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Cooper,
COUNSELING
GottliebCONTRIBUTION
/ ISSUES
PSYCHOLOGIST
WITH MANAGED
/ March
CARE
2000
With the advent of managed care, counseling psychologists are encountering vexing ethi-
cal issues. These issues arise not only for practitioners but for researchers, educators,
and trainers as well. In this article, the authors briefly describe the evolution of managed
care and review basic biomedical ethics and ethical decision-making models. The
authors then examine specific ethical issues and offer suggestions for practice, research,
and education and training. This article concludes with a research agenda, a review of
projected general trends in health care delivery, and a discussion of counseling psychol-
ogys role in addressing current concerns as well as influencing the future evolution of
health care delivery.
During the course of the last decade, psychology has witnessed an explo-
sion in the growth of managed mental health care organizations across the
nation. Although psychology has encountered many challenges over the
years, none may have as far reaching an impact on our profession as the man-
aged care movement. As managed care rapidly evolves, counseling psy-
chologists are, and will continue to be, faced with numerous challenges in the
foreseeable future. In light of these challenges, managed care has become
quite a loaded topic among psychologists regardless of their specialty.
In the largest survey of the managed care era, commissioned by the
American Psychological Association (APA) Committee for the Advance-
ment of Professional Practice (CAPP), Phelps, Eisman, and Kohout (1998)
explored the activities and concerns of almost 16,000 psychologists whose
primary work settings included independent practice, academia, govern-
ment, medical settings, and other settings such as schools, forensics, and
business. They found that half of the sample was in full-time independent
practice and another third engaged in part-time independent practice. More
important, they found that, regardless of primary work setting, 4 out of every
5 respondents reported that managed care was having a negative impact on
their professional work and that ethical dilemmas were one of their top five
concerns.
179
180 THE COUNSELING PSYCHOLOGIST / March 2000
Given the varying familiarity that readers may have with managed care,
we begin with a brief historical review, description of key concepts, and sali-
ent characteristics of MCOs to assist with the discussion that follows regard-
ing ethical issues with managed care. For a more comprehensive review of
the following information, see Corcoran and Vandiver (1996), Lowman and
Resnick (1994), and Austad and Berman (1991a).
Two-Party System
In the early 1900s, our health care system involved a straightforward pay-
ment arrangement between the provider and the recipient who directly paid
for services. The majority of health care costs was paid for by the persons
receiving services (Harris, 1994). Insurance plans were available, primarily
through employers, but the employee purchased them from the employer
(Corcoran & Vandiver, 1996).
Three-Party System
Following the Great Depression, a significant number of people were not
able to pay their medical bills. The two-party system of provider and recipi-
ent/payor was no longer working. To ensure payment for services, hospitals
began offering insurance, creating a three-party system (i.e., provider, recipi-
ent of services, and third-party payor). This became the model for Blue
Cross. In this arrangement, the cost of health care was still being paid by per-
sons insured by the plan (Corcoran & Vandiver, 1996).
During World War II, while a period of wage controls was in effect, some
employers began to offer benefits other than wage/salary increases, such as
health insurance coverage. As more and more employers began to offer this
benefit, there was corresponding growth in the insurance industry. This
development contributed to the current expectation that employers should
offer such benefits to their employees. Until recently, the current American
health care system placed a significant amount of responsibility on employ-
ers. However, the federal government accepted some of this burden as well
through programs for the elderly (Medicare), the disabled (Medicaid), and
federal workers (CHAMPUS). Nevertheless, at this time more than 40 mil-
lion Americans, many of whom are employed, have no health insurance at all
(Austad, Hunter, & Morgan, 1998). It is important to note that the United
States is the only industrialized country other than South Africa that does not
offer health care to all citizens (Corcoran & Vandiver, 1996).
182 THE COUNSELING PSYCHOLOGIST / March 2000
Prior to the 1950s, mental health care was generally not included in benefit
plans. One reason for this was that people did not believe that mental health
problems occurred very often. Furthermore, the domain of mental health
treatment was seen as involving only persons with severe mental illness who
were institutionalized. The care for these persons and expenses were sup-
ported at the state level (Corcoran & Vandiver, 1996).
Beginning in the 1950s, several factors contributed to the inclusion of
mental health benefits in most insurance plans. For example, studies began to
provide evidence that mental health problems were more common than was
originally believed (Corcoran & Vandiver, 1996). Mental health services
began to be provided more often on an outpatient, rather than inpatient, basis
(Austad & Berman, 1991b). General hospitals began to include psychiatric
units and many psychotropic medications were developed (Corcoran & Van-
diver, 1996). Also, the number of mental health providers increased, as well
as the number of theoretical schools and related interventions (Austad & Ber-
man, 1991b). Furthermore, with the Health Maintenance Organization Act of
1973, federally qualified managed care programs were required to include
mental health services (DeLeon, VandenBos, & Bulatao, 1994).
Four-Party System
The three-party health care system was based on the premise that a large
group of persons would pay a premium to offset the cost of care for the few
who were ill. As the number of insured persons using their benefits increased
and the cost of services increased, insurance companies (the third party)
began to grapple with methods for controlling costs (Broskowski, 1994). For
some employers, mental health care costs accounted for as much as 25% of
total health care costs, with inpatient mental health care comprising the
majority of this percentage (Austad & Berman, 1991b; Patterson & Berman,
1991).
Managed care represented one method for responding to these cost
increases. Adding managed care to the preexisting relationship established a
four-party system: the client, the provider of services, the insurance company
(MCOs employer), and the managed care company (Corcoran & Vandiver,
1996). Managed care is not a new approach, having been in existence for sev-
eral decades. However, with the Health Maintenance Organization Act of
1973, which provided federal funding for the development of managed care
programs and required employers to offer a managed care option to employ-
ees, managed health care began to expand (DeLeon et al., 1994). Toward the
Cooper, Gottlieb / ISSUES WITH MANAGED CARE 183
mid- to late 1980s, managed mental health care grew in strength (Corcoran &
Vandiver, 1996) and has become a major force influencing health care in gen-
eral and psychological services in particular.
tion in which clients are followed for brief periods during the course of the
life span (Austad & Berman, 1991b; Cummings, 1991a). Fourth, there is usu-
ally mandated communication with the primary care physician (PCP), as
well as increased interaction with other types of health care professionals
(Austad & Berman, 1991b; Cummings, 1995). Fifth, working with MCOs
involves the monitoring of the therapy process by the MCO (Austad & Ber-
man, 1991b; DeLeon et al., 1994; Resnick et al., 1994), and typically
includes at least documentation of treatment necessity and periodic submis-
sion of treatment plans.
The process of monitoring therapy is called utilization review (UR), and
refers to the use of predefined criteria to evaluate treatment necessity, appro-
priateness of treatment intervention, and treatment effectiveness (Corcoran &
Vandiver, 1996). UR can take place before, during, and after treatment. That
is, MCOs tend to use some form of prospective, concurrent, and retrospective
UR. Prospective UR refers to the demonstration of treatment necessity and
obtaining authorization to initiate treatment. How MCOs determine treat-
ment necessity and approach varies. With regard to concurrent UR, MCOs
evaluate ongoing services when practitioners request authorization for con-
tinued treatment. With regard to retrospective UR, MCOs are interested in
treatment outcome and often assess client satisfaction with services received
(Corcoran & Vandiver, 1996).
freedom to contract with other plans or private-pay clients (Patterson & Ber-
man, 1991). Potential disadvantages for the practitioner may include the
potential for utilization review procedures to become burdensome and/or
adversarial for the practitioner. The MCO may have more difficulty control-
ling costs, or experience cream skimming (i.e., practitioners refusing to
accept less-desirable clients) (Patterson & Berman, 1991).
