Fat, Muscle and Bone

(originally published in the spring, 2011, Illinois Psychologist, the newsletter of the Illinois Psychological Association)

In the early 1980s I was teaching organizational psychology at The Management Center of Aurora University, where my students were mostly first-level through mid-level supervisors and managers from companies and organizations along the Fox River valley. It was the era of leveraged buyouts, and one student spoke simply and eloquently about the effects of multiple takeovers on his company. “The first time we were purchased it was good for us. The new ownership got rid of fat, and we became lean and efficient. The second time we were bought, the reductions and layoffs imposed by the new owners to pay off the debt of the acquisition cut into muscle. Now we’ve been bought again, and this time they’re cutting into bone.”

A decade or so later I was in private practice, on the panel of an insurance company. A parent called me about an adolescent, an early high school student in severe crisis. The adolescent--let’s call him “Jack”--turned out to have an agitated depression with psychotic features. The insurance company’s treatment authorizer, a social worker, was supportive of intensive outpatient treatment as an alternative to hospitalization. Working collaboratively with Jack’s psychiatrist, who prescribed a combination of antipsychotic and antidepressant medications, I began seeing him three times a week in individual and family therapy. Treatment worked, Jack gradually improved, and it became possible over time to discontinue antipsychotic medication and reduce therapy frequency to twice weekly, then to once, over a period of about a year and a half.

Jack began his senior year relatively stable, on once weekly, mostly individual, therapy and 80 mg. of antidepressant medication. I submitted a treatment plan, which Jack, his parent, and his psychiatrist all supported, to continue weekly therapy throughout his senior year with the goal of eventually discontinuing antidepressant medication. By that time a psychologist had become Jack’s treatment authorizer for the insurance company, and he disallowed continuing therapy; explaining that, since Jack was stable on medication, further therapy was not indicated. The fact that weekly therapy was contributing to Jack’s stability wasn’t noted by that psychologist, who was content to leave the patient on antidepressant medications and call treatment complete. What was therapeutic muscle and bone, to me, to the patient, to his parent, and to his psychiatrist, was fat to the psychologist working for the insurance company.

I resigned from that insurance company’s panel, negotiated a fee with Jack’s parent, and successfully completed the treatment plan. At the time I was on the affiliate staff of a hospital where a psychiatrist consulted for the insurance company, and I asked him why the company’s policy had changed so much over the course of a few years. “The company’s been bought twice since you starting treating that patient,” he told me, and it had acquired a lot of debt to pay off. “It’s all about the bottom line, now.”

Most psychologists who provide therapy do so as sole practitioners, in small groups, or in small community agencies. The insurance and managed care companies that provide or manage third party payment, on the other hand, are usually very large organizations with substantial needs to manage costs in order to pay down debt associated with purchase or other expenditures, and reward owners or shareholders for their investments. So when a psychologist-practitioner speaks with a psychologist (or other mental health professional) working for an insurance or managed care company about authorizing psychotherapy, there can be quite a difference of perspective when it comes to perceptions about what is fat, what is muscle, and what is bone, when it comes to patient needs and treatment.

Because of this and similar experiences, addressing the gap between psychologist-providers and psychologists (and other mental health professionals) working for insurance and managed care organizations has been a goal of mine since becoming a Council member a couple of years ago. I am currently facilitating an ad hoc committee of Council members drafting an aspirational statement regarding the relationship between psychologist-providers and psychologists (and other mental health professionals) working for insurance and managed care companies, for presentation to the Council. Surely the foundations of such a relationship include mutual acknowledgement that the patient’s best interests is a core value shared by both providers and payers, and also acknowledgement that we are all stakeholders, as taxpayers and insurance rate-payers, in a system in which we all want to provide necessary services to people who need them in an economically viable way. Let’s see if there’s a middle ground where psychologist-providers and psychologists (and other mental health professionals) working for insurance and managed care organizations can meet collegially, when we discuss the fat, muscle and bone of psychotherapy.