Group Therapy Requires Good Clinical Judgment, Careful Screening

Group therapy expert Irvin Yalom, M.D., calls the increased use of group treatment by HMOs a wise ideal, but he is concerned that insufficient time is spent screening and matching prospective patients. "There's a lot of evidence to show that preparation for groups is exceedingly important or you're going to get high dropout rates," Yalom told Psychiatric Times. "You really have to prepare patients for group treatment and have to compose your groups and select patients for that particular group with some care."

Yalom is not alone in his views. Concerned by what they see as a push by HMOs to steer subscribers into group therapy, many clinicians shared their concerns with PT that managed care organizations are putting their bottom lines before their patients' clinical needs.

Joanne Ritvo, M.D., chair of the American Psychiatric Association's committee on managed care explained, "I don't think there's any question that there's an increasing trend among HMOs to use group therapy."

Ritvo believes that many patients are being pressured into group treatment by HMOs. Restrictions on patient choice have resulted in a greater number of patients who are willing to pay out-of-pocket to see her and others for individual therapy, she added. "[Patients] see themselves as being marginalized to group therapy when they don't feel that it's what they want, need or would choose." As a result, Ritvo said the companies who contract with HMOs often pay for services that go unused.

Ritvo is particularly concerned that mergers among managed care organizations have eroded the influence of organizations such as the APA when it comes to the implementation of practice guidelines. "The more of the market you've cornered, the less you have to listen to other people's advice," she explained. "They're able to say, 'Look, we've got however many thousands of covered lives and providers, and we have a huge database and that's what we follow.'"

Kaiser Permanente's Robin Dea, M.D., disagrees and believes that pressure from consumers will force HMOs to stay focused on clinical priorities if they want to survive. "Many of the complaints that are being lodged right now, especially toward for-profit plans, won't be there three years from now," said Dea, chair of psychiatry of Northern California Kaiser Permanente. "They'll have no choice but to stop some of the practices they've been [using], even if there's no legislation, because the people buying their services don't like it. If you're the benefits manager, you don't want to spend your time dealing with complaint after complaint. If the organization you've hired to provide services consistently underserves, you gets lots of complaints and sooner or later decide to go with someone who doesn't have that record."

Careful screening, referral by licensed clinicians and one-on-one pre-group orientation make good business and clinical sense, Dea said. "There needs to be clinical judgment as to who is appropriate and would benefit...In addition, there is patient choice. If you put a patient in a group and the patient really doesn't want to be there, it's not going to be an effective treatment," Dea added. "Our organization clearly doesn't believe in forcing anyone into group therapy."

Dea said clinicians with Kaiser, the nation's largest nonprofit HMO, have been conducting group therapy for over two decades, adding that the biggest changes have to do with the referral and triage infrastructures. According to Dea, 18% of all mental health visits in the Northern California Kaiser Permanente treatment program were group visits in 1996; that figure rose to 22% in 1998. Dea attributes the increase to the concerted efforts to include group therapy in Kaiser's treatment options, particularly for such conditions as depression, anxiety and panic disorders, and attention-deficit/hyperactivity disorder.

"What we have found...operationally, experientially and [through] data-based [review], is that shorter-term therapies are quite effective for the majority of patients who come in," Dea said. "Anyone who says...that everyone should be in individual treatment...is just irresponsible."

Typical Kaiser subscribers currently are eligible-if they meet modified medical necessity criteria-for up to 20 group sessions after they have used their standard 20 mental health visits, regardless of the treatment modality used. "We want people to use those visits if they fulfill the criteria...Those visits are there for people who are at high risk of decompensating," Dea said. "It's not good treatment for the patient and not financially good for us to withhold from patients treatment that is medically necessary; they end up needing a higher and more expensive level of care if you don't take care of them on an outpatient basis."

