Mangaged Care And Mental health Coverage
(Just good business, or just plain crazy?)


Traditionally, health insurance protected us from having to pay for the treatment of a major illness at a cost that could wipe out a life’s savings, and we paid for routine health care ourselves. Today, insurance pays the cost of treating both catastrophic and routine illness. The cost of health care has been rising, and there’s a lot of talk about how to cut costs.  Many think covering the cost of services for people who are not sick would be just plain crazy.  Others however, think it would be just good business.

During the years when (HMO’s) Health Maintenance Organizations managed themselves, providing services for people who were not sick was considered cost effective, just good business. Studies show early detection and treatment for emotional problems reduces the potential for physical health problems. HMO’s covered the cost of marital therapy, family therapy, and therapy for individuals with normal problems of living.  They chose to pay up front to reduce the stress of their healthy members, before that stress could make them sick.

HMO administrators realized, healthy people who are experiencing stress from unsolved problems of living are more likely to get a major physical illness like cancer, for example. Cancer can be very expensive to treat. Even on a routine basis, people with untreated emotional problems are heavy users of costly medical services.

Apparently (MCC) Managed Care Companies think covering the cost of services for people who aren't sick is just plain crazy. When the HMO was taken over by MCC everything changed. While the HMO sought to cut costs by preventing illness, MCC cut costs by cutting benefits, they require healthy people, with unsolved stress producing problems to wait until they’re sick before the cost of their treatment will be covered.

MCC rely on the (APA) American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders IV  (DSM IV) to determine what’s considered a medical necessity in the area of mental health.    They don’t just rely on it, they insist on it. Your therapist cannot bill for the treatment of emotional problems without using a diagnosis of mental illness.

As it turns out, insisting on a DSM diagnosis is like no gate keeping at all. The APA has found a loophole in the system. If we just call everybody sick, treatment for healthy people with problems of living, marital problems, or family problems will be covered by their insurance company. Just about every human behavior you can think of will qualify for a diagnosis of mental illness in the DSM IV.  Now, regardless of what your problem is, if your therapist calls it mental illness, your treatment will be paid for. The DSM IV lists over 300 mental disorders in its 800 plus pages. The only thing that’s really changed since the time when HMO’s managed themselves and routinely offered preventive mental health care is, now a diagnosis of mental illness is required for the same treatment to be covered. And, the diagnosis must include intimate personal information in your medical record to justify it.

Most therapists know a diagnosis of mental illness isn’t necessary in order to help people solve emotional problems. It used to be common practice for therapists to give clients the least harmful diagnosis possible, to protect their privacy. Now, they give bigger more serious diagnoses, to get more sessions approved for payment. When more serious diagnoses are used however, more serious and more detailed information about people must accompany them. Of course, we all know that no matter how many laws we enact, information in medical records cannot be adequately protected.

Just good business, or just plain crazy?

You decide.

—M. LaCourt

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