Conference 7.286::digital

Not to minimize your concerns, but my understanding is that all the HMOs have
very limited mental health coverage (typically 20 visits/year).  The Digital
Medical Plans pay 80% of the first $2000 and 50% after that.  People with
long-term mental health needs probably can't afford to be in HMOs.

    HMO's don't send out notices, and things change quite often.  If they
    discovered that they can provide in-house services cheaper than
    contracting, then that's what they'll do.  You should contact your
    health plan and ask them what is (is not) covered, and if they are
    changing the service providers.
    
    Mark

    to .0
    
    Not so much 'profit hungry insurance companies' but the reality of
    having to make choices of where to spend limited health care dollars.
    This kind of choice is an integral part of rationed health care, and
    just about every other proposal having to do with the U.S. health care
    system. With no value judgement intended, it has to do with dealing
    with mental health, which clearly involves quality of life, versus
    dealing with life threatening illnesses. The buck only goes so far.

I think we are all missing out on the point in .0.  It can take months, even
years for a sufficient level of trust to be built between patient and mental
healthcare provider such that the causes of problems, rather than the symptoms,
can be treated.  As such, to suddenly force a patient to change providers could
cause a major setback in the treatment which could easily cost more than the
HMO would be saving by switching providers.

Mental healthcare rarely works well when provided on an assembly-line basis.

Also, please note that .0 concerns an HMO, not JH.

Bob

Re: .3

>    system. With no value judgement intended, it has to do with dealing
>    with mental health, which clearly involves quality of life, versus
>    dealing with life threatening illnesses. The buck only goes so far.

I'd say this is a pretty strong value judgement all the same, intended or
not.  I agree that the buck only goes so far, but somehow I don't see health
care being quite so black and white.

Bob

    Therapists are certainly NOT interchangeable.
    
    Moves like this will injure the people in therapy,
    either buy forcing them to pay out of their own
    pocket rather than endure the disruption of
    changing therapists, or they will be unable
    to afford this, and will stop therapy or endure
    a painful transition to the company sanctioned therapist.
    
    And these people go around advertising about protecting
    the "wellness" of their clientele?
    
    Sheesh!
    
    Dan

    
    I think the *real* issue is this changing of the rules after
    they've sucked you in for a year. I agree to pay a certain
    amount of money to join an HMO.  I make this agreement
    in November, and am committed for more than a year.  That,
    in my view, is an implied contract between me and the HMO.
    I made my decision based on the level of service advertised
    by that HMO in a "fair" during the fall.  Why should they
    be allowed to make changes during the contract period, when
    I am not allowed to change HMOs?
    
    Glenn

    
    Re: .3
    
    > Not so much 'profit hungry insurance companies' but the reality of
    > having to make choices of where to spend limited health care dollars.
    > This kind of choice is an integral part of rationed health care, and
    > just about every other proposal having to do with the U.S. health care
    > system. With no value judgement intended, it has to do with dealing
                                                +++++++++++++++++++++++++
    > with mental health, which clearly involves quality of life, versus
      ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
    > dealing with life threatening illnesses. The buck only goes so far.
      +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
    
    Really?  Are you an expert on the interrelationship between mental
    and physical health?   Do you have any idea how much of our physical
    health is directly connected to emotional illnesses?  
    
    Also, since when, for example, is hay fever, or eczema, or a small
    laceration a "life threatening illness."  None of those are slated
    for reduced or eliminated coverage.
    
    Steve
     
    
    

>    I think the *real* issue is this changing of the rules after
>    they've sucked you in for a year. I agree to pay a certain

  I agree, the #1 issue is that the one-year HMO contract is apparently binding
on only one side, that is, they can drastically reduce the level of service 
halfway through the contract year but we (employees) can't get out of the
contract until yearend.
  This HMO's proposal was probably driven by bean-counters who actually believe
that providing X number of session hours per year limited to their staff mental
health professionals is equivalent to providing the same number of session
hours per year from a long list of mental health professionals under contract.
As several replies have said, psychotherapy can NOT be done on an assembly line
basis. I doubt that this HMO would have made this proposal if their staff and
contract mental health professionals had had any real power in the decision-
making process.

    CMHC is one of the smallest, if not the smallest HMO in central Mass.
    The competition is stiff and some HMO's aren't expected to survive.
    My guess is CMHC isn't going to be a survivor.
    
    
    Mike

    And you go in and find out that the on-staff counsellors all have
    degrees in Social Work or Education, instead of Psychology.  Big
    difference in training.
    
    Some mental health problems *are* life threatening.

    
    
    .11....off the beaten path but...
    
