How Can a Psychiatrist Make a Fair Agreement With a Patient?

All the mental health care professionals we know have been whipsawed between their ideals for practice -- based both on knowledge of patients and on their own self-image -- and the narrow demands of managed care. It is remarkable, however, how often they gossip among themselves ("triangulate," in Murray Bowen's term), yet are unable to speak publicly or articulate a coherent discussion with a new patient.

We are no different. We adapted well to managed care at the outset, then objected with indignation and have cast about with confusion since then. No ready-made solutions have had staying power for this novel situation. Still, we have continued to search for a method that answers the question in our title, and we believe we have found a middle path, which we will describe here. It is a bit more complicated than the usual -- like many things in life -- but we think it benefits both patients and us.

We are two private practice general psychiatrists in our early 60s who happen to like seeing patients from all diagnostic categories and economic classes. This may be a disadvantage for niche marketing. We have been active in our state professional society, but we have seen this organization and its national counterpart as splintered and limited in their impact. (On occasion, we looked to these organizations for help with our troubles and were snubbed; our hopes were dashed until it dawned on us: Could it be that our leaders were just as frightened as we were?)

For several years, we printed a newsletter of commentary, The Mental Health Canary, which aimed to be multidisciplinary -- including workers in managed care -- and to stimulate dialogue, but stopped when the expense grew too great and the dialogue faltered.

Legal action against managed care abuses holds some promise. It is the American way. However, it will set off protracted courtroom battles and will take too long; meanwhile, our busy daily practices will go on. Our conviction that the power of large insurance companies and the U.S. Congress is huge and hard to budge has grown. The motive for that power is money, and the circulation of money in the present managed care system is pumped by the average citizen's faith that his employer or Congress -- some parental figure -- will ultimately take care of him. Ambrose Bierce's definition has never been more accurate: "Corporation: An ingenious device for obtaining individual profit without individual responsibility."

There is a risk -- even a probability -- that in the present state of conflict all parties will withdraw into the murk, "triangle in" or "pair off with" a collaborator and not speak openly as an individual to the other members of the circle. Many mental health care professionals do not explain the usual required treatment plan to patients -- perhaps feeling it is only window-dressing -- or how it is transmitted. The case managers prefer to stay in the background, pulling the strings. If they oppose a particular treatment or deny further sessions, they ask the therapists to explain and are reluctant to communicate their thinking to patients. The professionals have conflicted loyalties. They can explain different options, their recommendations and the managers' stand to their patients, and together they can decide to appeal the manager's decision. Of course, this is often the best course, but there are inhibiting forces on all sides. The professionals have to give extra (uncompensated) time to argue with upper-level managers (often psychiatrists near retirement) who are not sympathetic. Some professionals decide it is easier to side with the managers before doing that. A patient may be intimidated by an appeal too. If they think a growing number of managers and the increasing documentation will be included in the discussion of their case and are worried enough about their problems already, they may simply decide it is easier to drop the issue and stop treatment. Even if professionals never bring up the notion of an appeal with patients, but instead shift the treatment schedule and goals to accommodate the managers, it is hard to imagine that a patient who is alert will not sniff out the kind of process they are involved in -- that their professional is being secretly influenced.

On the whole, managed care has set up a triangle -- or an obscure nest of triangles -- in which the patient cannot tell who is paying whom and where the information is going. What has been lost is that transparency of the set-up -- the financial transaction and the flow of information -- which safeguards the privacy and consequent free speech of the patient. Robert Langs, M.D., has shown the crucial importance of this framework for the patient's ability to speak freely, think freely and reach an understanding. Confidentiality is the sine qua non because even the breath of a breach can chill the warmth of free associations. Of course a sensible patient has always hesitated to reveal fantasies in the beginning of therapy, at least until he trusted the discretion of the therapist. Now a prudent patient has many reasons to define the limits of discourse in a superficial fashion (e.g., stick with the job and kids rather than personal relations). The commodity of mental health has become less costly and is also being widely viewed as having less real value.

Many younger professionals have grown up indoctrinated in managed care, and some older ones have scrambled to catch up. We have seen some young professionals adapt to third-party management at first, then think through the process as patients teach them its shortcomings, and subsequently become older and wiser therapists. More than a few middle-aged and older professionals have simply abandoned the field, admitting that it is not good for their mental health to work in mental health. (We know one who went into carpentry, another went into stocks and bonds -- and mourns the old days when he helped people.) Some of us, however, cannot give up and feel there is still an important value in providing psychiatric treatment, even if we could make ends meet in other ways. And while some of our colleagues have followed the route of specialization (e.g., pure psychopharmacology), our aspiration has been to remain generalists with a commitment to psychotherapy.

So the dilemma for us die-hards is: how can an honorable mental health care professional make a fair agreement with a patient? How can we work within the rules of society and fulfill what we regard as a higher fiduciary responsibility to an individual patient?

One clear-cut position some mental health care professionals have taken is that they will treat self-pay patients and indemnity insurance patients only, but no patients with managers (HMOs or managed care contracts). This is admirably simple, as well as clear for patients to understand, but it eliminates a significant proportion of the population in different parts of the country, reducing the chances that such a patient would see a professional with the notion of the type of treatment we are advocating.

