The cost of outpatient mental health care has, contrary to popular belief, kept pace with inflation for decades — since economists have been keeping records on such matters. There is overwhelmingly strong evidence that the cost of outpatient treatment is self-limiting and highly predictable.
There was, however, a period in which the use and cost of inpatient adolescent care and inpatient substance abuse care increased rapidly. Managed care firms took full advantage of this cost increase, then asserted that mental health treatment costs in general had been both too high and out of control. They moved in as wholesalers, inserting themselves between the purchasers of services (employers) and mental health professionals. In the guise of controlling “runaway” costs, they applied standard management practices to control mental health care delivery. They broke care delivery down into simple units of measurement such as numbers of sessions. They promoted medication and ultra-short-term treatment for almost all treatment cases. They sold employers on the idea that third-party management and “decision support” of the treatment was necessary to insure cost control and quality. Speaking the business language of employers, they focused employers' attention on the care delivery system rather than the care delivered, and on the cost of care rather than its value.
The resultant de-professionalization of treatment has substituted a different kind of service for psychotherapy. It even has a new name: managed behavioral health care. It has led to denial of needed care, difficult access to treatment, and violations of privacy and confidentiality. The application of standard management practices has effectively deconstructed the therapeutic episode into sessions or “doses.” This practice creates the impression that therapy is a commodity composed of easily administered units instead of a complex, contextual, and progressive experience leading to healing. The costs to businesses and individual subscribers of lack of treatment or inadequate treatment remain undiscussed, because these costs are not easily measured or estimated. It is abundantly clear that the transformation of psychotherapeutic treatment into a commodity has lowered psychotherapy's perceived value and demoralized the mental health care professions.
There is no evidence that managed care has actually saved money on outpatient mental health care. In order to maximize the value of their stock, managed care companies consume 40 percent to 50 percent of the mental health care dollar in administration and profit, according to the Wall Street Journal (8/13/95). Thus the treatment dollar is diverted from treatment to corporate earnings. The trend to alter, limit, or block access to outpatient mental health care will certainly continue, and it will escalate as competition between managed care companies forces them to cut costs while maintaining profits.
The American Mental Health Alliance (AMHA) offers an alternative. It began in Massachusetts in 1995 with an interdisciplinary group of concerned clinicians who wanted to stem the industrialization of mental health care and return control of treatment to patients and professionals. Many of them were psychoanalytic psychotherapists or psychoanalysts and comprehended fully the destructive impact of managed care on psychoanalytic practice. AMHA is now a national federation of state-run interdisciplinary organizations of licensed mental health professionals. It has spread to Arizona, Arkansas, California, Maine, Maryland, Michigan, Missouri, Montana, New Hampshire, New Jersey, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, Virginia, and Washington, D.C. The cooperative alliance of state AMHAs is coordinated through the national AMHA, which helps them form, administer interstate contracts, address regulatory matters, and market their services. The not-for-profit structure of AMHA allows it to deliver the full range of mental health and substance-abuse treatment services at a competitive cost. AMHA offers contracts directly to businesses, municipalities, government agencies, and other organizations.
AMHA in each state is organized cooperatively; each member owns only one share of stock. Each professional invests a modest amount of money in a share, but then earns money only by providing service to patients — not by dividing profits. There are no passive stockholders who benefit from limiting care, and no select group that might benefit from a corporate sale or other windfall profits at the expense of insured individuals.
On a state-by-state basis, all AMHA members and alliances agree to operate under a set of principles known as Cooperative Mental Health Care. These principles place the primary decisions about care with the patient and therapist, and the management of the care delivery system in the hands of cooperative professional communities. Confidential information about the patient remains with the therapist, not at some centralized location.
Some other principles of Cooperative Mental Health Care:
A progressive or negotiated series of co-payments.
Normal session limits of 50 per year. Limits may be removed when intensive outpatient treatment is needed to prevent hospitalization.
A requirement that the patient's outpatient therapist be a member of the treatment coordinating team when he or she is admitted to a hospital. This ensures continuity of care.
The requirement that members be active in clinical consultation with respected colleagues and involved in an outcome research program.
AMHA is a self-managed system. It relies on creating and maintaining a community of colleagues who consult with and learn from one another. Operationally, members organize themselves into smaller regions within states, each with its own board to coordinate services, and each with its own Clinical Consultation Team of professionals with special expertise in conditions requiring extraordinary care. Thus, instead of being managed by a wholesaler of services, the Alliance forms a system that manages itself. The focus remains on clinical issues and not on passive (shareholder) profits.
The result of this attention to the value of psychotherapy and other treatment is that fundamental treatment processes are fully respected. Since there is no clinical or financial reason to “manage” outpatient treatment, AMHA members have no need or wish to intrude on the therapeutic relationship. This preserves privacy, confidentiality, and free choice of practitioner and treatment modality. Access to treatment is facilitated rather than hindered. The care delivery system is both clinically focused and cost conscious, and it emphasizes value as defined by the client's needs and the professional's training.
Jane Buckwalter, C.S.W., Peter Gumpert, Ph.D., and Daniel Kagan, Ph.D., are, respectively, Chairperson of AMHA-NY, Chairperson of AMHA-MA and AMHA-National, and Marketing Director of AMHA-MA. For more information, visit the AMHA Web site at .
Even though AMHA's methods neutralize financial pressures to maximize profits in delivering health care, the alliance still operates in a business environment. Employers in modern, highly competitive, turbulent markets are cost-conscious. Therefore, a voice is needed to reinvigorate the image of therapy as an effective and valuable healing process that has beneficial outcomes for both the individual employee and the groups or teams of which he or she is a member.
AMHA can serve as the voice for the mental health professional in the business community. It removes the managed care wholesaler from the conversation and directly presents the evidence that good treatment works both for the patient and the employer and therefore should be valued. From both the professional and the strategic perspective, individual therapists may find it difficult to make this argument to focused business people. As owners and influential members of a self-managed health care delivery system, however, professionals can influence marketing functions by providing valuable information and consultation. AMHA allows practitioners to engage in these relationships with businesses without violating their professional perspectives.