By Any Other Name, Managed Care Is Still a Major Manager of Mental Health Care

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PSYCHIATRIC VIEWS ON THE DAILY NEWS

It has been a while since I have written about managed care. This business intrusion into medicine started in the 1980s due to a worrisome rise in health care costs that was hurting our businesses, as well as the need to improve quality of care. After much criticism for putting profits before our medical priority for quality of patient care, managed care seemed to have become a dirty name. Other designations started to be used, including accountable health care and even aspects of so-called Obamacare, and perhaps most deceptively, just as plain old insurance companies.

But, never fear (or hope), managed care is still alive and very well—financially—but perhaps not operationally and ethically.¹ UnitedHealthcare, the largest for-profit giant, just got in the news after a ransomware attack on their medical claims subsidiary. Other aspects of UnitedHealthcare and other similar companies are also being investigated, especially in regard to antitrust laws.

One of the most growing and profitable managed care businesses is Medicare Advantage, which costs the government more than traditional Medicare, and has over half of the enrollees. There is no evidence that it has any quality benefits or even the equivalent quality of traditional Medicare. The same has been true for governmental funding of Medicaid.

The key to the growth of these companies is called vertical integration, that is, consolidating the control of as many aspects as possible, to include more and more physicians as well as pharmaceutical benefits managers.

Most of this is all too familiar to me. Desiring to be a participant/observer of this new system, I became the Medical Director of the first academic not-for-profit managed mental health care capitated system at the Medical College of Wisconsin in 1989. I was alternately praised and pummeled by colleagues. That led to a request to do a book on the ethical challenges that I and the profession were encountering.² Our own outcome studies confirmed that we did control costs adequately, while our quality of care was better than the prior public system.

Managed care had hit psychiatry the hardest of all the specialties because of our relative lack of precise treatments and tests that could be monitored and defended. Inpatient stays, psychotherapy sessions, and reimbursement were cut by policies and procedures like utilization review of medical necessity.

It was no coincidence that burnout began to rise after about a decade of managed care. Similarly, antipsychiatry criticism also escalated. The reason seemed obvious in retrospect: controlling what psychiatrists and other physicians could do, impairing our dedicated healing capabilities. When I resigned from my medical school system a dozen years ago, we were down to scheduling medication follow-up visits to an inadequate 10 minutes each.

That leaves us with the essential solution to our current burnout epidemic. Self-care and work/home balance, as positive as that always is, is not nearly enough. For-profit managed care needs to be managed itself, if that is still possible. Or, since we are in an election year, we should get back to politically advocating for a national single payor system like virtually all the rest of the major world’s countries. Whenever possible, mental health care clinicians must be careful about the choice of the system in which they work. We have the highest documented rate of physician burnout in the world along with the highest of any profession in the United States, and that is an unhealthy and unnecessary outcome of capitalism for the richest country in the world.

Dr Moffic is an award-winning psychiatrist who specialized in the cultural and ethical aspects of psychiatry and is now in retirement and retirement as a private pro bono community psychiatrist. A prolific writer and speaker, he has done a weekday column titled “Psychiatric Views on the Daily News” and a weekly video, “Psychiatry & Society,” since the COVID-19 pandemic emerged. He was chosen to receive the 2024 Abraham Halpern Humanitarian Award from the American Association for Social Psychiatry. Previously, he received the Administrative Award in 2016 from the American Psychiatric Association, the one-time designation of being a Hero of Public Psychiatry from the Speaker of the Assembly of the APA in 2002, and the Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill in 1991. He is an advocate and activist for mental health issues related to climate instability, physician burnout, and xenophobia. He is now editing the final book in a 4-volume series on religions and psychiatry for Springer: Islamophobia, anti-Semitism, Christianity, and now The Eastern Religions, and Spirituality. He serves on the Editorial Board of Psychiatric Times.

References

1. Rooke-Ley H, Shah S, Brown EC Fuse. Medicare advantage and consolidation’s new frontier - the danger of UnitedHealthcare for all. N Engl J Med. 2024;391:97-99.

2. Moffic HS. The Ethical Way: Challenges & Solutions for Managed Behavioral Healthcare. Jossey-Bass; 1997.