Economic
Grand
Rounds
Managed Care for Patients Who Are Treatment Resistant Lori Steven
Hood,
M.D.
S. Sharfstein,
M.D.
as well as her husband’s to make the mortgage payments and to pay for
The authors are associated with the Sheppard and Enoch Pratt Hospital, 6501 North Charles Street, P.O. Box 6815, Baltimore, Maryland 21285. Dr. Hood is a third-year psychiatric resident and Dr. Sharfstein is chief executive officer and medical director. Dr. Sharfstein is also editor of this column.
the son’s college tuition. Mrs. T was hospitalized for five weeks. Less than two weeks after discharge, her symptoms worsened, and her intense suicidal ideation returned. She was rehospitalized at the same facility for four weeks. Following her discharge, she continued to have marked difficulty with depression and was unable to return to work for any substantial time. In addition, the family experienced much discord as the result ofthe financial and emotional burden of her illness. During this period Mrs. T’s case was transferred to a psychopharmacologist, who began an extensive trial of antidepressants, benzodiazepines, mood stabilizers, and neuroleptics on an outpatient basis. However, the patient continued to experience severe symptoms, and several more short-term hospitalizations at the same facility were necessary. Each resulted in minimal benefit, and her symptoms recurred within several weeks of discharge. Pressure from third-party reviewers became an issue during these hospitalizations, leading the treating physician to consider discharging the patient sooner than desired. Two hospitalizations on standard medical wards of a general hospital for electroconvulsive therapy (ECT) were arranged to avoid psychiatric hospitalizations. Following the second hospitalization for ECT, the patient again experienced recurrence of her symptoms, and she was transferred back to the psychiatric hospital for “more definitive” treatment. At the time of her admission, the family was $8,000 behind on the mortgage payments and in danger of
774
August
Although managed care can be effective in reducing length of hospital stay, it often poses great difficulties for patients with long-term, treatment-resistant mental illness. The following case illustrates why assessment of a patient’s financial and health care resources early in the treatment process is an important aspect of treatment planning. The case Mrs. T, age 38 and married, was admitted to a psychiatric hospital for treatment of refractory depression. Her problems began approximately a year before admission, when she became depressed following the hospitalization of her son. At that time she sought treatment and was referred for outpatient psychotherapy. However, despite therapy and several trials of antidepressants, her symptoms worsened to the point that she became intensely suicidal and required hospitalization. Two weeks before her admission to the psychiatric hospital, Mrs. T took a leave of absence from her highlevel job in the health care field. The leave placed a financial burden on her family, who depended on her income
1992
VoL
43
No.8
having to sell their home. Their son’s admission to college was on hold, and they had to sell some personal property as well as borrow money from relatives to make ends meet. On admission to the psychiatric hospital, Mrs. T was extremely depressed and anxious and felt the hospitalization was her last hope for recovery. She was on several medications, none ofwhich offered any relief from her symptoms. She had some symptoms suggestive ofa personality disorder in addition to her depression, so the treatment team decided the best course ofaction was to taper offall medications and allow a drugfree period of three to four weeks for evaluation and determination of further treatment. Mrs. T’s primary insurance coverage was through the indemnity plan of her husband’s employer; she also had secondary coverage under her employer’s indemnity plan. Within two weeks of Mrs. T’s admission, calls from both insurance companies began. The first was from a nonpsychiatrist reviewer for the company providing secondary coverage; the plan was not paying for the current hospitalization, but would pick up where the primary insurance left off. The reviewer asked to be “educated” about the need for observing a patient off all medications. After that discussion, the reviewer referred the case to a physician reviewer. A physician reviewer for the primary insurer called the following day (Friday) to say that he would approve benefits only up to the following Monday. He engaged in a very frustrating game of telephone tag that ignored specified times the treating physician indicated she would be available. He informed the treating physician that the treatment plan was outdated and would not be acceptable to the insurance company, despite the patient’s repeated failure on various medications. He suggested using internal peer review to come up with another treatment plan. The treating physician finally gave in to this pressure and started the patient on an antidepressant three weeks into the hospitalization out of fear coverage would be denied. A second reviewer from the pri-
Hospital
and Community
Psychiatry
mary insurer began his relationship with the treatment team by leaving a message admonishing the primary physician for not adhering to the insurance company’s policy that all calls be returned within 24 hours, even though the physician had left messages
indicating
specific
times
when she would be reachable. This reviewer approved three days of coyerage at a time, a strategy that hampered both the treatment and discharge planning. Four weeks into the hospitalization, additional benefits were denied after an appeal, including four days of benefits since the reviewers’ last call. During this time, Mrs. T and her family were forced to endure the uncertainty of the situation. Although she had begun to make some progress, she feared that premature discharge would lead to yet another decompensation.
