The Care in Managed Care

Posted by James Driver, With 0 Comments, Category: managed care, Tags: ,

In one week’s time, Relationships Aotearoa will close due to a funding shortfall.  3 years ago, the country’s only 24/7 sexual abuse support line, HELP, nearly closed for the same reason.  In a couple of month’s time, the Problem Gambling Foundation will hear the results from the court ruling that will determine whether they will keep their contracts, or whether they will be forced to close as well.  These situations arise out of our current culture of ‘managed care’, whereby healthcare decisions are largely made on the basis of finance by administrators with little or no healthcare training.  On the face of it, ‘managed care’ should imply both management and care, but right now we seem to be getting a great deal of the former and far too little of the latter.  As my local NZAP (New Zealand Association of Psychotherapist’s) branch stated in their press release about the closure: “Counselling and psychotherapy are not commodities to be negotiated to the lowest bidder, they are a specialist health service that values and respects peoples need for an ongoing private, trusting relationship to work through emotional health needs.”

Of course, with limited resources it’s important that the care we provide is cost-effective.  In the case of Relationships Aotearoa, they have received no funding adjustments for inflation in seven years.  With average inflation sitting around 2.7% since 2000, this means that their funding in real terms has decreased by about 19% over the last seven years – in other words, they’ve been trying to do the same work with 19% less resources.  Or possibly more work.

I don’t work for Relationships Aotearoa so I don’t know about their internal processes, but I do work and have previously worked for a number of other third sector counselling providers and my experience there has been consistent – that over time, reporting and administrative requirements increase in order to retain the same contracts.  New measures get introduced, new note-taking procedures become requirements, and clinicians end up spending less and less time actually with clients and more time at their desks recording data for external funders.  At times, clinicians become perversely incentivised to do their jobs less well or to alter the way they work in order to meet funder requirements rather than because it makes clinical sense.  Clinicians become burnt out, leading to the very high rate of turnover in mental health services, and as always it is the client who suffers.

I’m not inherently opposed to reporting on outcomes – after all, some of this data could be used to improve services.  The problem is that 99% of the time it isn’t.  Having worked as a strategy consultant, I’ve seen the other side of this picture, which is that the vast majority of reported data gets shelved or added to some database never to see the light of day.  At best, it gets included in some report that a handful of people read and which they may use in some abstract way to inform their decision making (or more likely, which they use to support a view they already held).  Very rarely, if ever, are the data used in a meaningful way to make changes to services such that clinicians or clients actually benefit from the changes.

Then there’s the management within the organisations themselves.  Reports from both the US and UK have shown that when there has been an increase in funding within healthcare, that funding has primarily been used to hire administrators rather than more clinical staff.  In the US, 95% of new hires in healthcare have been in administrative roles according to a Harvard Business Review blogger.  I don’t have New Zealand data on the topic, but my experience suggests that the same would be true here.  In general, there is a trend of more management, more reporting, and fewer clinical staff who typically have less autonomy than previously.

So that’s the management side of managed care.  And what about the care?  As NZAP has pointed out, and as anyone who’s had longer term therapy or counselling will know, the therapeutic relationship is not something that can be immediately replaced by another provider.  It takes some people many visits to develop enough trust to talk about let alone explore painful and difficult feelings and experiences, particularly if those experiences have caused shame or embarrassment in the past.  Treating clinicians and providers as interchangeable misses this important truth, and could in some cases set back weeks or months of hard work on the part of clients and clinicians.

Then there are the skills that clinicians possess.  Again, as anyone who has been to more than one or two counsellors or therapists will know, there are good clinicians and bad ones.  Good clinical training is rigorous, time consuming and expensive.  Working in different contexts and with different groups requires specialist skills.  In the case of Relationships Aotearoa, very few other agencies retain staff trained to the same degree in working with families and family dynamics, and if these staff cannot find new jobs then there will be a substantial loss of this specialist skill set.  If we continue down this path of contracting to the lowest bidder, then the predictable outcome is that we will have the lowest quality service with staff who are minimally trained to deal with some of the most complex and challenging circumstances.  Relationships Aotearoa staff have been routinely dealing with individuals and families who have experienced intergenerational dysfunction, abuse, substance problems and deprivation.  Who else will be equipped to support these clients with the same level of understanding?

This isn’t just a problem in mental health, this is a problem with healthcare in general.  The last two decades have seen a shift away from a position where clinicians are trusted to make decisions about what are necessary interventions and those that would be ‘nice to have’ to one where it is assumed that administrators are needed to keep clinicians in check, to limit their availability and to ration healthcare.  A recent article in The Independent illustrates the cost that this has for GP services, and similar problems arise for counsellors and therapists.  It is a sad day when this trend leads to the loss of yet another valuable and irreplaceable service, and I hope that our government will start to recognise the cost – both financial and social – of continuing down our current path.