    	Prior to working for DEC I was a graduate Clinical Social
    	Worker for over ten years.  My undergraduate training was 
    	in psych (as it is with many SW's) and according to many 
    	of my psychologists co-workers, my graduate training was 
    	similar to their training.  In fact, if you put aside the 
    	rhetoric from our professional orgainzations, we were very
    	much alike in how were were educated, trained and practiced.
    
    	The important point in all this is not if you see a social
    	worker, psychologist or counselor; it's that both the
    	client and therapist trust and respect each other and to 
    	do this the therapist must put the client first.  I don't
    	know if a therapy staff employed directly by and exculsively
    	for an HMO could keep the best interests of his/her clients
    	always ahead of the HMO's interests.....I don't know that 
    	this can't be done satisfactorily.  
    
    	As was mentioned earlier, times being what they are, stress 
    	(heavy duty) is now a way of life and if someone needs pro-
    	fessional help to keep on an even keel or to climb out from 
    	a situation, then they have a right to that treatment as 
    	outline in the HMO contract they signed; not a "surprise" 
    	six months down the road.
    
    	IMHO	                                            

re 2913.11 >>>  regarding social workers in clinical settings as opposed to 
psychologists...i need to point out some stereotypes....

My husband is a trained, practicing, licensed clinical social worker who is 
responsible for providing psychotherapeutic service to individuals, families
and couples in a private mental health clinic. He has a BA in Psych and 
MSW in Psychiatric Social Work.  His therapy work does not differ from
that of clinical psychologists or psychiatrists except that psychiatrists
are MDs and can prescribe drugs. 

My husband has social workers, psychologists and psychiatrists working for him. 
The psychiatrists on staff are there to dispense medication only (and at a
very high salary, I might add). The counseling and therapy is performed 
mostly by social workers.

The point is: In terms of hand-on psychotherapuetic training, these social 
workers have had more graduate school experience in clinical therapy than 
'psychiatrists' who spend the majority of the time studying medicine. In 
addition, alot of people who are 'psychologists' are not really practicing 
clinicians; they are more involved in other disciplines of psychology:  
education, testing...not the same as helping an individual or family in crisis.
     .....not the same as providing short or long term therapy. 
    
    Most MSWs have undergraduate degrees in psych. 

When you are dealing with very severe mental illness requiring hospitalization,
medication, etc...you are more apt to deal with a psychiatrist.

What you are looking for in a outpatient mental health setting is a high 
degree of clinical hands-on, interactive, experience...graduate AND 
post-graduate credentials....There is a misconception that this service 
is dispensed only by MDs or 'psychologists'.  Someone can call themselves 
    a 'psychologist' with a BA, MA, or PhD, MEd. The title is not
    definitive... same with the term 'social worker' which is traditionally 
    interpreted as someone who deals with public service and welfare issues 
    only. 

    As with anything...there are good and bad ones.  As with anything,
    buyer beware.

    
    
    Re: .13
    
    You have made some good distinctions, but my understanding is that
    programs which turn out MSWs, psychotherpists, psychologists, etc.
    usually have very different focuses.
    
    For example, as I understand it, you could pursue an MSW program and
    later be able to hang out a shingle as a pyschotherapist, but that the
    training and clinical experience you would need to do pyschotherapy
    work might come out of a personal interest you pursued via electives in
    the course of your MSW work and not necessarily an intended result of
    the program.
    
    fwiw,
    Steve
    

    re .14 ....yes..i agree..you can, by electives, pursue your interests and 
    strengths within different degree programs...it depends on what you want to
    actually do when you get out...also...within the psychological world
    there are many types of therapeutic techniques that differ from
    school to school. 
    
    I find that many many people are confused by all the titles, etc. There
    is definitely a hierarchy protected by the likes of the AMA.  There is
    a lot of overlap that is not really understood by the lay person.
    

Re: many previous -

Having been a 99% RO noter for 6 years, I think a great cost savings measure 
would be as follows:

 1) Pool the funds users would expend for mental health services -

 2) Set up a dedicated NOTES conference paid for via #1 -

 3) Presto! - Tele-therapy.

 4) Apply cost savings  (#1 - #2) directly to #3's paychecks

Might work.

    A managed care company, either an HMO or a PPO, developes a panel of
    providers which meet its own criterion for providership.  Most of the
    time, a client can only access his/her mental health benefits if 
    he/she sees a therapist who is a member of that provider panel and then
    only for as many sessions as the reviewer for that company feels is
    justified as medically necessary. Sometimes there is a provision for
    the client to see an out of network provider, at a reduced benefit and
    with a higher deductible. As an altrnative it may be desirable for a
    client to stay with a provider he/she knows and negotiate a fee with
    that provider for self payment, since in long term therapy only a
    portion of the fees over a years period will be reimbursed by
    insurance.
    