At Magellan Behavioral Health Inc., group treatment made up roughly 14% of authorized mental health visits in 1997, while individual therapy visits made up 59% of authorized mental health visits, according to Jonathan Book, M.D., chief medical officer and executive vice president. Group figures dropped to about 11% in 1998; individual authorizations also declined to 56%. Book would like to see more group treatment but doesn't have a magic number in mind, stating "We don't have a target because we don't know." In terms of research on what works best for patients, Book commented, "The jury's still out on a lot of this."

Book said the use and management of group therapy services preceded HMOs. He rejects what he sees as a common belief that financial incentives for clinicians who do group therapy is creating a surge in group services. "It is a fact that there is a potential financial incentive for clinicians to provide group treatment with their professional clinical time," he said. "It also needs to be clear that managed care, let alone Magellan, didn't create this. Our intention is to help provide the wherewithal and incentive for a comprehensive array of clinical services to our subscribers."

Encino, Calif.-based psychiatrist and former California Blue Cross medical director Ronald S. Mintz, M.D., said it has also been his experience that patient interest in groups outnumbers openings, particularly for "middle-of-the-road" and high functioning individuals. In Cincinnati, Walter Stone, M.D., also points to a shortage of group openings, particularly for long-term groups. Unlike Book and Mintz, however, he believes "it's much more about the limitations of reimbursement" in that managed care organizations typically will not pay for long-term group therapy.

Mintz believes that HMOs "could do a better job than they do in terms of providing information on groups available in their geographic areas." He supports the idea of a centralized group registry that could be used by patients and referring clinicians. He also would like to see increased flexibility on the part of managed care organizations regarding how group treatment is used. For example, patients might benefit from group therapy for three weeks each month, with individual therapy during the fourth week.

Magellan's Book said several other administrative factors continue to slow the growth of group treatment, noting, "One of the reasons there hasn't been more group therapy has to do with the administration and logistics involved...It was such a common model in the pre-managed care era for clinicians to start individual therapy practices." As a result, they wouldn't have been part of an organizational care setting necessary for networking. He explained that managed care has played a role in the increased organization of outpatient practices and that the growth of group practices has helped generate "the adequate core of administration and critical numbers of patients where you can identify patients with common needs."

According to Book, still another barrier is graduate training programs that place little emphasis on group modalities. "I think the therapists themselves, because of their training, are more comfortable with, capable at and value more, individual therapy over group therapy," he said. He added that in his experience clinicians rarely call and ask for anything except individual therapy visits unless they are in a practice that already offers group therapy. "On the patient's side, I think the American public is familiar with, understands and therefore values more, individual therapy."

Anne Alonso, Ph.D., professor of clinical psychiatry at Harvard Medical School, agrees that many patients see group therapy as second-class treatment. "The culture and the HMOs, also, are promoting the idea that 'you're not really sick so you can go to a group,'" Alonso said. While she firmly believes groups are as clinically effective as individual therapy accross the diagnostic spectrum, "patients need to feel that this is a treatment that has been recommended after a careful evaluation of their needs and isn't just an automatic triage."

Like the APA's Ritvo, Arizona psychiatrist Gary Grove, M.D., believes that referring clinicians best understand their patients' needs and should not be overruled by managed care organizations. "If a managed care company wants to say, 'Look, have you considered group rather than individual therapy and here's some information that we'd like you to consider,' that's fine as far as I'm concerned," said Grove. "But when the clinician refers a patient for individual therapy and feels that's what's appropriate for his or her patient, it's not good care when that doesn't happen."

Grove also believes that efficacy research doesn't always reflect the diagnostic complexity of patient populations. "Research is based on statistics and percentages; there are always those who are in the 30% who didn't respond to treatment or have complications who are excluded from research trials [by virtue of Comorbid Conditions such as Axis II pathology or substance abuse]." The result, Grove worries, is the referral to a modality that doesn't always fit the clinical needs of actual patients.

Despite the sometimes heated debate about how, when and why to refer patients for group therapy, HMOs and clinicians alike share the belief that patients can gain much from the experience of making the therapeutic journey with others. "Having to share the therapist's attention initially feels like a big burden," said Alonso. However, she added, "once you get in, you realize that you have eight or nine people to share that burden with you."