March 31, 2003 -- Close the MHRF?  Mental Health Already Neglected

How could the Health Department even think of shutting down the MHRF
as a subacute facility and eliminating mental health day treatment
when care for mental health is already so bad?


Sunday, March 30, 2003, San Francisco Chronicle, Living Section

MANAGED HEALTH CARE NEGLIGENT

Editor -- Thank you for Christopher Heredia's article, "Health care
system plays mind games with emotionally ill, critics say" (March 23).
I'm furious, but not surprised, at managed health network's lies about
their patient satisfaction surveys. Please do not let them get away
with it!

I am a practicing physician in San Francisco. HealthNet and Managed
Health Network are defrauding San Francisco consumers. Patients with
mental illness are a vulnerable population and are being cruelly
mistreated by these companies. A HealthNet/Managed Health Network
patient who needs psychiatric consultation is forced to make a cold
telephone call to Managed Health Network.

They are given the names and phone numbers of "participating"
psychiatrists. Every one of the psychiatrists then tells the patient
that his or her practice is closed to new HMO patients. It took me
three months to get an appointment for a suicidal patient, and then
only after threatening to take the story to the media and reporting
the company to the Department of Corporations.

I have written letters to everyone I could think of. Those who
bothered to reply said, "It's not my problem." These insurers,
HealthNet and Managed Health Network, shouldn't be allowed to get away
with this cruel shell game.

BOB DOBROW, M.D.

San Francisco

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This is the article that Dr. Dobrow wrote in response to:



Health care system plays mind games with emotionally ill, critics say

Christopher Heredia, Chronicle Staff Writer

Sunday, March 23, 2003



At a time when improved therapies are leading more people to be
treated for depression, mental health care advocates say doctors and
health insurance companies are pushing pills instead of counseling for
emotional illnesses, sometimes at the expense of the consumer.

Critics of managed care say that as a result of health care companies'
efforts to cut costs, patients routinely face obstacles while seeking
psychotherapy. Some give up trying -- with dire consequences.

"The for-profit managed care companies can only make a profit by
rationing (mental health) care," said Dr. David Byrom, president of
the National Coalition of Mental Health Professionals and Consumers.

Byrom said health insurance companies use ambiguous terminology in
handling mental health referrals, provide outdated lists of therapist
networks and severely restrict the number of sessions.

"It's unethical," Byrom said. "The result is increased anxiety in the
consumer at a time of stress. It's probably had some impact on people
not even following through."

LAWS GO ONLY SO FAR

Legislation has been passed to ensure that insurance consumers have
similar access to mental health care as they do to medical care, but
Byrom said the new rules have gone only so far, and the consumer is
often left to fend for himself.

"You really need people working out their own individual and marital
problems (in therapy) sufficient to return to a better level of
functioning," Byrom said. "Instead, managed care's approach seems to
be, 'Take 12 steps and call me in the morning,' " referring to the
Alcoholics Anonymous approach to recovery. Many HMOs, he said, are
referring patients to community groups such as AA, which don't cost
the company a dime.

Ann, a 55-year-old secretary from Oakland who asked that her full name
not be used, said she decided to pay a therapist out of pocket after
failing to get a referral for individual therapy for depression
through her insurance company, Kaiser Permanente.

Kaiser sent her to a psychiatrist who put her on Prozac and suggested
that she attend group therapy, neither of which, she said, helped her
with the insomnia, anger and depression she was suffering from a
childhood trauma.

"It seemed like the psychiatrist's primary job was dispensing Prozac,"
Ann said. "There was no mention of psychotherapy. I was sent to a
group and listened to other women's horror stories. It was really of
no help."

BENEFITS OF TALK THERAPY

Since she began seeing her current therapist, she said, her anger has
begun to subside, and her mood has improved.

"I'm not sure if I would be here if it weren't for therapy," Ann said.

Research shows that a combination of psychotherapy and medication work
best to treat severe depression. But many psychologists have become
increasingly concerned with the trend toward prescribing medication as
the primary means of treating depression and other emotional problems.

Part of the reason for the increasing use of anti-depressants such as
Prozac, Paxil and Zoloft is that the medications have milder side
effects than their predecessors, said Dr. Charles Faltz, director of
professional affairs for the California Psychological Association.

"The drug companies reap the profits from sales of medication, and
consumers want them," Faltz said. "They're asking physicians for these
medications, and in many cases they work. Still, for the health
insurance companies, controlling utilization seems to be more their
focus than maintaining quality.

"We really believe that there is good data to get back to a
combination of psychotherapy and medication. It produces a better
result in the long run, at a lower cost. Also, catching the patient at
the earliest possible stage of the disorder, you can help them get
better and be on their way."

DEFENDING MANAGED CARE

A spokesman for Managed Health Network, the company that contracts to
handle behavioral health for Health Net (one of the largest insurance
providers in California), said its member surveys continue to come
back positive when it comes to evaluating mental health services.

Dr. Alan Savitz, a psychiatrist and corporate medical director for the
network, said new mental health parity laws have required that
insurance companies provide extended access to psychotherapy for major
depressive episodes. Somebody diagnosed with bipolar disorder, panic
attacks, childhood trauma or other severe disorders could have 50 to
100 talk therapy sessions per year, depending on the situation, he
said.

But coverage for most psychotherapy is under tight controls requiring
referrals, a specific plan and time limits, which Savitz said studies
have shown to be most effective.

"Indeterminate talk therapy -- the Woody-Allen-character approach to
therapy -- may be effective for self-actualization, but not for the
treatment of depression," Savitz said.

"We're certainly not limiting access. Every patient who calls and
wants to see a therapist sees a therapist in our network. Patient
satisfaction is quite high."

Arletta Cortright, a 49-year-old stay-at-home mom from Fairfield, said
she benefited greatly from Kaiser Permanente's mental health coverage
when she suffered a severe bout of depression after losing her father
and best friend to heart failure.

She witnessed her father die on a road trip to San Diego for her
parents' 50th wedding anniversary in 1996.

Then in January 2002, her best friend, with whom she attended church,
died at age 49.

"It really threw me for a loop," Cortright said. "She was the same age
as me. She left two children and a husband. It was a shock to the
church community. She was the type of friend you could depend on for
child care or to help out with a favor on a moment's notice."

Cortright noticed she was having chest pains. "I was getting panicky.
I had a feeling like I was going to die."

After Kaiser doctors did all the physical tests and they came up
clear, Cortright's primary-care doctor referred her to a psychiatrist,
who met with her weekly and suggested that she try an antidepressant.

"I've seen a big difference," she said, adding that she continues to
see her therapist once a month. Her doctor has also used eye movement
therapy, in which Cortright is trained to substitute a positive memory
for the painful flashbacks of her father dying.

Herbert Klein, publisher of Psychotherapy Finances, a newsletter
geared to therapists, said you get what your employer pays for.
Companies negotiate with insurance companies, sometimes down to the
number of therapy sessions that employees are allowed.

"The whole system is pushing prescription medication," Klein said.
"The system is under financial stress, and as a result companies are
ratcheting down care."