Group for the Advancement of Psychiatry - The Story of GAP


Patient Care and the Future of Psychiatry in the Age of Managed Care

GAP - Committee on Planning and Communication
April 1997

The Problem

Managed care has become the dominant force shaping the future of psychiatry.  While managed care was conceived as a means of providing high quality service in a cost effective manner, in practice this has often meant an overriding emphasis on reduction of cost of care.  In the process, patients with mental illness have suffered.  This focus on cost has led to reduction in length of inpatient stays, cuts in day treatment, and limitation of outpatient services.  We believe that these cuts often have been excessive and have damaged the quality of patient care.

In some managed care settings, psychotherapy has been taken away as a reimbursable treatment performed by psychiatrists.  In others, reduced reimbursement for psychotherapy and increased demand for paperwork has created powerful disincentives for psychiatrists to provide psychotherapy services.  To the extent that psychotherapy is recognized as medically necessary by managed care, it has been drastically reduced in length and depth.  An additional problem created by this managed care climate is that psychiatric residents are finding it increasingly difficult to receive adequate training in psychotherapy.  This has long range implications for the quality of psychotherapy treatment and supervision of other mental health care providers by psychiatrists.  If these trends continue, psychiatric practice can become primarily triage, consultation, medication management, and team management.  Individual and group therapy will no longer be within the psychiatrist's job description or expertise.

Many managed care companies are severely limiting the number of psychiatrists on their provider panels.  These reductions and the changes in practice patterns forced by managed care could radically reduce the number of psychiatrists available to treat patients with mental illness.  For example, a highly successful physician management consultant recently told the 41 psychiatrists on staff of a private psychiatric hospital, that with 150 inpatient beds, 200 day hospital patients, and 10,000 outpatients, they only needed 10 psychiatrists. Some estimates are even more draconian, for example suggesting that the United States only needs one psychiatrist for every 200,000 people.

The rhetoric of managed care argues that more "efficient use of resources" will allow treatment of more patients through outpatient services.  Financial reports suggest that the savings have been used for greater profits to the managed care companies, their executives, and shareholders.  Rarely do they reach the large number of individuals with mental illness who are not being treated.

Managed care arose from a social and economic need to control health care spending and correct an unfair distribution of health care resources.  But, it has created serious problems of its own that must be addressed and corrected.  The future of patient care for those suffering with mental illness depends upon our ability to address this challenge.

What Must Be Done

I.Psychiatrists must hold firm to certain guiding principles.

A.We are physicians committed to our patients

The quality of care our patients receive is our first priority.  As a profession, we must identify and resist attempts to compromise our medical responsibility by those who would dictate the patient's treatment.  We must reassert our commitment to our patients and must protect their confidentiality.

B.The bio-psycho-social approach must guide our work.

The purely biological approach that ignores the psychological and social complexities of our patients lives is inadequate and detrimental to quality care.

II.Psychiatrists must be more assertive in defining the practice of psychiatry.

A.We must base the practice of psychiatry on the best interests of our patients, not primarily on the economic demands of those who consider economic factors to be primary.

We must not be blind to social and economic imperatives, but we must advocate for the care of our patients as we design more cost-effective and socially responsible systems of care.

B.Psychiatrists are the most qualified clinicians to do initial evaluations for many patients. 

This is especially critical for more complex patients.  Examples include:

1.Patients with serious and persistent mental illnesses

2.Patients with co-morbid medical conditions

3.Patients with suicidal, homicidal, and other dangerous behaviors

4.Patients with treatment resistant illnesses

5.Patients who don't fit standard treatment approaches

C.Psychotherapy is an essential treatment for many patients.  Performed by psychiatrists, it becomes uniquely valuable when coupled with other treatment modalities which only a physician can provide.

We must vigorously resist the devaluation of psychotherapy and reverse the severe limitations placed upon psychiatrists who provide needed psychotherapy.
Examples include:

1.Patients with persistent psychiatric illnesses who need frequent visits

2.Patients who find it difficult to work with multiple care providers

3.Patients who already have a special working relationship with the psychiatrist

III.Psychiatrists must insist upon quality care for our patients; quality care requires  that:

A.Medical decisions must be made by treating physicians in collaboration with their  patients, with minimal interference by third party representatives.

B.Confidentiality, an essential element of quality care, must be protected to the greatest extent possible .

We must be sure that patients are fully informed about waivers of confidentiality they may be asked to sign.

C.We support the American Psychiatric Association's work to establish published  treatment guidelines for specific psychiatric disorders. 

These need to be used within the context of sound medical judgment and an individualized treatment plan specific to each patient.

D.Outcome studies must be supported.

These should be well designed and meaningful rather than simply a marketing ploy.  They should measure treatment efficacy and the efficiency of resource utilization.  The results of these studies should be used in developing our evolving treatment guidelines.

E.It is or duty to identify and address patterns of poor patient care wherever they  occur.

These patterns lead to misdiagnoses, poor triage decisions, poor treatment planning, use of unskilled providers of care, and stigmatization of and discrimination against psychiatric patients.  Any limits on exchange of information including gag rules cannot be tolerated.

IV.Psychiatry as a profession must address these issues now.

Direct psychiatric care including psychotherapy by psychiatrists is critical for many patients.  Reaching the underserved populations must be a high priority.  Realistic estimates of the need for psychiatrists must be based on clinical needs, not simply the economic imperatives of managed care or any other system.

Submitted by the GAP Committee on Planning and Communication:

Doyle Carson, M.D.
Paul Fink, M.D.
Robert S.  Garber, M.D
Robert W.  Gibson, M.D.
Richard Harding, M.D.
Donald Ross, M.D.
Harvey Ruben, M.D.
Melvin Sabshin, M.D.
Michael Zales, M.D.

Ginsberg Fellows:
Sunil Chhibber, M.D.
Jacqueline Haimes, M.D.
Michael McBride, M.D.
Alan Newman, M.D.

Ittleson Consultants:
Robert Higgins
Justin McCarthy