In contrast to fee-for-service systems of managed care, practitioners may
provide services within a capitated system. The capitated or pre-paid sys-
tem of managed care has sparked much debate. In this system, persons within
a catchment area (e.g., university employees) pay a predetermined fee to
enroll, which is usually done via a payroll deduction. The MCO then sets a
spending cap or limit on expenditures. Risk or financial responsibility is then
distributed between the MCO and the provider; that is, the MCO and provider
share the risk that there will be enough money to cover the cost of services
provided and still make a profit. Herein lies one of the major points of debate:
the fewer sessions used, the greater the profit.
One of the most frequently encountered models of a capitated managed
care system is a Health Maintenance Organization or HMO. The stereotypi-
cal HMO employs its own salaried practitioners who are housed in the same
place as primary care medical personnel (Patterson & Berman, 1991;
Resnick et al., 1994). As with fee-for-service systems, services typically are
provided at a discounted rate, authorization for treatment is required, and
treatment plans must be submitted. However, HMOs usually have a closed
provider panel; that is, a subscriber can obtain services only from those pro-
viders employed by the HMO (Resnick et al., 1994). In addition, services
tend to be more closely monitored (e.g., more frequent submission of treat-
ment plans).
With capitated systems, members deductibles and copayments generally
are much lower than those of traditional indemnity insurance, and usually
somewhat less than fee-for-service plans. In addition to lower cost to the con-
sumer, potential advantages of capitated systems include lower cost to the
MCO because of increased organization, centralized care, and better man-
agement of emergencies. Also, there can be improved communication
between health care providers due to the primary care physician serving as
the on-site informational hub (Patterson & Berman, 1991). Potential disad-
vantages include limited choice of practitioner for the consumer, long waits
for appointments, and risk of insufficient care due to session limitations or
practitioners caseloads being so large that they can only offer clients infre-
quent sessions. Practitioners may face increased routinization and decreased
flexibility in the choice of procedures available to them (Austad & Berman,
1991b; Patterson & Berman, 1991).
186 THE COUNSELING PSYCHOLOGIST / March 2000
Biomedical Ethics
When examining ethical dilemmas, it can be useful to evaluate them with
respect to the following four moral principles of biomedical ethics presented
by Beauchamp and Childress (1994): autonomy, nonmaleficence, benefi-
cence, and justice. The first principle is respect for autonomy that, among
other things, involves respect for the clients independent decision-making
capacity. The second principle is nonmaleficence, or the primary importance
of avoiding harm to the client. The third principle is beneficence. This refers
to the injunction that we work to benefit others and strive to balance benefits
against costs or risks. The fourth principle is justice, which refers to the fair
distribution of benefits, risks, and costs.
These four principles were integrated into the APAs ethical principles
(APA, 1992) at the aspirational level of general principles, as well as at the
Cooper, Gottlieb / ISSUES WITH MANAGED CARE 187
more specific and sanctionable level of the Code of Conduct. For example,
with respect to the biomedical principle of autonomy, Principle D states that
Psychologists . . . respect the rights of individuals to privacy, confidentiality,
self-determination, and autonomy (APA, 1992, pp. 1599-1600). With
regard to nonmaleficence and justice, Principle E states that psychologists
weigh the welfare and rights of their patients or clients. . . . When conflicts
occur among psychologists obligations or concerns, they attempt to resolve
these conflicts . . . in a responsible fashion that avoids or minimizes harm
(APA, 1992, p. 1600). At the more specific level, Ethical Standard 4.02 incor-
porates the principle of autonomy by stating that the practitioner must obtain
informed consent from the client before proceeding with treatment.
Beauchamp and Childress (1994) also discuss the following four moral
obligations of health care professionals that express the four core principles
mentioned above: veracity, privacy, confidentiality, and fidelity. First, the
obligation of veracity entails the need to deal honestly and speak truthfully.
Second, privacy involves clients rights to control knowledge of information
about themselves. Third, confidentiality comprises a pledge to not divulge
information to others. Fourth, fidelity consists of the notion of faithfulness or
professional loyalty and the disposition to be true to ones word.
These four moral obligations also are incorporated into the ethical princi-
ples (APA, 1992) at both aspirational and specific levels. For example, at the
aspirational level, veracity is reflected in Principle B, which states that Psy-
chologists . . . are honest . . . do not make statements that are false, misleading,
or deceptive (APA, 1992, p. 1599). Privacy and confidentiality are
addressed in Principle D, which states, Psychologists . . . respect the rights
of individuals to privacy, confidentiality (APA, 1992, pp. 1599-1600). At
the more specific level, veracity is emphasized in Ethical Standard 1.25
(APA, 1992, pp. 1602-1603), which states, Psychologists do not misrepre-
sent their fees, and 6.21, which states, Psychologists do not fabricate data
or falsify results in their publications (p. 1609). Privacy and confidentiality
are discussed in an entire section of the ethics code (APA, 1992). Fidelity is
reflected in several ethical standards including those addressing issues of
informed consent (4.02), confidentiality (5.02), clarification of roles (7.03
and 8.03), and terminating the professional relationship (4.09).
With this information in mind, the practitioner then explores the APAs
ethical principles and finds relevant standards. For example, Ethical Standard
4.02 informs the practitioner that he or she must discuss all possible treatment
options with the client, including referring the client to a practitioner who can
provide longer term therapy. Also, Ethical Standard 8.03 informs the practi-
tioner that, in the case of a potential conflict of interest, the practitioner must
discuss his or her dual role (i.e., therapist and HMO employee) with the cli-
ent. In addition to reviewing the APAs ethical principles, the practitioner also
consults with a colleague to discuss these issues. Together, they generate a list
of possible approaches to this situation and evaluate the cost and benefits of
each. After careful consideration, the practitioner chooses to discuss various
treatment options with the client. After this session, the practitioner again
consults with his or her colleague to review how the chosen strategy worked.
Haas and Malouf (1995) acknowledged that their ethical decision-making
framework did not take legal considerations into account. This is a limitation
of their model because practitioners, as a matter of course, must consider
legal as well as ethical matters. For example, given the scenario presented
above, what if the practitioner signed an MCO contract that contained a gag
clause that prohibited the practitioner from disclosing information about cost
containment practices? If the practitioner then disclosed information to the
client, the practitioner could be accused of breach of contract. What Haas and
Malouf argue is that it is appropriate and helpful for the practitioner to con-
sider the ethical issues as a first step when confronted with both legal con-
flicts and ethical dilemmas. This is good advice and we agree with it. How-
ever, we would go further and suggest that the goal in all cases of ethical
decision making is that the ethical decision be one that is both legal and clini-
cally indicated. We recognize that such a goal is an ideal, but it is one worth
striving for and with effort often can be attained.
Managed care has significantly reduced the amount of time that practitio-
ners spend with certain clients. Although this is not always the case, many
practitioners feel tremendous pressure to get to the work of therapy as quickly
as possible to comply with managed care restraints. Sometimes doing so can
result in giving ethical issues insufficient attention. However, it is our funda-
mental belief that, although understandable, such practice is not defensible.
