MANAGED-CARE MEDICINE
Edited By Mickey Skidmore, ACSW
Editor’s note:
The majority of this piece is taken from a Journal article entitled: “Psychiatry, Managed Care, and Crooked Thinking”, by Lloyd A. Wells, Ph.D., MD. The article is copyrighted (1998) by the Mayo Foundation for Medical Education and Research. The sequencing and length of the material was edited and reorganized to emphasize points of interest shared by the editor. Additionally, some pronouns and subsequent syntax were also changed to ensure grammatical congruence. To avoid the appearance of plagiarism, all material from this article will be reflected in italic print, in an effort to clearly differentiate additional positions and material from the editor.
The United States has experienced a proliferation of “managed care,” often operated as a profit-making venture. Virtually all systems of managed care or managed competition currently operating in the United States present major ethical issues for physicians, many of which are inherent in the system and its profit motive and most of which have been widely discussed in the literature.
Medicine has rich traditions that date back at least 3,000 years. For many centuries, medicine was a professional endeavor. The physician’s ideal was service and the advancement of the art, not the acquisition of large financial rewards. Although the modern era has provided many exceptions to this old rule, few physicians have acquired the amount of money paid to the chief executive officers of many of the managed-care firms. With managed care, medicine has become appreciably more entrepreneurial than it was a few years ago. In contrast to the traditions of medicine, managed care has few traditions and relies on the ethos of the marketplace, as illustrated in this following vignette:
A 16-year-old patient had taken a massive overdose of acetaminophen. She had severe liver damage but recovered after a few days in the intensive-care unit. She was suicidal but did not want to be in the hospital. Thus, she was transferred to the adolescent psychiatric unit, begging to be dismissed. The attending psychiatrist discussed the case with physician-reviewer of the managed-care company, and he agreed that she could stay in the hospital. Later in the day, however, a nurse at the managed-care company telephoned the patient and asked her if she would “contract” not to kill herself. The patient, of course, agreed. The managed-care company then refused to pay for further hospitalization because the girl had “contracted for safety.”
Such “contracts” are not useful. These contracts have rapidly become lore and tradition in managed care, but they have little established research base. Furthermore, the nurse who telephoned the patient had no fiduciary relationship with the patient.
The role of physician-reviewers in managed-care systems poses complex ethical and clinical issues for physicians treating patients. Yet, public discussion of the role of physician-reviewers who work for managed-care companies is minimal. These physician employees of managed-care companies, who have never examined the patient, approve or disapprove the treatment decisions of the practicing physicians whom they indirectly supervise. They are often anonymous, and their credentials and work experience are frequently unavailable, and some have been known to misrepresent their credentials and experiences.
THE MANAGED-CARE VERSION OF EMPERICISM
The traditions and philosophic underpinnings of business differ from those of medicine. Nevertheless, they have been imposed on medicine, and many physicians, without thoroughly thinking through the issue, are beginning to accept them.
Without a credible empirical research base, managed-care companies opt for biologic treatment of almost all psychiatric disorders; indeed, those disorders that do not respond to biologic treatment are deemed, ipso facto, to be non-psychiatric disorders. Managed-care companies do not acknowledge principles of medicine such as the biopsychosocial model; the distinction among disease processes, syndromes, and illnesses as encountered by patients; and differences among patients. Decisions are presented in pseudoscientific verbiage but are driven by the marketplace. For example, attention-deficit disorder is a common disorder of childhood with pronounced morbidity. An extensive biologic research base has demonstrated a state of hypoarousal in the reticular activation system. Numerous other biologic findings are relevant to this syndrome. Nevertheless, perhaps because it is common, chronic, and expensive to treat, some managed-care companies believe that it does not exist or that it is a “social problem.” The hazard is that, over time, clinicians can easily acquire the same style of skewed thinking.
In managed-care medicine, patients seem to be viewed as widgets on an assembly line. The assumptions are that patients are somehow standard, that their illnesses are identical to the illnesses of all other patients in the same diagnostic group, and that treatments should be the same and precisely standardized. Individualized patients are not considered in this type of medicine. Complicating this issue further, is how “managed-care science” is in direct contrast to federal, state, or other regulating bodies that strive for and emphasize “individualized” treatment plans for each patient. Or, that the standards of such regulating bodies have not kept pace with the managed-care-market-driven forces dramatically impacting the delivery of (inpatient) psychiatric services.
Although drugs have been developed that are heuristically useful in the treatment of certain psychiatric syndromes, ridiculous conclusions are sometimes stated by managed-care reviewers. Because an agent that seems to help depressed people inhibits the reuptake of serotonin, as well a many other pharmacologic actions, managed-care reviewers argue that it is evident that depression must be a disorder of serotonin regulation.
