Letters to the Editor
Dorothy W. Cantor, Psy.D.
It has come to my attention that the on-going problems I have had in being paid for my services have not yet been resolved. I am also disturbed to think this may represent a very misdirected company policy.
The patient was only covered by your services from March through December, 1996. For the first two months, because I was not network provider, she was reimbursed at a lower rate than she would have been had I been in network. Therefore, I submitted my application to be a network provider on April 30, 1996, and from that point on, things deteriorated rapidly. Let me enumerate.
1. Although I was admitted to the network on June 15, 1996 my admission was backdated to May 9, 1996, the date on which you received my application. That may sound generous, but it resulted in your refusal to reimburse at all for sessions between May 9 and June 15, 1996 because they had not been authorized. I have already discussed this with you in a letter dated December 10, 1996, and I thought that the matter was resolved.
2. The patient, in a letter dated March 26, 1997, to Ms. Amy VanBuren, resubmitted bills for my services in June, July and October of 1996, which had not yet been reimbursed. She was told that there was no record of any claims for those dates. She, of course, had copies of the bills which she had submitted to you. After much further discussion, checks were issued on May 14, 1997 for the June and July, 1996 sessions.
3. I called Ms. VanBuren again two weeks ago to inquire about why the bill for the October, 1996 sessions had not been paid. My call was returned late last week by Ms. Amy Austen, who informed me that those sessions had not been authorized. When I asked her to look into the matter further, since my records indicated that I did indeed have authorization, she did so. She informed me on June 18, 1997 that only 24 sessions had been authorized, and that I had used some of them in May of 1996! So we are back at the point where we were in December, with the sessions authorized AFTER I became a network provider being applied to sessions PRIOR to that time. I have forwarded to Ms. Austen copies of the authorizations for the October period in question. Two days ago Ms. Austen called to inform me that she had done everything she could with the claims department, but had been unsuccessful. She gave me the name of yet another representative, Ms. Elizabeth O'Driscoll, who represents the AT&T Team. I called Ms. O'Driscoll, who was aware of the situation, and indicated that she would straighten matters out forthwith and forward a check for the October, 1996 sessions. That leads me to wonder about several matters: a) When will the check arrive? It is already eight months since the services were delivered. b) Why was Ms. O'Driscoll able to so easily accomplish what others were unable to do over a lengthy period? c) And if she could authorize payment so readily, why wasn't I referred to her to begin with?
My patient also shared with me a copy of a confidential evaluation of my performance which you had asked her to complete. She did not complete this evaluation because she found it intrusive and offensive. I am concerned with the impact of such a document on the therapeutic relationship. If you feel the need to get feedback from patients about their therapists, it should be with the therapist's knowledge, just as the patient is aware when information is being shared with you by the therapist.
It is frustrating and annoying to work under these circumstances. The amount of time which I have spent on the phone and at my computer, trying to collect fees which I have earned is unconscionable. On behalf of myself, my colleagues who are also subjected to this treatment, and our patients who are being poorly served, I wish to register my complaint.
Dorothy W. Cantor, Psy.D.
I am responding to Dr. Safran's letter to the editor which commented on Dr. Ragusea's article about the Pennsylvania Psychological association's Practice Research Network (PRN). I welcome the opportunity to clarify the issues he raised.
Dr. Safran had two major points in his letter. First, he commented on the low number of clients who had reported outcome data (at the time of the article it was an average of 1.68 clients per therapist). This small number reflects the fact that only a few patients had completed their treatments at the time the article was written. There is no attempt to "cherry pick" patients who are likely to have a favorable outcome. Unfortunately, the brief article by Dr. Ragusea was unable to fully explain all of the details of the study.
The second issue deals with the basic methodology used in our project. Dr. Safran criticizes the PRN because it has no control group, no placebo group, and no blind experimenters (therapists). This is a limitation on the design of the PRN, but psychologists should be aware that the PRN is neither trying to replicate nor to replace traditional outcome studies. Instead, it is acquiring data that traditional outcome studies are unable to provide.
Traditional outcome studies have limited generalizability because they typically deal with highly delineated problems, use detailed treatment manuals or protocols, and limit the number of sessions. As the internal validity of these studies increases, their external validity becomes more problematic. It is not known how well the results from these methodologically strong outcome studies apply to the daily practices of the average professional psychologist. Do the average psychologists provide a lower level of service because they are not using the up-to-date protocols found in the controlled outcome studies? Or do they provide a higher level of service because they are free to vary the treatment according to the unique personal needs and circumstances of the individual patients? Or do the results from outcome studies using carefully delineated patient samples fail to generalize to the real-world population at all where patients are more likely to have co-existing disorders or other complications?
Furthermore, in the limited space available, Dr. Ragusea was only able to describe the "core battery" data which is being gathered. Another fundamental goal of the PRN is to establish a network of practitioners and researchers who are interested in creating unique studies. We cannot preclude the possibility that some of these psychologists may be develop outcome studies with more of controls of internal validity than is found in the current core battery study.
Thank you for the opportunity to clarify the nature and purpose of the Practice-Research Network.
Samuel Knapp, Ed.D.
I want to take a moment to express some of my concerns and observations over the last several years regarding the issue of managed care. I am currently working on my undergraduate degree in psychology at California State University, Pomona. I will soon be applying to graduate school with he hope of obtaining my Doctorate in Psychology. Ever since my junior year in high school I have wanted to become a counseling psychologist. Unfortunately, due to the increasing monopoly of managed care I feel I should explore other possibilities.
