Emergency Psychiatry : Is Managed Care Managing Not to Care?

Health care reform, especially the expansion of managed care, may be adversely affecting the humanitarian aspects of care in emergency psychiatry. Webster's dictionary defines "humanitarian" as "concerned with the interest of all mankind." Patients may define the humanitarian aspects of care as concern and compassion. Regulatory bodies have legally defined characteristics of humanitarian care. For example, the 1985 Federal Consolidated Omnibus Budget Reconciliation Act (COBRA) outlawed dumping, the practice of transferring or refusing to admit potentially unprofitable patients (1).

The humanitarian aspects of care are threatened particularly by the increasing time and financial pressures exerted by managed care. These pressures also create difficulties in training residents and maintaining quality clinician-patient interactions and make providing optimal treatment more of a challenge than before. This column explores the effects of these changes in psychiatric emergency settings.

Managed care puts pressure on emergency clinicians to triage patients quickly and places a priority on delivering the least costly services. To reduce expenditures, expensive services such as inpatient admission are limited (2). These limitations place the psychiatric emergency service in the awkward position of potentially rationing treatment (3). Making a referral or submitting a claim for a patient can become an arduous task because too few operators are available to receive calls, managed care triage personnel are not adequately trained in medical care, and out-of-plan claims are routinely denied (1).

Training under siege

Opportunities for training psychiatric residents and other mental health clinician trainees are likely to be reduced due to the effects of managed care. Managed care companies claim that benefits that exclude care by trainees increase the quality of care by ensuring that all care covered by the managed care plan is provided by clinicians who have completed their training. However, some research suggests that this assumption may be incorrect. A study comparing treatment decisions of trainees and attending physicians showed that in a structured, supervised setting, care provided by trainees is similar to that provided by experienced clinicians (4).

Aside from issues of quality, efforts by managed care companies to control expenditures discourage programs from employing trainees to provide services because doing so can substantially raise program costs. For this reason, insurers are increasingly likely to exclude trainees as providers of psychotherapy (5). These limitations place a burden on mental health clinicians in programs that rely on trainees to provide services. Such restrictions also make it more difficult for future generations of clinicians to be adequately trained.

One program that employs trainees developed a creative way to deal with managed care organizations that do not reimburse trainees for psychotherapy services. The program follows the model of psychoanalytic institutes, offering a lower fee for "training cases" (5). In this type of program, residents can be trained and patients who might not otherwise be able to afford psychotherapy can receive treatment.

The therapeutic relationship

Managed care may also affect the quality of the clinician-patient relationship. It can significantly increase clerical demands on clinicians, requiring tasks that may absorb significant amounts of time and may actively compete with high-quality clinician-patient interactions. A possible reflection of the increasingly strained relations between clinicians and patients under managed care is the reported rise in the incidence and severity of malpractice litigation against psychiatrists (6).

In addition, many methods of quality assurance place little or no value on humanitarian aspects of care because they are not easily quantified (7). Factors such as the amount of time a patient waits to be seen, the length of the interview, and the number of medications prescribed receive a higher priority than subjective factors such as rapport, satisfaction, and empathy between the patient and clinician.

These competing demands may tax the clinician and, in some cases, adversely affect the clinician's caring attitude. The situation creates harried clinicians who may increasingly resent the needs and demands of their patients. This resentment, without the clinician's awareness, can lead to pejorative diagnoses.

For example, a recent study by Yates and colleagues (8) examined how often clinicians in a psychiatric emergency service made the diagnosis of malingering, a diagnosis that is known to place the clinician and patient in an adversarial relationship (9). The authors found that 6 percent of patients seen over a two-month period were thought to be malingering. However, none were given a primary diagnosis of malingering, and less than half were given a secondary diagnosis of malingering. None of these patients were treated or counseled for malingering.

The study findings are valuable for two reasons. First, they show that clinicians are willing to believe that a significant number of patients are being dishonest with them. Second, they suggest that although clinicians may believe a patient has a true diagnosis, they may be reluctant to make a primary diagnosis of malingering and to treat or counsel patients for this condition.

Cost-effectiveness of compassionate care

The importance of compassionate care in the psychiatric emergency service is underscored by a recent study in which homeless adults presenting to a psychiatric emergency service were assigned to a group who received "compassionate contact" from trained volunteers or to a group who received standard care (10). In the compassionate-contact condition, trained volunteers established rapport with patients over several encounters and discussed everyday experiences involving the patient's living situation and family, as well as patients' experiences at other hospitals. Also, patients often received food during these encounters.

Both the compassionate-care and the standard-care groups were followed over one year through the records of their subsequent visits to hospitals in the region. Interestingly, the patients who received compassionate care made fewer subsequent visits to the psychiatric emergency service after the initial intervention than the patients who received standard care (.43 visits per month versus .65 visits per month for the standard-care group). The group receiving compassionate care had a 33 percent reduction in their rate of return visits per month to the psychiatric emergency service, compared with their rate of use before the intervention. The authors theorized that patients tended to return frequently until they were satisfied with their treatment. Although the study did not involve a managed care population, the findings are significant because they demonstrate the importance of compassionate care. Humanitarian treatment of patients can reduce the number of visits, which is a goal of most managed care organizations.

Medication options

Another goal of managed care organizations is to decrease pharmaceutical costs by paying only for medications that are listed in their formularies. This goal is of particular interest to clinicians who prescribe antipsychotic medications because the newer atypical antipsychotics are substantially more expensive but generally more effective than the traditional neuroleptics and have a more favorable side-effect profile.

For example, the atypical antipsychotics are associated with a lower incidence of extrapyramidal symptoms (11). These medications can greatly improve patients' quality of life and increase the effectiveness of treatment due to better compliance with the medication regimen. In addition, use of the newer atypical antipsychotics could decrease overall expenditures as a result of fewer relapses requiring hospitalization.

Whether a managed care organization will include the newer antipsychotic agents in their formularies depends on its perspective. An organization that provides contracted long-term care may offer these medications based on the overall savings associated with their use. However, a managed care company with a more short-term responsibility has little incentive to allow use of the more expensive medications (11), and the long-term prognosis and quality of life of patients covered by the plan may be adversely affected.

Conclusions

Is managed care affecting provision of humanitarian care in psychiatric emergency services? Although the effects are difficult to quantify, several trends can be noted. Psychiatric inpatient admissions are being limited as managed care seeks to decrease expenditures. Managed care tends to exclude trainees as providers in an attempt to reduce costs. The quality of the clinician-patient relationship may be affected as increasing demands for paperwork and record keeping compete with time spent with patients. Also, managed care may have a great influence on the patient's quality of life as a result of the medications managed care companies are willing to provide.

Mental health emergency clinicians face many challenges in providing humanitarian treatment in the current managed care environment. The Hippocratic oath states that medicine is both a science and an art. Whether defined operationally or legally, humanitarian care of patients is the art of being a clinician. The art of medicine will endure under managed care only if clinicians are aware of the threats to humanitarian care and pursue means of defending the trusted clinician-patient relationship.

Dr. Spiggle is a resident in psychiatry at the Veterans Affairs Medical Center, 150 South Huntington Avenue, Boston, Massachusetts 02130. Dr. Hughes is associate chief of psychiatry at the VA Medical Center and associate professor of psychiatry at Boston University School of Medicine. This month he becomes editor of the Emergency Psychiatry column, replacing Ole J. Thienhaus, M.D., M.B.A., who had served as editor since December 1995.