After
eight
months
of
unemployment and the enormous debt they had incurred, she and her husband knew they could not afford for her to be unemployed. While she was still in the hospital, they informed their son that they would not be able to pay his college tuition. The patient was discharged five weeks after admission due to the denial of further coverage by the insurance company. She is living at home and has filed fur disability. Her parents have agreed to make the house payments temporarily.
and defeated, to the shelters of disability payment and no active treatment. Costs are then shifted away from the health care budget and toward the family budget, social services, and disability payments. If more extended treatment or emergency care becomes necessary, the public hospital and clinic system is the best or only recourse for these patients and their families. Outpatient benefits are more limited than inpatient benefits in most insurance plans. Thus the opportunity to develop a treatment plan in the outpatient sector is constricted unless inpatient benefits can be exchanged for outpatient benefits, as is done in the management of high-cost cases. In Mrs. ‘F’s case, outpatient benefits were very limited and required high copayments. The insurance company involved was unwilling to exchange inpatient for outpatient benefits, even though adequate outpatient
benefits
might
have
of-
Discussion Mrs. T is one of many patients who are casualties of our recessionary economy and of efforts to contain medical and psychiatric costs. Hospitals designed to help these patients are no longer able to follow through on definitive diagnosis and treatment because of restrictions on benefits and aggressive managed care. Patients and families are caught in the middle of the crossfire between clinicians who want more time to break a treatment-resistant depression and reviewers who are charged with containing costs. These patients often come from families who have experienced severe financial reversals complicated by a mental illness in a family member. They are less able to pick up the costs and consequently retreat, resigned
fered the chance for more extended and extensive psychotherapy and psychopharmacology. Too often, patients like Mrs. T are labeled “custodial,” a term synonymous with hopelessness and incurability. Despite data showing that a certain percentage of these patients can be helped by persistent and innovative approaches, the payment system generally prevents careful management of resources to make continuing treatment available. The emphasis is on saving health care costs for employers despite the costs to the family and society. Of course, the providers of care are often at fault as well. During the first episode of treatment, valuable resources may be used up in costly inpatient stays. It is important that in the early phase of treatment of an acute illness hospitals remain cognizant of the need for future benefits in case of relapse or a longer-term trajectory of illness.Using up allbenefits in the firstor second episode is just as tragic as the premature termination of potentially effective treatment by intrusive managed care. Thus from the beginning, all involved should take a longer-term perspective and consider such questions as, What will be the lifecourse
Hospital
August
and Community
Psychiatry
1992
VoL 43
No.8
ofthis illness? What private benefits will be available to help treat it? How can cost shifting be minimized? What are the desired outcomes at each stage? Case management approaches that review those issues with families early in a hospitalization would be most helpful. Too often patients are referred for case management after benefits are exhausted. A combined clinical and economic perspective is necessary if patients with catastrophic psychiatric illnesses are to receive effective treatment. Clinicians must be trained to evaluate
the
economic
resources
of
patients just as they evaluate their mental status. Specially trained case managers must be involved early in the planning process to assess the total family resources, including the potential insurance resources and the ability ofthe managed care company to offer flexible benefits through a high-cost case management process. Managed care should take a long view as well, offering flexible benefits and making it possible for other sectors ofsociety to realize cost savings. Fee-for-service reimbursement combined with utilization management is an inefficient and costly approach to managing treatment-resistant patients. Prospective payment approaches
have
the potential
to per-
mit clinicians to be mindful of economic resources while planning for optimum clinical outcomes. Unfortunately, some of these approaches provide such poor up-front reimbursement that treatment-resistant patients must be sent to alternative settings such as public hospitals. This has been the.experience of such patients in many health maintenance organizations, which have been described as “fee for no service” when it comes their receiving mental health and substance abuse benefits. Perhaps special funds should be set aside for patients with catastrophic mental illness. The big loser in the cost-containment struggle is the catastrophically ill patient. There are many Mrs. T’s in this world. We must plan more carefully as a society for the needs of these patients and their families in both the public and private sectors.
