HMOs and Responsible Psychiatry, Part I

THE OPEN MIND
Host: Richard D. Heffner
Guest: Dr. Robert Michels
Title: HMOs and Responsible Psychiatry (Part I)
VTR: 10/8/97

I’m Richard Heffner, your host on The Open Mind.

My guest today has graced this table many times before, partly because I’m so intrigued by a doctor who speaks in paragraphs, indeed, speaks brilliantly and meaningfully in paragraphs, and mostly because he so extraordinarily well has incorporated open-mindedness in his much-honored career as a practicing psychiatrist, as psychiatrist in chief at New York Hospital, and as professor and chairman of the Department of Psychiatry, and then dean at Cornell University Medical College.

Now Dr. Robert Michels is Cornell’s distinguished Walsh-McDermott University Professor of Medicine and Psychiatry. And while last time he was here on The Open Mind I questioned Dr. Michels generally about the future of healthcare in America, today I want to probe with him the particularly difficult matter of HMOs, and the responsible practice of psychiatry.

Is that, Dr. Michels, a contradiction in terms: HMOs and the responsible practice of psychiatry?

MICHELS: A lot of psychiatrists fear that it may be, Dick. I was thinking, in your very generous opening lines, when you talked about my speaking in paragraphs, in the modern world of managed care, that’s terrible; I should be talking in sentences, or maybe four-letter words in order to condense the time.

HEFFNER: Well, you say “four-letter words.” I was thinking of another kind of four-letter word. HMOs, I see and hear everywhere around me negative things. I warned you before not to talk about today or yesterday or tomorrow, but last night, watching a program on television, once again, in a dramatic program, HMOs taken over the coals. Tell me about it in psychiatry.

MICHELS: Well, the broader notion than an HMO, which is a specific type of organized system of healthcare delivery, would be the broader range of managed-care entities, ways in which there are others involved in the doctor-patient relationship, who see themselves as monitoring the use of medical care, of giving the patient permission to see the doctor, of giving the doctor permission to treat the patient, and of defining how long and what kind of treatment will be acceptable. That’s management. And the managed-care industry is a gigantic one.

The reason for it is, of course, healthcare’s always been managed. Decisions have to be made, options have to be selected. But historically it was managed by the doctor. And the doctor’s motives were certainly, first and foremost, what’s best for the patient. Others were worried that the motives were sometimes colored by what’s best for the doctor. But the new management structure is third-party managers: neither doctor nor patient, but an insurance company or a health-delivery system. And a new set of motives: neither what’s best for the patient, nor what’s best for the doctor; but what’s best for the company. Most of those companies are for-profit companies, and that ends up meaning what’s best for the stockholder of the for-profit company that’s managing healthcare. That’s the broad picture.

When you move to mental health and psychiatry, in some ways the problems get much worse. Partly because frequently patients aren’t their own best advocates, and they’ve historically relied on the system taking care of them rather than pursuing their self-interests. Psychiatric illness can interfere with the patient’s ability to seek out appropriate care and monitor it himself. Secondly, because of the stigma of mental illness. We’ve always historically given less resources to taking care of psychiatric patients, and generally, as a society, done a poorer job of it than we’ve done with physical care.

A third problem is that the patterns of utilization of healthcare are very different in mental-health care than in physical-health care. Frequently people seek out care that aren’t as sick as others who don’t seek it out in psychiatry. So there are problems. Do we use our resources to find the sickest patients who don’t want help, or to take care of the less-sick patients who can profit from help and are able to seek it out?

All of those decisions end up in a complicated system where, in the old days, a patient who wanted help went to see a psychiatrist, arranged for that help with that psychiatrist, and got the help. In the new days, in the managed-care system, in the emerging current world of healthcare, a patient with a psychiatric problem calls up the organization that provides him with health insurance coverage, tells him what his problem is, and they, after listening in on this most private matter, tell him which doctors to go see, how many hours he’ll be allowed to see them, and that the doctor should check back at the end of three or five or ten hours and tell them what’s going on and how things are going before they decide whether they’ll allow another ten hours. That’s a wild change in the system, an incredible intrusion into the doctor-patient relationship, and a real change in the basic fabric of the kind of mental-health care that’s available in our nation.

HEFFNER: This is a matter of supervision, isn’t it?

MICHELS: Supervision, regulation, and one can say other words: intrusion, control. Now, once again, supervision, control isn’t bad. It could raise quality. It could prevent bad things from happening. But, unfortunately, the supervisors and the regulators, as their bottom line, don’t have optimal quality of healthcare for the patient; they have as their bottom line maximal return on capital to the investory.

