurance companies
to pay for services. Just because we live in "The Information Age" does not mean
that self-serving concerns have a right to the intimate details of our lives! There are
better options you can use if confidentiality is important to you and you do not want
outside interests dictating the terms of your counseling.
At the present time, our society is undergoing rapid and unstable change
with regard to the economics of the healthcare industry. Financial policies, such as fees
for services, are less and less established by the actual care-givers as the corporate
mentality of "big business" continues to enter the picture. Major changes
continue to occur as managed care (including HMO's, PPO's, etc.) and health insurance companies dominate both the provision of services and payment
Problems in the area of medical care (recently given media attention) are
even greater and more complicated, in some respects, in
the area of mental health/behavioral healthcare. These problems, related to provision of services and payment in this
area of healthcare, are significant in that they can have lifelong negative impact on the
personal, social, career, and financial well-being of the patient or client. While
respecting that policies change frequently and vary between different organizations, I
feel morally and ethically obligated to inform potential clients of mental health-related
policies that are typical of managed care and health insurance companies, as well as my
understanding of the harm they can bring.
Historically, compared to medical care, mental/behavioral healthcare of any nature has
not received the same respect in our society. Coverage by health insurance and managed
care companies has been
inadequate and has required a DSM-IV psychiatric diagnosis, denoting "mental
illness," in order to receive treatment. As a result, in a
society which historically stigmatizes persons with a history of mental illness, the
trade-off for any reimbursement received amounts to a psychiatric diagnosis which becomes a permanent part of the client's insurance records.
Considering that counseling services
for many situations can be provided without such a diagnosis, persons who are given enough
information to truly make
choice often opt to pay out-of-pocket.
This is especially the case when counselors offer better alternatives, like fairly
negotiated fees, sliding scale fees based on income, and the brief therapy approaches
pioneered by the counseling profession.
My greatest single reason for avoiding involvement in managed care, and avoiding
reimbursement arrangements with many health insurance companies, is the
virtual absence of confidentiality for the client under such circumstances. Once
considered the cornerstone of the therapeutic relationship, confidentiality is the last
interest of these companies as they compare records in deciding coverage, making decisions
and sharing information to protect and maximize each other's economic interests.
I shall not elaborate here on the potentially devastating consequences clients face as
their most vulnerable and guarded secrets are flashed through cyberspace to the
God-knows-how-many files that are maintained by greed-driven institutions. A review of the
history of this industry will reveal
risk of diagnostic/treatment information leakage
to present/potential employers, other insurers, finance organizations,
educational institutions, investigators, and even nosey neighbors.
The majority of health insurance companies and managed care conglomerates
are self-serving business concerns, first. They make
more income the less service they have to pay for, manage, or provide.
under the guise of ensuring appropriate and competent professional care, they use record
review and telephone supervision to manage and limit the professional care of clients and
patients with whom they have no first-hand, personal knowledge or experience. The result
often is a sort of tug-of-war; between therapists using records to justify treatment, and
company reviewers using records as a basis for limiting or denying treatment. Indeed, the
provider signs a contract with the managed care company which considers the company's
needs over the client's.
By contract, the client's records (once the private domain of therapist and client) are
now the property of the managed care
company. And when the managed care company
decides to terminate treatment, the counselor's contract typically stipulates that the
counselor shall not continue to see the client...not even for free. Such policies are a gross violation of the sanctity of
the counselor-client relationship.
In the hands of an ethical practitioner, the client
ultimately determines length of treatment. Under such circumstances, anybody intelligent
and sensitive enough to seek counseling in the first place is more able to recognize the
extent of their own relief and recovery than the self-interested managed care company.
In response to these conditions, I refuse to be a part of any arrangement that is
likely to compromise the best interests of my clients.
At TRANSITIONS, confidentiality and privacy are still considered
essential. With the growing encroachment
of managed care, this position has resulted in financial hardship for me. Although the
majority of my colleagues in counseling and psychotherapy have "gone with the system
in order to survive," I believe I stand with a growing minority who uphold the
dignity and confidentiality needs of the client and, therefore, say no
to the managed care conglomerates. Upholding original standards, we offer viable
therapeutic and financial alternatives to their economic stranglehold on the
mental/behavioral healthcare system.