In short, a patient’s treatment is rarely approved by a managed-care company unless the patient is receiving medicine. For example:
A 16-year-old girl who had been doing well in life until 3 weeks before admission, when she had sudden onset of a complete inability to walk. After an initial misdiagnosis of a neuromuscular disease, it was concluded that the patient had a conversion disorder, and she was referred for hospitalization. She had classic conversion with “la belle indifference.” She was apparently free of conflict and reported that she had never even had a bad dream. She was treated with psychotherapy, physical therapy, and imagery and relaxation. Two days after admission, she began to experience dysphoria and to express he sadness and anger, which was interpreted by the attending psychiatrist as a hopeful sign. The managed-care reviewer, however, viewed this behavior as a sign that the patient was depressed and insisted that she be treated with a high dose of fluoxetine. The attending psychiatrist disagreed completely, explaining that, in fact, her dysphoria about her situation was a sign of progress. The psychiatrist refused to treat her with an antidepressant, and the reviewer discontinued payment for hospitalization. Fortunately, the girl’s parents could afford her treatment and agreed to pay for it. The initial treatment regimen was continued, and the girl was walking normally within 3 days.
Thus, this neurobiologic reductionism, based on a poor understanding of both neurology and psychiatric phenomena and presumably favored by managed-care companies because of the apparent cost saving involved, can harm efficacious, brief, and definitive treatment. All reductionism is not inherently a “bad” process. Scientific advances occur in part because of reductionist thinking, but the reductionistic thinking of scientist and that of manage-care companies may be very different entities and processes.
Another example of these differences can be illustrated with a brief review of the concept of “outcomes.” For example, “clinical outcomes” are not always clinically meaningful. Yet, “outcome measures”, which have come to be associated with managed-care, are an unusual blend of medical research, quality improvement approaches, and business strategic outcome applications.
In managed-care approaches, so-called providers – individuals or agencies – are asked to demonstrate that they have superior “outcomes,” usually in relationship to a specific clinical entity that may in fact be an artificial composite of several clinical entities. Good outcomes for providers lead to a better relationship with the managed-care company and ultimately more money or less supervision (or both). Thus, in contrast to the situation in research, a major incentive exists for an outcome to be “good”—indeed is expected to be good. Therefore, efforts are made for the studies to demonstrate good results.
Outcome studies often seem slanted toward convincing the reader that one facility is better than another. Thus, short-term rather than definitive results are usually analyzed. By design, factors are few. Statistics are often extremely primitive, and the techniques of design of experiments are often inadequately applied. Usually, actual outcome, which complex and multifaceted, is not studied; instead, a perceived correlate of good outcome is studied. Occasionally, some validity and scientific rigor are demonstrated in the study of this correlate but not always. For example:
An adolescent patient was involved by his managed-care company in an outcome study of hospital treatment of schizophrenia. No effort was made to categorize schizophrenia by type – it was assumed to be a unitary entity. The patient did not actually fulfill criteria for schizophrenia. The perceived correlate of good outcome being studied was outpatient compliance with medication. Of note, compliance with medicine is often a necessary condition of "good" outcome, but it is certainly not a sufficient condition. This particular patient complied well with his medicine – it did not appear that he missed a dose. Indeed, he helped bolster the statistics of this particular outcome study and had one of the best "outcomes" in the cohort. Clinically, however, he took not only every dose of his neuroleptic medicine but also every dose of psychotomimetic substances, especially LSD and phecyclidine, that he could obtain. He was soon completely out contact with reality and had to be rehospitalized immediately and for a long time frame.
Thus, this good "outcome measure" was an extremely bad outcome.
True research on outcomes necessitates a knowledge of the natural history of syndromes and their many variants, much of which remains obscure. Good outcome studies also necessitate complex design and multivariate analysis.
The outcomes movement in psychiatric managed care is inherently simplistic an made even more simplistic by the implicit assumption that all syndromes and their variants are diseases. In fact, many psychiatric syndromes seem to be final common pathways with differing caused and outcomes. For example, a child can be oppositional and defiant during the course of a decade or more, or s/he can have development of oppositional and defiant behavior in the context of grief. These hardly represent the same pathologic process -- indeed, in child and adolescent psychiatry, "pathology" is sometime adaptive – but this is assumed in many outcome studies.
Some colleagues in psychiatry, numerous colleagues from other mental health disciplines, and many residents view outcomes studies as synonymous with research. This perception is unfortunate and augurs poorly for the scientific base of clinical psychiatry. If there is to be outcomes research, it should be research – not a series of venal efforts to convince businessmen in managed-care companies that one treatment is better and less expensive than another based on statistical tricks and sleight of hand.