Six years ago I began to work for an OB/GYN group where I got my first experiences with insurance companies. Those were the days when managed care was an up-and-coming possibility and not the harsh reality it is today. Patients said they would not join and doctors said they would not participate. Managed care was a concept that was expected to fail. Patients eventually signed up due to lower premiums and the idea of office visit co-payments instead of the traditional deductible. It was at this point when the doctors I worked for realized they better jump on the "bandwagon" or lose valuable patients.
As time went on increasing limitations were placed on physicians. Along with the limitations came cut-backs in "reasonable and customary" or "allowed" amounts. Translated for the physicians this simply meant less money. What happens to the level of care a physician can given when he or she now has to see more patients in less time to break even? It almost seems degrading for some committee in a managed care system to tell the professional that is actually working with the patients what he or she should/should not do and what he or she can/can not do.
As I complete my undergraduate degree, I am working in the mental health field doing insurance billing fro psychologists. I did this in order to get some "hands-on" experience and learn more about my field. So far, my findings have been rather discouraging. Managed care seems even worse here. The number of patients having to terminate their psychotherapy due to very limited approved benefits is frightening. Psychotherapy is intended to promote meaningful methods of coping with difficulties, but it seems as though managed care is throwing that out the window and degrading it to a form of crisis intervention.
It was also frightening to learn that managed care companies offer incentives to providers who do not use all of a patients allowed visits. In the office I am working at the doctor became very upset due to a recent contract she was offered where an incentive bonus would be given if she did not use all the benefits assigned to a given patient. In other words, they are paying therapists not to do his or her job! I really do not wish to be discouraged to follow my dream and become a counseling psychologists, but how can I not be when therapists are being forced to worry too much about the money and not enough about the health of the patient, which is why we are in this field in the first place.
Ryan D. Morgan
I am sending you this letter in order to bring your attention to an extremely grave situation. I am a recent Southern California clinical psychology Ph.D. graduate and currently employed as a psychological assistant (P.A.). The grave situation I am referring to concerns managed care. I do not understand the logic or reasoning managed care companies possess when they deny clients their rightful coverage if they choose to be seen by a clinical psychology Ph.D., P.A., from an APA accredited institution. Many potential clients have come to me, utterly confused about why they can not come see a "Dr.", but yet are "allowed" to see someone who has completed their Master's degree. Receiving one's Ph.D requires many more years of continued education, completion of a dissertation, combined with 1500 or more hours of professional experience. Are managed care companies devaluing my expertise? This devaluation process is then filtered down to the managed care recipients via the manner in which they are forbidden to see a Ph.D., P.A. This whole process is completely unethical. Of course, this is only one unethical violation, among many committed against the APA ethics codes, by managed care companies.
Just to intensify matters, what do you think the ability to "forbid" or "allow" another human being does for the power distribution. Managed care is breeding a race of disempowered individuals. I literally see this look of disempowerment on the faces of my potential clients as they realize that "big brother" has not given them permission to talk to me.
It is definitely a grave situation, when managed care companies have violated not only the APA ethics codes, but also our inherent constitutional rights! Where will it end?
Carol Elias, Ph.D., P.A.
Managed Care should be labeled RATIONED CARE - since that is what it is.
I have been a member of APA for fifty-two years and was one of the people who established Division 39. When I read about what our APA is doing about RATIONED CARE, I am reminded of our struggles to establish licensure for psychologists in New York State and how minimal their efforts were - I refer to the central office of APA. We face powerful forces in the Wall-Street-greed that has taken over health care. Our legislators - except for a few - are quickly coopted by the insurance industry.
I believe that the two great movements of the last fifty years - civil rights and the ending of the Viet Nam war - emanated from grass roots movements. In south Florida, where I live a "new life style" since I left active practice, I have organized and worked with every type of grass roots organization to combat RATIONED CARE. As past president of a B'nai B'rith unity in Palm Beach I have enlisted the cooperation of the local medical societies, Floridians for Health Care, AARP, clergy and every group that is concerned about profit forces driving health care. We are part of picket lines and protests that capture media interest. Professionals MUST join grass roots organizations. We must point out the "cherry picking" that is at work - keep the healthy and drive out the seriously ill as well as the chronically ill. As mental health professionals we MUST stress the total invasion of privacy by insurance companies. We MUST stress that as professionals and clinicians we accept the responsibility for those people who come for our professional services.
Observe how outraged people became when they read about drive-through mastectomies. There is a time for long term care, a time for short term intervention, a time for medicating, a time for listening but there is NO TIME for insurance companies to dictate to us what we shall do.
Insurance companies are motivated by profit. Repeat it over and over; Profit is not part of health care.
We MUST stress that we are the people who work with those who come to us for our professional service and WE are not interested in stocks, stock options, bonuses or the varieties of greed that have entered health care. Wear a button that says: QUALITY PATIENT CARE. When people question you, tell them what it is all about.
Tell people about RATIONED CARE and how it is moving us all to mediocrity in health care. Meet with the clergy in your community. We have many clergy in Palm Beach County who have signed a statement which we are ready to publish in which they express concern and dismay about profit as the driving force in health care. Encourage the clergy to speak about it from the pulpit. But above, all, stimulate, organize and join grass roots organizations. They want our help and are eager to have our input. Remind them of Ghandi's statement: There is enough for need but never enough for greed.