Rationing care to the poor

Henry Tomes

Over the past several years, I have heard many health professionals talk about the hurdles and hoops they've encountered in today's changing health-care environment. It doesn't matter whether the discussions involved psychologists, physicians, dentists or nurses, there is a strong dislike for the way the system is managed. They resent the interference with doctor-patient relationships, the second-guessing of their diagnostic and treatment plans, the increased (some say onerous) record-keeping, the worries about confidentiality of client information and the constant frustration about rates paid for services rendered.

By and large, it seems that the process of managing health care has become one of substituted judgment derived often from computerized data bases that provide historical service and payment information intended to make the system efficient and effective within certain cost parameters.

When psychologists, particularly independent practitioners, talk about the management of health care, they often reflect how things have changed for them. Loss of autonomy, difficulty in adjusting the clinical process to seemingly arbitrary visit decisions and the reduced reimbursement levels for expenditures of considerable professional time and effort. Case managers are perceived as unwanted but omnipresent partners in the practice. Some psychologists continue to struggle with the referral process--which is, of course, critical for maintaining a viable practice--while others, usually more senior practitioners, have mastered this complex business. Then, of course, there are issues associated with a variety of mental health professionals trained at different levels, chasing too few consumers of behavioral health services.

A look at the consumers of health care

From a Public Interest perspective, one is quite sympathetic to the changes taking place in the delivery system and how providers are affected by them. However, it is also important to look at how the recipients of services are being affected by these systemic changes. When this nation decided that there was only a finite amount of money available to provide health services, a kind of apportionment or rationing of funds and services took place.

Generally, the money available was used by management companies to purchase services from a network of providers who cared for a group of enrollees with enough money left over to provide a profit. Behavioral health managers, particularly in the early days of managed care, were able to make arbitrary decisions about the kind and duration of interventions necessary to treat mental and emotional disorders. Although some behavioral health companies lost money through poor contracting or underbidding, others made considerable profits, too often at the expense of providers and consumers.

Before these changes came about, clinical decision-making--taking into account individual client needs--was crucial in determining treatment issues. While there were some abuses, there were also many more judgments that fit the intervention to the client. However, with the advent of managed care, poor people, for example, whose services are paid by the Medicaid program were allocated session limits that took little account of the role played by poverty in initiating or maintaining their behavioral disorders. Nor were providers usually selected with an understanding of consumer diversity.

It was soon learned that even poverty cannot mask the differences that arise from gender, race, ethnicity, age and other factors. In fact, some of the most visible efforts to manage care on a large basis took place in the Medicaid program as states, attempting to reduce their health-care costs, rationed care to poor people. All aspects of care were affected by the rationing of care, but behavioral health, whether "carved in" or "carved out" of the overall system often became primary "profit centers" often to the detriment of intended beneficiaries: poor people.

Partnering for change

There is a gathering mood in the country that will likely bring about changes in some of the more egregious practices of health-care management. Providers, including psychologists, are moving to legislatures and courts to redress perceived inequities in the system. Consumers and consumer advocates are also approaching policy-makers to get relief from rules limiting access to services and providers of choice.

It is likely that the greatest changes will come about as consumers make their concerns known to state and federal policy-makers. In fact, it would probably make both strategic and tactical sense for providers to partner with consumers to bring about those changes. They need each other. Over the past several years I've been able to have discussions with a variety of health professionals about the changes in the way health services are made available to consumers and all the hurdles and hoops they encounter in the process.



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