THE EMPIRICAL LOGIC & RATIONALE OF MANAGED-CARE
Nonetheless, the twisted thinking of such argumentation is fascinating. And many psychiatrists spend a substantial amount of time discussing cases with managed-care reviewers for the purpose of continuing treatment for their patients. What follows are some examples of "Straight and Crooked Thinking in Medicine" (Asher, BMJ 1954) – applying some of these principles to situations involving managed-care reviews of patients' treatment:
1) Post Hoc Ergo Propter Hoc: One of the most common logical missteps. Many managed-care reviewers use this liberally, and they assume a causal relationship between temporal events. For example:
A 15-year-old girl was being treated for sever anorexia nervosa. She was making considerable progress. Nevertheless, the managed-care reviewer demanded that she be treated with the drug sertraline, and if she not receive this drug, her bills would no longer be paid. No pressing clinical rationale existed for the use of this medicine – the girl was not depressed, and the drug has no demonstrated efficacy in the treatment of anorexia nervosa. Because the patient continued to require the treatment that was being provided and because use of sertraline seemed relatively benign, I acceded to the demand of the company after a thorough and frank discussion with the parents and the patient and with their consent. The patient continued to progress, and the eventual outcome was good, as expected. At the end of treatment, the managed-care reviewer said, "Well, now you know that these people respond to setraline."
2) Reification of Syndromes: Another logical lapse in the managed-care industry is the reification of syndromes, in which a constellation of behaviors is assumed to be a disease process.
3) All Instead of Some: A frequently demonstrated logical error is the implication of all when only some is supported. A managed-care reviewer insists that patients taking specific serotonin uptake inhibitors will do better when a tricyclic agent is added. This is sometimes true but certainly not always. A common, illogical argument by reviewers occurs when the patient has more than one syndrome. Basically, this argument is that, because Y is worse than X, no rationale exists for treating X. Adolescents who have been horrifically abused and have PTSD often have major depression as well. Reviewers consistently argue that, because major depression in adolescents can be life-threatening, only the depression needs to be treated. They do not acknowledge that each patient's illness is unique, multifaceted, and complex.
4) Splitting the Difference: When the clinician and the managed-care reviewer disagree, some reviewers suggest the adoption of a mean between the two extremes – "splitting the difference." If the disagreement concerns whether to use 20 or 40 mg of fluoxetine, a trial of 30 mg may be reasonable. If, however, the physician advocates a vigorous effort to treat the affective component of a psychotic illness and the reviewer disagrees, compromising on a homeopathic dose of an antidepressant makes little clinical sense.
5) Technics of Argument (or discrediting the provider): Sometimes these logical errors are masked or even overwhelmed by this approach used by some managed-care reviewers. Discussions are often filled with emotionally toned words as well as caustic, ad hominem comments about the expertise of the physician. Under attack for incompetence, the treating physician may become grateful for any crumbs thrown his/her way. S/he may accede entirely to the demands of the reviewer simply to demonstrate that s/he is competent. Reviewer techniques to anger the clinician often lead to a poor argument by the clinician. One approach to induce this angry response is the attribution of prejudice or other motives to the clinician.
6) Diversionary Tactics: Irrelevant diversions and objections are a frequent component of the managed-care reviewer's armamentarium. Threatened on an irrelevant point, the physician may be willing to agree to the reviewer's proposed protocol.
7) Suggestion by Prestige: Claims of association with a prestigious program, name dropping of experts and the facile use of jargon. Imperfect and false analogies are common.
8) Pseudoscience: The use of pseudoscientific models by managed-care firms causes many problems. Most of the companies are moving toward symptom-specific protocols for treatment. This approach is based on an assumption that syndromes are diseases and that their course is relatively invariable. Such protocols do not consider the nature of clinical decision making, which is not a purely scientific process. Clinical reasoning, however, is full of caveats and inferences that the protocol cannot simulate. This sort of thinking represents clinical wisdom and should not be discarded.
9) Reliance on Protocols: Protocols, used to their worst extremes, can endanger patients' lives. The following three vignettes are examples:
An 11-year-old girl with malignant, rapidly advancing anorexia nervosa was covered by a managed-care company. She was allowed, by protocol, to see a family practitioner for her syndrome, but the family practitioner was not allowed to monitor electrolyte levels because this type of follow-up was not in the protocol for this (temporal) stage of the disorder and its treatment. Her course progressed rapidly downhill. Her parents brought her to the emergency department after she had become weak and disoriented. She was admitted to the hospital. The managed-care company refused to pay for the hospitalization because the "outpatient protocol has not been completed." One supposes that, in this instance, "completion" would have meant "death."
