Hi again, sasquatch77...
I will have to speak primarily from experience here, since
this is not an area where you will easily find statistics
documented in black and white.
I would say, in general, that those who work in the field
of mental health have the clients' best interests at heart,
while this cannot as easily be said of insurance companies
or managed care agencies, whose focus is more often on the
bottom line of cost containment.
While I've never known a psychiatrist to mis-diagnose in
order to justify treatment that is unneccessary, simply
to 'pad the bill', I have seen subtle changes made in a
diagnosis which would justify the use of a more effective
medication or a longer, more effective course of therapy,
both of which are more expensive but happen to be what
the client really needs. These subtle changes are not
misdiagnoses as such. They are meant to provide clarity
as to what will constitute effective treatment.
I've also seen insurance companies fight such diagnoses
and the prescription of certain, more expensive medications,
as well as limiting the types and length of treatment
sessions.
There is certainly some evidence of this to be found on the
internet, in the writings of clients who have experienced
such things, and the published policies of therapists who
have experienced such difficulties.
Priscilla Kelly, e.g., is a Licensed Mental Health Counselor
who notes on her site:
"Be aware -
Insurance companies usually do not pay for preventative
type services, such as relationship problems. They might
pay where a severe condition exists.
Insurance companies dictate treatment. They control how
many sessions you are allotted and what type of therapy
you receive.
Insurance company involvement violates your right to
confidentiality. They can ask for details of counseling
sessions.
For these reasons and others, I do not accept insurance
company involvement in my services. I will keep my fees
affordable and will work with each client to see you get
the help you need."
http://www.priscillakelly.com/fees_insurance.htm
There was a time when inpatient stays in mental health
facilities might be extended by the staff who worked
closely with treatment coordinators in the facility who
kept a close eye on how many inpatient days were left
in the client's insurance entitlements, but truthfully,
there was seldom a situation where these extensions would
not produce improved results in the client. In my
experience, you might easily say that there's no such
thing as 'too much' treatment for the average client.
But those days are long gone, and very few such private
facilities exist anymore, primarily due to the increased
vigilance and restrictions which were implemented by the
insurance companies over time. The hospitals simply
went out of business over the years, closing one by one.
In the medical field, there are even instances of
hospitals suing the insurance companies over the
restrictions on treatment, and threatening to drop
their contracts with the insurance companies, as
seen in this article on LookSmart:
http://www.findarticles.com/cf_dls/m3230/1_32/59458489/p1/article.jhtml
Private sector mental hospitals, for the most part,
lost this battle long ago.
Increasingly, the trend is to move away from long-term
therapies such as traditional Freudian psychoanalysis
and toward more effective short-term therapies, also
known as 'brief therapies'. There is some value to this,
since traditional psychoanalysis, e.g. has only been
shown to be effective in about 25% of all cases, and
of those, the benefits have been shown to decrease
even more when therapy is terminated. Focusing on
short-term therapies which demonstrate effectiveness
and have the added value of educating the client in
techniques which can continue to be applied solo,
after the therapy sessions end, has benefits to all
involved.
This doesn't excuse an unwillingness to pay for therapies
which might take longer, such as Art Therapy, when it is
the treatment of choice for clients with a limited ability
to verbalize their experiences and emotions, e.g., and
who will not receive any benefit from a talk-oriented
group format.
Nor does it excuse the use of a cheaper medication
when a more expensive one is truly more effective,
e.g., because the more expensive medication limits
the common side effect of weight gain, which would
cause the client to eventually stop taking the less
expensive medication which causes this, and relapse
into psychosis.
I haven't seen any specific evidence that a managed
care agency has threatened to drop the contract of
a practitioner, but this is mitigated by the fact
that it is increasingly difficult to hire full-time
practitioners, and the only option is temporary
practitioners called 'locum tenens', whose services
cost much more. Yet, I suppose that if the temporary
practitioners are more cooperative with treatment
restrictions, this could offset the higher cost of
using them. Nonetheless, my experience is that there
is a tremendous amount of pressure on agency practitioners
to stay within cost containment guidelines, and some
of them do eventually accede to some restrictions,
though most of the ones I know tend to negotiate
shrewdly, bowing to some restrictions, while
insisting on leeway with others.
Please do not rate this answer until you are satisfied that
the answer cannot be improved upon by way of a dialog
established through the "Request for Clarification" process.
sublime1-ga
Searches done, via Google:
"drop their contracts"
://www.google.com/search?q=%22drop+their+contracts%22
"mental health" "insurance companies dictate"
://www.google.com/search?q=%22mental+health%22+%22insurance+companies+dictate%22 |
Clarification of Answer by
sublime1-ga
on
10 May 2004 15:56 PDT
Hi sasquatch77...
The only other influences of which I'm aware, which might
contribute to a change in diagnosis, are not normally
considered 'external' to the diagnostic process. These
might include extended history from the client's family
of origin; observations made by neighbors and reported
to the treatment team; physical exams which unearth an
organic component to the mental state; and so on.
These factors may influence a practitioner's diagnosis
so that the needs of the client will be better addressed,
but this happens routinely. For example if a blood test
taken during hospitalization following an auto accident
reveals the presence of illegal stimulants, this may
radically alter a diagnosis from Psychotic Disorder,
Not Otherwise Specified, based on the client having
reported hearing voices, to Major Depression with a
secondary diagnosis of Substance Abuse or Dependency,
based on a reassessment of the client's lifestyle, and
the recognition that the voices only manifest when the
client is abusing drugs, which s/he uses to offset the
depression.
I consulted with a case manager who is a former co-worker,
and the only other outside influence she could think of
was something neither she or I have ever seen, but which
she has read about. That is the modification of a diagnosis
in consideration of a cultural or ethnic stigma attached
to a particular diagnosis. In other words, if the client
and their family might be stigmatized by family and
friends belonging to a culture that considers a diagnosis
of, say, schizophrenia to be a reason to reject the family,
the practitioner might choose to alter the diagnosis on
paper, without changing their treatment. I would submit
that this is a relatively rare situation, and increasingly
unlikely as knowledge of mental illness becomes more readily
available.
Best regards...
sublime1-ga
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