Suicide by Managed Care: The Cost of Care Versus the Value of
Life
Rand Partridge, Ph.D.
Part 1-- primum non nocere
The resolution to the conflict posed in the title was resolved for health care providers as long ago as ancient Greece, when Hippocrates stated "As to diseases make a habit of two things-to help, or at least, to do no harm" (Epidemics, book 1, chapter 11). In the modern era, the Ethical Principles of Psychologists supports the ancient proclamation. As psychologists, a prominent principle governing our activities concerns avoiding harm, expressed in Principle 1.14 as "Psychologists take reasonable steps to avoid harming their patients or clients, research participants, students, and others with whom they work, and to minimize harm where it is foreseeable." Many health care providers whom I know were originally motivated by the desire to help others lead healthier, more fulfilling lives. Our ideals remain at the heart of our professional activities, even though pressing concerns may lie in earning a daily living.
Psychologists often confront a different principle in making everyday decisions about health care, however. By 1996, managed care organizations commanded the overwhelming majority of all enrollments in private health insurance. Conversion of the public component of the health care market was underway. In a managed care environment, cost-containment seems to be the over-riding principle governing the provision of health care. The notion of cost-containment in providing health care does not appear in the ancient proclamation of Hippocrates or in the modern ethical principles of psychologists. Taking cost-containment into account in decision-making about health care may have important implications for psychologists.
Differing notions about the standard of care may bring providers and managed care organizations into conflict with respect to malpractice liability. Traditionally, psychologists made treatment decisions without regard for cost, only considering what might prove in the best interests of the client. The standard of care established in malpractice liability law developed without reference to cost. Today, psychologists working within managed care environments apply a standard of care defined by a managed care organization. This standard of care takes into account the cost of care in decision-making. Costs are contained through procedures such as utilization review, financial incentives given to providers who limit treatments, restrictive clauses regarding communication between the provider and the client about treatment options, and other contractual features. In respect to malpractice liability, however, the standard of care remains the same as before the advent of managed care organizations. Contractual limitations are not a factor in the standard of care expected of psychologists. The malpractice liability standard has not changed with the changes in health care delivery. Thus, psychologists may find themselves caught between two conflicting requirements, complying with the cost-containment policies of a managed care organization to ensure future revenue or ignoring such provisions to avoid malpractice liability.
Imagine yourself in the following situation. You have diagnosed a new client as exhibiting an Adjustment Disorder with severe Depressed Mood. This client, whom you have been just begun treating in outpatient psychotherapy, calls you one night. The recently divorced client, who is a single parent with financial problems arising from the divorce, expresses anxiety and hopelessness about the future. The client also states that he or she is considering suicide, but the client refuses to consider hospitalization. Instead, the client agrees to come in for a session the next morning. You also obtain agreement from the client to possible changes in the treatment plan just submitted, increasing the number of sessions from once to twice a week and providing for daily telephone contact. After finishing this conversation, you immediately call a representative of the managed care organization which is the third party payor, seeking approval for the additional care. With the representative, you discuss the need for immediate changes to the treatment plan, informing this representative that the client is suicidal. Not obtaining approval, you ask this representative to connect you with a reviewer who is a physician or licensed mental health provider. This representative states that you can’t talk with such a reviewer because the diagnosis provided, Adjustment Disorder, is not a covered benefit. However, this representative does state that you may send a detailed letter, which will be reviewed. What do you do now? Why? Further, suppose the client commits suicide that night. What liability exists for malpractice?
What do you think?
Share your views on the Mental Health Resources Forum
| The entire Series:
Part 1-- primum non nocere |