Dr. Bursztajn is associate clinical professor of psychiatry and Mr. Brodsky is senior research associate, both in the Department of Psychiatry at Harvard Medical School in Boston, MA.

Acknowledgments: The authors thank A. Stone Freedberg, MD, Patricia M.L. Illingworth, PhD, JD, and members of the Program in Psychiatry and the Law at Harvard Medical School, Massachusetts Mental Health Center, for their helpful dialogue. The authors report no financial, academic, or other support of this work.


 

Abstract

How does managed care contribute to the psychiatric hazards of medical illness? How can primary care physicians and psychiatrists (as treaters or consultants) recognize and manage the clinical dynamics that result, together with their liability implications? For patients in managed healthcare settings, a latent subjective sense of captivity triggered by care restrictions can exacerbate feelings of helplessness and hopelessness brought on by the threat of serious illness. This sense of captivity can also intensify the patient’s feelings of alienation and betrayal when managed care constrains patient-physician decision making. These emotional dynamics, together with the rigid, defensive reactions to which physicians sometimes fall prey in the face of managed care’s restrictions on professional autonomy, can compromise the patient-physician relationship and the quality of clinical care while heightening liability risk. In the extreme, some patients will experience the escalating distress characteristic of posttraumatic stress disorder. Clinicians can prevent this emerging form of iatrogenesis by using such strategies as crisis anticipation and preparedness, intervention, and damage control, with the goals of enhancing the patient’s decision-making capacity and recovering a sense of choice in the patient-physician relationship. The introductory, ongoing, and termination phases of the treatment alliance are analyzed as focal points for particular clinical interventions.

 

Introduction

There has been a growing recognition of the influence of managed health care on the doctor-patient relationship,1 including the forcing of primary care physicians into an alienating, ethically ambiguous, and clinically conflicting “gatekeeper” role.2,3 While financial constraints have always been a factor in clinical cases, one major consequence of managed care practices has been a concern as to the lack of meaningful healthcare choices for both doctors and patients. In this atmosphere, patients and their physicians—who face the threat or actuality of a major illness—may experience heightened feelings of helplessness and hopelessness, especially when healthcare benefits are denied. More dangerous still, some patients and physicians come to distrust each other, as when patients feel that physicians are not advocating for them, and when physicians feel that patients are “shooting the messenger” (ie, blaming the physician for managed care-initiated restrictions). In this atmosphere, physicians often avoid consideration of treatment alternatives they view as likely to be denied by a managed care reviewer, or feel compelled to focus on the catastrophic possibility in the differential diagnosis to obtain otherwise denied benefits.4 The final stage of this downward spiral of the physician-patient relationship can be a kind of mutual resignation, where the patient leaves with silent resentment while the physician acquiesces in the silence of a de facto gag clause.

The sense of virtual clinical captivity that patients and physicians can experience in the face of benefit denial need not be taken as a fait accompli. By becoming aware of the dynamics and dilemmas of the physician-patient relationship under managed care, treating physicians can create greater freedom for their patients and themselves to work together effectively. Useful clinical interventions can be implemented to recover a sense of choice in the doctor-patient relationship, while decreasing liability risk, by effectively anticipating, preparing for, identifying, and responding to the distress that is likely to accompany managed care restriction of clinical care.

There are compelling clinical and ethical considerations favoring a proactive stance by physicians who are aware of potential negative managed care influences on their patients. Given that helplessness and hopelessness have been documented to be predictors of negative patient outcomes (eg, in breast cancer),5 the undermining of the clinical process and the resulting loss of trust also undermine the potential for healing relationships and, in turn, the likelihood of positive health outcomes. Physicians who work to reverse this process are not just protecting themselves from liability, but also providing quality care by protecting patients from the consequences of helplessness, hopelessness, and distrust.

Although specialized consultation (eg, psychiatric) can be helpful in the face of a denial of healthcare benefits, it is important that primary care physicians have the tools and perspectives needed both to advocate for the patient and to support the patient when individually indicated benefits are deemed not “medically necessary.”6 An understanding of the dynamics of the physician-patient relationship in the managed care context can be helpful in adapting one’s clinical skills to the task of supporting the patient’s capacity for choice, hope, and trust.

