Managed "Care" & Inadequate Science

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=90 BGCOLOR="#FFFFFF" TEXT="#080000" background="127015b3.jpg"> <div> <B>Managed "Care" & Inadequate Science</B><B>  |  </B><FONT SIZE="5" COLOR="#000000" FACE="Arial" ><A HREF="http://help4self.net" TARGET="_top" TITLE="http://help4self.net"><B>Home</B></A></FONT></div> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <A HREF="divorce_links.htm" TARGET="_top" TITLE="Divorce Links">Divorce Links</A></div> <div> <A HREF="id89.htm" TARGET="_top" TITLE="McTherapy">McTherapy</A></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700c800000000.png" HEIGHT="13" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Managed "Care" & Inadequate Science</B></div> <div> <A HREF="id91.htm" TARGET="_top" TITLE="Marital Happiness Poll">Marital Happiness Poll</A></div> <div> <A HREF="id95.htm" TARGET="_top" TITLE="Types of Providers">Types of Providers</A></div> <div> <A HREF="id64.htm" TARGET="_top" TITLE="Finding a Therapist">Finding a Therapist</A></div> <bR> </td> <td valign="top" height=390 width="100%" BGCOLOR="#FFFFFF" TEXT="#080000"> <div> You can read a scholarly look at the false assumptions used by the managed cost industry to justify its policies. The article was written by a former President of APA, Martin E. P. Seligman, who oversaw the 1995 Consumer Reports examination of psychotherapy.</div> <div> ------------------------------</div> <div> MANAGED CARE POLICIES RELY ON INADEQUATE SCIENCE<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> Martin E. P. Seligman, President APA</div> <div> Ronald F. Levant, Recording Secretary APA</div> <bR> <div> In the past decade health care corporations have been aggressively driving down costs. Psychological expenditures are increasingly restricted by routing patients to less-well-trained caregivers and by only authorizing brief therapy. Being an experienced, highly trained doctoral-level psychologist and skilled in long term therapy has become a disadvantage, rather than an asset, in today's market.</div> <bR> <div> Independent practice has been hurt as services become subject to pre-authorization and intensive review and as "medically necessary" comes to mean the bare restoration of functioning. Public sector practitioners are also hurt, as government embraces managed care and embarks on "privatization", drastically reducing jobs.</div> <div> Is there empirical justification for cutting length of therapy and lowering the qualifications of mental health providers? We do not think so and conclude managed care organizations (MCOs) have seized upon inappropriate and inadequate data to rationalize their downsizing of mental health care. Critical to our thinking is the distinction between "efficacy" and "effectiveness" psychotherapy outcome research.</div> <bR> <div> EFFICACY VS. EFFECTIVENESS:</div> <div> Two methods have arisen to evaluate the outcomes of psychotherapy. Each makes inferences about therapy in the "real world", and each does so from its own perspective.</div> <div> Efficacy Research: The "efficacy" method tests a laboratory distillation of therapy. Typically, the therapy is manualized; delivered for a fixed number of sessions; uses volunteers with well-diagnosed, relatively uncomplicated disorders; and has random assignment to different treatments, hopefully including placebo treatment. There exist hundreds of well-done efficacy studies. Some conclusions: cognitive therapy is the "therapy of choice" for bulimia and panic; behavioral therapy and drugs for agoraphobia; and interpersonal therapy, cognitive therapy, and SSRIs for unipolar depression.</div> <bR> <div> However, such conclusions are inferences from imperfect data. This is true of both the efficacy and effectiveness methods, but interestingly the imperfections are different and complimentary, and bear heavily on managed care cost-saving schemes. The core imperfection of efficacy ("threats to external validity") is that what is tested only slightly resembles therapy as it is actually practiced. Therapy "in the field" is not of fixed duration and rarely follows manuals; patients are not randomly assigned to therapists and modality, rather they choose; and, patients usually have multiple problems and differ in many ways from clinic volunteers. "In the field" patients often have severe and complex problems including co-morbidity of substance abuse with affective or anxiety disorders, Axis II diagnoses, and neuropsychological deficits.