HEFFNER: Well, to the degree that supervision can be a good thing, do you anticipate the possibility, at least, of making the bottom line something other than what it is? Now the bottom line is the bottom line. Could we have that supervision and the possible benefits that come from it without a for-profit system?

MICHELS: I think that’s possible. And I think there are ways that you can see certain pieces of the system moving toward it. But there are still major barriers. It’s by no means clear we’ll end up there. And that’s why you’re hearing all that noise about governments trying to regulate the managed-care industry, television programs making fun of managed care, and the fact that the system that was supposed to avoid the intrusion of federal control has ended up being more intrusive itself.

What can be done? Certainly the notion that doctors should maintain their credentials and their competence, and demonstrate that competence regularly, is a good idea. And then, so far as the old system didn’t require it, we’re in a better place if the new system does require it and does guarantee the appropriate level of competence and training and continued education of practicing physicians. That used to be done in the better parts of the old system, but it wasn’t required in the poorer parts. And the managed-care industry has made some moves in that direction. So that’s a plus.

A second thing is: certainly, consultation, advice, and review of ongoing treatment’s an excellent idea. But if you were seeing me or some other psychiatrist, and there was some reason for consultation, who would you want to do that consultation?

HEFFNER: Someone you would suggest?

MICHELS: You would want a good psychiatrist to do it. Hopefully one better than me. But in the current managed-care system, the reviews are done by people who have no medical training, often, or minimum medical training.

HEFFNER: But now, but wait a minute. Literally so?

MICHELS: Literally so. There are people involved in working for the companies who do the reviews by asking the doctor what’s going on and checking prearranged lists of criteria for proving or not approving continued stay, and you have high-school graduates or college graduates monitoring the treatment given by board-certified specialist physicians. Because the goal is not maximizing quality; it’s minimizing cost. And those are different goals.

A very simple test in my mind: a good monitoring system would sometimes say, “You’re giving that patient too long to stay in the hospital, or too many sessions,” and would sometimes say, “You’re giving that patient too few sessions, or too short a stay in the hospital.” I would be very wary of a system that frequently thought there was too much treatment, and that never thought there was too little treatment. But that’s the system we have.

HEFFNER: Dr. Michels, you say that’s the system we have. Is there something inexorable about this?

MICHELS: I think there’s a historical explanation for it. I don’t like “inexorable,” because it sounds locked in. A psychiatrist’s job is to turn things that look inexorable into possibilities or challenges for change.

HEFFNER: How would you do it in this instance?

MICHELS: Okay. I think we got locked into it because historically we got into this system because of the immense social concern with the very rapid rise in healthcare costs, a rise at a faster rate than the general rate of inflation, and the sense that if we couldn’t control those costs we were going to be in a national disaster in terms of the amount of our gross national product going in that direction, our competitiveness with the rest of the industrial world, etcetera. So we devised a managed-care system that was designed and intended to lower the cost of healthcare rather than to optimize the use of resources or to maximize the cost-benefit. One way to lower cost is to lower services. Unfortunately, we’re not good at discriminating good services from bad services, so we’ve been lowering services across the board. Sometimes when you lower services you save a dollar today, but at the risk of somebody becoming sick next year that will cost many hundreds of dollars. And we’ve done that in important areas of mental health.

To get out of it, we have to know how to measure quality, as well as measure cost, and have real quality measures that will lead us to select our managers not on the basis of the cost they save, but of the ratio of cost to benefits: on the cost they save compared to the quality they deliver.

Let me take a specific example: The companies compete with each other, and the hope was that competition would lead to better quality as well as lower cost. But, for the most part, they’ve been competing on cost alone, and the lowest cost has won regardless of real quality. That’s because the quality measures they’ve developed are irrelevant to real healthcare. They measure how long you wait on the phone before somebody answers your phone call, how new the magazines are in the offices you have to wait in. You and I are willing to go to doctors with very old magazines if they’re very good doctors. But they treat all doctors as identical: the most well trained, the most experienced, the most highly qualified with the average or lower-than-average practitioner. They treat them as units, as widgets. We have to develop tools for measuring quality.

We also have to develop tools for measuring their finding patients who need treatment and delivering it to them. For example: we have excellent information about how many people in our culture have… Take an illness like depression. We know that five percent of the population in the United States will develop a depressive illness every year. Some of these companies are taking care of 20 or 30 million lives. They know how many people they’re treating for depression every year. If they’re treating significantly fewer than five percent, they know they’re doing a lousy job at finding the people who need treatment and delivering it to them. In fact, that is the case. They’re treating way under that five percent. We have to insist that they make that data public, and that we can select managed care company A versus B, not on the basis of how many dollars per year it charges, or on the basis of how quickly they answer their phone call, but on the basis of how effective they are in finding the patients that they’re taking care of who need treatment and making sure they get that treatment.

