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CHAPTER ONE: INTRODUCTION
In the 1997 film "As Good As It Gets," actress Helen Hunt plays the mother of a chronically ill son. She had asked her Health Maintenance Organization for expensive tests that she thinks clearly might have led to a cure for him. She discovers the HMO has just turned down paying for her boy's testing. "HMO bastards!" she rages. "Pieces of shit!" "Actually," says the doctor talking to her, "I think that's their technical name." In the movie theater the night I saw this scene, virtually the whole audience stood up and cheered loud approval. I have heard that many other audiences did the same. This phenomenon suggests that, in health care, something very unusual is going on. Given this level of acrimony, it is time to review the fast-accumulating recent professional literature on outpatient mental health care. I found that the last dozen years of psychiatric, psychological, social work, and business literature describe key factors in the historical development of managed care and a number of problems or "losses" reported by consumers and clinicians, unintended consequences of the otherwise successful operation of managed care in its recent stage of development. As I studied the clinician and consumer perspectives, I sorted them into categories of significant "loss" and coalesced them into four major themes: (1) the consumer’s loss of choice in selecting a psychotherapy clinician, (2) the clinician loss of access to the client's health plan for reimbursement for client treatment, (3) the increasing loss, by both consumer and clinician, of the right to determine the nature and direction of their psychotherapy together, and (4) the loss by both of the right to determine duration of covered therapy. (A fifth category of loss reported, loss of privacy of personal information, is not covered in this study directly but could be improved by changes that would ameliorate losses 1 through 4.) Nevertheless, many managed care mental health professionals, many employers, and some other primary groups are satisfied with managed care mental health. Some have visions of a new day for mental health science. Some even sense an inevitability about the managed care directions being taken, the course the industry is taking, and the short-term or crisis-intervention approach to treatment they most often support and use. This research study does not concentrate on the substantial supportive literature about the activities and results of the managed care mental health plan movement, nor the literature about moderating and even lowering cost trend lines it is producing, particularly in residential treatment. Such material has been well reported and is widely known. This study focuses, instead, on (a) how apparently unintended consequences in managed care outpatient mental health appear to have developed, (b) four losses which that development appears to have produced, and (c) whether and how elements of system redesign may reduce those losses. This was an academic study also action research within Fairweather's (1967) description of entering the "arena of social change through action" (p. v). My motivation to study this set of losses emerges from my personal and professional concern for the importance of these losses, the sufferings that the losses entail, the threat to health plan coverage as part of the system of financing outpatient psychotherapy in recent decades, and the implications of these losses for the future. The design I have been developing may be of help, but it needs testing of various kinds. In any case I want to take action to explore the possibility that the tragedies listed below can, indeed, be ameliorated. This dissertation reports some of that action.
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