775
Grand
Rounds
Managed Care for Patients Who Are Treatment Resistant Lori Steven
Hood,
M.D.
S. Sharfstein,
M.D.
as well as her husband’s to make the mortgage payments and to pay for
The authors are associated with the Sheppard and Enoch Pratt Hospital, 6501 North Charles Street, P.O. Box 6815, Baltimore, Maryland 21285. Dr. Hood is a third-year psychiatric resident and Dr. Sharfstein is chief executive officer and medical director. Dr. Sharfstein is also editor of this column.
the son’s college tuition. Mrs. T was hospitalized for five weeks. Less than two weeks after discharge, her symptoms worsened, and her intense suicidal ideation returned. She was rehospitalized at the same facility for four weeks. Following her discharge, she continued to have marked difficulty with depression and was unable to return to work for any substantial time. In addition, the family experienced much discord as the result ofthe financial and emotional burden of her illness. During this period Mrs. T’s case was transferred to a psychopharmacologist, who began an extensive trial of antidepressants, benzodiazepines, mood stabilizers, and neuroleptics on an outpatient basis. However, the patient continued to experience severe symptoms, and several more short-term hospitalizations at the same facility were necessary. Each resulted in minimal benefit, and her symptoms recurred within several weeks of discharge. Pressure from third-party reviewers became an issue during these hospitalizations, leading the treating physician to consider discharging the patient sooner than desired. Two hospitalizations on standard medical wards of a general hospital for electroconvulsive therapy (ECT) were arranged to avoid psychiatric hospitalizations. Following the second hospitalization for ECT, the patient again experienced recurrence of her symptoms, and she was transferred back to the psychiatric hospital for “more definitive” treatment. At the time of her admission, the family was $8,000 behind on the mortgage payments and in danger of
774
August
Although managed care can be effective in reducing length of hospital stay, it often poses great difficulties for patients with long-term, treatment-resistant mental illness. The following case illustrates why assessment of a patient’s financial and health care resources early in the treatment process is an important aspect of treatment planning. The case Mrs. T, age 38 and married, was admitted to a psychiatric hospital for treatment of refractory depression. Her problems began approximately a year before admission, when she became depressed following the hospitalization of her son. At that time she sought treatment and was referred for outpatient psychotherapy. However, despite therapy and several trials of antidepressants, her symptoms worsened to the point that she became intensely suicidal and required hospitalization. Two weeks before her admission to the psychiatric hospital, Mrs. T took a leave of absence from her highlevel job in the health care field. The leave placed a financial burden on her family, who depended on her income
1992
VoL
43
No.8
having to sell their home. Their son’s admission to college was on hold, and they had to sell some personal property as well as borrow money from relatives to make ends meet. On admission to the psychiatric hospital, Mrs. T was extremely depressed and anxious and felt the hospitalization was her last hope for recovery. She was on several medications, none ofwhich offered any relief from her symptoms. She had some symptoms suggestive ofa personality disorder in addition to her depression, so the treatment team decided the best course ofaction was to taper offall medications and allow a drugfree period of three to four weeks for evaluation and determination of further treatment. Mrs. T’s primary insurance coverage was through the indemnity plan of her husband’s employer; she also had secondary coverage under her employer’s indemnity plan. Within two weeks of Mrs. T’s admission, calls from both insurance companies began. The first was from a nonpsychiatrist reviewer for the company providing secondary coverage; the plan was not paying for the current hospitalization, but would pick up where the primary insurance left off. The reviewer asked to be “educated” about the need for observing a patient off all medications. After that discussion, the reviewer referred the case to a physician reviewer. A physician reviewer for the primary insurer called the following day (Friday) to say that he would approve benefits only up to the following Monday. He engaged in a very frustrating game of telephone tag that ignored specified times the treating physician indicated she would be available. He informed the treating physician that the treatment plan was outdated and would not be acceptable to the insurance company, despite the patient’s repeated failure on various medications. He suggested using internal peer review to come up with another treatment plan. The treating physician finally gave in to this pressure and started the patient on an antidepressant three weeks into the hospitalization out of fear coverage would be denied. A second reviewer from the pri-
Hospital
and Community
Psychiatry
mary insurer began his relationship with the treatment team by leaving a message admonishing the primary physician for not adhering to the insurance company’s policy that all calls be returned within 24 hours, even though the physician had left messages
indicating
specific
times
when she would be reachable. This reviewer approved three days of coyerage at a time, a strategy that hampered both the treatment and discharge planning. Four weeks into the hospitalization, additional benefits were denied after an appeal, including four days of benefits since the reviewers’ last call. During this time, Mrs. T and her family were forced to endure the uncertainty of the situation. Although she had begun to make some progress, she feared that premature discharge would lead to yet another decompensation.
