How Broken is the Mental Health Delivery System?

Most psychotherapists agree that the mental health delivery system is broken. Where two or more psychotherapists are gathered together, complaints abound. While this article addresses the broken mechanics is the mental health delivery system, it does not even begin to address the mishandling of individual cases.

People, in general, and psychotherapists, in particular, are afraid to "buck the system." Fear masquerades in a variety of acting out, defensive behaviors, such as anger, denial, criticism, withdrawal and aggression.

This is especially true when discussing the managed care system. Most psychotherapists in the US have chosen to practice as in-network providers for the insurance companies. That means that the therapists have agreed to a discounted fee, in hopes of receiving more referrals, because they are in-network. It also means the therapist usually must have their services authorized prior to seeing the clients.

After all, our present mental health delivery system, which has been around since the early 1980s, has developed inbred power, not only in individuals but in the system itself. I can remember the anger of my clients 25 years ago, when the found their insurance company dictating the amount and kinds of service they could receive, but within five years, as a nation we accepted the managed care concept without a fight.

Therefore, I am challenging a very large, money-hungry system, established to feed on itself, but not adequately supply services that meet the needs of its members or the realistic needs of the health care providers.

So I challenge anyone to deny that our present mental health delivery system is fragile and broken. Here are eight reasons why;

1. Diagnosis is made by professionals who are not in intimate touch with those individuals who come for help. Insurance companies and third party payers demand a medical diagnosis before they will reimburse for a claim, starting with the first visit. It is unrealistic that under the present delivery system today that most psychotherapists can positively and accurately determine the diagnosis code required.
2. The diagnosis criteria often change from one edition of the Diagnostic and Statistical Manual(DSM) to the next Diagnostic and Statistical Manual, the psychotherapists diagnostic bible. For instance, a common presenting problem is identity disorder. Yet identity disorder is no longer listed in the DSM, so therapists may have to "fudge" a bit on the diagnosis...if they want to get reimbursed. Further complicating the situation is the fact that not all DSM diagnoses are reimbursible. Because many insurance companies will not reimburse for autistic spectrum disorders, therapists become creative.
3. Thousands of individuals who need therapy are not receiving it. In these economic times, small businesses are dropping health insurance as a benefit. Because of the high cost of insurance for even large corporations, many are increasing the cost of insurance to their employees, and many benefit packages have very high deductibles and larger co-payments due at the time of visits.
4. All therapists are not created equal, when it comes to their skills. I recommend that the terminal degree for all psychotherapists (except hypnotherapists) would be a Ph.D., not necessarily in psychology. Many agencies use B.A. degreed graduates or even interns "to do therapy," because they are supervised by licensed clinicians.
5. Costs of our present mental health delivery system are often prohibitive, while third party payers often offer fewer benefits with higher deductibles for mental health. Mental health still appears in all practicality to be exempt from the Parity Law. My personal clients generally have seen higher co-payments for specialists (mental health is a specialty), while being given unlimited visits. What my clients do not realize is that some of them are paying almost my entire fee, leaving the insurance companies responsible for $10 or $15 per session in many cases.
6. Managed Care companies often outsource their customer service to India, Argentina or the Philippines, and benefits are quoted inaccurately by people struggling with basic language skills.
7. Some of the largest managed care companies simply require a completed computerized form to obtain an authorization for service. Upon submission of the form, initial visits or additional visits are granted automatically without any human review. I assume that there is a pre-set criteria, set by the company, that must be met for this to happen. In some cases immediate authorization is not given but forwarded for further evaluation by a live body.
8. Most important of all, mental health care is not directed by the client and the health care professional. Until 2010, therapists could see individuals for a specific, often limited number of sessions based upon their insurance benefit package and/or the authorization from the insurance companies. Furthermore, many therapists feel that therapy is something that is done to the client, rather than building a partnership for brief therapy treatment planning.

If this does not mean the mental health system is broken, what does?