Can managed care accommodate mental health?

USA Today (Society for the Advancement of Education), July, 1996 by Ralph Hyatt

There is concern that HMOs will end up with the healthiest patients, leaving the most needy and their huge bills to Medicare and Medicaid.

THE NATION has experienced the American Revolution. Industrial Revolution, Computer Revolution, and now the Telecommunications Revolution. Vast amounts of complex information can be stored and retrieved. The Internet has turned the world community into electronic conversationalists and communicators. Yet another radical alteration in American's ever-changing lives has been spawned--the Managed Health Care Revolution.

Wishful thinking will not impede the ongoing overhaul of the health delivery system many of us have enjoyed and thought never would end. Complete freedom of choosing a hospital, family doctor, and specialists is evaporating before our eyes, except, perhaps, for the affluent who are able to pay dearly for such an option. Managed care organizations, it cynically has been said, manage costs, not care. It need not be that way, though.

Just as the ubiquitous horse-and-buggy doctor of old gave way to the overworked general practitioner who seldom had the time or energy to make house calls, so the modern internist eventually had to call on the expertise of urologists, gynecologists, dermatologists, psychologists, and other specialists to diagnose and treat complex symptoms that he or she was not trained for specifically. There is just too much knowledge for one person to know. The internist, however, continued to be the dynamic center of the process. The patient ultimately relied on his or her informed, objective judgments, warm concern, and personal relationship. The physician was a confidant, but that is changing swiftly.

With HMOs, that conception of professional service is being turned on its head. "Gatekeeper," the new key word in HMO vocabulary, potentially places the primary doctor (internist, family physician, general practitioner) in the regrettable position of feeling coerced--either by the HMO, which presses hard for lower costs (since that equates to more profits), or the physician's desire for greater income. Pressure is applied to use particular hospitals, radiology centers, and specialists who are on the HMO payroll. The primary doctor is "encouraged" strongly to limit the number of consultations with any specialist so as to hold down costs.

The HMO--an insurer that very well may own the physician's practice--becomes the ultimate judge of who gets to receive what kind of care at which place for how long. The patient--the actual reason for the existence of both the HMO and referring physician--potentially is the greatest loser! Meanwhile, psychologists--and all other specialists--find themselves fighting for professional lives that make sense.

The American Heritage Dictionary defines health as "Soundness, especially of body or mind; freedom from disease or abnormality." Mind and body distinctions regarding human health disappeared many years ago. Holism--an integrated physiological, psychological, and spiritual approach to health--now is accepted widely as a theoretical basis for understanding and treating human discomforts. To focus solely on physical symptoms in today's world would be to treat less than half the person.

An American Psychological Association national telephone survey in 1995 showed that most people understand the interplay of mind and body in matters of health. Ninety percent of adults agreed that psychological health plays a role in good physical health, with 61% saying it plays a large role. These percentages were higher for those who had some personal experience with a mental health professional. More than half of the respondents indicated they would be more likely to use a physician who works with a psychologist than one who did not since psychological services would be accessible more readily.

It has been estimated that more than 75% of the complaints brought to primary care physicians have no clear organic cause, and 80% of patient symptoms are accompanied by significant psychological factors. Sadness, fatigue, insomnia, loss of appetite, and the inability to feel any pleasure in living continue to rip apart the lives of depressed people, both in and out of hospitals. Depression affects more than 11,000,000 Americans each year. Sweaty palms, flushed cheeks, pounding hearts, and upset stomachs are all too familiar to many of us who race around in our pressured daily routines. Suicide rates are mounting, especially in the younger set. The listing of emotionally related problems can go on and on.

What is believed to be purely a physical condition seldom is that simple. Who would argue that people with heart disease, cancer, and AIDS do not have an important accompanying psychological response, as do those who have undergone any type of serious surgery? Stress, worry, guilt feelings, and anger have been shown to breed a host of physical complaints, sometimes imagined, mostly real. Such emotions exacerbate existing physical problems.

Ulcers, obesity, hypertension, headaches, asthma, and insomnia are common conditions related to psychological stress. Stress has been shown to weaken the immune system, which influences the course of cancer. Clinical psychologists have developed and refined methods of diagnosing and treating stressed-out individuals. Can a sensible plan for human health care afford to deny a person's mental state?