Cancer patients find anxiety not covered under managed care

Managed-care companies don't distinguish between mental illness and psychosocial interventions for cancer.

By Lisa Rabasca
Monitor staff

"We don't deal with fear." That was the response a managed-care company caseworker gave David Wellisch, PhD, when he recently asked the company to authorize psychological treatment for the daughter of a breast-cancer patient who feared suffering the same fate.

Wellisch's frustration is typical of psychologists treating cancer patients and their families. Because managed-care companies are only willing to pay for psychological interventions for diagnosable mental illnesses, psychologists are required to give their patients a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders.

But the manual doesn't address physical health or include any specific diagnosis for the psychosocial aspects of cancer treatment, says Wellisch, a professor in residence with the department of psychiatry at the University of California, Los Angeles, School of Medicine.

While the manual does recognize that a medical condition can cause a patient to have an adjustment or anxiety disorder, most psychologists say they would rather not give cancer patients a mental health diagnosis because managed care limits mental health treatment unless one truly exists. Also, managed-care companies limit mental health treatments even if the patient is given a diagnosis, says Wellisch.

For instance, managed-care companies expect an adjustment disorder to be treated in three months, says Carol Goodheart, EdD, president of Div. 42 (Independent Practice). But, many cancer treatments continue for much longer.

The problem, Goodheart says, is that managed-care companies don't distinguish between mental disorders and psychosocial interventions for cancer.

"Most patients don't have a mental illness," she says, "they have cancer."

While some psychologists are trying to remedy this problem by demonstrating to managedcare.html"managed-care companies the value of psychosocial interventions for cancer patients, most psychologists are forced to use a piecemeal approach to obtaining coverage for their patients, appealing to caseworkers as individual cases arise.

Different goals

A common frustration facing practitioners is that managed-care companies often have different expectations when it comes to treatment goals for cancer patients.

"The goals of managed care are to quickly and effectively make the symptoms go into remission," says Wellisch. "But the goals of working with a cancer patient, especially one who has widespread disease and may be facing death, is not to make the symptoms go away, but to raise the patient's level of coping with an ongoing problem that's not going away."

A cancer patient's symptoms often fluctuate over time, depending on the medical treatment and whether there's a recurrence of cancer, Wellisch says. Research shows that psychological symptoms worsen as the disease progresses so patients who relapse might need more than the eight sessions typically allowed by managed care, he says. Yet managedcare.html"managed-care companies often deny additional treatment, claiming that the psychologist is treating the same thing over and over again. As a result managed-care practices often compound the stress patients already feel living with a cancer diagnosis.

"The patient never knows when his or her treatment will be cut off because the managed-care company dictates the terms of treatment, not the patient and the psychologist working together," says Goodheart.

Be proactive

One way psychologists can encourage managed-care companies to pay for psychosocial interventions for cancer patients is to explain to the managed-care company's administrator when and why psychological treatment is necessary, says John Fontanesi, PhD, director of Kaiser Permanente's Center for School Problems in San Diego.

For instance, children who receive cancer treatment should also receive neuropsychological testing and follow-up treatment, Fontanesi says. He and several colleagues working in pediatric oncology sent Blue Cross/Blue Shield information listing the types of psychological treatment and testing that would be appropriate for each of the major childhood cancers based on available research.

"Rather than saying, 'Here's a kid who had cancer that's having trouble in school, please pay for this,' we're proactively contacting the managed-care companies and saying, 'We want you to be aware of these issues,'" says Fontanesi, who is also professor of medicine at the University of California, San Diego, department of pediatrics. As a result, Blue Cross/Blue Shield now pays for neuropsychological assessments for children that have been treated for cancer.

Another way to encourage managed-care companies to pay for a psychosocial intervention is to develop a cost-effective treatment. Maryland social worker Irene Pollin has developed what she says is a cost-effective psychological intervention that she is marketing to managed-care companies. The intervention seeks to treat the fears cancer patients typically face, including the fear of losing control of their lives, feeling isolated, being stigmatized by their illnesses, dependent on others and abandoned by friends and family.

"The Taking Charge Program" is delivered over the telephone in six, half-hour sessions by specially trained medical social workers. The patient also receives an educational videotape and companion book. Family members receive an audiotape about the intervention. A large Milwaukee-based employee-assistance program, whose clients include NationsBank, is using the program, Pollin says.

While psychosocial interventions like Pollin's may provide some relief to cancer patients, psychologists say a larger solution is necessary.

Psychology needs to be a routine part of cancer treatment, says Goodheart.

Wellisch agrees. "We need to have a dialogue with managed care, Medicare and the federal government to determine what kind of psychological care is helpful to cancer patients and their families and what type of system should be set up to provide that care," he says. "And that system will have to be different from managed care."

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