The question originally posed: Can they decide to stop reimbursing my
therapist? (paraphased)

    Must be answered 'yes'.  It has been happening increasingly, not only
    with HMOs but with other 'managed care' plans for at least two years. 
    To the best of my knowledge, no one has yet successfully challenged
    this in court.

    It is brutal for the therapists and can be terrible for the patient/
    client.  In fact, many skilled and licensed clinicians are being slowly
    driven out of business, at least in Massachusetts, because they are
    refused membership in provider panels.

    It has the responsible-sounding name "managed care".  In fact, the
    insurance companies cannot control cost by limiting demand for 
    psychological services so they've chosen to restrict supply by limiting
    the pool of providers [therapists] and limiting the number of sessions. 
    Note that there is a serious loss of privacy that resusts from the
    provider having to convince a reviewer that more sessions are needed.

    We have opted for HealthNet or whatever they call it this year.  At
    least we have some benefits for mental health that we can control. We
    are fortunate that Digital offers this option, most employers don't.
    Not that this helps you now that the window is past for changing your
    choice.  About all you can do is to press your case with Human
    Resources here at Digital (good luck).

    But the trend is ominous.  Highly trained, skilled, experienced 
    therapists whose services are needed more than ever, are being forced
    out of the field.  Many have been clinging to a fond hope that the
    Clinton plan would improve matters.  That grows increasingly unlikely.

    The societal impact of limited mental health care at this time in our
    history can only be frightening.

    Finally, re .14:  Psychologists aren't all created equal either.  Your
    Ph.D. psychologist may have learned more about rats and statistics than
    clinical matters, but it won't keep him or her from hanging out a 
    shingle in most states.  But when I need help, I look for the person I
    have the most confidence in, and I have no preference for a 'doctor'
    over a 'social worker' (I'm too knowledgable about the business to buy
    into that nonsense).
    

    Regarding the general issue of dealing with any large bureaucracy:  get
    complete documentation.
    
    My HMO (Pilgrim) has a long, boring document called the "Summary Plan 
    Description" that describes my benefits and relationship with Pilgrim 
    in far more detail than the pamphlets you get when you sign up.  It has 
    all sorts of stuff about appeals and grievance procedures.  Yours might 
    have information about changes to the plan and how subscribers are 
    to be notified.
    
    I got my copy by making a few calls to my HMO (they apparently weren't 
    used to sending this out to subscribers).
    
    Reading this document can be a useful exercise.  When you are done,
    you might end up knowing more than some of the folks at your HMO.  For
    example, I learned that percentage co-payments are based on a
    "reasonable and necessary amount", set by my HMO.  Providers will often
    charge you based on their _billed_ amount, which can be much higher.
    
    -andy

    re .18
    
    True about reduced jobs for therapists.  My wife, with an MA degree
    in counseling psychology and 10 years experience at the clinic where
    she works is losing her job in a month.
    
    It is hard getting into private business in New Hampshire with only
    an MA, because the state licensing law requires you to have the
    highest degree in your specialty.   Since there exists a PhD in
    psychology degree, you have to have that to get licensed.  But
    since an MSW is the highest degree available in that specialty,
    even though the course contents are very similar to an MA-psych,
    somebody with an MSW *can* get licensed in New Hampshire.  Amount
    and nature of experience is not considered, which is probably a
    greater determining factor than the letters after the name.
    
    Without the license, you can still practice, but insurance companies
    will not pay you.  The patient has to pay the whole bill.  This
    cuts down on the number of patients who can afford to see you.
    
    She could get licenced in Massachusetts - but the application form
    is the thickest government document I have ever seen, and they want
    to know everything about you.  (Actually, our IRS tax return last
    year was thicker...  :-( )
    
    As for the difference between MSW and MA-psych, the variation between
    schools is probably greater than the variation between the degrees.
    Where my wife went to school, the MA-psych program had more time
    spent in internship.
    

    The anonymous author of .20 has requested that .20 be deleted.
    
    Bob - CO-moderator DIGITAL

    The following entry has been contributed by a member of our community
    who wishes to remain anonymous.  If you wish to contact the author by
    mail, please send your message to QUARK::MODERATOR, specifying the
    conference name and note number. Your message will be forwarded with
    your name attached  unless you request otherwise.

