Several stories in the Los Angeles Times in the week of March 8 - 13 report two trends that are alarming in health care:

1. Doctors are radically changing and even giving up their practices in growing numbers because of the restrictions of managed care insurance programs. Many physicians are leaving California to practice elsewhere because managed care is more developed here than in any other state. Others are giving up managed care contracts and returning to private pay practices on a much smaller scale with lower costs, lower incomes, and fewer patients to serve. Others are leaving the practice of medicine altogether. Insurance restrictions are reducing their incomes, complicating the practice of medicine, and making the profession less meaningful. Patients risk losing out since their physician of choice may no longer be available to them under the terms of their insurance coverage.

2. One managed care program, Med Partners, has been taken over by the state regulatory agency, the Department of Corporations. This program has over 200,000 claims that remain unprocessed due to a shortage of funds. The insurance program, which manages medical practices, has made overpayments to hospitals worth many millions of dollars, and underestimated the costs of providing services to patients. Premiums collected are insufficient to pay claims. The state stepped in to prevent the program from suddenly shutting down, which would leave patients abandoned without care. There is still no clear plan to protect the patients, which number more than one million in California. Other states have already experienced such unexpected shut downs.

These two developments may portend a brewing crisis in health care, which threaten the quality and continuity of care for patients. Legislative leaders are just beginning to realize that action will be needed.

In the March 1999 edition of "Clinical Update", the newletter of the California Society for Clincial Social Work, Judy Rhinestine, reported on the 10th Annual Behavioral Healthcare Tommorrow conference held in Chicago in mid September, 1998. This conference was attended by every important managed mental health care company in the country. The opening night remarks by key CEO's and industry leaders were quite interesting. One of these CEO's is Nick Cummings. He commented that "We have lost the PR war, we are now the political football of the nation; patients are grateful to their doctors, not their third-party payers; when we enraged the doctors it filtered down to the patients who are now calling their congressmen. " He believes there is no more profit to be made from behavioral health care "carve outs". He thinks "all the fat has been taken out of mental health." Another speaker said that the company's "failed to be respectful to the practitioners, and to the patient-therapist relationship…We did micro-managing when we didn't need to. There was an absence of clear ethical guides and industry standards. .. We promised things we couldn't deliver."

Ms. Rhinestine's observations on an ethics seminar at the conference included the fact that the presenters, when prodded, admitted that managed mental health care "has created a considerable number of ethical problems, the biggest , of course, arising when the providers of benefits (either insurers or practitioners) put their interests before the interests of the patient. Confidentiality, continuity of care, lying to patients, providing minimal or substandard care were also understood as significant problems for all who try to make a living under managed care."

The author also reports on a recent article in Harper's (March 1998) in which Ronald Glasser, M.D. has written on "the managed failure of managed care" as a "Ponzi Scheme" or a "pyramid scheme" (organizations which by definition, need to keep expanding to get new money, or they die). He states: " A physician is not by nature a commodities broker, a clinic is not a meat-packing plant, and unless the health care industry quits caring for money instead of people, its chronic pathology almost certainly will be referred to the consulting rooms of government. Not that the politicians will assent to take the case, but let enough people make strong enough complaint, and the therapeutics committees in the country's legislatures might be forced to write a new an not so mean-spirited set of guidelines."

Let's hope that this is good news for patients and therapists alike. We have had enough bad news about mental health care in the last ten years to last a lifetime.