 

Patient Dynamics: “Virtual Captivity”

Even as the prevalence of mental health problems such as mood and anxiety symptoms in primary care settings has come to be recognized,7 the cost containment strategies of managed health care have been found to inhibit the recognition and treatment of psychiatric disorders in medical treatment settings.8 Not only has a diagnosis of depression been found to be associated with patient dissatisfaction with medical care,9 but patients with high levels of depressive symptoms are less likely than the general population to act on their dissatisfaction by switching health plans.10 At the same time, the inability to choose one’s personal physician has been found to be a major determinant of patient dissatisfaction with their healthcare plan.11 The existing pool of trapped, frustrated, disillusioned patients also represents a potential tinderbox of litigation in the wake of tragic outcomes associated with managed care-influenced restrictions on effective treatment—in particular, restrictions on the building of therapeutic alliances in the doctor-patient relationship.

Serious illness that threatens an individual’s bodily or psychological integrity already poses a threat to a person’s sense of autonomy and control. Serious illness can heighten dependency while bringing with it feelings of helplessness, hopelessness, and distrust associated with depression. When faced first with a lack of choice of a provider, and then with restriction or even denial of care, the vulnerable patient, already feeling like a prisoner of the threat of serious illness, may now also begin to feel like a lonely captive of the healthcare system. This trapped, “nowhere to turn” feeling may persist after the illness is treated or even cured, as the patient, once burned by the denial of anticipated care or by worry over the prospect of such a denial, may come to think, “What if I get sick again? What care will I receive?” At the extreme, the patient may begin to experience, subtly but significantly, the emotional traumas associated with abandonment12 and captivity.13

Clinically, such experiences can generate cognitive distortions driven by anxiety—and depression—that may impair the patient’s capacity to temper realism with the hope necessary to tolerate uncertainty and to choose wisely from available alternatives.4,14 Moreover, the prospects for a supportive patient-physician alliance are undermined when the physician is seen by the patient as either untrustworthy or largely powerless to implement his or her own clinical recommendations and protect patient choices due to managed care pressure. The patient’s perception of physician trustworthiness may suffer, for example, when managed care drug formularies restrict the physician from prescribing a medication of choice. Even a trusting relationship, especially when it is founded on blind optimism,  can be destroyed by adversity together with perceived abandonment. As the patient’s distrust increases, responses can include such modes as “fight” (litigate), “flight” (drop out of treatment), or “freeze” (become numb, passive, demoralized, and unable to act effectively in the interest of one’s own health care). The resulting anxiety and depression can lead to a greater likelihood of dissatisfaction with medical care9 and to an impaired capacity to act on that dissatisfaction by changing health plans.10

 

Physician Dynamics: “False Necessity”

The human tendency toward resignation or self-deception and denial of what is too painful to see is not limited to patients. Often, the treating physician may not have freely chosen to be part of a particular managed care organization (MCO) nor to treat a particular patient, except as the best of a set of undesirable choices or the lesser of necessary evils. The physician is also likely to have experienced a substantial reduction of economic and professional autonomy in the shift to managed care. Like the patient, the physician may have few options and insufficient time to recognize, reflect upon, process, and put into perspective the feelings engendered by the managed healthcare context. Under any circumstances physicians are likely to react to a patient’s rejection by withdrawing emotionally from the patient. This reaction is especially likely, however, if the physician faces one frustrated, recalcitrant patient after another in a time-pressured managed care setting. At the same time, from the patient’s perspective, emotional withdrawal by a hurried and frustrated physician can easily be experienced as indifference to the patient’s suffering and a perceived abandonment.

Physicians are far from immune to the contagion of pessimism that can sweep through an institutional atmosphere, as in end-of-life care. Physicians who risk being penalized for caring for patients when, in the judgment of an anonymous third-party reviewer, there is no medical necessity to do so, are more likely to succumb to institutional pressures. Careful “not to raise the patient’s expectations” by effectively disclosing all possible options and advocating for the patient’s right to the best available care, they “hang crepe”15 as a prelude to premature discharge. In the extreme, some clinicians will automatically advise the patient and their family that only low-cost palliative measures be taken, not mentioning the more costly, intensive alternatives that may hold out a slim but real hope for the patient.

