Lim-Sanity: The Middle and Working Class — Profitizing Mental Health.

THE MIDDLE AND WORKING CLASS carry another profit burden — profitizing mental health.

If you can afford to pay out-of-pocket or carry premium health insurance, then for the most part, accessing behavioral health services is typically an after thought.  For others, however, there is a reason why they are members of Health Maintenance Organizations or Cooperatives — its what they can afford.

AND there are definite beneifts.

For example, members benefit because of cost breaks.  A  $25 (approximately) per-session co-pay makes it possible for people to explore the possibilities of reducing anxiety and/or depression symptoms,  work through painful issues, reach goals, improve relationships, become better parents, beat addictions. A discounted co-pay and hefty insurance break on meds also represents a legitimate value.

Members also can go out of network and get some percentage reimbursed.  However, there is a lag time between payment and reimbursement. Many members stay in-house and find convenience and value with integrated care (Primary Care Physicians, Psychiatrists, Psychologists, Nurse Practitioners, Psychotherapists, Nurse Practitioners, RNs working as a team all under the same roof).

So that’s all good. And here is the challenge:

The profit “medicalization” of behavioral health as used by University of Wisconsin professor Bruce Wampold (national advocate and critically acclaimed author of “The Great Psychotherapy Debate” ), is similar to “regressive taxation.”

First a very brief explanation of “regressive taxation,” (with extreme apologies to my cousin Diane Rogers, a brilliant economist, who writes a pretty cool blog called “the economist mom” ): A tax is “regressive” when tax revenues are collected from a disproportionate majority of middle and lower income classes and then used to benefit the entire community (e.g. proceeds from a state lottery, cigarette tax)

Everyone, therefore, affiliated with the HMO benefits from the revenues garnered by the working and middle class consumers. And it’s no secret that insurance companies and HMO’s are profit-seekers

So what’s the best way for the HMOs to profit in behavioral health?

  1. Make a psychiatric diagnosis of a disease of ALL PATIENTS seen – thus setting everyone up for medications.
  2. Treat the disease with the most cost-effective/profit-maximizing solution as possible (cookie-cutter approach, use the same therapeutic “program” for ALL PATIENTS)
  3. Treat them as quickly as possible (as to get new patients to pony up new revenues)
  4. Keep them OUT of hospitals

A patient is seen by a psychiatrist and gets a prescription, refill, change prescription, or increase in prescription. The more patients the HMO psychiatrist can see per day, the more potential $$ to the HMO. The psychiatrist then refers patients to the psychotherapist or psychologist. It’s their jobs to:

  1. Make sure the patient does not go OR go back for psychiatric hospitalization.
  2. Make sure the patient stays on medication or gets refills when needed
  3. Uses the same psychological approach as mandated by the organization (in an attempt to efficiently assembly line the most consistent outcome (profit) with the lease amount of effort)
  4. Get the patient out of the door as quickly as possible and/or convince the patient to go to psychotherapy group

Group therapy is a cash cow — the more people per group, the higher the total co-pay per therapist. Therefore, more $$ per therapist time (e.g. one patient for 60 minutes per therapist =$25 co-pay. 10 patients per group for 60 minutes per therapist = $25 x 10 co-pay. Therefore, $250 vs. $25).

However, what we are starting to realize with some certainty is this:

  1. The psychiatric medical model (which drives behavioral health care) is primarily based on dispensing medicine to make symptoms go away … HOWEVER … Medications alone, in the long run, might be making most people worse (Dr. Joseph Burgo has a fantastic blog called “After Psychotherapy.” Check out His blog cites plenty of research and points to this: A person who only uses medications to treat depression or anxiety, in the long run, will get worse. In other words, they will get sicker.
  1. Certain communities with people who have GREATER mental health needs and greater hospitalization rates receive FEWER services than communities with fewer needs. Why? Because the community with greater needs and hospitalization needs cut more into profit than the community with fewer needs. Therefore, the  community with members who are prone to more hospitalizations, who have fewer routine “maintenance” visits to the psychiatrist or therapist is LESS PROFITBALE. The HMO will a) attempt to engage members more b) if that fails, consider cutting back on that community. The community with members with lower hospitalization rates, who frequent psychiatrists and therapists more often (are “maintaining” health) are MORE PROFITABLE. More profit = more $$ to invest. Less profit = less $$ to invest.  Again, the sick get sicker.
  1. Standardizing psychotherapy approaches do not improve outcomes in the long-run.  According to an NIH meta-analysis (click on link), psychotherapy outcomes are better predicted based on the connection between client and clinician, the expertise of the clinician, and far less than what kind of therapy the clinician is using. The meta analysis shows that CBT and non-CBT techniques have no outcome differences in the long-run.  I happen to agree. I also happen to practice mindfulness CBT and ACT (two “evidence-based” approaches).  The HMO, however, puts a premium on standarization and process and “evidence-based” practice (because “evidence-based” practice is the “easiest” to standardize and, thus, in the mind of the HMO, most cost-effective.

What is this all mean?

The HMO has to profit.  That’s the honest truth. However, mental health is not the same as producing widgets and wedges.  The assembly-line, process model WILL produce efficiencies, reduce bottle-necks, and maximize profit for widgets and wedges. However, mental health is not concrete. It is not a widget.  Slapping everyone with a medical diagnosis, placing an emphasis on medication, using the same cookie-cutter approach, WILL profit a company if mental health were as simple as widgets and wedges.  And in the short-run, the HMO will profit. But in the long-run, members will become more dissatisfied and disgruntled with cookie-cutter psychotherapy and being put on an assembly line. Thus, people will frequent therapy less — which, in turn, may increase dependence on medication, refills, change in medications, increase dependence on medications (e.g. benzos), AND increase chances of hospitalization (the very thing HMOs are desparate to avoid).  In the field, there is a growing belief and validation that psychiatry is becoming “iatrogenic,”  that is, making a problem worse or at times creating a problem that didn’t exist by over-prescribing.

Studies show that for people who use only medications to treat mental illness, tbe more medications they are on, with increasing dosage frequency, the longer they are on them, the greater chance that their symptoms will get worse.  Hence, increasing the chances of hospitalization (the very thing the HMO is trying to avoid).  The only long-term winner is the pharmaceutical company. In addition, because of high work loads (to maximize profit), this approach will also continue to burn-out good practioners.

For the HMO, in the long-run, they must shift their metrics away from process numbers (how many patients seen by practitioner per day, per week, per month, per year), efficiency measurements (how many times a person returns per practitioner, per month, per initial intake; what percentage are referred to this or that) and focus on a new type of metric — wellness metric. The claim would be this:  it is impossible to accurately quantify “wellness.”  The counter-claim I would make is this:  It’s not impossible. It’s just difficult and you increase the uncertainty variable in the equation.  Profiteers do not like this. Thus, they will not take chances.  They do not like change.  When “Activity Based Cost Accounting”  was created, traditional accountants said, “ba hum bug,” it’s too subjective.”  Activity Based Cost Accounting is now common place.  The HMO that moves away from processing mental health as if it were widges and wedges, is the HMO that will have members who are healthier and happier. That HMO may profit just a bit less … however, it will be still in business of behavioral health.

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About David Lim

David (LCSW) is a licensed therapist (LW60177117, State of Washington) and parent coach. He holds a MSW from the University of Southern California, an MBA from the Merage School of Business, University of California, Irvine, and has Bachelor’s Degrees in Communication and General Science from Purdue University. David has a diverse professional background – which includes providing individual psychotherapy, facilitating psychotherapy groups, serving as a parent coach, teaching (adjunct professor at the University of Southern California), business and non-profit leadership in Seattle and Los Angeles.

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