Managed Care And Your Mental Health

Quality of Care

It is nearly impossible for a consumer to judge the quality of care provided by a managed health plan, and the National Commission on Quality Assurance (NCQA)- created by the managed care industry to accredit HMOs and other organizations- at present offers limited help. The NCQA measures such things as the percentage of plan physicians who are “board certified.” It does not measure many indicators of quality--for example, the number of participants treated for depression who resume normal functioning. To determine overall member satisfaction with the plan, request the plan’s “patient satisfaction data” from your benefits manager. However, this survey data is unreliable without knowing how the questions were asked, cannot be compared with other plans, and may not give you an indication of how seriously ill patients rate the plan. Also, ask how many member appeals were filed, and how many were denied. A high denial rate may mean the plan is rationing care to save money.

User Friendliness

Plan hospitals, clinics, and physicians should be conveniently located near your home or work place, with flexible hours of service. You should be able to get an appointment to see a psychiatrist or other professional within a reasonable period of time, and your waiting time to see the clinician once you have arrived should not be excessive. If you travel extensively, make certain you are covered for care in other cities or countries.

Open Communication

Patients should be able to have a free and open conversation with their psychiatrist or other physician about their care. The psychiatrist should be free to tell you about all treatments that may help you; even those not covered by the plan. The physician should also be allowed to tell you about his or her financial arrangement with the plan-whether he or she benefits financially by limiting treatments and tests according to goals set by the plan. Over 95% of people responding to a recent survey said they wanted more information about financial incentives HMOs offer their physicians to reduce costs. Managed care plans can dismiss physicians who order more tests or hospital days beyond the plan’s “norm.” Some plans have “gag rules” prohibiting full communication between doctor and patient, or “antidisparagement” rules prohibiting any comments critical of the plan. (So far, 16 states have passed laws barring these practices.)

When You Are Dissatisfied...

With the Plan Offered You

Call the plan’s customer service department, and talk to your employer’s benefits manager or your union representative about your concerns. And remember: you don’t have to have mental illness in your family to be worried about the adequacy of the mental health benefit.

With the Services Provided

First talk to your psychiatrist or other physician and ask him or her to appeal on your behalf. If you have been denied treatment in what you consider a life threatening situation, do not hesitate to get the care you need from outside the system, even if you have to pay the entire bill yourself. Otherwise, use the plan’s appeal process. File a formal written complaint with the plan, with a copy to your employer’s health benefits manager and to the state insurance commissioner. Write to your state and federal legislators. Seek advice from your local psychiatric society. If you have a very strong case, consider taking it to the local news media. Consider talking with an attorney about your rights. In all cases, do everything in writing, and make as much noise as you can. In managed care, the squeaky wheel does get attention.

For More Information About Managed Care:
American Psychiatric Association
1000 Wilson Boulevard
Arlington, Va. 22209-3901
E-mail apa@psych.org

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