</div> <bR> <div> It is quite a stretch to generalize from laboratory efficacy studies to "therapy in the field". Each difference introduces artifacts into efficacy studies which systematically underestimate the effectiveness of "real" therapy. For example, treatment manuals: </div> <div> Treatment Manuals: There are two relevant problems with the treatment manual approach. Short-term approaches lend themselves to treatment specification and manualization while long term approaches do not. It is no accident that the overwhelming majority of the "well-established treatments" of the Division 12 Task Force Report are behavioral or cognitive-behavioral. Psychodynamic treatments are deemed "probably efficacious". </div> <bR> <div> Long term psychodynamically-oriented clinicians are urged to become more like behaviorists and develop more clearly specified treatments and manuals. Actually, the solution is quite the opposite: based on these data, psychodynamic therapists should not change; researchers should use a better method than efficacy studies for assessing long term therapy. The effectiveness method, which does not require manuals or brief therapy, is more relevant for long term treatment. </div> <bR> <div> A second problem relates to the venerable idiographic-nomothetic polarity.</div> <div> Practitioners tend to be idiographic; they typically tailor their treatment based on ongoing, often theory-driven assessments. Practitioners are especially good at this. Treatment manuals, on the other hand, are nomothetic. Manuals specify particular protocols for particular diagnoses. Sophisticated treatment manuals may allow for the individualization of treatment. However, the essence of manuals is systematically minimizing individual tailoring; i.e., reducing independent thinking by therapists and downplaying specific needs of individual patients.</div> <bR> <div> Effectiveness Research: The efficacy laboratory method contrasts with the "effectiveness" or "clinical utility" approach. The effectiveness method investigates the outcome of therapy as it actually delivered "in the field". It is important to appreciate how therapy "in the field" is actually performed to contrast the two methods. Typically, therapy investigated by the effectiveness method is done without a manual; with duration yoked to patient progress; and with patients who have multiple interacting problems including comorbidities and Axis II diagnoses, who choose the particular modality and therapist they believe in, and with the whole gamut of severity.</div> <bR> <div> The virtue of the effectiveness method is its realism -- it has no threats to external validity because it tests therapy as it is actually conducted "in the field". One can generalize from effectiveness studies to therapy as it is actually practiced with impunity. There have been many fewer effectiveness studies than efficacy studies; the former are larger, longer, and considerably more expensive. The 1995 Consumer Reports (CR) study, is a recent example. We have been working with NIMH regarding the importance of funding effectiveness research and expect to ultimately be successful. </div> <div> The CR study concluded, among other things: psychotherapy worked very well, 90% of patients doing well in contrast to efficacy studies which are usually in the 65% range; long term therapy worked much better than short term therapy; no particular modality of therapy or medication exceeded any other for any disorder; and insurance limits on choice and duration of therapy predicted worse outcome. These conclusions are notable because each contradicts what is often found by the efficacy method and suggests that the outcome of therapy "in the field" may be quite different from findings of laboratory efficacy studies. But these conclusions, like those of efficacy studies, resulted from imperfect and incomplete data. The core imperfections of the CR study were: there was no external control group; sampling may have been biased; it was retrospective and based on self-report; what happened in treatment was not documented; and patients were not randomly assigned to modality or therapist. </div> <bR> <div> MANAGED CARE:</div> <div> Both methods of evaluation have imperfections, but efficacy studies can by their very nature "validate" only brief, simple, and inexpensive treatment. </div> <bR> <div> Efficacy studies cannot test longer and more complicated modalities much less "validate" them. Effectiveness studies, however, can. Today psychotherapy is seriously threatened by MCOs drawing inferences from efficacy studies about appropriate treatment, justifying business practices. Only by overlooking the questionable external validity of efficacy studies, can MCOs justify brief and inexpensive treatment. No one benefits by this misuse of the efficacy data, except stockholders -- and then in the short run only. Psychotherapists have their autonomy and livelihood diminished. Skill, experience, and training become handicaps, rather than virtues. Patients receive briefer therapy from less skilled providers.