We are two private psychiatrists with an office that is far from Park Avenue or Harley Street. Some of the patients in our neighborhood are well-off, most are middle class and some are definitely hard up (it is characteristic of patients with serious mental illness that they may not adjust to work or manage money well). We would rather not redline. We feel nostalgia for the community mental health care movement. We would miss a wide range of patients of all diagnoses and classes and the opportunity to interact with them in a variety of therapy modes. We sometimes ask ourselves, "Why do we insist on this diversity?" when it would be to our economic advantage to specialize in med checks or a limited area such as forensics or eating disorders (brand-name recognition to grab the consumers' attention). Well, we like doing psychotherapy (individual and group) and some couples and family intervention, as well as the art of psychopharmacology. We know the fine and zigzag line between eccentricity and creativity -- a paradox lost in the neat logical world of manualized treatments -- and basically prefer to rub shoulders with all kinds of our brother animals. We have been fairly well analyzed, if not fully churchified (certified), but of course we see that the gold of pure analysis is neither possible nor desired by the majority.

Given our personal goal of a broad mix of patients and the current conditions under managed care, how can psychiatrists like us set up practices to handle funding, be fair to all, be flexible, make a clear transaction with a patient, maintain privacy and pursue the always elusive goal of informed consent?

Our method is a blend of approaches from elsewhere and our own preferences. Two years ago, we first heard of an expanding group of family physicians in the state of Washington, SimpleCare (<www.SimpleCare.com>), who fostered continuity and the doctor/patient relationship by encouraging self-payment. Starting independently, Ivan Miller, Ph.D., founded the Boulder Psychotherapists Guild (<www.psychotherapistsguild.com>), which illuminated the particular needs of mental health work and promulgated his method, which emphasizes full disclosure.

For us, the mechanics are simple and should be as clear as full daylight. They feel liberating to us, and we know that they are for many patients. All our rates are posted on a sign in the waiting room, along with the comment that talk of money is not taboo; patients are welcome to question our policies. After the first session, we tell the patient as much as we know about their diagnosis (and that all diagnoses are provisional in psychiatry) and outline all treatment options. We encourage psychotherapy, or psychotherapy in combination with pharmacotherapy, sometimes integrated with one person treating, but respect the patient's right to choose only the latter.

We ask how they want to pay and involve them as much as possible (considering their condition) in the arrangement for our reimbursement. It is their insurance money, usually earned by the sweat of their brow, not really the managers'. It is a part of our ongoing discussion with them to reveal the opinions and values conveyed by this essay, although we try not to waste valuable appointment time expanding too much on our own gripes. We hand new patients an information sheet describing our policies and their options -- which some read carefully but many skim or discard -- and talk about funding for 10 minutes in the first meeting or two. We may not discuss it further unless a glitch develops. We tell them everything we know about the treatment plan and what information goes to the managers, letting them edit or overhear, or hold back information if they decide it should be private. We say we are willing and happy to take their insurance/HMO/managed care money, so long as it fits within the framework of private and effective treatment as they decide it, or we would be equally happy -- even happier -- to take their self-payment, which we would reduce 30% below our usual charge.

With self-pay, there is no documented treatment plan or risk of breach of confidentiality, and the form and duration of treatment is entirely in the patient's hands. (We estimate our overhead is slightly less than 20%, and managers usually deduct 20% to 30% off our fee, so a 30% reduction in the self-pay charge to patients seems a reasonable deal for their peace of mind and ours.) We ask if patients can afford their share or need a fee reduction, and we make reductions particularly when a patient is motivated and apt to benefit. With HMO patients, we fairly often make appeals; the main difference in our system now is that if the patient is aware of treatment plans, cost and options from the outset, they may be more motivated to advocate for themselves as well. Many of our patients intelligently use their insurance/HMO funding and, when that runs out, switch smoothly to self-pay. The goal is informed consent and an increase of patient autonomy within the boundaries of the community.

With this system and (fortunately) two incomes, our gross and net have looked magnificent to us -- almost an embarrassment of riches. Like many psychiatrists, we have more than enough patients -- the challenge is in balancing the books, loyalties and standards. With flexible funding, we are able to see a broad mix of patients who tend to be more motivated. The main pay-off, of course, is a better alliance with patients who see the business setup and respect our honesty. When patients are empowered to make choices, they use their resources better and become active participants in treatment. If a patient chooses to do psychotherapy, this kind of negotiated understanding is apt to be trusted, safe, a secure framework and allow them the freedom to say anything.

Freud said: "Money matters are treated by civilized people in the same way as sexual matters -- with the same inconsistency, prudishness and hypocrisy." We aim to work against those defenses.

Both the SimpleCare and Guild systems have been marketed in some places and probably should be marketed more widely. We have not done it yet because we have been too busy. The only kind of psychiatric practice that might find our approach troublesome or a waste of time would be one in which the doctor prefers to be a pure psychopharmacologist, delegates or opposes psychotherapy, or does not want to talk with patients about choices. A psychiatrist who needs to maximize profit might choose other methods.

In our view, decisions about how to proceed in the maze of forms, contracts, jargon and companies with imposing titles should be in the hands of the patients, with the professional offering a candid evaluation of the problem and honesty about their own needs. The goal is for the patients to feel they have met and engaged with a professional -- someone with an interest in them, not just another salesperson. Just as in other walks of life, people should look each other in the eye and talk straight (not a bad definition of good psychotherapy). The real business of mental health treatment ought to be the patient's setting an agenda for living, not goals set by either therapists or third parties.

We cannot go back to the old days -- and really do not want to -- but the value of plain dealing and a handshake between individuals, always open to on-going discussion, is apt to endure long after the era of industrial management -- or so we hope.