Cover Story

The California Psychological Association (CPA), APA and Aetna U.S. Healthcare of California, Inc., reached an agreement on July 20 that will improve consumers' understanding of their mental health benefits with Aetna, Russ Newman, PhD, JD, APA's executive director for practice, announced at APA's 2000 Annual Convention in Washington, D.C.

The suit, filed in 1998 by CPA against Aetna U.S. Healthcare of California and its behavioral health subcontractors, Human Affairs International of California (HAI) and HAI's subcontractor, Adventists Health Behavioral Care, charged that the managed-care companies were misleading the public about their mental health benefits in Aetna's California health-maintenance organization. In particular, Aetna's advertising to employers and beneficiaries claimed enrollees could obtain a mental health treatment benefit of 20 to 50 outpatient visits per year with its contracted mental health providers. In reality, however, the health-maintenance organization regularly limited patients to a four- or five-visit "crisis" benefit only.

The test cases are part of APA's multifaceted attack on the problems of managed care, which also includes federal and state legislative efforts. In the test cases, APA has singled out some of the most egregious managed-care practices and used lawsuits filed in state courts--typically by the state psychological associations--as a means of demonstrating that such practices violate the legal rights of both psychologists and their patients.

A few weeks before APA's Annual Convention, CPA finalized a favorable settlement with Aetna and its subcontractors. Key elements of the settlement include:

  • Aetna, HAI and Adventist will increase the number of initially authorized outpatient mental health visits for patients, and mental health providers may request additional visits early in the patient's treatment program.

  • Aetna will modify its advertising and other documents to help consumers better understand the coverage for outpatient mental health benefits, how Aetna and its subcontractors determine benefits and Aetna's process to maintain the confidentiality of mental health records. These documents will explicitly state that Aetna may limit the number of the mental health visits to the minimum it deems to be covered benefits.

  • Aetna agreed to form an Aetna-CPA-APA Joint Study Group to evaluate ways to improve Aetna's utilization review process.

The full details of the settlement are confidential but may be viewed by APA and CPA members on the members-only sections of those associations' Web sites.

The study group is an important component of the agreement, Newman said.

While part of the agreement extends the number of sessions before utilization review takes place, the study group will examine the utilization review process itself.

"We hope that this effort will result in innovative ways to put decision making about patient care back in the hands of psychologists and other mental health care professionals," Newman said. "This fits with the underlying theme of the California suit--that the undisclosed limitations on mental health coverage effectively replaced the psychologists' professional judgment about the necessary course of treatment with an arbitrary and hidden bureaucratic fiat. APA is hopeful that other managed-care companies will also reexamine the impact of utilization review on mental health care, and even look for ways to achieve their objectives that are less intrusive (and possibly more cost-effective) than utilization review."

Lorryn Wahler, executive director of the New Jersey Psychological Association (NJPA), joined Newman in his presentation. Wahler announced that a favorable settlement appears to be close in NJPA's suit against MCC Behavioral Health, the first of the test cases. In that case, NJPA alleged that MCC terminated seven New Jersey psychologists on the basis that they were "not managed-care compatible."

Further developments in the test cases will be reported in upcoming issues of the Monitor.