State Report: Managed Care Compromising

 Child Psychiatric Treatment

By John Voket

Newtown residents seeking mental health support and counseling services, especially for children, are facing longer waits to see professionals. And those lucky enough to have some type of health plan in place to cover mental health services may find their own providers lack adequate professional resources to answer their call.

But folks from Newtown in this situation are far from alone.

The situation statewide prompted Attorney General Richard Blumenthal and Child Advocate Jeanne Milstein to commission a survey of child and adolescent psychiatrists which the state officials say proves managed care is compromising — or blocking altogether — quality psychiatric treatment for countless children.

The officials released the survey and recommended significant reforms as part of an ongoing joint investigation into the availability of mental health care to Connecticut children.

In one case, for example, the officials heard from a mother unable to locate a psychiatrist participating in her health insurance plan who was willing to treat her two sons, both suffering bi-polar disorder. After calling a list of 90 doctors provided by her insurance plan, the mother said none were accepting new patients, and some doctors on the list were duplicates or even deceased.

“This survey sounds a sharp alarm about managed care companies disastrously failing countless children in need of psychiatric care,” said the Attorney General. “Our survey shows a snapshot of a more pervasive problem — managed care companies shortchanging children. We will all reap the whirlwind of untreated illness — violent crime, dysfunctional families and repeated cycles of sickness.”

“The real tragedy…is that Connecticut children most in need of quality psychiatric treatment have been abandoned,” Ms Milstein said. “Children with the most severe illness, or those who need urgent attention, are those most likely to go without adequate care. Managed care companies need to operate health care plans that allow children to get the psychiatric care they need within a reasonable time.”

Locally, Beth Barton, executive director and spokesperson for the merging Newtown Youth Services and Family Counseling Center told The Newtown Bee recently that appeals for services are far outpacing the availability of slots among her limited mental health professionals and support staff.

“The amount of new patients we are serving has almost doubled from last year,” she said, adding almost all similar nonprofit agencies in the region have waiting lists for services exceeding four to six weeks.

“The demand for services far exceeds the number of providers,” Ms Barton said.

Diminishing Reimbursements ‘Troubling’

According to a release from Mr Blumenthal accompanying the report, psychiatrists are angry about low reimbursement rates and burdensome coverage determination procedures. Almost half of those responding to the survey refuse to even participate with any of Connecticut’s seven largest managed care plans.

Chris Gardner, chairman of the merging Youth and Family Services calls the report, “troubling,” pointing to the collateral increasing costs to his agency because of demand. He measures this against dwindling compensation through various health plans and reimbursement programs.

“As a board member it scares me a lot,” Mr Gardner said. “This will require us to be more creative in funding this agency because we won’t be getting the reimbursement we need.”

Mr Gardner said he does not look at the situation as losing money, however.

“We look at it as helping a person,” he said. “Besides, the merging agency’s main goal is seeing more people.”

“But we have to keep paying the bills,” he added. To that end, the agency recently acquired personnel to develop additional revenue streams, and to locate and apply for more grants.

“That’s another reason why this merger makes so much sense at this time,” Mr Gardner said “It puts us in a better position to qualify for more revenue without going to the taxpayers.”

Adding to the concern, psychiatrists surveyed say managed care companies are covering only brief visits — perhaps 15 minutes — that barely allow quick patient assessment and re-prescribing medication. The doctors claim the plans deny coverage or require voluminous documentation for longer visits that allow the “relationship-based” psychiatric care.

As one responding psychiatrist said, managed care is “…bilking patients, hospitals and doctors of millions, billions and trillions for a cheap product, not consistent with our values, our best interest, or our expanding knowledge and capabilities.”

Doctors also claim managed care companies have forced them to inappropriately focus solely on prescription drug treatment and abandon quality, “relationship-based” psychiatric care. While medication treatment alone may be adequate for some children and adolescents, many require more intensive care, the officials said in a release.

Blumenthal and Milstein said, based on the psychiatrists that participated in the survey, they found:

A shortage of child and adolescent psychiatrists available to treat patients results in substantial and potentially dangerous delays in a significant number of cases for new patients with “urgent” problems.

Doctors believe managed care plans are poor or below average in fairness of reimbursement, bureaucratic “hassle,” and support of quality care.

The current managed care system is “much worse” than the previous “fee-for-service” financing system.

Many doctors with advanced certification in child and adolescent psychiatry decline to participate in managed care.

Connecticut’s Parallel Systems

Connecticut appears to have two parallel child psychiatric care systems — about one-half participate and are paid by managed care; the other half refuse to participate, and are supported mainly by patients paying high fees out of their own pockets with no, or only limited, contributions from managed care plans, the Attorney General’s release states.

Managed care companies avoid paying for much necessary care by driving out many experienced and qualified child and adolescent psychiatrists. Parents enrolled in managed care are often forced to rely on non-participating doctors because there are no participating physicians able to treat their child or because their child requires more than the low cost medication-focused care their plans will cover.

Some managed care plans have significantly misstated the participating providers available to treat the children and adolescents enrolled in their plans — misleading families into believing that their plans’ networks have sufficient psychiatrists available to meet their needs.

“Managed care has abandoned its responsibility to reimburse doctors for much of the psychiatric care needed by children and adolescents,” Blumenthal said, “Managed care companies must meet the promises implicit in their contracts with employers and enrollees ensuring children receive medically necessary psychiatric care. Doctors and patients — not managed care companies — should dictate decisions on health care without bureaucratic blockades.”

“Hardworking, worried parents trying to do the best for their kids are also being abandoned...left on their own to cope,” Ms Milstein said.

Ms Barton said as a nonprofit, the local second and third tier and nonprofit organizations like the merging Youth and Family Services agency are the last chance for many people.

“Private doctor’s and therapists can opt out of managed care and only accept fee for service and cream who can afford their fees,” she said. “We won’t turn people away, that is one of the reasons for our waiting list.”

Steps To Change

Mr Blumenthal and Ms Milstein recommended several steps to improve child access to mental health care, including stronger requirements that managed care companies:

Accurately inform enrollees concerning child and adolescent psychiatrists participating in their networks.

Better and more timely review of their provider panels to ensure the accuracy of their lists — that their doctors are actually available so that enrollees are not forced to telephone their way through the provider list only to learn that the doctors listed are not taking new patients or are no longer a provider.

Ensure that children and adolescents with urgent care needs can be seen by participating doctors without delay.

Pay psychiatrists reasonable fees required to deliver relationship-based care when needed, and cease abusive coverage determination practices so that doctors enroll in, and continue on managed care provider panels.

Adequately reimburse child and adolescent psychiatrists to encourage treatment for patients who need more than medication.

A recent poll of Fairfield County physicians by the Fairfield County Medical Association doctors report limiting the scope of their practice, up from 38 percent in 2005, which itself was up from 18 percent in 2002. Over a third — 39 percent — say they have been forced to limit the number of sicker patients with complex illnesses. In 2002, only 14 percent said they altered their patient mix in response to medical liability insurance costs.

Doctors say they are also practicing more “defensive medicine” by ordering more tests than necessary in their medical judgment, to protect themselves in case they are sued. In 2006, more than two-thirds of doctors say they practice “defensive medicine,” up from 63 percent in 2005, 59 percent in 2004, 56 percent in 2003 and 36 percent in 2002.