In summary, in their economic self-interests, the managed care and health insurance
conglomerates have developed a system which especially compromises mental/behavioral
All covered services
require a psychiatric diagnosis and many services (for example, marriage counseling and
family therapy) often are not covered at all.
(Some therapists get around this by a psychiatric diagnosis of at least
one person in the couple or family.) It is recommended that you research these issues
(check out the Internet: see below).
As a result of these circumstances, professional ethics and moral
inspired me to develop professional counseling services which can financially survive
outside the business-based (as opposed to service-based) managed care environment.
of TRANSITIONS Personal & Family
Counseling Services is
to provide optimum professional counseling care without
risking compromise of clients' confidentiality or counseling needs under pressure of
Safer Payment Options: Assured
Confidentiality Where Your Needs Come First
If you are considering counseling, and your healthcare is covered by an
HMO, PPO, or other health insurance-type program, the above warning may have discouraged
you, yet left you wondering how you might pay for services. Like most people who have
become fully informed about the risks and consequences, you would be open to other
We have to begin by asking about all of the over-all costs, long and short-term, of how
we pay for healthcare.
Perhaps the best
place to start is discussion of the costs that you will not incur by paying for counseling
on your own.
The business world has been
increasingly involved in bargaining concerning the costs of your health needs. Being good
business folks, initially insurance companies, then managed care companies, made great
issue and fed the media over the practices of a minority of greedy health care providers.
They were able to leverage themselves between the consumer (that's business-speak for
patient) and the care-giver. They bargained themselves with employers and other industry
concerns, arguing that they could run things more efficiently than those greedy doctors.
To be honest, as in our materialistic-obsessed society, there is a lot of greed in the
health care industry. (Take the drug companies...have you tried filling a prescription
However, health care costs are also being driven up by the costs of a growing
technology and the further education of care-givers: both legitimized by obvious
improvements in the capacity to provide better healthcare. Now, managed care seems to be
taking over the whole industry and compromising care by wholesale cost-cutting policies.
With all this in mind, let's ask ourselves a simple question. Considering primary
values, whom shall we vote for as to which group would have a higher score on greed as a
primary value in their motivations: health professionals (healers, helpers and service
workers) or business professionals (executives, investors and their lawyers)? To which
group would you rather trust your life? Yet, which group has the most training in
stepping-in and taking-over skills? (How about that for a quick course on, "How'd we
get into this mess?") By the way, the former group would refer to you as a
"patient" or a "client." The latter group would refer to you as a
Orwell...it's a small wonder they re-invented the concept of confidentiality as,
"Your private concerns and everybody who has a present or possible financial
investment in them.")
It's not working, and (sometimes
tragically) there are casualties every day. Each of us has to use our best
judgment as to
when we can safely use our "health benefits" program, and as to when we must pay
up front for the sake of our better health and well-being and the preservation of our
I am truly sorry if you find yourself caught in our national healthcare industry
dilemma. You have rights to proper benefits, without compromise, but that may not be
happening for you. My rights to provide old-fashioned professional and ethical counseling
services are being challenged every day as managed care gobbles-up would-be clients who
are not aware of their risks or who choose to take the risks. I cannot eliminate or reduce
my fees past a certain point and maintain a livelihood. That is how managed care has
managed to suck-in so many of my worthy colleagues who only want to survive. Every day, I
question if I am doing the right thing: for my family; for my clients; and for my would-be
clients. And I wait for things to change -- which they are, constantly.
But I feel compelled to maintain my position of not participating with managed care and
some health insurance companies
primary reason: once people are aware of the risks, in my experience, they almost always
decide to pay out of pocket.
When it comes to counseling, people
don't want to give up privacy and control. Since everybody cannot afford the standard fee,
it is the only ethical recourse to use a
fee scale, and employ creative uses of time to honor the client's financial investment and trust
in seeking my services. I am open to your feedback and opinion about my continuing
decision to maintain this position. If you would like to share your opinion with me;
particularly how relevant confidentiality and autonomy are in provision of counseling
services these days, please feel free to
e-mail me and, with your permission, I might possibly post it
anonymously to this web page.
