HEALTH

`I'll say I'm suicidal'

The mentally ill struggle through the maze of managed care

BY SUSAN BRINK

Kathy Rhinehart knew the routine. Voices in her head. Paranoia. She thought the television set was talking about her. The lyrics of a song--a Carly Simon tune, she thinks--took on personal and ominous meaning. A 15-year history of manic-depression had taught her what to do when those symptoms hit. "I know when I need to be in the hospital," the Cedar Falls, Iowa, woman says.

But her insurer, one of the new managed-care companies specializing in mental health, thought otherwise. Rhinehart spent several hours in a hospital waiting room talking to doctors, nurses, and clerks, who in turn talked to managed-care representatives from Medco (since bought by Merit Behavioral Care Corp.), which administered her mental health benefits. Company officials eventually sent word back that she must go home. "I think they said it was because I wasn't suicidal," she says. But the voices got louder and more urgent, and she grew increasingly terrified. She returned to the hospital the next day, only to be turned away again. What had always worked--checking into a psychiatric unit for care and medication adjustment--wasn't working under the new managed-care rules.

Within two days, she saw another way out. "I had all my pills. I got the glass of water. I was ready to take them," she says. But before she swallowed anything, her boyfriend came home and rushed her to the hospital, where she was admitted. Now, she's learned a new aspect of the routine: "Next time, I'll just say I'm suicidal, so I can get into the hospital." (Ronald Geraty, executive vice president of Merit, would not comment on Rhinehart's story but said his organization works closely with consumer groups in establishing treatment guidelines.)

Demanding a say. Administrators of health maintenance organizations and other managed-care programs are entering the once private sanctum of mental health treatment and demanding a say in who gets what kind of care. "Instead of working just with the patient, now there's an 800-pound gorilla in the room," says Jeremy Lazarus, Denver psychiatrist and consultant to the managed-care committee of the American Psychiatric Association.

Of the 180 million Americans with health insurance today, 75 percent are enrolled in plans with some type of managed mental health care coverage. That's up from 5 percent as recently as 1984. Back then, the vast majority of Americans had insurance policies without mental health coverage or with coverage that was extremely costly to the patient. Before managed care, a typical mental health benefit allowed for 30 days of inpatient care and 20 days of psychotherapy--usually with stiff copayments. The hospitals acted accordingly. "Lo and behold, everybody got 30 days in the hospital [and] 20 days of psychotherapy," says Clarke Ross, executive director of the American Managed Behavioral Healthcare Association, a Washington, D.C.-based trade organization. Treatment was built around insurance caps, not research.

Managed care has turned payment incentives upside down, paying set fees that encourage therapists to make their profits by shortening treatments. But therapists say the pressure to cut costs is restricting what kind of treatment is offered, and how long it can continue. Psychotherapy is often approved for three to five visits. Thereafter, the patient or therapist must argue for each subsequent visit.

Companies that pay the bills, the nation's employers who provide insurance for their workers, are taking a closer look as well. James Wrich, a Chicago consultant whose firm audits managed mental health companies for employers, worked with a large employer that once spent $10 million a year on mental health care for its employees. A managed mental health care company promised to provide comparable care for $7 million. When Wrich examined the insurer's books, he found that the managed-care company was spending only $2.3 million on direct care--with the rest going to profit and administrative costs. "It was never the employer's intention to reduce the direct-care expenditures that low. After the audit, they got a new managed-care company," says Wrich.

Trust in the marketplace. Changing plans is precisely what a dissatisfied employer should do, says Keith Dixon, president of United Behavioral Health, a San Francisco managed behavioral health company. "We're a believer in markets. If a company is doing bad things to patients, we're hopeful the marketplace will drive them out," he says.

So far, market-style reforms have made the process of getting treatment more challenging for many patients. In many of the big systems, patients call a toll-free phone number and begin pouring out their problems to a stranger, who decides if a referral for psychotherapy is necessary. Valerie Raskin, a Chicago psychiatrist and author of When Words Are Not Enough (Broadway, 1997, $16), has seen people after they've gotten bad information over the phone. One such patient with a severe anxiety disorder had been treated successfully with anti-anxiety medication. When she became pregnant, she called her managed-care doctor and talked to a nurse who advised her to immediately stop taking the drug--common advice during pregnancy.

