In early November UnitedHealthcare, the nation’s second-largest managed care company, announced that it was returning decision making to physicians, yet implied that its largesse didn’t extend to psychiatrists. Psychiatric dismay whizzed over the Internet and the APA M2M list serve. "Outrageous" and "discriminatory" were the coinage of the day. The UnitedHealthcare "Santa," it seemed, had a holiday present for all of its insureds except those being treated by psychiatrists.

It turns out, however, that the facts are more complex than the lay press had published.

Specifically, UnitedHealthcare announced its "good news" reform—that it was ending preauthorization for physician-ordered services—on November 8. Then on November 12 the company issued a statement saying: "This week, UnitedHealthcare, a UnitedHealth Group company, announced its newest evolutionary step in health care services. Recognized broadly as a watershed event, CareCoordination eliminates the hassles associated with prior authorization, keeps decision making between physicians and their patients, and makes it easier for people to get the health care they need when they need it. . . . [M]ental health [has] not fully transitioned to CareCoordination. . . ."

Also on November 12, Sam Muszynski, director of the APA Office of Health Care Systems and Financing, informed APA officers, the APA Board of Trustees, and the APA Assembly and district branches: "We are making every effort to obtain from UnitedHealthcare a full explanation of this policy and its impact on psychiatrists and their patients...."

On November 18 Muszynski got the information, then shared it with Psychiatric News:

United Health Group is the equivalent of a holding company, the parent of 10 companies. One of those companies is UnitedHealthcare. It was UnitedHealthcare that announced it was returning decision making to physicians, but implied that it was not doing the same for psychiatrists. UnitedHealthcare does only a tiny amount of mental health business by virtue of a peculiar merger it made. About 98 percent of UnitedHealthcare’s mental health coverage is offered through United Behavioral Health (UBH)—one of the 10 companies in the United family.

UBH, said Muszynski, is more progressive in its policies regarding mental health care than are many other managed care companies. Recently UBH launched a policy in which psychiatrists do not have to call for authorization or outline their treatment plan for the first 10 outpatient visits. The only factor UBH is concerned about is whether a patient is eligible for UBH coverage. There are some areas in the United States where UBH has not yet migrated toward this new policy, but 100 percent implementation is the eventual goal, according to Muszynski.

"I think that is a good thing," he contended. "This is where we want to see managed care go." In fact, he hopes that the limited decision-making freedom that UBH has extended to psychiatrists will also inspire other large managed care companies—such as Magellan and Value Options—to do the same or more.

UBH also is conducting a study to examine the feasibility of giving psychiatrists decision-making freedom beyond 10 outpatient visits. Further, Muszynski is engaging in a dialogue with UBH about the possibility of extending physician decision-making freedom to psychiatric inpatient care. If the company does, the situation, Muszynski said, would be parallel to UnitedHealthcare’s new CareCoordination policy.

Also, UBH is the only managed care company that has a policy of integrated treatment for mental illness—that is, treatment is not split between psychiatrists and mental health providers.

"Make no mistake," said Muszynski, "the new UnitedHealthcare policy remains discriminatory against psychiatric patients, and we will pursue redress with the company. Nonetheless, our preliminary review indicates that the new policy might indeed be the Trojan Horse of managed care, offering the gift of less managed care while using other techniques, such as aggressive physician profiling, that may increase the stranglehold on physicians and their ability to provide appropriate and needed patient care. We are now pursuing a meeting with UnitedHealthcare and United Behavioral Health to discuss these and other issues."

The reasons that mental health care was excluded from UnitedHealthcare’s new policy are not altogether clear. In its November 12 statement, the company suggested that it was because of contractual prohibitions. However, on that same day, Saul Feldman, chief executive officer of UBH, gave another explanation quoted by the Associated Press: "Mental health holds a lot more intangibles than medical care in determining what treatment someone needs."

APA President Allan Tasman, M.D., told Psychiatric News, "To the extent that UnitedHealthcare recognizes that it is inappropriate for anyone but the treating physician to make clinical decisions, we applaud their action. But there is no rationale to continue policies harmful to individuals with psychiatric problems."

One reason that UnitedHealthcare decided to give decision making back to physicians in general is that policing their decisions had presumably cost more than it saved—some $100 million in reviews to save about $38 million in medical care expenses, said Muszynski.