				Steve






    My wife has been seeing the same therapist (technically a pastoral
    counselor since he has a clinical and divinity degree) for nearly 10
    years.  She suffered severe abuse as a child.  In the words of her
    therapist "In over 17 years of practice her case is the most severe he
    has encountered."  She suffers post traumatic stress syndrome because
    of it, has flashbacks triggered by present events where she is actually
    transported back to her childhood and "hides" from her stepfather who
    alternately verbally and physically abused her, and in the last three
    years has been hospitalized twice for this.  In spite of this she
    functions quite nicely most of the time.
    
    She is a member of a well-know NH-based HMO which has already done what
    has been described in this note.  It is/has been like pulling teeth to
    get the HMO to approve continued service from her current therapist
    *AND* even difficult to get them to do for their own providers.  The 20
    visits guaranteed in the policy is a joke.  They are out to maximize at
    the expense of their clients.
    
    fwiw...
    

    In Cincinnati, the HMO is ChoiceCare -- a BIGGGG joke!!
    
    ChoiceCare gave approval to admit my daughter for attempted suicide,
    stating that we had 8 days in-patient time remaining for the year. 
    The day after admission, ChoiceCare notified me that they had made an
    error, and that my daughter only had one day remaining.  I went to the
    hospital to have her released, but the doctor refused release because
    of her intent to commit suicide.  She remained hospitalized three
    additional days, for which I now owe nearly $2,000.  All ChoiceCare has
    so say is "we are sorry."
    
    Bull Crap!!!
    
    I'm waiting appeal.

Let me share a personal situation.

My son, who will be 5 in May, has developmental disabilities with behavioral
problems similar to those of autistic children.  The doctors he has seen
agree that there is no medical treatment other than regular, continuing
psychotherapy by a psychologist specializing in behavior modification.

We found a top-notch behavioral psychologist and have been working with him 
for over two years to handle our son's behavioral issues.  In addition, we 
are seeing another psychotherapist to deal with the stress that our special 
needs situation places on our entire family.  It is precisely because of the
trust and relationships built up over the long term that this treatment is
effective.

These services we are receiving are essential to the well being of our 
family.  Nobody in our family would be able to function effectively without 
them.  Unfortunately, none of the HMOs that serve our area will authorize 
treatment from our therapists.  Even if they did, they would cut off 
service after 20 visits (or less).  And forcing us to change therapists would
be immensely destructive to all the progress that has been achieved.

Our only viable choice is to continue in the Digital Medical Plan, even 
though the weekly payroll deductions over the past five years have gone from 
$7 to $15, $34, $55, $89 and now $108.  That's a 1500% increase, far in
excess of the rate of increase in medical costs.  After we make these 
payments, we are still liable for between 20% and 50% of the therapy bills, 
which are quite substantial (and ineligible for our out of pocket maximum).

The bottom line is no managed care program can come close to meeting our
family's essential mental health needs.  And we are not alone; there are
thousands of families in similar situations.  It is not pretty to see a
friend's four year old child hospitalized for nervous breakdown because
their family's managed health plan denies them the mental health care they 
need and they cannot afford to pay for continuing treatment on their own.

It is appalling that the managed health community economizes on mental health
care by dropping therapists and denying benefits.  This short-sighted policy
creates needless misery and suffering for many families and results in 
_higher_ costs over the long run.

    Here in the GMA healthcare region, one can choose an HMO-elect.  This
    allows one to have the good, the bad, and the ugly!  We finally broke
    down and went Harvard-elect in order to provide ourselves with the
    illusion that WE have control over our insurance destinies!  The
    mental health options are the same as JH Plan I (70% instead of 80%
    that we carried in JH Plan II).  

    justme....jacqui

    p.s.  I have been seeing the same t-pist since 1976 and was NOT about
          to change as she is a godsend (i.e.  a Dr. of Ministry and a 
          licensed psychologist)!  I had to change my internist to a new
    	  primary care but seem to have hit the jackpot there!  The other
    	  issue important to me was maintaining my present opthomologist 
    	  also as he has taken me through the blinding part of iritis with
    	  full success regaining eyesight!   

    It pains me to read all of these horror stories.  It seems like the
    only viable option these days is to have a working spouse who has REAL
    medical benefits at a reasonable cost.  I opted out of Digital's
    medical program two years ago, and my family is on my spouses Aetna
    managed health care plan.  All of our physicians are in the plan, and
    we have had no problems getting treatment under the plan.   I fully
    agree with prior noters that HMO's primary objective is profit -- not
    patient care.  I hope that those who have been having problems win
    their appeals, or, lacking that, win seven figure lawsuits.