But without medication, she relapsed. "She had volleys of panic attacks, a heart-racing sense of doom. She slept no more than two hours a night for weeks," says Raskin. Her obstetrician could offer no one within the referral network with expertise on pregnancy and mental disorders. Rather than tough it out, the woman found Raskin and paid out of pocket for care.

If getting into proper care is hard, staying in treatment can be next to impossible. A woman in group therapy was negotiating with her managed-care company for more sessions. "They decided that if she was well enough to do that, she didn't need treatment, so they cut her off," says Judy Roberts, director of the Washington State Coalition for Mental Health. The shorter time allowed for talk therapy upsets psychotherapists.

But managed-care industry officials say someone needed to put the brakes on psychotherapy that could go on for months or years with no measurable improvement. "We've got an increasing body of knowledge that short-term, goal-oriented psychotherapy, rendered at significant times throughout life, is very effective," says Dixon.

As for disabling disorders like schizophrenia, chronic depression, and manic-depression, "nobody throughout the entire history of mental health has been able to figure out how to render services to the severely, chronically mentally ill. We've never done that well," says Dixon.

Patients are more likely to get a drug treatment for a mental problem than ever before, though some studies show therapy is sometimes a better choice. A family doctor can be financially penalized by an insurer for referring a depressed patient to a psychologist. Writing a prescription can be less costly. "The training that primary care providers get in mental health is largely in the use of medications. So when you have a hammer, everything looks like a nail," says William Danton, psychologist at the University of Nevada School of Medicine. And therapists themselves report that they are increasingly pressured by the managed-care industry into prescribing drugs even when patients don't want them. Paul Ling, a Quincy, Mass., psychologist and cofounder of the Advocates for Quality Care, says, "I have personally been told that if the patient does not get on an SSRI [selective serotonin reuptake inhibitor--the new class of antidepressants including Prozac], they will not authorize any psychotherapy."

Keeping secrets. The heavy dose of bureaucracy in managed-care systems increases the fears of some mentally ill who need help. The stigma attached to mental illness keeps a lot of people silent about their problems. Professionals are united in the belief that for therapy to work, people must believe that their secrets will never leave the therapy room. But managed care's requirement that therapists prove that continued treatment is medically necessary gives people reason to worry about the HMO staff violating the sanctity of the treatment relationship. Ironically, the harder the therapist lobbies for more treatment for a patient, the more likely it is that increasingly personal details will be released to insurers. "Confidentiality goes out the window," Denver psychiatrist Lazarus says.

As an entire professional field reinvents itself, powerful groups are watching and offering counsel. The Institute of Medicine issued a report last spring calling on the federal government to monitor the quality of managed behavioral health plans. The National Alliance for the Mentally Ill, a patient advocacy group, issued a report card in September surveying nine of the country's largest mental health managed-care companies--and flunking all of them. Among the findings were that some plans still prescribed Haldol, a decades-old drug with side effects including severe and irreversible tremors, for schizophrenia rather than newer, more expensive drugs like Clozipine and Rispordol, says Laura Lee Hall, lead author of the NAMI report. Industry officials say that some survey results were based on outdated information.

Unfortunately, until the marketplace sorts out the good from the bad, patients are likely to continue doing what they have long done in the field of mental illness: Those with the resources will dig into their pockets and discreetly pay for care themselves.

Health problems we just whisper about

Mental illnesses, including schizophrenia and depression, are serious brain disorders. Some facts:

Gender differences. Over a lifetime, 21 percent of women will suffer major depression, but only 13 percent of men will.

Frequency. More than 5 million Americans suffer an acute episode of mental illness each year. One in five families is affected in its lifetime. Mental illnesses are more common than cancer, diabetes, or heart disease.

Treatment success. Schizophrenia can be successfully treated in 60 percent of patients; major depression can be successfully treated in 80 percent of patients; and the treatment success rate for manic-depression is 65 percent.

Hospital use. Psychiatric conditions such as schizophrenia and manic-depression fill 21 percent of all hospital beds, more than any single physical illness, such as cancer or heart disease.