Managed Care and the Manhunt for a Murderer

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PSYCHIATRIC VIEWS ON THE DAILY NEWS

The brazen, targeted murder of the UnitedHealthcare executive Brian Thompson has evoked concern not only for the specific crime and criminal, but also stimulated outcry about our health care industry. As we know, our health care system in the United States is unique in the world in being so fragmented and without some sort of general collective basic insurance coverage. Instead, we have giant insurance companies like UnitedHealthcare, which is the largest provider of the Medicare Advantage Plans, among others. There was a time when such companies were called managed care companies, but that controversial moniker has been put aside.

So far, speculation about a motive for the murder are the words found in permanent markers written on the bullet casings: “deny, depose, defend.” These are similar to the title of a 2020 book titled, “Delay Deny Defend: Why Insurance Companies Don’t Pay Claims and What You Can Do About It.” I haven’t read that book, but I’m confident that it did not include a recommendation to murder. However, there has been a public outcry on the internet about the denials of physician-recommended treatments, even some celebrating his death as a symbol of what is wrong with our for-profit business-controlled health care.

I have little expertise about such crimes, but I do know much about what used to be called managed care from a participant/observer point of view. I was the medical director of our medical school’s not-for-profit mental health managed care contracts from 1989-2002, the first of its kind in the country. Due to the growing ethical concerns that profits were being put ahead of patient care by large insurance companies like UnitedHealthcare, I was asked to write the book The Ethical Way: Challenges & Solutions for Managed Behavioral Healthcare (Jossey-Bass, 1997). Mental health and substance abuse was a particular target of what was viewed by the managed care companies as medically unnecessary or poor treatment.

What I found in writing the book, using the conceit of a mock managed care company, was that there were major problems on both sides of psychiatric care: inappropriate denial on the part of the insurance companies and the prior need for improved quality of care by clinicians. Gratefully, outside research about the quality of care in our system turned out to be quite positive.

A most unique, fascinating and informative part of the book was the editor’s inclusion of brief commentaries by many participants that influenced patient care. Fortunately or unfortunately, most is still relevant today.

I often felt caught in the middle and was even called “evil” by a president of the American Psychiatric Association at a conference. If “looks could kill”— he was that angry about managed care. After he actually read my book, he apologized for that episode and his overreaction.

As time went on, it became clear that this business control over what physicians did was the major cause of our continuing physician burnout epidemic, let alone compromised quality of care. Being disempowered limited our healing ability and has seemingly led to learned helplessness on our part. Ironically, it looks like our country’s new presidential administration wants to shake-up the health care and public health systems, including the drugmakers, but some of the plans seem as potentially destructive and unscientific as others might be helpful.

Whatever comes out of the investigation of the personal tragedy, it is beginning to evoke some necessary discussion about how these insurance companies operate. It may turn out to be a wake-up call not only for security and safety for health care and other business executives, but how we can improve our quality of care of patients and well-being of healthcare clinicians.

As more relevant information arrives, I will likely follow-up this discussion in a future column.

Dr Moffic (he/him/his) is an award-winning psychiatrist who specialized in the cultural and ethical aspects of psychiatry and is now in retirement and refirement as a private pro bono community psychiatrist. A prolific writer and speaker, he has contributed a weekday column titled “Psychiatric Views on the Daily News” and a weekly video for his series “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.