Such an atmosphere increases the risk that patients and families will give up prematurely while clinicians who are too distracted or time-squeezed to do the hard work of eliciting the patient’s and family’s deeper intentions go through the motions of obtaining informed consent.16,17 At the same time, some physicians react to their loss of autonomy and choice by making a premature cognitive commitment to diagnostic and treatment decision strategies designed to avoid punitive profiling practices. For example, a physician who is concerned about being identified as readily willing to hospitalize a patient for observation and evaluation will tend to avoid the risk of being deselected by the MCO. This avoidance can manifest itself in the doctor-patient encounter as a fixed, overly rigid stance or a reluctance to present alternatives to the patient other than the treatment least likely to engender MCO scrutiny. Such an attitude interferes with the informed-consent process vital to clinical care, and is often a pivot point in liability.

Of course, some denials of benefits by MCOs do represent a genuine effort to weed out unnecessary treatments and excessive costs. Nonetheless, other treatments that are medically appropriate (in that they are effective relative to individual patient values) come to be discounted as medically unnecessary by reference to an interpretation of “medical necessity” that is insensitive to individual patient values18 as well as to broader health-related social values.19

Medically appropriate care is care that is indicated based on the doctor-patient dialogue as informed by scientific research and accepted practice. Ideally, medically appropriate care considers the whole patient.20 By contrast, the term “medically necessary,” as used by third-party reviewers, is a misapplication of triage principles from military and disaster medicine to individual patients.21 Even treating physicians, when compelled to be time-pressured and hyper cost-conscious (as in many fixed-fee per subscriber capitated systems), tend to narrow their focus to overly concrete, readily measurable “necessary” benefits. Easily overlooked in such calculations are the costs of incomplete treatment22 to a patient’s freedom to live in the least restricted manner, as well as the biopsychosocial benefits of treatment that considers the patient’s overall well-being and level of independent and interdependent functioning.

Excessive reliance on managed care-driven “practice guidelines,” in the guise of being evidence-based, is also used to justify a denial of care. Such guidelines are often very selective as to the evidence they cite, as in the paucity of studies with outcome measures that reflect quality-of-life issues or the widespread neglect of many well-grounded outcome studies showing the efficacy of mental health treatment for patients with many medical and surgical conditions. In any case, decision making for patients in the aggregate is no substitute for individualized clinical decision making.

 

Prevention and Management of “Managed Care Side Effects”

Whether or not in conjunction with specialized consultation, a variety of clinical tools are available for prevention and management of the increasing iatrogenic harms experienced as side effects of managed care. To begin with, it is helpful for the treating clinician to keep in mind the complex interactions between medical and psychiatric disorders that are often obscured by various managed care influences, such as the lack of time to take a careful history that is objective and empathic. Although psychiatric consultation or referral is helpful in cases that present special difficulties, it is now less accessible than ever given the restrictions of managed health care.7

Thus, diagnostically, it is now more important than ever for treating physicians to be aware of psychiatric comorbidity within both acute and chronic physical illness. Patient suffering accompanying physical illness can present as depression, “sick role” adaptation, chronic pain, exacerbation of substance abuse or dependence, obsessive or dissociative reactions, and conversion reactions. In a person who has had a life-threatening illness, such suffering can sometimes rise to the level of disorders in the posttraumatic stress disorder (PTSD) spectrum.23

The flip side of the tendency to overlook psychiatric disorders exacerbated by managed care is the tendency to use psychiatric disorders as convenient labels to rationalize the denial of medical care and to neglect the existential dimensions of the patient’s suffering. Thus, it is important not to write off patients in panic as simply hypochondriacal because of time pressure associated with managed care. If a person presents with symptoms similar to those that marked a previous life-threatening illness, the physician first rules out a recurrence of that illness. When there has been a recurrence, any posttraumatic sequelae need to be attended to, even in the face of managed care constraints. These sequelae may include symptoms of depression, demoralization, dissociation, flashbacks (eg, “Oh my God, it is happening again!”), and an increased risk of panic and suicide. It is helpful for physicians to keep in mind that a patient who suffers from PTSD (or other emotional vulnerabilities) is especially susceptible to an exacerbation or recurrence of symptoms.