That is, we believe that it is precisely because of the constraints placed on
practice by managed care that addressing ethical issues with clients is so
important. It may seem a paradox to some that we recommend spending a
190 THE COUNSELING PSYCHOLOGIST / March 2000
Informed Consent
Before initiating therapy, practitioners must obtain informed consent
from the client (APA, 1992). Informed consent is a concept derived from the
biomedical principle of respect for the persons autonomy (Beauchamp &
Childress, 1994). There are four elements to informed consent that were
included in the latest revision of the APAs (1992) ethical principles. Ethical
Standard 4.02(a) states the following: Informed consent generally implies
that the person (1) has the capacity to consent, (2) has been informed of sig-
nificant information concerning the procedure, (3) has freely and without
undue influence expressed consent, and (4) consent has been appropriately
documented (p. 1605).
INITIAL SESSIONS
DeLeon et al., 1994). Not having adequate information can, for example,
result in the client having unrealistic expectations regarding his or her psy-
chotherapy benefits. It is important for the practitioner to educate the client
about these matters, offer clarification at every opportunity, and reevaluate
expectations for treatment when needed (Gottlieb, 1992).
In the difficult situation where an MCO has not practiced truth-in-
packaging, that is, the MCO has been misleading in its advertising, a practi-
tioners informed consent procedure must be very clear (Bak, Weiner, &
Jackson, 1991; Gottlieb, 1992). For example, a clients benefit information
may state that the client is covered for 20 sessions per year, yet the MCO may
only authorize 6 sessions. When such situations arise, practitioners should
inform the client of available options and explain the limitations of their role
(Gottlieb, 1992). It is also recommended that clients be encouraged to report
situations such as this to their benefit managers because employers are con-
cerned with the welfare of their employees and are the MCOs customers
(Bak et al., 1991). Remember that year to year, MCOs make various changes
in their policies and procedures. It is recommended that the practitioner
and/or client contact the MCO and make sure benefit information is accurate
and current.
FINANCIAL ISSUES
man & Bricklin, 1994). When relevant, practitioners are advised to disclose
information regarding financial arrangements in a sensitive and supportive,
but straightforward, manner.
We should note that such financial arrangements are at the center of much
debate at the present time. As a matter of good risk management, we recom-
mend that the practitioner consult with his or her state licensing board and per-
sonal attorney before signing contracts that might include such provisions.
Confidentiality
Numerous ethical standards exist regarding confidentiality. Ethical Stan-
dard 5.01(a) of the APAs (1992) ethical principles states the following: Psy-
chologists discuss with persons and organizations with whom they establish
a scientific or professional relationship (1) the relevant limitations on confi-
dentiality . . . (2) the foreseeable uses of the information generated through
their services (p. 1606). Ethical Standard 5.01(b) states that Unless it is not
feasible or is contraindicated, the discussion of confidentiality occurs at the
outset of the relationship and thereafter as new circumstances may warrant
(p. 1606). Furthermore, Ethical Standard 5.04 (APA, 1992) states that Psy-
chologists maintain appropriate confidentiality in creating, storing, access-
ing, transferring, and disposing of records under their control, whether these
are written, automated, or in any other medium (p. 1606).
The practitioner-client relationship is crucial to the delivery of mental
health care services. A defining component of the practitioner-client rela-
tionship is confidentiality (Barnett, 1998a; Walsh, 1998). Given confidential-
ity, clients feel secure and are able to disclose upsetting personal information
to the practitioner. However, within a managed care context, confidentiality
may no longer be presumed in the therapy situation. Managed care shifts the
traditional basis for limits on confidentiality to issues of cost containment
(Walsh, 1998). For example, traditionally, a practitioner would waive a cli-
ents right to confidentiality only in those situations in which a client was a
risk to self or others. With managed care, the practitioner is obliged to provide
client information to the MCO for purposes of determining treatment
necessity.
ISSUES
RECOMMENDATIONS
Clients should be clearly and fully informed of the managed care compa-
nys role in their treatment, including the potential problems regarding confi-
dentiality that may arise (Barnett, 1998a; Gottlieb, 1992). As always, it is
helpful if the practitioner can anticipate ethical issues. Thus, the practitioner
is well advised to obtain a copy of a managed care companys policy regard-
ing confidentiality. This allows the practitioner to review the companys pol-
icy, anticipate problems, and then, if necessary, make suggestions to the man-
aged care company (Corcoran & Vandiver, 1996; Gottlieb, 1992). In the
event that a managed care companys policy for processing confidential
information is not adequate and cannot be changed, the practitioner should
only release the minimum amount of information needed to protect the cli-
ents privacy (Barnett, 1998a; Gottlieb, 1992; Hoyt, 1995). The practitioner
should also inform the client of the MCOs policy and discuss the implica-
tions of it with the client. It is important that the practitioner remember that
the client owns the privilege to release confidential information, and to
Cooper, Gottlieb / ISSUES WITH MANAGED CARE 195
remain mindful that the practitioners primary obligation is to work for the
benefit of the client. The managed care company may not have the same pri-
orities (Gottlieb, 1992).
It may be helpful for the practitioner to develop his or her own policy
regarding the release of confidential client information (Gottlieb, 1997). For
example, the practitioner might have a policy that states that he or she will
only release a treatment summary, rather than case notes or an entire client
record. In the event that a managed care company requests information about
a client that is not compatible with the practitioners policy, the practitioner
can then discuss this dilemma with the client and ask the client to decide if
and how much information should be released (Gottlieb, 1992).
In some instances, the practitioner will be asked by managed care compa-
nies to have general releases of information signed by the client during the
first treatment session. In other cases, the client may have already signed a
general release of information before ever seeing the practitioner. Clients
often do not even remember signing such forms. Even if they do, they will not
always recall their contents or understand the implications of having signed
them. Therefore, in all instances, it is important that the practitioner inform
clients about the nature of the release form and the implications of their signa-
ture (Barnett, 1998a; CAPP Task Force on Ethical Practice, 1998; Gottlieb,
1992; Resnick et al., 1994).
After a client signs a release form, practitioners will be periodically
required to submit treatment information to the MCO. As a rule, information
should not be released without first discussing it with the client, allowing the
client time to ask questions and discuss the implications of the release (Bar-
nett, 1998a; Gottlieb, 1992; Hoyt, 1995). Involving the client in this process
is not only good risk management but when done well also can provide a
therapeutic function.
In some cases, managed care companies may request case notes from the
practitioner. In our view, case notes are akin to raw test data (Gottlieb, 1992),
and we believe that it is inappropriate for nonmental health professionals to
review them. We recommend that practitioners avoid sending case notes, but
offer to send a treatment summary or other documentation that the MCO may
require. It is our experience that managed care companies generally respect
this boundary and are receptive to this alternative when they view the practi-
tioner as generally forthcoming.
