Cost Containment or Quality Care? Health Issue

By Kathy J. Marshack, Ph.D., P.S.

Are you a good old-fashioned American Capitalist? Most of you who are reading this article are entrepreneurs or business owners or executive or managerial employees of local businesses. This makes you American capitalists in the truest sense of the word. You believe in working hard, competing for profit, and setting your sights on the American Dream of financial success and security. Is it any surprise then that health insurance companies are American capitalists too? They were founded by visionaries who recognized a market just waiting to be tapped, employers and employees who needed help paying for medical expenses and who were willing to pay in advance for the insurance that the costs would be covered. Being capitalists, they used the existing American system for setting up their businesses and arranged to make a profit. As more people founded insurance companies, the competition began to heat up, which only fueled the enthusiasm of these early entrepreneurs. Competition honed the industry into the incredible, unbeatable American Dream Machine it is today. Don’t some of you secretly wish you could have been in on the ground floor of this multi-billion dollar industry?

Most of you readers were not in on the ground floor, nor do you own a piece of an insurance company. Primarily you have not been looking at the profitability of a particular insurance company, nor the investment potential of the market/insurance industry as a whole. Rather your main interest in the health insurance business is whether you have a fair and cost-effective plan to offer your employees and whether you, yourselves have the type of insurance that will take care of your health needs. However, in making decisions about buying and using health insurance plans, it is important that you understand that health insurance companies are businesses, just like yours. Their goal is to make money by providing a service/product that can be produced as competently and efficiently as possible. The problem is, can insurance business owners make medical decisions that affect your health, without the advice of professionally trained physicians, psychologists, chiropractors, dentists and so on?

The insurance companies of the nineties, and their cost-management sub-contractors, managed care companies, are indeed making medical decisions for each and every member of their plans. And they are doing so without sound medical and/or psychological advice. They are making these decisions based upon actuarial tables, not upon the unique individual needs of each patient. For example if the cost of a mammogram is cheaper than an ultra-sound to detect breast cancer (and it is), your cost-management company may deny the claim for an ultra-sound. If the actuarial tables suggest that most cancer is detected satisfactorily by mammogram and self-exams alone, then to contain costs, they will deny the ultra-sound. However, if you have a history of “breast lumps,” and so far all of them have been benign, but your doctor is concerned that with advancing age there could be an increasing likelihood of cancerous tumors, or that the benign lumps are hiding the tumor, and in your case an ultra-sound is vital, there is still no recourse with the cost-management company. You may still have your claim denied because you do not fit into the range of what is most cost-effective according to the actuarial tables. There just is no room with insurance companies for the exception to the rule.

In psychology and psychotherapy, the picture is even gloomier. If you have a broken arm, the insurance company will authorize treatment. But if you are suffering from anxiety or depression, regardless of the cause or the intensity of the problem, your claim will be challenged by the cost-management company. One reason is that it is not the event per se that is paid for, but your reaction to it. For example, if you are in an automobile accident and your child/passenger loses his or her life, but you survive, you would be expected to be in shock, to be grieving intensely, to be unable to carry on your daily routine for weeks, months or even a year or two. Yet this event may not be allowable under your mental health coverage because you are reacting normally to the stress. In other words, you can only be covered under your mental health coverage if your reaction to the stresses of life are abnormal. But in my experience, even if you are suicidal (which insurance companies do consider abnormal) you will need to get prior authorization from your cost-management company before you can schedule an appointment with a psychologist. Because the psychologist is a specialist, cost-management companies do not make as much money on their services, so they have established a gate to keep the number of referrals to specialists at a minimum. If you are suicidal you must first call your cost-management company for authorization or make an appointment with your primary care physician, who in turn will make a recommendation to the cost-management company to refer you to a psychologist!

What this all amounts to is that psychological and emotional health do not mix very well with health insurance and cost-management companies. It is important to understand the distinctions between the two realms. Health insurance companies and their colleagues, cost-management companies (euphemistically called managed care companies), are in the business of making a profit by containing the costs of health care. While this goal may be needed or even admirable, it has nothing to do with providing the specific medical or psychological care that you or your employee needs today. The kind of mental health treatment that you or your employee needs today should be a decision between the patient and the doctor based upon the specialized needs of one unique human being. While what the patient can afford, either privately or through their insurance plan, should be considered by the doctor and patient, the best medical/psychological treatment that is necessary for this one human being should always be considered first, not secondarily to what the cost-management company will authorize.

Obviously you cannot ignore the costs of health care, even though psychological health care is relatively inexpensive. However, the biggest mistake that patients make is assuming that their cost-management company is making the wisest health care decision for them, when in fact the cost-management company is diagnosing by the actuarial tables. I know of suicidal patients who went untreated because their cost-containment company could not act as quickly as a phone call to the therapist. I know of patients who want a cure for serious clinical depression within the unrealistic five sessions authorized by their cost-containment company.

I know of patients whose personal, confidential medical records are reviewed by the employer’s human resources department before they are reviewed by the cost-containment company clerk, before they are reviewed by the cost-containment supervisor, before they are routed to the insurance company for a similar series of reviews, before the claim is authorized or denied.

Whether the insurance industry needs cost-management or not is not the question here. What is at stake is the quality of your psychological and medical health care. When making these very important decisions about your health care, consider that your insurance company is not the best source of advice on quality of care. They can only advise you on cost of care. For example, if you choose one of their preferred providers the costs may be lower but cost is no guarantee of quality. For quality of care decisions you have more work to do. Searching for a psychologist, for example, requires assessing just what your needs are, what approach would work best for you, what type of professional you can relate to, what credentials and qualifications make this provider better than another and so on. Furthermore, you may wish to work with a psychologist about problems that are perfectly normal, but that you want help with nevertheless, such as a divorce, child behavior problems, career planning, family stresses at work, work stresses at home and so on. Remember, your cost-management company is not under contract to help you with these problems, only those issues that you are handling abnormally.

When it comes to insurance, Americans are soft. We assume that we are entitled to “life, liberty, the pursuit of happiness and health insurance to cover every conceivable medical expense.” Health insurance is an extra. It has its limits. It is time for Americans to build some unused muscle and start making decisions for themselves again. Stop looking for someone to take care of your every health or emotional need. Stop turning these decisions over to cost-management companies. Instead utilize your good old common sense and decide for yourself, with the help of professional advisors such as your trusted doctors, just what is the best psychological or medical treatment for you, your loved ones and your employees.