Even if a recurrence of the illness has been ruled out, the illness may have left a vulnerability in that the emotional memory of its painful and frightening initial presentation may be reactivated simply by the recurrence of general symptoms. There is the possibility of life-threatening complications for the patient, such as depression, panic disorder, and suicide or “suicide equivalents.” The latter may include self-medication of panic by excessive drinking or medication overdoses, or counterphobic risk-taking such as driving under the influence of alcohol. With the threat of illness recurrence, the feeling of being alone and the lack of choice in the managed care situation can increase the likelihood of such self-destructive reactions. The patient’s anxiety may also be amplified by acute somatic symptoms associated with vulnerable body image areas.24

Even when practicing in a time- and resource-restricted environment, with access to psychiatric consultation severely limited for patient and physician alike, treating physicians can be alert to make emotional contact with patients. Physicians can create provisional alliances even when they do not have the usual time and ongoing involvement required for sustained alliance building or for providing psychotherapy per se.25 In creating such alliances, it is important to convey certain understandings and attitudes, as delineated here, in whatever wording comes naturally to the individual physician.

 

Remedies for Each Phase of an Evolving Relationship

In the introductory phase of the relationship, the physician can make contact with the patient while observing the patient for indications of a potential (or hidden) but deep sense of helplessness and hopelessness which accompanies the experience of captivity.13 At the same time, it is helpful to initiate a meaningful dialogue as a first step toward creating a therapeutic alliance and detoxifying feelings of aloneness and abandonment. This step can include engaging in an informed-consent process (not merely a pro forma litany of risks and benefits).4,14 Such a process needs to address clinical and economic risks and potential ethical and role conflicts that might be engendered when a clinician is a dual agent (eg, both a “gatekeeper” and the primary care treating clinician in a capitated system).26 By the same token, the clinician can tactfully but effectively disclose all substantial treatment alternatives, including those not covered by the patient’s health plan.

These disclosures can enable the patient and physician to decide together how to respond to economic restrictions on treatment without the patient being overwhelmed by anxiety and pessimism. Likewise, if it is reasonably foreseeable at the outset that continuity of care will be interrupted by changes in the patient’s insurance coverage, then reminding the patient of how helpful it can be to keep abreast of possible insurance changes will be part of the economic informed-consent process. In our experience, patients can sometimes influence employers’ choice of insurance providers and managed healthcare packages. Subsequently, if a change in coverage is threatened, the physician can support the patient by actively inquiring about how any prospective benefit changes might affect continuity of care.

Given the distrust of physicians engendered by managed care policies,27,28 it is important to sensitively inform the patient of economic considerations such as provider profiling, managed care guidelines, and capitation contracts that may affect the quality of care that the patient receives. Openly acknowledging such dilemmas can enhance the possibilities for a therapeutic alliance. To provide for continuity in sharing uncertainty, it is helpful to articulate questions left open to be addressed in future visits, and to anticipate which questions may arise before the next visit. Such open communication is vital despite the fact that the “gag clauses”29 eliminated as explicit provisions in physician contracts with MCOs may still be implicitly enforced through healthcare provider profiling, economic deselection, and other often hidden rules and procedures.

In the ongoing care phase, the physician can implement treatment with as much continuity and mutual planning as possible while continuing to respond to managed care treatment restrictions in light of the patient’s evolving attitudes and preferences and changing clinical status. Treatment can proceed in a manner that respects the patient’s best interests, including autonomy interests, without being overwhelmed by considerations such as how this will affect the physician’s profile. The physician who needs or wants to apply practice guidelines, as noted above, is also faced with translating what any diagnostic or therapeutic option actually means for this particular patient given the patient’s life history and individual values.

In the event of a denial of benefits, every effort must be made to continue the relationship and avoid abandonment. While the denial of some benefits can reduce the quality of other benefits and the clinical care that the patient receives, it need not result in a catastrophic end to the doctor-patient relationship. For example, even when indicated hospitalization is denied, the physician can work with the patient on an appeal and remain available to help the patient consider the life choices that chronic illness periodically poses.

