Managed Care

[Sunny]

Do you have Managed Care in your area? Anything you'd like to share about it...

Here's a paper I wrote during an Ethics class:

Pros and Cons of Managed Care from an Ethical Perspective

Mental health counseling services have made a transitional development over the past 25 years going from a primarily fee-for-service delivery system in which the therapist could control all dimensions of services to a managed care model in which services delivered are dictated by a third-party payer.  There are various benefits that have arisen in the service delivery during this time period, as well as, compromises that have affected the treatment clients receive in the therapeutic arena due to the paradigm shift between the two systems.  It appears that the adverse affects of managed care, such as ethical conflicts, may potentially outweigh the benefits on the mental health field; however, both facets will be discussed and addressed.  Additionally, an ethical perspective will be illustrated in discussing constraints managed care has placed upon therapy service delivery in relation to the ethic codes currently established by the counseling profession.

Managed care has provided the benefit of time efficiency in that it has changed the therapy mindset of open-ended service delivery to a system in which services are time limited.  Short-term or time-limited therapy provides a natural intervention to prevent a dependency being fostered between the client and therapist that could possibly occur in long-term therapy.  Managed care has also created an atmosphere in which the goals of treatment must be very specific for the services to be authorized for payment.  This helps the client to have informed expectations from the therapy experience.  Additionally, this is a benefit that is parallel to the Code of Ethics currently instituted by the American Counseling Association (1999) which states that counselors have a responsibility to the client?s welfare and ?Counselors [should] encourage client growth and development in ways that foster the clients' interest and welfare; counselors [should] avoid fostering dependent counseling relationships?.   

Another benefit that has resulted from the managed care system is that services have become more cost effective as the system has placed cost containment on services that individuals may not have other wise been able to afford (Corey et al., p.380).  Therapists under managed care systems do not set their fees as they would in the fee-for-service delivery system.  Under that standard, a client may have been charged thousands of dollars for services received, whereas now services are more affordable due to insurance coverage.  According to the U.S. Department of Health and Human Services (Managed Mental Health, n.d., para.10), ?Money saved can be used to expand outpatient benefits, reduce member costs, or help make health insurance affordable to more people?.  Additionally, the managed care system also has paved the way for ?expanded choices? in the community giving the client more service options.

On the contrary, there are also several drawbacks to the managed care system regarding mental health services.  According to Corey, Corey, and Callanan (2003), ?Ethical dilemmas are often created when diagnosis is done strictly for insurance purposes, which often entails arbitrarily assigning a client to a diagnostic classification, sometimes merely to qualify for third-party payment? (p.369).  This dilemma impacts therapists when they must decide between basing their decision regarding a client?s treatment goals on practical vs. ethical diagnostic criterion.  This results in potentially negligent treatment of the client and is also a violation to the counselor?s code of ethics. 
For example, the American Counseling Association (1999) states in their Code of Ethics that ?Counselors must practice only within the boundaries of their competence? (Section C2a.).  Therapists that defy their acquired competence may not be as well versed in the understanding of what a particular diagnosis entails if they fall into the trap of diagnosing for reimbursement purposes, rather than what they are competent to diagnose based on experience.  A therapist must attempt to avoid making a client fit into criterion just to get payment from the insurance company.

Another ethical issue arises in managed mental health care when therapists provide informed consent to a new client.  To abide by ethical standards, therapists must inform their clients of what to expect during service.  According to the text, the therapist is sometimes conflicted with this issue because some managed care companies may contractually intervene with a therapist educating the client about limitations of treatment by having ?gag clauses? in place which prohibit the therapist from disclosing any negative information about managed care policies (Corey et al., 2003, p.151).

An ethical conflict the therapist may encounter when working within the managed care system is the obligation to maintain the confidentiality of the client.  Due to cost containment, many managed care companies challenge the therapist?s obligation to respect the client?s confidentiality and will demand client information before payment is given to the therapist for services rendered.  They should inform the client of the fact that during treatment, the managed care company may require the therapist to release treatment records.  The therapist will need to establish a protocol in which to notify the client of this possible conflict (Corey et al., 2003, pp378-379). 

A fourth ethical issue that managed care has brought to the mental health arena regards possible client abandonment.  The American Counseling Association?s Code of Ethics (1999) addresses abandonment (section A.11) by stating that, ?Counselors do not abandon or neglect clients in counseling. Counselors assist in making appropriate arrangements for the continuation of treatment, when necessary, during interruptions such as vacations, and following termination?.  Traditionally, the therapist and client collectively agreed when therapy services when end; however, in a managed care environment it has become expected of the therapist to abide by limits placed by the provider based on policy.  Regardless of the client?s therapeutic needs, the frequency and duration of services are often both dictated by the managed care company.  If services must end quickly, a client may be left to feel abandoned by the therapist unless the therapist agrees to institute alternative methods of payment for services rendered.  The therapist could institute the ethical expectation of counselors to provide a portion of services pro bono, or for free.  Another option may be for the therapist to refer the client to another therapist for ongoing treatment (Corey et al., 2003, p379).

The final ethical issue to be discussed is that therapists in the managed care system must comply with utilization reviews.  According to Miller (1998), ?Managed care?usually requires sharing private information with several people who are not chosen by the patient, such as gatekeepers and utilization reviewers, and storing it in files accessible to hundreds or thousands of employees?.  Therapists must provide documentation of the client?s treatment received for utilization review purposes.  This reportedly assists the company in monitoring the cost effectiveness of the services; however, this can also have a negative impact on the confidentiality of the client?s privacy being maintained (Corey et al., 2003, p380).

Overall, it appears that the pros of managed mental health care are outweighed by the cons.  The focus of this delivery system appears to be on economics versus quality of care provided.  As Ivan Miller, Ph.D., of The National Coalition of Mental Health Professionals and Consumers (1998) states, ?Managed care?s primary focus is on cutting costs and raising profits; its concerns about ethics and quality of care are only secondary.?  The therapist must ultimately serve as the advocate agent in regards to taking care of the client?s best interests.  Additionally, for the therapist and the mental health system to be the most beneficial to those it serves, the client ultimately must be empowered to have a voice in the evolution of the system. 

References

American Counseling Association (1999). Code of ethics and standards of practice.  Alexandria, VA: Author.

Corey, G., Corey, M., & Callanan, P.(2003). Issues and Ethics in the Helping Professions

(6th ed.). Pacific Grove, CA: Brooks/Cole Publishing.

Miller, I. (1998, August). Eleven Unethical Managed Care Practices Every Patient

Should Know About (with emphasis on mental health care). Retrieved February

24, 2005, from http://www.nomanagedcare.org/eleven.html

United States Department of Health and Human Services. (n.d.). Managed Mental

Health: What to Look For ? What to Ask. Retrieved February 25, 2005, from

http://mentalhealth.about.com//library/ken/blmmh.htm