Technological advances have resulted in serious challenges to confidenti-
ality. For example, treatment plans sent by fax machines may be sent to the
wrong place, conversations over cellular telephones may be overheard by
others, and information sent via e-mail may be retrieved from computers
without our knowledge. In light of these advances, it is important that the
practitioner take certain precautions (CAPP Task Force on Ethical Practice,
196 THE COUNSELING PSYCHOLOGIST / March 2000
Competence
Psychologists are obliged to maintain high standards of competence
and to use only those techniques for which they are qualified (Principle A)
(APA, 1992, p. 1599). Given the managed care environment, some issues
regarding competence become particularly salient. We will review these
issues in light of Ethical Principle A (APA, 1992), which states the following:
may help the practitioner assess whether she or he is competent and willing to
work within the parameters of that particular MCO. If a practitioner has the
requisite training and experience and is comfortable working within these
constraints, she or he may proceed.
On the other hand, if a practitioner endorses a long-term, insight-oriented
theoretical orientation, the practitioner should carefully assess whether it is
advisable to work within the managed care context (Gottlieb, 1992). If a prac-
titioner fails to perform this self-assessment, several problems may arise.
First, it is unethical for a practitioner to join a managed care panel if the prac-
titioner does not have adequate training and experience to practice within a
brief therapy model. Agreeing to do so is tantamount to misrepresentation.
Second, the practitioner who is not adequately trained in brief therapy
approaches may harm clients. For example, a 40-year-old man presents with
what appears to be an acute depressive episode. During the third session, he
reports frequent flashbacks of an upsetting event that occurred in his early
20s. At this juncture, the practitioner who subscribes to the MCO model must
respond differently than would someone working from a long-term perspec-
tive. To allow the client to believe that he will have unlimited time to process
this experience only to have his time severely limited could result in harmful
consequences. Finally, disingenuously agreeing to work in this way is not
good for the practitioner personally as he or she may become increasingly
frustrated with what may come to be viewed as an insensitive and hostile
MCO. Such feelings can lead to burn out on a long-term basis that may harm
both practitioner and client.
DIVERSITY
Where differences of age, gender, race, ethnicity, national origin, religion, sex-
ual orientation, disability, language, or socioeconomic status significantly
affect psychologists work concerning particular individuals or groups, psy-
chologists obtain the training, experience, consultation, or supervision neces-
sary to ensure the competence of their services, or they make appropriate refer-
rals. (p. 1601)
Working with managed care companies may give the practitioner the
opportunity to work with groups that are typically underrepresented in many
practice settings (Gottlieb, 1992). For example, persons who are members of
an HMO plan that requires a 10% copayment may be able to seek counseling
services, but would not be able to do so if he or she had to pay 100% out-of-
pocket or even 50% of therapy fees according to a traditional indemnity
198 THE COUNSELING PSYCHOLOGIST / March 2000
insurance plan. On the other hand, some contend that managed care systems
may limit access and treatment for persons with chronic mental disorders
(Corcoran & Vandiver, 1996; Hoyt, 1995) or for underrepresented groups,
citing research demonstrating that ethnic minorities in the United States, for
example, experience more health-related illnesses than European Ameri-
cans, encounter more barriers to health care services, have fewer resources
with which to obtain health care services, and may receive lower quality
health care services (Abe-Kim & Takeuchi, 1996).
To increase access and provide sensitive and appropriate treatment, it is
critical that the practitioner assess whether he or she is competent to work
with the clientele of the MCO. If the MCOs clientele includes persons repre-
senting particular socioeconomic groups, ages, levels of education, racial and
ethnic groups, and/or sexual orientations, then the practitioner needs to
assess whether she or he has had sufficient education, training, and experi-
ence working with these groups. If a practitioner is referred a client and
decides that she or he is not competent to work with that particular individual,
the practitioner is ethically obliged to contact the MCO and obtain an appro-
priate referral (Gottlieb, 1992). Unfortunately, things are seldom so simple
because there may be no qualified practitioners available within the MCO
network. If so, the practitioner has a duty to advocate on behalf of the client
and should notify the MCO regarding the need to recruit competent providers
in the particular area of need (Newman & Bricklin, 1994). In such situations,
it is tempting to work with the person nonetheless, especially if urged to do so
by the MCO, which may prefer not to be inconvenienced by the request.
Doing so is generally inadvisable because the probability of iatrogenic risk
becomes much higher.
Integrity
Ethical Principle B (APA, 1992) states that
Ethical Standard 1.26 (APA, 1992) states the following: In their reports
to payors for services or sources of research funding, psychologists accu-
rately state the nature of the research or service provided, the fees or charges,
and where applicable, the identity of the provider, the findings, and the diag-
nosis (p. 1603). In order for clients to be covered for services by their benefit
Cooper, Gottlieb / ISSUES WITH MANAGED CARE 199
plans, most MCOs require that a client meet diagnostic criteria for a disorder
listed in the Diagnostic and Statistical ManualFourth Edition (DSM-IV)
(American Psychiatric Association, 1994). Depending on the diagnosis, the
MCO may or may not support the practitioners assertion that the treatment is
medically necessary and then authorize treatment. Such situations may pres-
ent some serious ethical dilemmas.
UPCODING
DOWNCODING
Human Welfare
When working within a managed care environment, practitioners may
encounter challenging ethical dilemmas when striving to promote human
200 THE COUNSELING PSYCHOLOGIST / March 2000
Psychologists seek to contribute to the welfare of those with whom they inter-
act professionally. In their professional actions, psychologists weigh the wel-
fare and rights of their patients or clients. . . . When conflicts occur among psy-
chologists obligations or concerns, they attempt to resolve these conflicts and
to perform their roles in a responsible fashion that avoids or minimizes harm.
(p. 1600)
APPROPRIATE TREATMENT
TREATMENT REFERRAL
The practitioner must also determine whether the client is able and/or
willing to pay out-of-pocket for treatment. If the client does not have the
Cooper, Gottlieb / ISSUES WITH MANAGED CARE 201
PREVIOUS THERAPY
A more complex issue may arise when, upon intake, a practitioner learns
that a client has had therapy in the past. In such cases, before developing a
treatment plan, it is important to ascertain whether past treatment was helpful
or successful. If it was not, it is good clinical practice to obtain the records
from the previous therapist, inform the MCO, and consider a consultation or
second opinion before initiating treatment (Gottlieb, 1992). In some cases,
the MCO may already have an established mechanism for peer consultation
with a like provider that may be helpful. In any event, working within a man-
aged care environment may mean anticipating treatment issues with clients
whose treatment may be difficult to manage or who have histories of non-
compliance or treatment failure.
Abandonment
As previously mentioned, working within a managed care context typi-
cally requires using a brief therapy model of treatment. Thus, practitioners
must plan for termination virtually from the outset of treatment (Gottlieb,
1992). Ethical Standard 4.09(a) states that psychologists do not abandon
patients or clients (APA, 1992, p. 1606). Ethical Standard 4.09(c) (APA,
1992) also states the following:
Prior to termination for whatever reason, except where precluded by the pa-
tients or clients conduct, the psychologist discusses the patients or clients
views and needs, provides appropriate pretermination counseling, suggests
alternative service providers as appropriate, and takes other reasonable steps to
202 THE COUNSELING PSYCHOLOGIST / March 2000
DENIAL OF REQUEST
nately, doing so is not always easy as many MCOs insulate appeals reviewers
with many layers of bureaucracy. Therefore, although the practitioner should
request to deal directly with that professional, doing so will often be easier
said than done.