By working throughout the benefit denial and appeal processes to maintain as much patient confidentiality as possible under the circumstances, the physician can avoid feeling pressured into establishing “secret” manipulative agreements with the patient. An example of such an agreement is selecting, for billing purposes, differential diagnoses that increase the likelihood of receiving managed care benefits. Physicians who feel that their only recourse is to “spin”30 or lie for their patients31 are often expressing the underlying helplessness and hopelessness that they themselves feel. Such secrecy and misalliance based on deceiving the MCO can all too readily undermine the trust necessary for the doctor-patient relationship to be open and healing. The patient may ask, “If my doctor is willing to lie for me, might he/she also be willing to lie to me?” Moreover, a relationship built around secrecy and deception rather than confidentiality and open commitment is vulnerable to a sudden, panicked withdrawal by a guilt-ridden physician, culminating in abandonment.

The termination phase is critically important in any clinical relationship in which an emotional bond has been formed. Prior to the patient’s transferring to another care provider, it is helpful to consider what choices the physician and patient have made together, what other choices they might have made, and how managed care pressures may have influenced those decisions. The physician whose contract is terminated by an MCO can inform the patient of the MCO’s action and coordinate the transfer of care while supporting a patient’s choice to take steps to oppose involuntary termination. If involuntary termination is brought about because the patient’s employer has changed its health plan, the physician can attend actively to both the practical and emotional aspects of termination. The physician need not allow his or her own feelings of anger and frustration toward the MCO to become displaced onto the patient, leading to abandonment via failure to inform patients of the foreseeable consequences of “involuntary” abrupt termination. When the process of saying goodbye is properly attended to, even an involuntary termination can be borne without sliding into an abyss of abandonment and paralysis.

 

Conclusion

We have offered guidelines for prevention and management of observable clinical harms resulting from managed care’s control of choices made by patients and physicians, including anticipated and actual benefit denial and restrictions on care. Medical outcomes are affected not only by the quality of technical care given, but also by the process of care, including patient participation in decision making.32 Denial of choice reduces quality of care in that the patient loses both the psychological benefits of exercising choice and the medical benefits of individualized treatment. Moreover, irrespective of the structure of healthcare delivery, the physician retains a primary duty to advocate for the patient’s interests, including the right to make informed choices based on effective disclosure of treatment options.3 A considered clinical response to managed care constraints can help physicians fulfill this ethical duty to provide effective and compassionate care.

As risk management, attention to the clinical process can also help prevent malpractice liability in the event of a tragic outcome. Both bad medical outcomes, reasonably attributable to MCO-initiated distractions from a clinical focus on the patient’s best interests, and bad feelings arising from managed care restrictions on patient autonomy tend to feed malpractice risk.1 Moreover, attention to the clinical process allows physicians and patients to initiate, proceed with, and terminate relationships appropriately even when each phase of the relationship is subject to substantial external control.

Although clinical intervention is no substitute for instituting fundamental changes in healthcare financing and regulation of third-party control, even today the ethically sensitive primary care physician or psychiatrist practicing in a marketplace dominated by managed care need not feel too overwhelmed to practice effectively on the individual doctor-patient level. By identifying and then preventing or alleviating the negative biopsychosocial side effects of the restriction of available patient choices, a substantial reduction in the clinical complications and liability risks of MCO control and denial of patient choice and care can be achieved.   PP

 

