At 02:04 PM 10/25/96 +0100, Emmanuelle Tulle-Winton wrote:
>John
>I read your piece with interest. However it has left me confused and I
>think it would be good if you could clarify a few points:
>1. firstly a very daft question about context: where are you? managed care
>is not something i recognise in a british context. Is it similar to care
>management?
Emmanuelle,
My apologies for not taking into account that my post on Surveillance and
Pyschotherapy would sound rather parochial to those on the list not of the
USA. I am writing from Knoxville, Tennessee to be more exact.
>2. <snip> I think that it would be useful to
>know what the management structure which you allude to and to which
>psychotherapists are accountable actually is. Clearly psychotherapists are
>accountable to their clients but also to the achievement of particular
>outcomes, like the standardised or 'normalised' delivery of service, the
>achievement of which you argue is being operationalised through a set of
>techniques of surveillance. What I am interested in - and I wonder if this
>is just another way of analysing and conceptualising the processes which
>you identify - is the extent to which managed care is subjected to a
>process of bureaucratisation and how the achievement of outcomes and the
>techniques of surveillance are understood and justified by a range of
>professionals, beyond the psychotherapists themselves. However i am not
>sure I understand who these are, especially the macro-level customers whom
>you allude to. It seems to me that government departments and insurance
>companies must expect different things from the process of delivering
>psychotherapy and therefore you must make explicit how each customer
>applies their techniques of surveillance and the extent to which all
>parties are in agreement over the aims to be achieved in the practice
>process.
I need to explain what I mean by managed care to those who may not be
familiar with the term. It is an outgrowth of the free enterprise approach
to covering health care costs as this is administered primarily by private
insurance companies and secondarily by government programs, such as medicare
(government sponsored insurance for the elderly) and medicaid (government
sponsored insurance for the disabled and impoverished), in this country.
Managed Care is an outgrowth of the large increase in health expenditures
over the last decades in this country. This increase has placed an
increasing burden on industry, which typically pays for the health care
benefits provided to its employees, as well as government sponsored programs
supported with tax dollars. Managed Care is an ancillary aspect of the
insurance industry which works by inserting a level of review between the
physician and the patient. This review would be for the purpose of
determining the "medical necessity" of what is about to be treated,
accertaining whether the procedure is appropriate for this "necessity", and
fixing what will be considered a standard fee. So if I went to the doctor
with abdominal pain and he ordered an appendectomy, the review process of
managed care would be interested in knowing whether I in fact had an
inflamed appendix and not a case of gas, whether I needed to be in hospital
and for how many days to have the procedure (versus outpatient, "one day",
surgery, for example), and they would set a standard fee that they would pay
for this procedure. Managed care companies are specialized companies that
sell these review processes to insurance companies, self-insured industries
(i.e., companies that use their own monies to be completely at risk for
covering what is insured--they don't buy insurance from another company),
and government programs. My prior post focuses particularly on the even
more specialized behavioral health managed care companies. Mental health
benefits are typically "carved out" from the rest of an insurance plan and
administered by these specialized managed care companies.
Thus, a managed care company's customer is, for example, a large
self-insured business or company, let's say IBM. A managed care company
might say to IBM, "Your health care costs have been climbing 10 percent a
year. You pay us what you paid last year for health care costs, and we'll
contain expenditures enough to cover our costs, our profit, and the actual
health care expenditures. You needn't worry about these cost going up like
they have in the past." The product that they deliver is a service. It is
a savings on health care expenditures, but it is achieved by way of the
machinery of managed care that I describe in my prior post. You are exactly
right to describe this as a process of bureaucratisation, and I'm sure that
there are similiarities to be drawn between managed care and any other form
of regulated health care. It doesn't really matter who the customer is (IBM,
Aetna (an insurance company), or the state of Tennessee). The service
product, consisting of their review apparatus, remains pretty much the same.
The main difference would be who the individual providers are that are
fitted to this arrangement, depending on the customer's geographical
location, for example.
>3. so could we argue that psychotherapists in fact represent a contested
>space and to what extent is the attempt by various parties to
>re-appropriate the process of delivering psychotherapy having a normalising
>effect beyond psychotherapists, ie on the clients themselves - a clear case
>of diffuse and dispersed power.
>I could say more, Im just thinking out loud so to speak! so Ill stop. I
>hope this is useful.
I am particularly interested in the application of managed care to
psychotherapy (in addition to my being a psychologist), because it seems to
push to its limit the conceptualization of psychotherapy as a medical
procedure based upon science. Again, you are exactly right. Insofar as the
practice of pychotherapy becomes standardized by making it transparent to
the normalizing gaze of managed care, wouldn't the therapist have to treat
the patient in the same objectifying manner? How would this managed care
sanctioned psychotherapy differ from psychotherapy paid for out of pocket by
an individual.
My interest in these issues go beyond a political agenda. Although I am
cetain that managed care and psychotherapy are incompatable, if we mean by
psychotherapy anything more than giving advice, the real issue for me is
that managed care forces psychotherapists to evaluate their understanding of
what psychotherapy is and how it works. It is trying to articulate my
perception of the incompatability between managed care and psychotherapy
that interests me.
>Emmanuelle
>
>Emmanuelle Tulle-Winton
>Department of Social Sciences
>Glasgow Caledonian University
>Glasgow G4 0BA
>Scotland
>Tel: 0141 331 3330
>Fax: 0141 331 3439
>
Thanks for your asking your questions. I realize now that I overlooked too
much by simply posting what I had written as I did.