So, what kind of
options are there, if you decide not to use managed healthcare benefits for counseling? (The
following advice is both for persons local-enough to seek my services and for anybody on
the World Wide Web who is interested in seeking counseling.) In virtually all circumstances, you will pay for
services yourself in order to retain true privacy and confidentiality.
You will need to ask for assurance of the degree of
confidentiality of your records. If you are looking to begin counseling, feel free to
explore options with any counselor you call. Don't be afraid to attempt to negotiate fees
or to ask for a sliding scale fee.
In some instances, you may find that your potential counselor's work is being
supervised by a more-senior counselor or clinical educator. This is okay, and can still be
considered confidential, as the purpose of the supervision is to ensure proper development
and/or practice of counseling skills. Like your counselor, the legitimate supervisor's
primary concerns will be focused on your needs, not the interests of a third-party
company. Even under these circumstances, you have the ultimate right to limit the nature
of a counselor supervisor's involvement. Always ask for details in your particular
circumstances so you can make an informed choice. Regardless of your location, if you look
around, you should be able to find a licensed and/or certified counselor who will offer
you options at least similar to those offered by TRANSITIONS, my private practice.
My practice, TRANSITIONS Personal & Family Counseling Services, offers the
old-fashioned options of a
sliding-fee scale and a professional
commitment to see you all the way through
your present period of difficulty. There is the
possibility you will pay a little more than what your co-payment would be, but how much are
privacy and confidentiality worth?
There are a number of possible long-term costs that can significantly over-ride any
short term savings to be had in paying through the short term managed care/insurance
route. As a real-life-type example, would it be worth it to save, say, $30 per session for
a course of six sessions; only to wind up having to pay an extra $50 per month on a 30
year life insurance policy due to having a psychiatric diagnosis on record? In most cases, outside of managed care/insurance
dominated situations, counseling services can be provided without a formal DSM-IV
And, unlike the above, records would
not be available to the outside world without the client's written authorization. (There
are rare exceptions. See
Handbook for details. An example of an unusual exception would
be court subpoena of records due to criminal activity of a client.)
Further, the short-term counseling approaches touted by managed care are potentially
more effective outside that setting, as treatment is not being dictated by outside
interests. Short, solution-focused approaches to counseling were in existence long before
managed care and, when appropriate, they are routinely used outside that setting. However,
just as some circumstances would require only two or three sessions (even one), other
circumstances may require more than what a managed care or insurance program will allow.
The same way women and newborn babies have suffered or died by being sent home from the
hospital prematurely under managed care plans,
premature termination of counseling (especially dictated by outside
interests) can be devastating.
You are not obligated to use your
managed care or health insurance "benefits" for counseling if you prefer a
private-paying route. The companies don't
mind, as it saves them the cost, but it
does deny them any rights to your counseling records. They will not know you are in counseling unless you inform them (which I
do not advise you to do). In fact, with rare exceptions, record-keeping in private pay
situations is strictly between the counselor and client. Without a formal release, in
writing by the client, I will not even acknowledge that the client is receiving services.
TRANSITIONS offers a sliding fee
scale based on gross family income. The
first session is scheduled for at least 90
minutes, with the first half hour of the first session being free. It is important that you feel safe to come here and
explore the possibilities of counseling for the first half hour prior to feeling any sense
of financial obligation. Subsequent sessions last about one hour. All fees are due upon
delivery of services, unless prior arrangements are made. For additional details on
counseling services in Western/Piedmont NORTH CAROLINA, you are invited to refer to the
CLIENT HANDBOOK. Please feel free to call (704) 735-1554 for further information.
If you are interested in receiving
services, including telephone consultation, please go to transitions-counseling.com's
ONLINE RESOURCES for details on the advantages, disadvantages and options of receiving
counseling-related services through electronic media.
With Deepest Personal Regard,
Granville Angell, Ed.S., L.P.C., N.C.C.
Copyright 2/1997 by Granville Angell All Rights Reserved,
except: THIS Position Paper may be reproduced, in whole or in part, for non-commercial,
consciousness-raising purposes, provided that author's credit and contact data are
included. Web sites, please include links.
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