References

1.    Bursztajn HJ, Brodsky A. A new resource for managing malpractice risks in managed care. Arch Intern Med. 1996;156:2057-2063.
2.    Bodenheimer T, Lo B, Casalino L. Primary care physicians should be coordinators, not gatekeepers. JAMA. 1999;281:2045-2049.
3.    Council on Ethical and Judicial Affairs, American Medical Association. Ethical issues in managed care. JAMA. 1995;273:330-335.
4.    Bursztajn HJ, Feinbloom RI, Hamm RM, Brodsky A. Medical Choices, Medical Chances: How Patients, Families, and Physicians Can Cope With Uncertainty. New York, NY: Routledge, Chapman, Hall; 1990.
5.    Watson M, Haviland JS, Greer S, Davidson J, Bliss JM. Influence of psychological response on survival in breast cancer: a population-based cohort study. Lancet. 1999;354:1331-1336.
6.    Levinson W, Gorawara-Bhat R, Dueck R, et al. Resolving disagreements in the patient-physician relationship: tools for improving communication in managed care. JAMA. 1999;282:1477-1483.
7.    Nease DE Jr., Volk RJ, Cass AR. Investigation of a severity-based classification of mood and anxiety symptoms in primary care patients. J Am Board Fam Pract. 1999;12(1):21-31.
8.    Horn SD. Overcoming obstacles to effective treatment: use of clinical practice improvement methodology. J Clin Psychiatry. 1997;58(suppl 1):15-19.
9.    Wyshak G, Barsky A. Satisfaction with and effectiveness of medical care in relation to anxiety and depression: patient and physician ratings compared. Gen Hosp Psychiatry. 1995;17:108-114.
10.    Druss B, Schlesinger M, Thomas T, Allen H. Depressive symptoms and plan switching under managed care. Am J Psychiatry. 1999;156:697-701.
11.    Schmittdiel J, Selby JV, Grumbach K, Quesenberry CP Jr. Choice of a personal physician and patient satisfaction in a health maintenance organization. JAMA. 1997;278:1596-1599.
12.    Pollock GH. Abandonment. In: Rothstein A, ed. The Reconstruction of Trauma: Its Significance in Clinical Work. Madison, Conn: International Universities Press; 1986:105-120.
13.    Bursztajn HJ, Brodsky A. Captive patients, captive doctors: clinical dilemmas and interventions in caring for patients in managed health care. Gen Hosp Psychiatry. 1999;21:239-248.
14.    Gutheil TG, Bursztajn HJ, Brodsky A. Malpractice prevention through the sharing of uncertainty: informed consent and the therapeutic alliance. N Engl J Med. 1984;311:49-51.
15.    Siegler M. Pascal’s wager and the hanging of crepe. N Engl J Med. 1975;293:853-857.
16.    Curtis JR, Rubenfeld GD. Aggressive medical care at the end of life: does capitated reimbursement encourage the right care for the wrong reason? JAMA. 1997;278:1025-1026.
17.    Bursztajn HJ, Brodsky A. Authenticity and autonomy in the managed-care era: forensic psychiatric perspectives. J Clin Ethics. 1994;5:237-242.
18.    Rosenbaum S, Frankford DM, Moore B, Borzi P. Who should determine when health care is medically necessary? N Engl J Med. 1999;340:229-232.
19.    Emanuel EJ, Emanuel LL. Four models of
the physician-patient relationship. JAMA. 1992;267:2221-2226.
20.    Tucker JB. Modification of attitudes to influence survival from breast cancer. Lancet. 1999;354:1320.
21.    Bursztajn HJ, Gutheil TG, Brodsky A. Ethics and the triage model in managed care hospital psychiatry. Psychiatr Times. 1998;15(9):33-40.
22.    Simon G, Ormel J, VonKorff M, Barlow W. Health care costs associated with depressive and anxiety disorders in primary care. Am J Psychiatry. 1995;152:352-357.
23.    Green BL, Epstein SA, Krupnick JL, Rowland JH. Trauma and medical illness: assessing trauma-related disorders in medical settings. In: Wilson JP, Keane TM, eds. Assessing Psychological Trauma and PTSD. New York, NY: Guilford Press; 1997:160-191.
24.    Meissner WW. The self and the body. I. The body self and the body image. Psychoanalysis and Contemporary Thought. 1997;20:419-448.
25.    Meissner WW. The Therapeutic Alliance. New Haven, CT: Yale University Press; 1996.
26.    Miller TE, Sage WM. Disclosing physician financial incentives. JAMA. 1999;281:1424-1430.
27.    Hillman AL. Mediators of patient trust. JAMA. 1998;280:1703-1704.
28.    Grumbach K, Selby JV, Damberg C, et al. Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists. JAMA. 1999;282:261-266.
29.    Brody H, Bonham VL Jr. Gag rules and trade secrets in managed care contracts. Arch Intern Med. 1997;157:2037-2043.
30.    Illingworth PML. Bluffing, puffing and spinning in managed care. J Med Philosophy. 2000;25(1):62-76.
31.    Freeman VG, Rathore SS, Weinfurt KP, Schulman KA, Sulmasy DP. Lying for patients: physician deception of third-party payers. Arch Intern Med. 1999;159:2263-2270.
32.    Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract. 1998;47:213-220.