An 18-year-old patient with anorexia nervosa was admitted to the hospital because of major electrolyte abnormalities and a cardiac arrhythmia. She had advanced secondary osteoporosis, with bone age of someone older than 70 years and a severe mixed neuropathy. The managed-care company offered only a 2-day hospitalization because she had not had extensive outpatient treatment.
A 15-year-old boy jumped off a bridge, which spanned a freeway, and certainly would have died had a policeman not caught him as he was falling. The boy was then hospitalized. Because this was the "firs episode" of major depression, the managed-care company agreed to pay for a 23-hour period of observation.
Of course, in such cases, physicians and hospitals are left with little choice but to hospitalize these patients for a considerably longer time frame than recommended by their various managed-care companies, often without receiving further compensation.
THE LANGUAGE OF MANAGED-CARE
As part of this managed-care empirical style, managed-care is evolving its own language, a strange non-grammatical language. Words make a difference. In addition to a substantial amount of jargon, the managed-care language is replete with "verbing" and "gerunding." In this unusual language, day hospitalization programs are referred to as "day": partial hospitalization is referred to as "partial"; extended outpatient efforts are called "extended"; outcome measures are termed "outcomes"; and psychiatrists are relegated to performing "med checks" and "psych evals." Syntax and grammar become fascinating: "I'm going to med check him, and then he can probably go to partial." All of this of course, is at the cutting edge.
Language does matter. The Orwellian logic and semantic confusion described in this article have an effect on the providers of care. Physicians need to rationalize what they do. Consider the language when valued colleagues say things such as: "discharge advocacy is the highest ethical obligation." (Wouldn't Hippocrates be surprised?). Or, the hospital isn't really a place to treat patients." In the linguistics of managed care, there is little room for doubt, ambivalence, or abstraction. Less is more.
CONCLUSION
Psychiatry finds itself threatened by the violence of reductionism on two powerful fronts. On one hand, the predictions of the promiscuous use of psychiatry to address a world of problems that are not biomedical and are unrelated to individual patients or their families (Detre & McDonald, 1997) may very well be upon us. This trend clearly dilutes the specialty's focus and makes it what it should not be – a proposed solution to social ills. Coupled with the practices of managed-care medicine, psychiatry has been rapidly trivialized into psych evals and med checks, and many psychiatrists, intimidated by the comments and techniques of managed-care reviewers, capitulate. As one psychiatrist wrote, "Most of all, I am saddened when colleagues silently bow to this business pressure to do less in less time, as if it were proven to be better or more ethical treatment." Patients, poorly served are losing trust in their physicians and in medicine.
In his 1990 article entitled: Reminiscences: 1938 and since, (Am J Psychiatry, 1990), J. Romano offered some thoughtful comments about this situation:
"… it seems to me that we suffer from a deficiency disease. I think there is marked evidence of a deficiency of outrage. I do not think we are sufficiently outraged when we consider how pervasive are venality, corruption and ineptness …. Are there no sufficient reasons to be outraged? Perhaps the magnitude of this behavior is such that we have become benumbed and anesthetized of feel powerless to do anything about it."
In the face of all this, there is a compelling issue which should not be a surprise to anyone ... If we accept that managed care relies on the ethos of market principles and profit motives, why would we believe it when managed-care companies say they do not dictate or interfere with treatment? In the examples offered in this article, as well as, numerous others documented in the professional literature, newpapers, and magazines; the modus operandi of managed care companies is nothing short of extortion. While their "company line" might be "we're not interfering with your treatment decision, however, if you insist on this approach, we will not approve payment of this intervention." Regardless of whatever somantical argument one wishes to pose, in an economic-based, capitolistic-driven, profit-oriented system, to withhold payment may as well be for many, the same as declining treatment.
Perhaps, we are not completely powerless in facing the onslaught of the managed-care ethos. Strategies to challenge this system may come from an awareness of its ethical shabbiness and its logical fallacies. As professionals, we should realize this tawdry structure and behave accordingly. In particular, we owe it to our patients and our professions to point out ethical and logical fallacies as we deal with "managed-care medicine.".
REFERENCES
1) Wells, PhD, MD, Lloyd A. Psychiatry, Managed Care, and Crooked Thinking. (Mayo Clin Proc, May 1998, Vol 73).
2) Detre, MD, Thomas & McDonald, PhD, Margaret C. Managed Care and the Future of Psychiatry. (Archives of General Psychiatry, March 1997, Vol.54 [3]).
3) Romano, J. Reminiscences: 1938 and since. (Am J Psychiatry, 1990; 147: 785-792).
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