While going through an MCOs appeals process on behalf of a client, the
practitioner should continue treatment if it is practically possible to do so
until a referral can be appropriately accomplished (Corcoran & Vandiver,
1996; Gottlieb, 1992; Hoyt, 1995). To do otherwise may be considered aban-
donment and malpractice (Haas & Cummings, 1994; Simon, 1994). There-
fore, it is vital that the practitioner remember that he or she continues to be
responsible for the client whether he or she is being paid by the managed care
company or not (Austad et al., 1998).
Conflict of Interest
A conflict of interest may result when a practitioner has responsibilities to
two or more parties that have competing interests. APAs (1992) Ethical Stan-
dard 8.03 states the following:
TRIANGLES
With the two-party system, client welfare was more secure because the
practitioner was less likely to have obligations that might influence or con-
flict with her or his clinical judgment. When working in the four-party sys-
tem, the practitioner plays the role of both therapist and MCO employee,
even if one is an independent contractor. That is, the practitioner is expected
to provide quality care to the client and at the same time contain costs on
behalf of the MCO (Haas & Cummings, 1994; McDaniel & Erlen, 1996;
Newman & Bricklin, 1994). Therefore, working within a managed care con-
text can create a triangle that places the practitioner in the middle of poten-
tially competing interests (Backlar, 1996; Gottlieb, 1992; Haas & Cum-
mings, 1994; Pipal, 1995; Sabin, 1994). Although triangles are not inherently
problematic or unethical, they do pose risks for the practitioner. For example,
the practitioner may be caught between advocating for a client who requires
additional treatment and supporting the MCOs goal of cost containment. As
204 THE COUNSELING PSYCHOLOGIST / March 2000
the APAs (1992) ethical principles indicate, the practitioner has an obliga-
tion to address issues of conflict of interest with both parties to resolve the
conflict (Backlar, 1996; Higuchi, 1994; Miller, 1996a; Sabin, 1994).
If a practitioner has been referred a series of severely disturbed clients
who require a great deal of treatment, he or she may come to be seen as unco-
operative with the MCOs brief therapy philosophy. Such an assessment of
the practitioner, albeit incorrect, might result in a reduction of referrals or
even refusal to renew the practitioners contract. Regardless of these possible
adverse consequences, business considerations must always be secondary to
our ethical obligations to our clients (Newman & Bricklin, 1994).
A related conflict of interest may arise when the practitioner agrees with
the brief treatment model endorsed by the managed care company, but is
faced with a situation in which using a brief treatment approach is contraindi-
cated (Gottlieb, 1992). For example, with clients who present with signifi-
cant dissociative experiences, the practitioner may be tempted to provide
brief treatment and do the best he or she can given the circumstances (Gott-
lieb, 1992). However, this approach may not be in the clients best interest
and, in fact, may be harmful. On the other hand, the practitioner may elect to
communicate this dilemma to the MCO. Although diverging from the
MCOs treatment model may result in the MCO perceiving the practitioner as
uncooperative, it is also possible that, if the practitioner has been seen as sup-
portive of the MCO in the past, exceptions could be made. In this case, the
practitioner succeeds by doing the best thing for the client and avoids alienat-
ing the MCO in the process.
Record Maintenance
Practitioners have an ethical obligation to maintain adequate records
(APA, 1993). However, utilization review processes place additional respon-
sibilities on the practitioner. Before discussing these issues, it is important to
be mindful of relevant ethical standards including 5.03(a) (APA, 1992),
which states that To minimize intrusions on privacy, psychologists include
in written or oral reports, consultations, and the like, only information ger-
mane to the purpose for which the communication is made (p. 1606). Also,
Ethical Standard 5.04 (APA, 1992) states that Psychologists maintain
appropriate confidentiality in creating, storing, accessing, transferring, and
disposing of records under their control, whether these are written, auto-
mated, or in any other medium (p. 1606).
Cooper, Gottlieb / ISSUES WITH MANAGED CARE 205
Beyond regular record keeping, working with MCOs usually involves the
completion of additional forms and/or having telephone interviews for the
purposes of prospective and/or concurrent UR. Most often, the information
requested involves providing a diagnosis, the treatment plan, therapy prog-
ress, and/or anticipated termination. In general, these forms or interviews
serve the purpose of documenting the medical necessity of therapy. Despite
the common perception to the contrary, such reviews do not necessarily
ensure payment for services because the MCO does not make such decisions.
The MCO makes recommendations to the insurance company that makes the
final decision regarding payment.
One issue that arises during UR involves how much information the prac-
titioner should disclose to the MCO. Even though the practitioner obtained
the clients informed consent regarding the release of confidential informa-
tion, the client does not know specifically what information will be revealed.
This issue is important because once the information is revealed to the MCO,
the client and practitioner no longer have any control over it and, as previ-
ously mentioned, the information could become part of a national database of
health care records (CAPP Task Force on Ethical Practice, 1998). Therefore,
regarding how much information to release, it is recommended that practi-
tioners release only the information that is directly relevant to obtaining
authorization for additional sessions (Barnett, 1998a; Corcoran & Vandiver,
1996).
RETROSPECTIVE UR
review. Therefore, such matters should be addressed with the client at the out-
set of treatment as a matter of informed consent.
If the practitioner can reasonably anticipate such review, he or she must
consider just how much information should be contained in the record that
may be eventually provided to the MCO, and what, if anything, should not be
recorded. In our view, adequate records are an essential means of providing
good care and there is no excuse for failing to keep them. On the other hand,
given the questions regarding confidentiality we have discussed above, we
recommend that the practitioner be very judicious in this regard and only
record information that is directly relevant to treatment (Corcoran & Vandi-
ver, 1996). For example, if a 40-year-old client discloses to the practitioner
that she engaged in bulimic behaviors for 1 month following the breakup of a
romantic relationship several years ago, and these behaviors have not
occurred since then, the practitioner may choose not to include this informa-
tion in the record if he or she concludes that it is not relevant to current pre-
senting concerns.
Particular caution should be used when including information about other
family members in the client record. As a matter of good practice, MCOs
expect the practitioner to obtain a clients history and understand that the
information obtained is a function of the clients perception. However, the
practitioner should beware of the risk involved in providing information to
the MCO about other persons for whom the practitioner does not have a
release of information. This may become particularly troublesome if family
members are members of the same insurance plan and are pursuing treatment
from the same MCO.
plaint. For example, one may wish to document conversations with MCO
representatives, including the representatives name, the practitioners clini-
cal assessment provided to the MCO case manager, the decision of the MCO,
and further actions taken by the practitioner (e.g., an appeal if additional ses-
sions were denied). If an MCO refuses authorization for additional sessions,
it is recommended that the practitioner document this decision and request a
copy of the decision in writing to include in the clients record (Gottlieb,
1992). We understand that this recommendation imposes an additional bur-
den on practitioners already burdened with paperwork. Nevertheless, we
contend that doing so is good clinical practice, ethical, and a matter of sound
risk management.
Business Relationships
To become a participating provider for an MCO, practitioners are required
to sign legally binding contractual agreements with MCOs (Gottlieb, 1992;
Higuchi, 1994; Resnick et al., 1994). These contracts often are quite lengthy
and it is important that the practitioner read them carefully with an awareness
of both the potential ethical and legal issues that may arise (CAPP Task Force
on Ethical Practice, 1998). Ethical Standard 1.02 (APA, 1992), regarding the
relationship of ethics and law, states the following: If psychologists ethical
responsibilities conflict with law, psychologists make known their commit-
ment to the Ethics Code and take steps to resolve the conflict in a responsible
manner (p. 1600).