That’s not an important issue in many areas of medicine, where patients who need treatment ask for help. But in psychiatry it’s desperately important, where a considerable number of people who need treatment don’t come and seek it themselves, but have to be found.

HEFFNER: Do you think we can more rapidly come to some acceptable solution to this problem if we were out of the for-profit-marketplace model?

MICHELS: I think very much so. The for-profit model sucked a lot of capital into the system, and provided resources that weren’t available in the public, or not-for-profit spheres of care because they attracted investor money, attracted by the possibility of huge profits, of course. However, they failed to develop the system to optimize and maximize the quality of care. I think if the profit motive were less central, and that we had a system that was delivering care where the quality motive was going to be the competitive one, we’d have a much better chance of enhancing quality in the same way that we’ve reduced cost.

HEFFNER: American doctors have, to a very large extent, opposed what has been called in the past “socialized medicine.” Do you think they will continue to oppose government involvement, government as a final, not only arbiter, but payer, because of their disdain for what is happening now?

MICHELS: I think American doctors in general have been fiercely protective of their professional autonomy, their ability to be in the medical decision making role, and not having that role taken away from them by anyone. I think that a very effective public-relations campaign convinced the American public and the medical profession that a centralized federal healthcare system was going to intrude on that autonomy. It turned out, ironically, that the far greater intrusion on their autonomy came from Harry and Louise and their supporters than from the federal or state governments.

HEFFNER: Referring to the first year of the Clinton Administration and the fight over.

MICHELS: Right. I don’t think doctors are primarily concerned now with whether there’s a for-profit system, a not-for-profit system, a public system, or a private system; I think the critical issue is a system that allows medical decisions to be made by physicians who have medical competence and that is designed to deliver the highest quality care rather than the cheapest possible care. Any system that is effective in those things, whether for-profit or not, I think will get great support from the medical profession.

HEFFNER: Dr. Michels, is there any indication, other than the occasional horror story that we’ve heard so much about by the media in particular, any indication that indeed there has been poorer treatment of the mentally ill, or of the psychologically needy?

MICHELS: Right. That’s a very good question. I want to modify the question first slightly, because we wouldn’t be satisfied simply for not poorer treatment. We’ve been on the trajectory of ever-increasing quality of treatment, and ever-increasing access of previously unserved to treatment. I would not want our nation’s mental-healthcare system frozen in where it was in 1987 in perpetuity. I would want to continue to grow in quality and grow in the coverage of those who need help.

We do know that there are many communities that have moved to managed care, where the average quality of treatment has diminished as a result of it because patients are forced out of the hospital in shorter periods of time than is professionally appropriate, are given fewer outpatient contacts afterwards than are professionally appropriate, and that providers are discouraged from pursuing optimal courses of treatment. I have one very good indicator that may not be scientific but is totally convincing to me: people who are physicians or healthcare professionals, or who run those insurance companies, ask me for advice on how their families should be taken care of. None of them have ever been happy with the parameters of treatment that are acceptable to a managed-care company or with the providers the managed-care company refers them to. I assume that means they know what’s good.

HEFFNER: Now, what role do different modalities of treatment play in this conflict between autonomy on the part of the trained, concerned psychiatrist, and the managed-care organization? Are we moving more and more, as a consequence of managed care, to drug treatment? Are we abandoning traditional talk treatment?

MICHELS: That’s an important question. And, of course, we’ve been on a trajectory in that area before the beginning of managed care. If you go back 30 or 40 years, the only real treatments available in psychiatry were talk therapies, as well as custodial and humane care for patients who weren’t responsive to the talk therapies. In those few decades we’ve developed a very powerful and effective set of medications to treat psychoses, to treat anxiety disorders, to treat depression, to treat manic-depressive disease. And those have become a very important part of contemporary psychiatry.

Quality contemporary psychiatric practice tends to use all of the available appropriate, effective treatments that might be useful. That means that a great many patients receive both psychotherapy and pharmacotherapy. Some, a smaller group, psychotherapy only; another, very small group, pharmacotherapy only. Most studies of pharmacotherapy in psychiatric patients show that the majority of patients don’t have brief illnesses that can be treated, cured, and then forgotten about; but depressive disorders more than half the time recur, anxiety disorders are frequently long-term or recurrent. And the treatment involves a long-term relationship with a patient, which involves psychological and social aspects of the relationship, as well as the episodic use of medication when appropriate to manage the episodes of disorder that the patient has. Pharmacotherapy without that relationship is much less effective than pharmacotherapy with that relationship.

