End Secret Treatment Guidelines! 1

By Ivan Miller, Ph.D.

Imagine that your medical doctor tells you to take some unlabeled pills. When you ask what is in the pills, he tells you that the contents are the proprietary information of your HMO, and if the ingredients are disclosed, your HMO would be at a competitive disadvantage. Your doctor reassures you that your HMO medical board determined this was the most cost-efficient medication for managing patients in your disease classification.

He explains that, in general, professionals and scientists cannot be trusted to evaluate medications because they don't care about cost. However, you can trust the HMO medical board because it considers both cost and effectiveness. In addition, he reassures you, your HMO is committed to raising quality through outcome surveys of customer satisfaction. After treatment, you will be able to influence the future management of your disease classification by rating your satisfaction on a scale from 1 to 10. Future decisions will be based on your satisfaction as well as cost In this way, he explains, it is okay to use secret medication because your HMO is actually more accountable than the old fee-for-services medical model.

Managed mental health care is using secret treatment guidelines in the same manner described in this story. Traditionally, medical and mental health ethics required disclosure of treatment methods. Business, on the other hand, classifies internal operations as proprietary and requiring secrecy. Managed care has imposed this secrecy on mental health care. Neither consumers nor professionals can get the full description of the treatment offered by most managed care companies.

Just as a description of a medication includes both the ingredients and the amount of those ingredients, complete psychotherapy guidelines must include both the type of therapy and the number of sessions provided to the average client. The number of sessions is particularly important because this statistic varies greatly depending on financial incentives, utilization review procedures, and hidden barriers to treatment.

Also, the full description of psychotherapy services must include procedures that affect treatment quality. Gatekeeping practices may intimidate and shame clients, and frequent utilization review may make patients feel judged and insecure in the therapeutic relationship. If professionals are selected according to their "managed-care friendly" behavior, the fear of being rated "unfriendly" could keep some from being fully open with clients about the shortcomings of their managed-care benefit package.

The American Psychological Association Practice requested that managed care companies disclose their general treatment guidelines, and 7 of the largest 24 companies have done this. However, the disclosure of general guidelines is only a beginning: Without specific information about average length of treatment, policies, and procedures, these guidelines reveal little more than the idealistic goals of managed care.

Managed care companies often deny that full disclosure is necessary because they intend to gather outcome data, which they claim is the only quality measure that consumers need. This argument is deceptive. Good outcome studies are expensive, and managed care is not proposing expensive outcome studies. The studies proposed by managed care exaggerate the importance of friendly service, the placebo effects of treatment, spontaneous remission, and the easily-obtained, initial reduction of some symptoms. These studies underrate the importance of improved personal, social, and occupational functioning. The simplistic outcome studies of managed care are no substitute for full disclosure of the information that describes treatment.

The National Coalition of Mental Health Professionals and Consumers, Inc., believes that all managed care data about treatment services, guidelines, policies, and procedures should be open to public scrutiny.  Professionals and scientists need this information in order to evaluate the quality of managed-care services. Consumers have a right to know that their treatment will not be planned in secrecy or outside of the scrutiny of the professional and scientific community.

Consumers don't want to be given secret medications and don't want secret guidelines for their psychotherapy. No company has the right to secretly manipulate or influence the treatment of a patient's body or mind. The National Coalition of Mental Health Professionals and Consumers, Inc. will be inviting other organizations to join us in asking for full disclosure of managed care treatment data, policies, and procedures, we can move toward ending managed care's secret manipulation of the consumer's personal mental health care. Let's save privacy for patients and begin disclosure for corporations.

1 This article was published in the August 1997 issue of the American Psychological Association Monitor and is reprinted here with the permission of the APA.

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