By Lowell Rubin, M.D.

The primary vehicles for implementing "managed care" in outpatient psychiatry have been the treatment plan and treatment report, now supplemented by "prior authorization" of care. Through these intrusive instruments, insurance companies attempt to control the cost of psychiatric care, and especially in regard to outpatient psychotherapy, to practice medicine without a license.

They are trying to do this by first using clerical staff and then a variety of "mental health" professionals backed up by a "company" doctor. Through these intermediaries the insurance companies decide what is good medical practice and what treatment will be "allowed." This has confused the line between proper care and what care the insurance companies want to pay for. Proper medical care should obviously be the decision of the treating doctor rather than the company doctor, who does not know the patient. Standards must be set by professional-group decision and not left up to the insurance company.

What has been foisted on us is an illegal activity that has somehow escaped those who have responsibility for protecting the public. Why aren't states conducting full-scale investigations of insurance companies' practices of using nonmedical intermediaries as if they were doctors?

If you or your neighbor heard that someone down the street who was not licensed to practice medicine set up shop and was directing people's medical care, wouldn't you expect that health or law-enforcement officials would be notified in short order? I think it is time we notify those who are entrusted with protecting the public from unlicensed medical practice. A thorough investigation is in order that goes well beyond sporadic attempts to question the arbitrary denial of care.

After supposedly "authorizing" care, the insurance companies then request a treatment plan and reports from doctors or other health professionals to justify the care. From a legal point of view, presumably, if someone has insurance coverage, the insurance company is obliged to pay for care as decided by those who are licensed to deliver it.

Treatment plans and reports, I maintain, are being used in an illegal manner. These reports also violate patient confidentiality, a special issue in psychiatry. The forms we must fill out are excessively intrusive. They ask us to give confidential medical information that is to be sent to the insurance company's clerical staff. How many of the company's executives, I wonder, would feel that the process is secure enough to have such information about them sent in?

As physicians we are accustomed to sharing medical information with other doctors. Even then we have concerns about the security of that information. Insurance companies are, however, demanding that we sacrifice our patients' confidentiality to supply information of questionable value. Who reads the information? Not doctors, although at some point in the "review process" the company doctor may be asked to look at it. Who, we might ask, is looking at it before that, and what license do they hold to understand and interpret what is sent to them?

Furthermore, who decides what information should be in these plans and reports?

We need to seek regulation in this area immediately. First, the insurance companies should be investigated for trying to "practice medicine without a license"; second, restrictions need to be placed on what they can ask, particularly regarding sensitive information that could find its way into other data networks.

Overall it is clear that what is going on is the harassment of doctors and patients with reduction in usage of insurance coverage. Patients are being denied what they have paid for, and doctors have their time taken up with fake paperwork they are not being paid for. So an obvious move to regain control is to require that insurance companies pay doctors for their time in filling out reports beyond the most basic information_name of the patient, a statement that there is a medical condition that requires treatment, what the treatment is going to be, and some estimate of the treatment duration. Insurance companies should pay for any other information from the treating doctor, and the information should go only to another doctor. If the insurers were paying doctors properly to provide and read the information that they are requesting, the cost would make it prohibitive and it would stop.

Treatment plans and treatment reports in psychiatry are problematic in other ways. Since the doctor must tell the patient that reports are being sent, and since for patients to trust us they want to know what is in those reports, we are either sowing distrust by not fully sharing the information or are interrupting treatment and creating therapeutic problems by sharing information that might not be appropriate to discuss at that time. Meanwhile we have to spend a great deal of time figuring out how to protect confidentiality while supplying information to the insurance company. The whole process is a disaster for treatment, the therapeutic relationship, and the integrity of the therapeutic process.

We all know that at the outset of treatment it is often impossible to tell how much time is needed to treat the condition and that it often requires time to make a proper diagnosis, to determine the correct treatment, and to evaluate the response once treatment begins. This is the practice of medicine. Insurance may help people by paying for all or part of their care. But until they are licensed, it is not up to the business managers to determine what proper medical care is. And we should not be spending our time justifying our professional work to them.

Dr. Rubin is in private practice in Providence, R.I., and is an assistant clinical professor of psychiatry at Brown University medical school. A version of this article appeared in the April issue of the Rhode Island Psychiatric Society Newsletter.

(Psychiatric News, November 1, 1996)