John Sproule
>John
>I read your piece with interest. However it has left me confused and I
>think it would be good if you could clarify a few points:
>1. firstly a very daft question about context: where are you? managed care
>is not something i recognise in a british context. Is it similar to care
>management?
Emmanuelle,
My apologies for not taking into account that my post on Surveillance and
Pyschotherapy would sound rather parochial to those on the list not of the
USA. I am writing from Knoxville, Tennessee to be more exact.
>2. <snip> I think that it would be useful to
>know what the management structure which you allude to and to which
>psychotherapists are accountable actually is. Clearly psychotherapists are
>accountable to their clients but also to the achievement of particular
>outcomes, like the standardised or 'normalised' delivery of service, the
>achievement of which you argue is being operationalised through a set of
>techniques of surveillance. What I am interested in - and I wonder if this
>is just another way of analysing and conceptualising the processes which
>you identify - is the extent to which managed care is subjected to a
>process of bureaucratisation and how the achievement of outcomes and the
>techniques of surveillance are understood and justified by a range of
>professionals, beyond the psychotherapists themselves. However i am not
>sure I understand who these are, especially the macro-level customers whom
>you allude to. It seems to me that government departments and insurance
>companies must expect different things from the process of delivering
>psychotherapy and therefore you must make explicit how each customer
>applies their techniques of surveillance and the extent to which all
>parties are in agreement over the aims to be achieved in the practice
>process.
I need to explain what I mean by managed care to those who may not be
familiar with the term. It is an outgrowth of the free enterprise approach
to covering health care costs as this is administered primarily by private
insurance companies and secondarily by government programs, such as medicare
(government sponsored insurance for the elderly) and medicaid (government
sponsored insurance for the disabled and impoverished), in this country.
Managed Care is an outgrowth of the large increase in health expenditures
over the last decades in this country. This increase has placed an
increasing burden on industry, which typically pays for the health care
benefits provided to its employees, as well as government sponsored programs
supported with tax dollars. Managed Care is an ancillary aspect of the
insurance industry which works by inserting a level of review between the
physician and the patient. This review would be for the purpose of
determining the "medical necessity" of what is about to be treated,
accertaining whether the procedure is appropriate for this "necessity", and
fixing what will be considered a standard fee. So if I went to the doctor
with abdominal pain and he ordered an appendectomy, the review process of
managed care would be interested in knowing whether I in fact had an
inflamed appendix and not a case of gas, whether I needed to be in hospital
and for how many days to have the procedure (versus outpatient, "one day",
surgery, for example), and they would set a standard fee that they would pay
for this procedure. Managed care companies are specialized companies that
sell these review processes to insurance companies, self-insured industries
(i.e., companies that use their own monies to be completely at risk for
covering what is insured--they don't buy insurance from another company),
and government programs. My prior post focuses particularly on the even
more specialized behavioral health managed care companies. Mental health
benefits are typically "carved out" from the rest of an insurance plan and
administered by these specialized managed care companies.
Thus, a managed care company's customer is, for example, a large
self-insured business or company, let's say IBM. A managed care company
might say to IBM, "Your health care costs have been climbing 10 percent a
year. You pay us what you paid last year for health care costs, and we'll
contain expenditures enough to cover our costs, our profit, and the actual
health care expenditures. You needn't worry about these cost going up like
they have in the past." The product that they deliver is a service. It is
a savings on health care expenditures, but it is achieved by way of the
machinery of managed care that I describe in my prior post. You are exactly
right to describe this as a process of bureaucratisation, and I'm sure that
there are similiarities to be drawn between managed care and any other form
of regulated health care. It doesn't really matter who the customer is (IBM,
Aetna (an insurance company), or the state of Tennessee). The service
product, consisting of their review apparatus, remains pretty much the same.
The main difference would be who the individual providers are that are
fitted to this arrangement, depending on the customer's geographical
location, for example.
>3. so could we argue that psychotherapists in fact represent a contested
>space and to what extent is the attempt by various parties to
>re-appropriate the process of delivering psychotherapy having a normalising
>effect beyond psychotherapists, ie on the clients themselves - a clear case
>of diffuse and dispersed power.
>I could say more, Im just thinking out loud so to speak! so Ill stop. I
>hope this is useful.
I am particularly interested in the application of managed care to
psychotherapy (in addition to my being a psychologist), because it seems to
push to its limit the conceptualization of psychotherapy as a medical
procedure based upon science. Again, you are exactly right. Insofar as the
practice of pychotherapy becomes standardized by making it transparent to
the normalizing gaze of managed care, wouldn't the therapist have to treat
the patient in the same objectifying manner? How would this managed care
sanctioned psychotherapy differ from psychotherapy paid for out of pocket by
an individual.
My interest in these issues go beyond a political agenda. Although I am
cetain that managed care and psychotherapy are incompatable, if we mean by
psychotherapy anything more than giving advice, the real issue for me is
that managed care forces psychotherapists to evaluate their understanding of
what psychotherapy is and how it works. It is trying to articulate my
perception of the incompatability between managed care and psychotherapy
that interests me.
>Emmanuelle
>
>Emmanuelle Tulle-Winton
>Department of Social Sciences
>Glasgow Caledonian University
>Glasgow G4 0BA
>Scotland
>Tel: 0141 331 3330
>Fax: 0141 331 3439
>
Thanks for your asking your questions. I realize now that I overlooked too
much by simply posting what I had written as I did.
John Sproule