Generally speaking, it is only prudent to assume MCO contracts are not
standard or the same (APA Practice Directorate, 1996; Gottlieb, 1992), and a
practitioner should not sign a contract assuming that differences can be
worked out later (Gottlieb, 1992). It is recommended that the practitioner
have an attorney who is experienced with health care and relevant state and
federal law review the contract as well (APA Practice Directorate, 1996; Got-
tlieb, 1992; Higuchi, 1994; Resnick et al., 1994). In addition to these general
recommendations, there are some specific issues one should look for in an
MCO contract to avoid potential ethical conflicts because they may directly
impact the therapeutic relationship and/or directly affect the practitioner to
the degree that appropriate care may be compromised.
contract should state procedures and guidelines for sharing as well as protect-
ing client information (APA Practice Directorate, 1996; Gottlieb, 1992).
Utilization review. The practitioner should make sure that he or she fully
understands the MCOs UR procedures. If the procedures outlined by the
MCO could potentially result in providing negligent care, the provider
should not sign the contract (Corcoran & Vandiver, 1996). Also, the practi-
tioner should examine the procedures in place when a practitioner disagrees
with the UR decision and if there is an appeals process. In a contract, the
appeals process should be clearly delineated (CAPP Task Force on Ethical
Practice, 1998). Additionally, the practitioner should inquire if psychologists
are members of the UR panel (APA Practice Directorate, 1996).
STAFF PSYCHOLOGIST
UTILIZATION REVIEWER
POLICY MAKER
Ethical Standard 1.06 (APA, 1992) states that Psychologists rely on sci-
entifically and professionally derived knowledge when making scientific or
Cooper, Gottlieb / ISSUES WITH MANAGED CARE 211
SUPERVISOR
Numerous ethical problems may arise for psychologists who act in super-
visory capacities in MCO environments. For example, one of the authors had
a conversation recently with a social worker in a managerial position with an
MCO. The company had just won a large contract and had openings for 50
case managers. When asked about qualifications, he replied that anyone
licensed at the masters level would be eligible to apply. When asked if that
included those who had recently completed their training, he noted that hir-
ing newly minted professionals would not be a problem because the MCO
would provide the few weeks of training needed to do the job. What if the
212 THE COUNSELING PSYCHOLOGIST / March 2000
Confidentiality
Researchers are well versed in maintaining confidential, identifiable
information with which they are entrusted. As stated in Ethical Standard 5.02
(APA, 1992), Psychologists have a primary obligation and take reasonable
precautions to respect the confidentiality rights of those with whom they
work or consult (p. 1606). However, doing research in the managed care
arena may pose additional and unique ethical dilemmas. For example, what is
the researcher to do when he or she finds that client records are being trans-
mitted without proper releases or that unauthorized personnel have access to
client records? Another problem may arise when MCO personnel ask the
researcher for confidential client information for which they were not author-
ized access.
A less likely, but more serious, problem may arise in the following exam-
ple. Professor X was a professor at a major research university in a small
community. The university had its health insurance benefit managed and the
professor received permission to study various aspects of the managed care
function. In receiving permission, she was also given access to client records
with the understanding that such information would be confidential. In the
course of her research, the professor happens across confidential client infor-
mation regarding colleagues. Given these examples, it is important for the
researcher to be mindful of confidentiality guidelines and to anticipate chal-
lenges to these guidelines when possible.
Competence
Ethical Standard 6.07a (APA, 1992) states that Psychologists conduct
research competently and with due concern for the dignity and welfare of the
participants (p. 1608). We will not repeat the qualifications needed to per-
form competent research. However, the managed care environment is unique.
Therefore, we suggest that, no matter how competent a researcher may be,
researchers become familiar with the environment in which they will be
working. For example, familiarity with basic terminology will help research-
ers to ask better research questions. Knowledge of the lines of reporting will
help the researcher understand issues involved in the MCOs chain of com-
mand. Finally, it is important to understand just how much latitude profes-
sionals are allowed with regard to client management. All of the above will
help researchers better understand MCO organizational models, the prob-
214 THE COUNSELING PSYCHOLOGIST / March 2000
lems faced by MCO personnel, and the unanswered questions raised by these
models. Finally, researchers should be mindful that they are not working in a
traditional mental health care facility. The primary goal of the MCO is cost
containment, and it is organized structurally and functionally to that end. The
wise researcher will remain mindful of the role that this goal plays in service
delivery and the ethical issues that it may foster.
results might cost his or her job. Furthermore, if the MCO does not like the
results of a study, will they claim the data as proprietary information and pro-
hibit publication of a study that has occupied much energy and resources?
Although there are no simple answers to the preceding questions,
researchers may find themselves facing these and even more complex ethical
dilemmas in the future. Although adhering to aspirational goals may be diffi-
cult, it is necessary to remain mindful of these relevant standards regarding
the conducting of research. When faced with potential ethical dilemmas such
as these, it is critical that researchers think through these issues as thoroughly
as possible before engaging in such research endeavors. The Haas and
Malouf (1995) model may provide a useful frame for examining these issues.
Researchers also are encouraged to consult with colleagues who are knowl-
edgeable of the managed care environment, as well as their institutional
review board, for guidance.
Human Welfare
As psychologists and researchers, we are expected to pursue the aspira-
tional goal of promoting human welfare (Ethical Principle E) (APA, 1992).
MCOs, as noted above, do not view this as their primary goal, public advertis-
ing notwithstanding. As a result, researchers may find themselves working in
environments where their ethical values are not shared by the organization or
all who work there. This issue may not necessarily pose specific ethical
dilemmas for the researcher. However, one might think carefully about such
differences before proposing to do research in an environment where the staff
and researcher may not share very basic ethical values.
A more specific example may arise if the researcher becomes aware of
cost containment strategies that in his or her judgment deprive clients of
needed services. What is the researcher to do? To whom should one com-
plain? Would complaining matter? Could it jeopardize the research efforts?
Although we do not have answers to these questions, we strongly urge
researchers to consider such matters and develop their own decision-making
guidelines before agreeing to work for a particular MCO.
Business Relationships
Academic colleagues must proceed cautiously when considering accept-
ing research funding from an MCO. This is not to say that MCOs will neces-
sarily ask researchers to do things that would violate their ethics. On the other
hand, the prospective grant writer is well reminded of our comment above
regarding working in an environment that does not share his or her values.
Similarly, we suggest that all contractual elements of a research project be
216 THE COUNSELING PSYCHOLOGIST / March 2000
Psychologists who are responsible for education and training programs seek to
ensure that the programs are competently designed, provide the proper experi-
ences, and meet the requirements for licensure, certification, or other goals for
which claims are made by the program. (p. 1607)
Competence
For needed changes in curriculum and training to occur, applied and aca-
demic faculty must first educate themselves about managed care if they have
not already done so. Several authors have voiced concern that a majority of
psychology faculty do not have sufficient knowledge of the managed care
movement (Austad et al., 1993; Belar, 1989; Bennett, 1994; Berman & Aus-
Cooper, Gottlieb / ISSUES WITH MANAGED CARE 217
tad, 1991; Blackwell & Schmidt, 1992; Broskowski, 1995; Budman & Arm-
strong, 1992; Cummings, 1995; DeLeon et al., 1994; Hoyt, 1995; Kalous,
1996; Lowman, 1994a). There are understandable reasons why many aca-
demic and applied psychologists have hesitated to learn about managed care.
