A Race To The Bottom In Mental Health Care

I braced for an angry reaction from the public relations officials who work for such entities and from the bureaucrats who are busily crafting just such a system in New Mexico. Instead I've been deluged with information and anecdotes about just how far we've already gone down that slippery slope—long before the consolidation of all state-financed behavioral services is slated to roll off the assembly line.

In a nutshell, my informants tell me they've already seen the behavioral health system of the future and it is awful. “Profit before people” could be the banner flying over our presently privatized system. New Mexico's version of Medicaid managed care is called Salud! (Was there ever a less appropriate name to pin on a program that includes alcohol treatment services?)

It is certainly not as comprehensive or as extensive as the planned consolidated system will be, but as a prototype, an early model for a system which operates within the framework of privatized, managed behavioral health care, it is plenty scary all by itself.

But it is in the nonMedicaid part of the Presbyterian Health Plan, the “commercial product line,” that is sold to employers, public and private, all over the state, that the real shenanigans have been bubbling over.

Here's some of what's been going on. It tells us what we can expect (albeit on a grander, more inclusive scale) in a few months once the whole behavioral health enchilada is turned over for management to a Presbyterian, or a Cigna or a Value Options or whatever god awful computer-generated name the winner in the behavioral health giveaway sweepstakes has appropriated.

First, the premiums for Presbyterian's behavioral health plan were raised steeply. The employers had several choices. They could pay the 20 percent or more increase and tighten their belts in other ways; they could drop the package and leave their employees to their own devices for health care; or they could swallow a more modest increase and let the co-pays, the portion of care the employee is responsible for paying, go up dramatically.

Most opted to follow the third course. They cut their losses but retained the basic benefit package, even if the cost to the employee of using the service would be a lot more.

Step two was for Presbyterian to announce to the several hundred masters' level therapists (counselors and social workers, independent practitioners, not employees) who provide the lion's share of the actual behavioral health services to patients in the plan that their hourly rate was being cut from $70 an hour to $60. (I'm told that $70 is already lower than the going rate for private pay therapy in this town.) Those who didn't like it were free to work for other plans that would pay more for the care they provide.

This “Simon Legree” approach to enhancing productivity in behavioral health settings depends on two troubling premises: one, therapists are like mechanics; they are readily replaced or exchanged with no meaningful loss in quality of treatment, and two, the patients aren't going to follow the therapists elsewhere. Patients are only covered by Presbyterian if they are seen by a therapist willing to conform to the Presbyterian payment scheme.

Step three was to announce that the co-payments for each hour of therapy were to be raised from $15 to $25 in many of the plans. Ingenious! Scrooge McDuck himself couldn't have come up with anything more diabolical. Premiums go up, but therapists' charges are capped at $60 and co-payments are raised to $25, so Presbyterian's share is just $35. Net effect (or is it gross?). Patients pay more; therapists get less and Presbyterian pockets the difference between higher premiums and lower payouts.

Was there ever a clearer example of why mental health and addiction treatment should never be handed over to “management” companies motivated by profit?

Oh yeah, and let's be clear about something basic: There is precious little management involved in this scheme. It is a scam, pure and simple. Rare reviews of treatment plans are made. No one assesses possible methodologies, which leads to easy approval for extra sessions to accomplish a desired outcome. The system has but two brakes. One depends on how long the patient is willing to shell out 40 percent of the cost of each session and the second depends on how long the therapist is willing to work with the patient while absorbing a loss in revenue compounded by each visit.

Obviously the therapists with options will bail. There are other plans, other schemes, and those counselors or social workers who are able will migrate there, at least until those plans drop their reimbursement to match Presbyterian's. Or until the employers leave those plans for the cheaper pastures of Presbyterian. Or until the race ends and the bottom is finally reached.

What we are faced with in this behavioral health managed care fiasco is the analogue to what is happening in the retail sector with Wal-Mart. When “cheap” is the only consideration for making a choice, quality, just compensation and social impact all get tossed aside. That's unfortunate in buying toothpaste, lawn furniture or dog food. In mental health it's downright stupid.