After
eight
months
of
unemployment and the enormous debt they had incurred, she and her husband knew they could not afford for her to be unemployed. While she was still in the hospital, they informed their son that they would not be able to pay his college tuition. The patient was discharged five weeks after admission due to the denial of further coverage by the insurance company. She is living at home and has filed fur disability. Her parents have agreed to make the house payments temporarily.
and defeated, to the shelters of disability payment and no active treatment. Costs are then shifted away from the health care budget and toward the family budget, social services, and disability payments. If more extended treatment or emergency care becomes necessary, the public hospital and clinic system is the best or only recourse for these patients and their families. Outpatient benefits are more limited than inpatient benefits in most insurance plans. Thus the opportunity to develop a treatment plan in the outpatient sector is constricted unless inpatient benefits can be exchanged for outpatient benefits, as is done in the management of high-cost cases. In Mrs. ‘F’s case, outpatient benefits were very limited and required high copayments. The insurance company involved was unwilling to exchange inpatient for outpatient benefits, even though adequate outpatient
benefits
might
have
of-
Discussion Mrs. T is one of many patients who are casualties of our recessionary economy and of efforts to contain medical and psychiatric costs. Hospitals designed to help these patients are no longer able to follow through on definitive diagnosis and treatment because of restrictions on benefits and aggressive managed care. Patients and families are caught in the middle of the crossfire between clinicians who want more time to break a treatment-resistant depression and reviewers who are charged with containing costs. These patients often come from families who have experienced severe financial reversals complicated by a mental illness in a family member. They are less able to pick up the costs and consequently retreat, resigned
fered the chance for more extended and extensive psychotherapy and psychopharmacology. Too often, patients like Mrs. T are labeled “custodial,” a term synonymous with hopelessness and incurability. Despite data showing that a certain percentage of these patients can be helped by persistent and innovative approaches, the payment system generally prevents careful management of resources to make continuing treatment available. The emphasis is on saving health care costs for employers despite the costs to the family and society. Of course, the providers of care are often at fault as well. During the first episode of treatment, valuable resources may be used up in costly inpatient stays. It is important that in the early phase of treatment of an acute illness hospitals remain cognizant of the need for future benefits in case of relapse or a longer-term trajectory of illness.Using up allbenefits in the firstor second episode is just as tragic as the premature termination of potentially effective treatment by intrusive managed care. Thus from the beginning, all involved should take a longer-term perspective and consider such questions as, What will be the lifecourse
Hospital
August
and Community
Psychiatry
1992
VoL 43
No.8
ofthis illness? What private benefits will be available to help treat it? How can cost shifting be minimized? What are the desired outcomes at each stage? Case management approaches that review those issues with families early in a hospitalization would be most helpful. Too often patients are referred for case management after benefits are exhausted. A combined clinical and economic perspective is necessary if patients with catastrophic psychiatric illnesses are to receive effective treatment. Clinicians must be trained to evaluate
the
economic
resources
of
patients just as they evaluate their mental status. Specially trained case managers must be involved early in the planning process to assess the total family resources, including the potential insurance resources and the ability ofthe managed care company to offer flexible benefits through a high-cost case management process. Managed care should take a long view as well, offering flexible benefits and making it possible for other sectors ofsociety to realize cost savings. Fee-for-service reimbursement combined with utilization management is an inefficient and costly approach to managing treatment-resistant patients. Prospective payment approaches
have
the potential
to per-
mit clinicians to be mindful of economic resources while planning for optimum clinical outcomes. Unfortunately, some of these approaches provide such poor up-front reimbursement that treatment-resistant patients must be sent to alternative settings such as public hospitals. This has been the.experience of such patients in many health maintenance organizations, which have been described as “fee for no service” when it comes their receiving mental health and substance abuse benefits. Perhaps special funds should be set aside for patients with catastrophic mental illness. The big loser in the cost-containment struggle is the catastrophically ill patient. There are many Mrs. T’s in this world. We must plan more carefully as a society for the needs of these patients and their families in both the public and private sectors.
775