However, regardless of ones personal view of managed care, educators and
trainers have the ethical obligation to prepare graduate students for the man-
aged care environment and the changes ahead in the health care delivery
system.
At the aspirational level, Principle A (APA, 1992) states the following:
There are at least three ethical standards related to the need for educators
and trainers to maintain competence. Ethical Standard 1.04a (APA, 1992)
states that Psychologists provide services, teach . . . only within the bounda-
ries of their competence, based on their education, training, supervised expe-
rience, or appropriate professional experience (p. 1600). Ethical Standard
1.04c (APA, 1992) states that Psychologist provide services, teach . . . in
new areas or involving new techniques only after first undertaking appropri-
ate study, training, supervision, and/or consultation from persons who are
competent in those areas or techniques (p. 1600). Ethical Standard 1.05
(APA, 1992) states that Psychologists who engage in . . . teaching . . . main-
tain a reasonable level of awareness of current scientific and professional
information in their fields of activity, and undertake ongoing efforts to main-
tain competence in the skills they use (p. 1600).
It is obvious that the APAs ethical principles place a heavy professional
and ethical burden on trainers and educators. How are they to discharge their
obligations in such a rapidly changing health care environment? Certainly
doing so is difficult for all psychologists, but trainers and educators may find
maintaining their competence more of a challenge when they are forced to
divide their time between administrative, teaching, research, and/or practice
activities.
There are a number of ways to pursue continuing education activities
regarding managed care. A few suggestions are listed below.
Professional Responsibility
FIDELITY
Informed Consent
VERACITY
education and training that will prepare them for the more general world of
professional work, and many will interface with MCOs in various roles.
Therefore, it is our view, as a matter of fiduciary responsibility to students,
that program descriptions clearly describe what they do so that students will
have a clear idea of what type of experience they can anticipate. It is our view
that failing to do so does not adequately protect the welfare of the students
who seek education and training from these programs. We believe that train-
ing programs should reevaluate the extent to which certain areas of study are
pursued (e.g., managed care) as a matter of student welfare.
COURSEWORK
ogy programs. These needs included the ability to work on health care teams
(e.g., multidisciplinary teams), an understanding of how to conduct applied
research (e.g., treatment outcomes and program evaluation), proficiency at
conducting brief therapy and crisis intervention, knowledge of relevant ethi-
cal and legal issues, knowledge of how to apply business and economic prin-
ciples, knowledge of management and marketing, experience and confidence
using technology such as computer database systems, and an understanding
of psychologists role in health policy and advocacy.
TRAINING
begins working with a complex client and is uncertain how to proceed given
the MCO treatment model and procedures. As a part of his individual super-
vision or as part of intern seminar training, the intern could arrange for a
videoconference (or conference call if video resources are not available) with
an experienced consultant at an urban mental health agency.
did not lend itself well to empirical research. In writing this agenda, we reject
this presumption and contend that many aspects of ethics are amenable to
research study. Our suggestions follow.
Informed Consent
We have taken a rather uncompromising position regarding the impor-
tance of informed consent. We have done this as an ethical matter, but we
wonder if such procedures also enhance treatment effectiveness. Various
ways of providing differing degrees of information could be used as inde-
pendent variables with treatment outcome serving as the dependent variable.
On the other hand, is it possible that there is such a thing as providing too
much information? That is, would such a study also reveal that clients termi-
nated prematurely when they reached some point of information overload?
Confidentiality
Numerous issues regarding confidentiality require research, especially as
discussion increases regarding the advisability of a national data bank for
health care records. First, we would be curious to know if information about a
family member contained in a clients treatment record would be relevant to
decision making when that family member applied for services. For example,
if a wife alleges that her husband is an alcoholic, and the husband then seeks
services for depression, would the information provided by the wife be avail-
able to the reviewer to be considered before a decision to provide care was
made? Second, how is the therapeutic working alliance affected by the pros-
pect of reduced confidentiality and potential limits on time available to
develop the therapeutic relationship? We propose a study in which varying
levels of confidentiality are offered to determine if doing so would affect
treatment outcome.
Competence
Much anecdotal data exist regarding the qualifications of UR personnel. It
would be rather simple to determine their level of training, both in terms of
formal credentials and training for the particular task they perform. We
would be curious to know how comfortable they feel in their role with the
decisions they make and whether they have ethical qualms regarding those
decisions.
Cooper, Gottlieb / ISSUES WITH MANAGED CARE 225
Integrity
MCOs develop treatment guidelines for UR case managers so that deci-
sions can be made quickly and efficiently regarding whether care should be
provided. We worry that such policies are based less on the welfare of sub-
scribers and more on cost containment. We suggest that research be con-
ducted to evaluate not only how these decisions are made but whether persons
in need are receiving the services that are appropriate to their condition. For
example, what is the procedure and what are the criteria by which reviewers
make decisions for provision, continuation, or termination of care? Are there
empirical bases for these decisions? How reliably are these decisions made
across clients?
their ethical concerns regarding allocations and provision of care could prove
vital to understanding the decision making of MCOs.
Business Relationships
Because of the complex ethical issues that arise in doing research regard-
ing managed care, we fear that some researchers may have shied away from
the task, viewing it as too daunting and fraught with ethical pitfalls. If man-
aged care companies are serious about quality of care issues and truly want to
research the best way to deliver health care, we believe this could be done in
the following manner. An MCO could provide funds to an independent
research group, earmarking the money for research to improve methods of
delivering health care within a managed care environment. The agency or
foundation could then send out requests for project proposals and researchers
would submit their proposals. The independence of the foundation and the
arms-length relationship between the MCO and researcher could resolve
many of the conflicts of interest we have discussed above.
Social Responsibility
Several psychologists have emphasized the need for research to direct
future social policy. Ethical Principle F (APA, 1992), regarding social
responsibility, states the following:
We contend that managed care is the result of a larger systemic crisis in the
health care delivery system. That is, in response to spiraling health care costs
and limited financial resources in the 1980s, we were forced to allocate
and/or ration services. When President Clintons health care initiative failed,
the country made a decision that the government should not be in charge of
our health care. The practical result was that the gap created by this action
was filled by business interests that do not have advancing human welfare as
their first priority. The problems with leaving health care to the free market
are now quite apparent. As MCOs have been bought and later sold for
incredible sums, the profits have gone into the pockets of business leaders
rather than into the health care of our population. Now, as those profits have
begun to evaporate and more than 40 million people are without health
Cooper, Gottlieb / ISSUES WITH MANAGED CARE 227
that will offer the highest quality, yet cost-contained, mental health care.
Some notable examples of macro-level questions and analyses follow.
Lowman (1994b) demonstrated that spiraling mental health care costs
were largely due to inpatient treatment and that the efficacy of inpatient treat-
ment remains unproven. Thus, it could be argued that inpatient care is per-
haps the more appropriate target for cost-control efforts and that persons
should be given more access to outpatient care because it has been shown to
be more cost-effective (Cummings, 1991b; Lowman, 1994b).