</div> <div> Length of Therapy: The efficacy literature provides "empirical validation" for a number of brief therapies for a variety of disorders. But efficacy methodology, unlike effectiveness methodology, cannot even test, to say nothing of empirically validating, longer and more complicated psychotherapy. Manuals cannot be produced for long or complicated treatment and patients cannot ethically be randomly assigned to placebo conditions for the many months long term treatment may require. A control group of equally severe patients willing to eschew therapy and talk to sympathetic friends cannot be found. In contrast, effectiveness studies point to very substantial benefits of long term therapy. The conclusion from a review of both sets of literature: 1.) For some patients certain short term treatments are likely to work well and provide considerable benefit. 2.) For other patients long term therapy is necessary to produce substantial gains. And, 3.) Focused clinical effectiveness studies of the duration of therapy for different disorders and its cost-benefit ratio are urgently needed.</div> <bR> <div> Unfortunately, the current state of affairs allows MCOs to continue justifying predominantly brief therapy. They claim -- citing only the efficacy literature and ignoring the effectiveness literature -- that only brief therapy has been "empirically validated" and long term therapy has not. As long as the efficacy method is allowed to pre-empt the term "empirical validation", long term therapy will never be empirically validated. Efficacy researchers have become the unwitting vehicle for short-changing patients in need of more than brief therapy -- on a massive scale.</div> <bR> <div> Provider Qualification: Some have claimed the CR study "confirmed what we already knew": i.e., that increasing levels of experience, skill, and education do not make for better therapy. The CR study did nothing of the kind, nor do "we already know" it. This is a mischievous claim in today's marketplace. Unchecked, profit-driven health care will send patients to the cheapest providers available -- particularly if data can be invoked to justify the thesis that less qualified providers have equally good outcomes.</div> <bR> <div> The CR data is conflicting on this. Social workers (presumably MSWs) did as well as doctoral level providers. Marriage counselors (presumably nondoctoral providers), on the other hand, did significantly worse. This was not an artifact of the fact that marriage counselors see couples in troubled relationships. CR compared doctoral level providers to marriage counselors treating the same problems, and doctoral level providers did significantly better.</div> <bR> <div> In our judgment the scholarly argument for less qualified providers is seriously flawed. It wholly relies on studies where manuals are used, mild and uncomplicated clinical problems are diagnosed (by doctoral level providers), and duration of therapy is very brief and fixed. This is precisely where clinical judgment, experience, and education matters the least. It is no surprise that in situations in which clinical judgment, specialized education, and experience don't matter, people with less clinical judgment, less education, and shorter experience do as well as people who have better qualifications. </div> <bR> <div> Thus, </div> <div> 1.) If a case is simple, if a manual must be followed, and if treatment must be very brief, less qualified providers may do as well as doctoral level specialists. 2.) In therapy as commonly practiced "in the field", where cases are more complicated and severe, manuals are not used, diagnosis is an ongoing process, therapy is long and clinical judgment is important, more education and more experience improves outcomes. And, 3.) Effectiveness studies of level of education, qualifications, and experience of providers for different disorders, severity, comorbidity, and cost-benefit analysis are urgently needed.</div> <div> Some MCOs "justify" using less experienced and less well-trained providers even in complicated and severe cases. We believe patients are being deprived of adequately skilled treatment on a massive scale. Until this issue is resolved by appropriate clinical effectiveness studies, public policy should err on the conservative side and provide highly qualified providers in all but the simplest cases.</div> <bR> <div> We must reemphasize the lack of scientific foundation for managed care's policies of severely limiting the length of psychotherapy and systematically using less-well-trained providers. Awareness should better allow organized psychology to advance patient care in a marketplace increasingly driven by business considerations rather than by quality of care.</div> <bR> <bR> </td> </tr></table></body>