Marilyn came in from the rain but sat at home in her coat for three hours. She was paralyzed with anguish over a sick child who had been hospitalized.
Often overwhelmed by the problems of parenthood, she had seen a psychologist last fall and winter and believed that he could help her cope with this latest crisis. But Marilyn's health maintenance organization won't pay for her to visits to that psychologist any more, and she can't afford to pay the whole bill.
In fact, she is stuck with several hundred dollars' worth of bills for previous visits that may not be paid either, despite many frustrating calls to the HMO.
"It's like beating your head against a wall," said Marilyn, who did not want her real name used. "It's the most horrible thing."
Many users of mental health services are quickly learning that insurance companies and HMOs, under pressure from employers trying to cut costs, more and more are calling the shots. They are trying to reduce spending on therapy for people such as Marilyn, as well as for those seeking help for alcoholism and other drug abuse problems.
For many years, insurers have tried to limit hospital stays, which typically cost between $350 and $700 a day. Now the focus is also on the cost of office visits to psychiatrists, who charge $100 an hour and up, and psychologists, whose fees run to $95 an hour.
Some patients tell of their insurers curtailing benefits, delaying payments for months and leaving them in a stressful limbo, not knowing if coverage will continue.
And doctors and psychologists say that patients are often not getting the type or duration of treatment they need because of HMO rules. Some people, deterred by HMO screening procedures, are not seeking help at all, they say.
"It's a disaster," said Dr. James Bozzuto, a Hartford psychiatrist and assistant clinical professor of psychiatry at the University of Connecticut.
"HMOs are involved in the rape of the mentally ill in a way that hasn't been done since the turn of the century," said Bozzuto, who is under contract with Cigna Healthplan of Connecticut Inc., an HMO.
Michael Kahn, a professor of psychology at University of Hartford who has a private practice, said: "These organizations set up machinery to discourage both the provider and the consumer from getting the quality of service that's needed. Many patients deny (that they have a) problem. If machinery is set up to discourage people, they'll happily fold their tents and go away."
The HMOs and other insurers that offer coverage for prepaid fees say they are cutting out needless spending in the fastest growing segment of employers' health-care costs. They say they are improving the quality of mental care by channeling people into appropriate treatment. They say they are protecting them from overkill and dependency on therapists.
The companies have hired mental health professionals to decide whether people seeking such treatment really need it, who will provide the treatment and for how long. Some have changed their rules on payment to discourage what they regard as unneeded treatment.
Cigna Healthplan this year further restricted the way its members can get such help by narrowing the choice of therapists and tightening control over duration of therapy. Scores of patients had to switch therapists or face paying the whole bill themselves.
Travelers Corp. has introduced in five cities an employer plan that will require employees seeking therapy to be evaluated in person by a representative of the insurer.
Under the Psychiatric Systems Initiative program, Travelers refers people to therapists who are members of its own network. The company avoids using therapists it believes provide treatment when it is not needed, and expects the program to cut employers' costs for mental health care and substance abuse treatment between 5% and 35%.
Aetna Life Insurance Co., one of the first insurers to limit psychiatric hospital stays, last year bought Human Affairs International Inc. to improve its ability to review all types of mental claims.
Constitution Health Network, an HMO, stopped giving members their first 10 mental health sessions free, hoping to discourage unneeded therapy. The HMO wanted to avoid paying for counseling for stress that might be alleviated through changing jobs, exercising or a "change of perspective on the situation," spokeswoman Leslie Wright said.
The HMO now requires members to pay 50% of all mental health visits, up to $40 a visit.
The efforts to curb these costs are being spurred by employers who see group medical coverage costs skyrocketing and decide what benefits they want to offer, said Dr. Richard Kunnes, a psychiatrist and medical director for product management and development at Travelers Corp.
"The whole area of psychiatric care and substance abuse is an explosive area" of group insurance, Kunnes said. "I think most companies are scared to death by the whole problem."
Insurers say that U.S. employers spend up to 30% of their health-care dollars on mental health and substance abuse treatment for employees, compared to 6% five years ago. The industry, however, doesn't keep data on how much insurers are paying out.
While the overall cost of medical claims rose 18.6% for U.S. employers in 1987 and 1988, the cost of substance abuse treatment and other mental care climbed 27%, according to a survey by A. Foster Higgins & Co. in New York.
Many insurers believe that these claims are rising because therapy has become socially acceptable. "Yesterday's stigma is today's red badge of courage," Aetna's public relations material reads. "Now, a generation of baby-boomers willingly seeks professional help for a variety of life's problems."
To curb these costs, most HMOs now offer only the minimum mental health coverage required by state law. Conventional insurance plans may provide more coverage if the employer so desires.
Yet decisions about what treatment is necessary are often subjective, and the penny-pinching by insurers and HMOs may backfire, critics say.
An HMO or insurer should pay at least $5,000 a year for outpatient mental health care to avoid more serious and costly problems later, advises Lafe H. Myers, medical director of mental health services at Aetna Life, which has interests in HMOs nationwide.
In controlling the expenses of general medical claims, insurers and HMOs in the past have applied objective medical criteria, but the definition of mental health is largely subjective, Bozzuto said. "HMOs have learned the game of making believe mental illness doesn't exist."
Cigna, Aetna and others, however, said they use American Psychiatric Assn. criteria in assessing diagnoses to determine how much treatment they will pay for. The companies said that their own mental health professionals often negotiate treatment with the patients' therapists.
Yet many people complain about the way an HMO will authorize a certain number of therapy sessions, and no more, according to the diagnosis.
People build up patterns of behavior and emotions over a lifetime, said one Cigna Healthplan member who was in therapy. "I think it's ridiculous to assume you're going to handle this in two sessions, or nine, or whatever," she said.
Cigna Healthplan has been the most aggressive HMO in efforts to reduce mental health claims. Previously, Cigna had informal arrangements with dozens of psychologists whom it paid to treat members referred by their medical doctors. The HMO dropped that system this year and now has formal contracts with psychological clinics and independent psychologists. Cigna kept its contracts with psychiatrists.
For people whose therapists were dropped, Cigna Healthplan paid for transition sessions so patients could see them a few more times before switching to HMO-sanctioned therapists.
Now, members who feel they need counseling must be screened and referred.