Psychologists leaving managed care


Carol Houde, Ph.D., of Nashua, New Hampshire is satisfied with her decision to leave managed care behind. Having an independent practice has allowed her to to do her job in a sensible way, she says.

By Phyllis Hanlon

In 2001, the Massachusetts-based advocacy group Consortium for Psychother-apy conducted a survey of its membership and discovered that psychologists in independent practice who don't accept insurance possess a higher morale than those who do. In a world where managed care predominates, this fact may come as no surprise to psychologists who are taking that leap of faith and leaving the hassles of dealing with insurance carriers behind. But is the grass really greener on the other side?

For many psychologists, the frustrations of dealing with voluminous amounts of paperwork, lengthy authorization processes and ill-informed managed care personnel as well as low reimbursement rates have prompted the switch to independent practice. With 20 years experience, Paul Ling, Ph.D., president of the Consortium of Psychotherapy, eased out of managed care's clutches in the early 1990s. At that time, his appeals to extend therapy for a significantly traumatized patient met with flat-out denial and hostility.

"They wanted team players and if I didn't go along, they wouldn't refer me any other patients," Ling says. "I thought that was totally outrageous." When Carol Houde, Ph.D., of Nashua, N.H., attempted to join a managed care panel, she received an icy reception that, instead of disappointing, thrilled her. She says, "That [response] was very instructive to me. There is something very wrong that I am delighted by a failure in some ways of doing what I thought I was supposed to."

When another managed care company refused to cover therapy unless her patient submitted to pharmacology as well, Houde edged closer to an insurance-independent model. "I found myself not being able to practice in a way that was sensible to me. My work was being reviewed by people with less training and fewer credentials," she says. Those issues forced her to confront the truth. "I hated what I was doing in terms of having to work with the managed care system - filing reports, keeping track of authorized sessions." The decision to leave managed care was a bit scary, she admits, but "the sense of relief I felt that my life was my own was great."

The issue of confidentiality can be the catalyst for some practitioners to leave managed care. Marilyn Ritholz, Ph.D., a therapist at the Joslin Diabetes Center in Boston says, "You have to send in forms, sometimes by fax. How do you know who is seeing that information?" She adds that supplying patient information to an individual whose qualifications are not identified is also unsettling. "It seemed I was never talking to a clinician who understood the case, but to some bureaucratic person," she says.

Sarah Avery-Leaf, Ph.D., who practices in Durham, N.H., expresses similar apprehension. "There are very important ethical concerns around involving not just one or two, but a range of individuals connected with the managed care company in the confidential details of treatment. That, for me ethically, is a real bind."

Before breaking ties with managed care, psychologists should bear some important factors in mind, according to those who have made the break. To maintain the current patient base, a practitioner may have to consider lowering fees or adopting a sliding scale. "You have to count the time involved in going through all the song and dance," says Eric Mart, Ph.D. of Highland Psychological Services in Manchester, N.H.. Seeing patients at a lower fee he asserts saves "a lot of aggravation" and usually balances out in the end. Mart adds that psychotherapists whose spouses "have a day job," alleviate the financial pressure.

Having a well-established practice with a solid referral network also eases the transition to a practice without managed care. In some cases though, a marketing strategy is necessary to survive and grow. Pressured to perform "cookie-cutter therapy," Bruce Altman, Psy.D., of Associates for Cognitive Therapy in Portsmouth, N.H., opted out of the system with the understanding that he would have to undertake a more direct-to-consumer approach to maintain his practice. "We've started a community seminar series where we rent space at a local hotel and do our own advertising and give free talks," he says. In collaboration with other area psychologists, he is changing the way he does business.

Houde adds that the un- or low-compensated time you spend translates to marketing costs "to get your reputation established as someone who will go the extra mile." She emphasizes the importance of finding a specialty area that will substantiate your name as an expert in the community.

Avery-Leaf believes that making patients aware that they have personal choices regarding their medical decisions is vital. "Psychologists should educate clients as to their choices around mental health care because they might not be aware of the potential for privacy violation that comes with having their managed care company reimburse them or be billed directly for their services," she says. Those who take charge of their own therapy are sending a clear message. "They are saying I value myself and I value my needs and my emotional health enough to invest in getting help," she says.

Although there can be a few bumps in the road, most psychologists interviewed on this subject emphatically agreed that the downside to operating a managed care-free practice are minimal at worst. According to A. Richard Tomanelli, Ph.D., of Greenwich, Conn., determination and an ongoing belief in your abilities as a psychologist are the keys to success. "Psychotherapy is not something that social workers, counselors and psychiatrists do. It's different and it's a valuable, desperately needed commodity," he says. He advises psychologists to have confidence in the years of training and hard work they have endured. "I think managed care is the bane to the mental health professions. It is destroying professional mental health treatment."

Altman agrees. "When we have patients in abusive relationships, we advise them to get out," he says. "That's what I decided to do."

Psychologists leaving managed care (February 2003 Issue)

Psychologists leaving managed care
(February 2003 Issue)