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This article originally appeared in the Physician's Travel and Meeting Guide in April, 1993. It is provided here with the permission of the author, to encourage continuing discussion about psychoanalysis and neuroscience, and about mental health care generally.

(mis)MANAGED (don't) CARE:
Is managed health care really a necessary evil for physicians?

Elio Frattaroli, M.D

One of the jokes I never understood as a child was about a guy standing up to cheer at a baseball game. Someone sitting behind him called out "Down in Front!", and he replied "Sorry, I don't bend that way." Only since I have had to deal regularly with HMO's and managed care agencies am I beginning to understand the point of the joke. Unfortunately, most of my colleagues still don't get it. They seem to view managed care as a necessary evil, a deplorable but inevitable fact of life. Taking the cue from hospital administrators, they simply take it for granted that we have no choice but to accommodate to the demands of the managed care industry. I have heard grim predictions that managed care will soon control at least 80% of the health-care market, and that physicians simply won't be able to survive unless we go along with the program. My response is, "Sorry, I don't bend that way." And I would sooner give up practicing medicine than try to.

As a psychiatrist, I have treated quite a few self-mutilating patients in intensive psychotherapy, a treatment that allows the physician to know intimately the inner life of the patient. I have learned that, very often, the self-mutilator feels himself to be in mortal danger and seeks to ward off an uncontrollable injury from an external (often delusional) enemy by taking control of the feared mutilation and doing it to himself first, before the enemy can get him. This is essentially identical to the rationale used by the American Psychiatric Association for its recent decision to go into the business of writing managed-care guidelines: if we don't do it to ourselves first, someone less qualified and less sympathetic will do it to us and then it will be even worse. If this line of reasoning sounds plausible to you, please remember that it is the same line of reasoning used to justify many other successful suicides as well. You read it here first.

Consider an alternative line of reasoning: if someone unqualified and unsympathetic is trying to mutilate you, you should try to stop them, preferably have them arrested, not look for ways to be cooperative. When the leaders of organized medicine are willing to write treatment guidelines so that a nurse who has never examined the patient can tell me that my treatment plan is inappropriate, they aren't my leaders. That's why I did a little cost-containment of my own and quit the APA.

At this point in the story, colleagues, APA representatives and some readers will want to protest that the old "system" fostered unnecessary treatment, motivated by greed and incompetence, and that surely we need some kind of managed care to prevent such abuses. This argument, of course is precisely the one that managed-care administrators and managed-care psychiatrists use to justify their own greed, incompetence and abuses. By accepting that argument we are in effect conceding that before managed care our profession was corrupt, which to me is like saying that before I got AIDS I had a cold. Again I am reminded of something I have learned from patients about self-destructiveness. Abused children always need to justify the abusiveness of their parents by believing they deserve it, blaming, and often abusing, themselves. When they cannot avoid the painful realization of what is really being done to them, they dissociate, pretending it is not happening, or is not as destructive as it feels, or that they are not really there. In being so ready to concede the field to a managed care industry that most of us feel is tearing our hearts out, I believe we are reacting like helpless children to an abusive Big Brother.

I am a psychoanalyst. Most of the work I do involves seeing patients in individual 45-minute-long sessions more frequently than once a week, often for a period of years. Most managed-care physician reviewers I have talked to have a thinly disguised contempt for what I do, a contempt they believe is justified by scientific research. Because it just so happens that there is lots of so-called scientific research demonstrating the efficacy of just about every short-term psychiatric/psychological treatment you could imagine (ten visits or less, the amount covered by most HMO's) and essentially no research at all on long-term (more than a year) psychotherapy, it must follow that if I practice long-term psychotherapy, I am unscientific and probably exploiting my patients for financial gain.

How inconvenient for the psychoanalyst that there are no drug companies to fund research on the efficacy of long-term psychotherapy. How inconvenient that the psychoanalyst is interested in the intimate personal history and motivation that makes one individual different from the next, while scientific research is interested in how people respond similarly to each other, based on statistical analysis of questionnaire responses (Rating Scales). How convenient for managed care that it appears to be both cheaper and more scientific to disallow any treatment lasting more then ten visits! Ain't science great? In the face of this kind of logic, I do not expect to be able to persuade the managed-care physician that his or her so-called scientific research is mostly an exercise in self-deception, but at least some of the scientists are beginning to realize it. One noted psychopharmacological researcher wrote recently that "We mislead ourselves. 'Responders' in clinical trials may not, in fact, manifest the quality of outcome we would seek for a patient... Few of us would choose to live at the level of distress suggested by a score of 15 on the HRS-D [Hamilton Rating Scale for Depression]." That kind of treatment outcome wouldn't be acceptable to you or your family, but modern science is more than happy with it.

It's not hard to understand how profitable it is for managed-care to believe in that kind of science. But why do the scientists believe in it? Perhaps philosopher of science Michael Polanyi, writing about positivism in 1950, had an answer which still applies today.

"The fact that serious and wise people with penetrating minds have so long subscribed to such rigmaroles about the nature of science can be understood only as expressing a deep, underlying urge of our modern civilization. It is due to a fundamental reluctance to recognize our higher faculties, which our empiricist philosophy cannot account for. We dread to be caught believing- -and, in fact, knowing--things which are not demonstrable by the measurement of observed variables." I couldn't agree more with Polanyi. I make my living from the ability to know things about people which are not demonstrable by the measurement of observed variables or by the statistical analysis of rating scale questionnaires. Freud called that ability Menschenkennen, and it can be useful in many situations.

For instance, it helped me understand the real meaning of a joke I heard recently, told by the president of a large managed-care firm speaking to a group of psychiatrists at my hospital. He had been explaining to us how the new model of managed care was one of collaboration and partnership between the reviewers and the treaters, with the guidelines being derived not from financial considerations but from the state-of-the-art scientific research being published in our journals. The man was an effective speaker, and he got to sounding so righteous about the scientific basis of his business that I almost felt like saluting. "So much for my miserably unscientific way of life," I thought cynically. I wondered how many of my colleagues would accuse me of being unfair when I told them I was sure that the guy was simply trying to take money out of our pockets to put into his, at the ultimate expense of the patients we were supposed to be partners in serving. That's when he told THE JOKE, which he introduced as a kind of summing up of what he wanted to say to us about partnership:

It seems that a ninth-grader was given the assignment of writing an essay about an ethical dilemma, much to his chagrin. "What's an ethical dilemma?" he asked his father, sullenly. "That's easy," replied the father, brightly. "Say Mr. Jones leaves his suit off at my shop to be dry-cleaned, like he does every week, and I check the pockets first like I always do and say I find a hundred-dollar bill." (pregnant pause) "Yeah, so where's the ethical dilemma in that?" asks the son. "That's easy," replies the father. "The ethical dilemma is 'Do I tell my partner?'" And so, leaving us with this joke as a model for the ideal partnership between managed care agency and treating physician, the speaker closed his talk. Everybody got the joke, so he didn't need to add the obvious addendum, "Who gives a ____ about Mr. Jones!"

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