Another macro-level ethical question concerns who should receive mental
health benefits. For example, there are clients who have more severe mental
health conditions who will consume more mental health care resources. No
one would contend that these persons should receive less treatment, but in
effect, that is what capitated models are mandating (i.e., the same short-term
treatment model for everyone regardless of their condition) (Lowman,
1994b). Lowman (1994b) argued that a managed care system should be
evaluated based on the extent to which the mental health benefit plan meets
the mental health needs of all its members.
Research that evaluates practices within MCOs is much needed, such as
research on both the effectiveness of UR and the ethics of its practice. The pri-
mary purpose of UR is to ensure that the treatment is both medically neces-
sary and appropriate for the clients condition. However, there are few
empirical data to support the assumption that mental health care is improved
by UR (Resnick et al., 1994). Some psychologists have even speculated that it
costs more for the MCO to provide UR than is saved in health care costs
(Lowman, 1994b; Nickelson, 1995).
Another critical research question involves primary prevention versus
remedial efforts. What would be the impact if more resources and services
were aimed at prevention? For example, in a report by the Public Health Ser-
vice (1991), it was shown that the major causes of death and disability are
behaviorally based. Rather than allocating resources to end stage care, MCOs
could provide increased resources for preventative efforts, which are proba-
bly the best long-term cost-containment strategy. Cummings (1991b)
reported that clients who discuss their stress with their physician are more
likely to be referred for costly medical services, rather than for mental health
services that offset medical costs. Thus, he argued that MCOs need to
develop outreach programs to educate consumers and health care delivery
personnel alike regarding various psychological issues and how they affect
physical health. The idea is that preventive efforts would encourage more
persons to seek brief therapy and hopefully have less need for more costly
medical services later.
Cooper, Gottlieb / ISSUES WITH MANAGED CARE 229
As the health care system continues to evolve, several experts have pre-
dicted general trends with respect to the delivery of health care. We believe it
is important for counseling psychologists to be cognizant of these trends in
order to be involved in the discussion and proactive regarding ethical deci-
sion making and future policy. In this final section, we briefly review some of
these trends and discuss what counseling psychologists can contribute.
Expected Trends
Overall, experts agree that managed care, in some form, is here to stay, at
least in the foreseeable future (Cummings, 1995; Lowman, 1994b). In an
interview with Nickelson (1995), Russ Newman, the executive director of the
APA Practice Directorate, predicted several general trends including larger,
multidisciplinary health care practices; integration of health care service
delivery; and a greater emphasis on using business principles to make deci-
sions about how finite health care resources will be used (p. 367). Further-
more, there will be fewer and larger MCOs (Corcoran & Vandiver, 1996;
Hoyt, 1995). As these companies grow and capture even greater portions of
the health care market, it is anticipated that there will be fewer solo practices
and more group practices (Hoyt, 1995; Nickelson, 1995).
Many experts predict increased usage of outpatient mental health services
(Cummings, 1995; Hoyt, 1995). There are at least two reasons for this. First,
it is anticipated that there will be much less inpatient care due to its cost (Low-
man, 1994b). Second, it is expected that increased support will be given to
preventive efforts as awareness increases of the associated medical cost offset
or savings that result from these efforts (Cummings, 1991b; Hoyt, 1995).
Hoyt (1995) emphasized that practitioners can anticipate the need for
more treatment planning, greater focus on outcome measurement, and
increased attention to differential therapies (i.e., what works best with whom
for what problem when). It is expected that practitioners will be doing more
group therapy, especially psychoeducational groups (e.g., stress reduction)
(Cummings, 1995; Hoyt, 1995). Finally, we anticipate that there will be an
increase in the effort to use manualized therapy for various diagnostic catego-
ries to standardize practice and reduce cost.
may face and, more important, what role counseling psychologists can take
in addressing these issues. As we noted above, many have remarked that
managed care is here to stay. However, we do not expect managed care to sur-
vive over the long term. Instead, we view managed care as a transitional step
in a longer evolutionary process of determining how health care will be deliv-
ered. Although it is necessary to deal with managed care and the ethical
issues that it raises today, it also is necessary to remember that we are in a
period of rapid change, and it is reasonable to assume that managed care may
be replaced by some other system. If this is true, there are some things coun-
seling psychologists can do.
First, it is imperative for counseling psychologists to adapt to these chang-
ing times. We are acutely aware of the personal, financial, professional, and
moral difficulties faced by many of our colleagues in recent years as managed
care has taken control of the health care system. If we do not adapt, we do so
at our own peril. We are reminded of the famous saying from Ecclesiastes: If
I am not for my self, who am I; if I am for myself alone, what am I; and if not
now, when.
Second, counseling psychologists must be involved in the mental health
care decision-making process. This is especially necessary when ethical
issues arise that compromise the welfare of our clients and our own ethical
principles (CAPP Task Force on Ethical Practice, 1998). Two brief examples
of how counseling psychologists can begin to exert an impact on managed
care decisions will suffice. First, approaches to therapy that fall under the
heading of cost-effective practices need to be evaluated (Austad et al., 1998).
The movement to institute the broad use of manualized therapies raises ethi-
cal and empirical questions about their applicability to general populations as
well as the potential loss of practitioner discretion in treatment planning. Sec-
ond, counseling psychologists have been providing preventive mental health
care for several decades (Humphreys, 1996). We are in a position to educate
MCOs about the value and cost-effectiveness of doing so.
Third, we must help our graduate students cope with this new reality so
that they will know what to expect and be able to thrive. This involves not just
training our students for what they can expect to find in the marketplace today
but preparing them for a very complex future in which they must take an
active hand in managing their careers. As we previously mentioned, graduate
students may interface with the managed care environment in a variety of
roles and it is critical that they are prepared to function effectively and ethi-
cally in these roles. For example, Cummings (1995) predicted that, with
some managed care models (e.g., HMO), doctoral-level psychologists will
be needed to supervise masters-level practitioners. These supervisors will
need a supervision model that is composed of different aspects than some of
Cooper, Gottlieb / ISSUES WITH MANAGED CARE 231
the traditional models (e.g., incorporating business concepts into the supervi-
sory experience).
Finally, psychology as a profession must take a seat at the health care
policy-making table. Many of the events discussed in this article occurred
with no input from our profession. Although it is unlikely that this will hap-
pen again, psychologists have a unique role to play in the policy arena, and
our voice has not been heard. Policy makers need to know more about psy-
chology in general so that they can give needed attention to psychological
health issues and appropriate standards of care (Frank & VandenBos, 1994).
No one has found the perfect system for allocating health care. What we
do know is that leaving it solely to market forces results in serious ethical
challenges and the system must be revised. Counseling psychologists can
take a central role in evaluating various health care systems and thus influ-
ence future designs (Berman & Austad, 1991; Lowman, 1994b). This recom-
mendation not only applies to trying to improve the managed care system we
have today; it also applies to long-term policy making. These efforts are
beginning at this time, and it is not too late to find a place at the table if we act
promptly. For example, as previously mentioned, Oregon has developed a
unique and interesting system for rationing health care that has wide public
support. Whether this will become a model for the remainder of the country
remains to be seen. Nonetheless, it is a good example of the kind of experi-
ments that will be conducted in the near term. The long-term goal of our
country is to establish a new health care delivery system. We only hope that as
a profession, psychology will be a part of the decision-making process.
FINAL COMMENTS
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