Psychiatrists are trained to prescribe medication, and to do psychotherapy. And it’s that mix of skills that make them unique. Other mental-health professionals are often extremely successful in the areas in which they’ve been trained in competence. Psychologists and social workers are often trained to be effective psychotherapists and can work with patients who don’t require pharmacotherapy, or, at times, conjointly with a psychiatrist who delivers the pharmacotherapy.

The managed-care industry in its cost-control concerns has done several things that are very disturbing. One is it’s tried to stop treatment after the acute episode is over, even if the patient continues to be at risk for another episode. Because that’s much cheaper than maintaining the contact to prevent the next episode.

Secondly, they’ve tried to switch to low-cost providers. That usually means away from psychiatrists, toward other mental-health professionals, and use psychiatrists only to prescribe medication for patients who are getting their psychological treatment from someone else. That can work. But, ironically, there’s good data, data in the managed-care industry itself, that shows that that’s less efficient and cost effective; that you can treat a patient well with less cost and fewer visits if you have the same qualified person, a psychiatrist, delivering the medical pharmacologic treatment and the medical psychological treatment than if you split that into two different providers. That kind of information, though, requires a system that’s concerned, not with saving money, but with taking the best care of people. And it’s that mission that isn’t built into our current system.

HEFFNER: Okay, I can understand that. But let me ask whether we are saving money.

MICHELS: There’s no question that the managed-care industry has been able to lower the cost in current dollars of delivering healthcare. They’ve done it by switching to cheaper providers, discouraging utilization, and failing to find untreated cases in the community. They also pay the providers less than they used to get, and lead to the disastrous situation where a bright, ambitious, young college student might rather grow up to be an executive administrator in the managed-care industry than the doctor taking care of us when we’re sick. It may be self-serving, but I’d rather live in a society where the brightest and the best want to take care of sick people rather than make money off of their care.

HEFFNER: Spoken as the former dean of the medical school at Cornell.

Dr. Michels, is there any indication that within the managed-care industry itself there is a recognition of the validity of the points that you are making and that others have made, and some effort to correction, at self-correction?

MICHELS: It’s been a very interesting dynamic in the managed-care industry. There are many physicians who have gone into the industry. I have many friends in the industry. I would say that most of what I’ve told you I’ve learned from people in the managed-care industry who have told me how it works and what it means. However, the dynamic has been frightening. As I’ve said, the competition among managed-care companies has been almost exclusively in terms of cost. That means, in the competition, the cheaper company wins regardless of quality. At the same time, there’s been a huge consolidation in the industry, so there are only a few companies that are in charge of the “managed behavioral health,” which is what they like to call psychiatric care, for more than half the citizens of our country today. And as companies have bought and sold themselves to each other, the surviving companies have been the ones that can show the greatest saving to the purchasers of care rather than the greatest quality for the patients who get that care.

I have an old, very good friend in the managed-care industry, a psychiatrist, an excellent psychiatrist. And his joke is that his phone number, when doctors call up for permission to treat their patients, is 1-800-NO-NO.

HEFFNER: [Laughter] Dr. Michels, we have just a minute left. Let me ask you to be a prophet. What’s going to happen?

MICHELS: I think we’re going through a window of great stress, chaos, and some very bad things happening in our healthcare system. I think the public wants good healthcare, and I think they’re learning how bad some of the managed-care care they’re getting is. I don’t think it’s going to be more than a decade or so until political leadership recognizes that public demand and interest and forces regulation and control on the industry that either will improve its quality or help us shift to a simpler, maybe single-payer system. However, the next ten years are a little scary.

HEFFNER: “Scary.”

MICHELS: I think we’re going to see lots of unfortunately, unnecessarily bad care, until we are able to reorganize ourself in this transition period to a new level, a new plateau of organized but not intruded-upon, high-quality care.

HEFFNER: And how does one protect oneself in that period?

MICHELS: I’d say, if you know a good doctor, get your advice from that good doctor. Trust the organizations of people who touch patients; not those who play with charts and numbers.

HEFFNER: Nice way of ending, Dr. Robert Michels. Thanks so much for joining me today on The Open Mind.

And thanks too, to you in the audience. I hope you join us again next time. And if you would like a transcript of today’s program, please send $4 in check or money order to: The Open Mind, P.O. Box 7977, FDR Station, New York, NY 10150.

Meanwhile, as another old friend used to say, “Good night, and good luck.”

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.

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