Managed Care Deja Vu

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PSYCHIATRIC VIEWS ON THE DAILY NEWS

Although the designation managed care is not used much anymore, perhaps for PR reasons, I feel that I am reliving some of the evolution of for-profit managed care from the 1980s and 1990s. During that time, while running the first not-for-profit academic managed care system in the country, I was asked to write a book on ethics and managed behavioral health care.¹ The book used the conceit of how a mock managed care company tried to balance the business ethics of making a profit and the health care ethics of quality of care.

One of the developments that led to the managed care evolution was how mental health care systems kept patients overly long after finding one way or another to get them into the hospital, often unnecessarily. Substance abuse 30-day inpatient programs were a special target. Developing profitable processes like their own definition of “medical necessity” and “utilization review” for medical necessity did all the dirty work.

Recently, as reported on September 1, 2024, the New York Times reported “How a Leading Chain of Psychiatric Hospitals Traps Patients,” with the subtitle of “Acadia Healthcare is holding people against their will to maximize insurance payouts, a Times investigation found.”² Deja vu out of the 1980s again.

Like the for-profit psychiatric hospitals of the 1980s, Acadia Healthcare is a large chain of 54 psychiatric hospitals. Profits have escalated since the COVID-19 pandemic. Complaints from patients, employees, and police offers of the illegal detaining of individuals have been investigated and judges have sometimes intervened. The critics claim such patients are held for financial reasons rather than medical ones. Strategies include persuading insurers to cover longer stays with exaggerated symptoms, smaller medication changes, less food intake, and the falsification of records. Rapes, assaults, and unclean conditions are described.

In a more personal example, I was asked to consult about a patient suicide in a psychiatric hospital. Records clearly indicated inadequate staff monitoring of patients, inadequate psychiatric evaluations, and omission of standard treatment options.

So we have gone once again from too much unnecessary treatment to not enough treatment. Whether it is called managed care or not, we do seem to be repeating the same hospitalizations that emphasize profits, the exact situation that allows for-profit managed care to bloom and produce the same boomerang effect of overly limiting psychiatric and outpatient services. Really, for-profit psychiatric hospitals and managed care are 2 sides of the same coin, illustrating profits over patients but in almost opposite ways.

We still have managed care by any other name in the United States, and that means we are still struggling to find a health and mental health care system of higher quality of care. Anyone for a national single payer system like most all Western countries have?

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. Moffic HS. Challenges & Solutions for Managed Behavioral Healthcare. Jossey-Bass; 1997.

2. Silver-Greenberg J, Thomas K. How a leading chain of psychiatric hospitals traps patients. The New York Times. September 1, 2024. Accessed September 20, 2024. https://www.nytimes.com/2024/09/01/business/acadia-psychiatric-patients-trapped.html