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On The Lighter Side Health Care Parity: The Group Prostate Examination and Other Modern Developments

Martin H. Williams, Ph.D.

We may never learn who it was in the world of health care, insurance, and profit taking who realized the way to turn mental health parity inside-out. Whoever it was, whatever under-appreciated, hard-working petty bureaucratic functionary, shall be appreciated forever by all the fat cats who will be pocketing the green fruits of his or her labors. The brainstorm didn't last long, and probably went as follows: "If we've been able to put limitations on mental health treatment, thereby saving ourselves tons of money, why can't we do the same for all medical treatment?" The rest, as they say, is history.

The first real translation of psychotherapy-type limitations to medical care was the prostate exam. As my readers well know, one way of limiting psychotherapy benefits is to require that patients who receive treatment do so in groups. Group therapy allows a single therapist to provide services to many people at once. One agency has been successfully treating depressive symptoms using CBT groups of up to fifty patients at a time.

The prostate exam allows for similar efficiencies. When a middle-aged man has a prostate exam, his doctor generally takes him into a private examining room, has him bend over, puts on a glove, and does the examination. How utterly inefficient! Using the new group prostate, the following advantages were immediately realized: First, less office space is required because the group examination can be done in a room full of about twenty men, but the room does not need to be as large as twenty individual examining rooms. Second, the doctor saves time because the instruction, "Bend over," only needs to be stated once, rather than twenty times. Third, any hesitancy that the patient might experience about bending over is overcome by the social pressure to comply. The patient looks around the room and sees all the other good citizens bending over and knows he must do the right thing. In the ideal clinic, all the prostate exams are scheduled for the same day, and the doctor goes from group room to group room, quickly moving from patient to patient, stopping only to change gloves and to write a note.

For greater efficiency, two modifications have been tried with some success. First, the instruction to bend over is given not by the doctor but by a nurse. Thus, by having the patients already waiting in the bent position, the doctor wastes no time as he or she first strides into the room. Second, some doctors have learned to do the exam with different fingers. With this method, as long as the doctor pays attention, the gloves do not need to be changed after every patient, but only after every two or three depending on the doctor's degree of proficiency.

The cost savings from group prostate exams can also be applied to group hernia exams, which have in common the need for minimal medical equipment. (Exams that require equipment, such as mammography, do not benefit as much from the group method, as the investment in redundant machinery outweighs the efficiency of group. For mammograms, the preferred cost-savings approach is simply to have the patients wait in long lines to ensure that they are ready as soon as the technician is, thereby avoiding any machine down-time). The hernia check is done in the same rooms as the prostate check, except the instructions, "Drop your trousers, turn your head, and be ready to cough when commanded," are somewhat different. The doctor rolls into the room on a small stool and then rolls himself from man to man, stopping for notes and gloves as with the prostate.

In fairness, the military, not managed care, should be given credit for the group prostate and group hernia exams. Both of these early forms of "digital technology" were perfected during wartime, when the military was forced to operate its own cost effective managed care program. Ironically, in the World War II era, these humiliating invasions of one's privacy occured despite the fact that, in a complete reversal of current trends, psychotherapy was still carried out in private--no case manager and group therapy only when clinically indicated.

The other mental health limitation that has been widely successful has been the visit limit. Patients are told that their health plan contract contains a limitation on the number of mental health visits to which they are entitled. No one can really explain the rationale for the treatment limit. If the person needs more visits, then they haven't gotten better. If they haven't gotten better, should they be punished by cutting off their care? Obviously, I am not in the proper frame of mind to understand health care, but I can tell you this: If it works for mental health, it can work for everything.

For example, let's take the cancer patient. Cancer is a serious disease, but so is mental illness. The same method of limiting care for personality disorders can be applied to cancer. If you can manage to say to your patient, "You have a personality disorder which requires long term treatment, and your coverage only allows you ten visits," then you ought to be able to deliver the same little speech to your cancer patient. Remember, the key to your delivery is to make it appear that the cancer--like the personality disorder--is somehow their fault, and, consequently, their responsibility. You can say, using your best sneering tone, "If you wish to get more treatment than your coverage allows, feel free to do so. But, remember, you must pay for it yourself."

This may lead to some very tragic situations, but, hey, who ever said life was fair. For most types of cancer, the limitation should be five chemotherapy visits, three radiation visits, and up to seven office visits per episode. Due to the kindness of our health coverage, we allow patients to trade between chemotherapy, radiation and office visits, but that's it. If the resistant patient refuses to give up the cancer during the allotted number of sessions, then that's it, case closed. What's good for the personality disorder is good for the malignancy.

Similar limitations can be placed on all sorts of care, as some already have. We now have "same day surgery." This makes the patient responsible for his or her recovery after major surgery. The recovery is done at home without the supervision and intervention of trained nurses. If the patient feels the need for more care--let's say the sutures open up--then the patient had better have the wherewithal to pick up the phone and call for advice. This is an exact parallel to the way we treat most mental illness at home. There used to be a quaint phrase, "the ambulatory schizophrenic." This apparently referred to the schizophrenic who did not need to be institutionalized. Nowadays, all schizophrenics are ambulatory, just as all inguinal hernias are outpatient surgeries. It's amazing what changes can be made in health care just by the stroke of a pen without even consulting the care providers.

The health care list of excluded conditions and procedures will some day be hailed as a medical breakthrough, equivalent to the discovery of penicillin. I can't wait to be in the emergency room, looking over the clerk's shoulder, when Mr. Earnest J. Schlemiel is told, "I'm sorry Mr. Schlemiel, but you're covered for only three visits for crushing chest pain per year. Your third visit occurred a week ago, so we're not going to evaluate you again." Mr. Schlemiel, already sweating profusely and white as a sheet, had no discernible reaction to what he had been told. Like many patients before him who unwisely had suffered from non-covered emotional problems, he turned and stumbled towards the door--a living (for now) example of real mental health parity.

Jeff McKee
Saturday, April 25, 1998