Expanded Benefits Sure to Bring Closer Monitoring by Insurers : Mental Health: The trade-off for increased coverage of psychological problems is likely to be a controversial approach called ‘managed care.’

Consumers who see their mental health benefits expanded in the future will also discover that insurers will be intimately involved in the process.

In managed care plans, employers and the insurance companies they hire monitor, evaluate and control how benefits are doled out.

Experts predict it is only through managed care that some states and private companies are taking timid steps to expand benefits.

“I think that self-insured employers will continue to turn to managed care as a way of preserving mental health benefits while controlling costs,” says Dr. Michael Freeman, president of the Institute of Behavioral Healthcare in San Francisco.

Under a managed-care plan, a third party would assess the need for mental health services, direct the patient to a provider, and determine if the treatment is working and how long it should continue.

Some see great benefits to such a system. Others see horrors.

Dr. Alex Rodriguez, of Preferred Health Care of Wilton, Conn., the largest U.S. provider of managed mental health care services, says a well-managed plan would provide widespread, high-quality services while holding costs down.

“There is very telling evidence that mental health benefits are a good buy in a system that is adequately staffed and where there is a high quality,” he says.

In private, indemnity plans, Rodriguez says, costs become exaggerated because there is no third party, or “gatekeeper,” to monitor effectiveness and halt excessive use of services. “In a managed-care system, that doesn’t occur.”

But others worry that the gatekeepers will lack compassion and expertise.

“The problem we see is with the gatekeeper, the person who is answering the calls on the 800 number who asks you to describe your symptoms over the phone and then they will refer you to someone in the network,” says Debbi Honorof of the National Foundation for Depressive Illness.

She worries that too many patients will be directed to social workers or psychologists when they should be getting more expensive psychiatric care.

Other critics fear insurers will rely on quick fixes through the use of medication while being stingy about long-term talk therapy.

Because the concept of managed mental health care is relatively new, there is great variability in quality and in how employers apply the plans, says Rodriguez.

“There are irresponsible managed-care programs,” he says. “There are organizations that routinely ration care, particularly for substance abuse programs.”

Therapists are among those most concerned about what is happening in mental health coverage.

One repercussion from mental health-care reform might be a decline in the fees charged by therapists as more restrictions are placed on the length of treatment and therapists compete for patients, says Richard Van Horn, chief executive officer of the Mental Health Assn. of Los Angeles.

But psychologists, psychiatrists, family counselors and social workers have also expressed fears that the third-party gatekeeper will be an intrusion in therapy. Can confidentiality be maintained? Will therapy be abruptly terminated? Will someone decide it’s not working? How will they gauge whether it’s working?

Mental health insurers and employers are trying to resolve those questions by setting up studies and scientifically based tools to assess whether a treatment works, Honorof says.

“What is happening now is that employers are looking for hard data to justify that this is the way to go,” she says. “If an employer can see a treatment is working to help an employee get better, that is what should get paid for.”

It’s not difficult to determine whether someone with anxiety, depression, addictions or scores of other mental health disorders are getting better under treatment, Rodriguez says. “There are some very sensitive and reliable ways to measure the effectiveness of substance abuse and mental health care. Most of these fears are unfounded.”

But experts contend that many decisions on what to cover will not be easy. It’s highly unlikely, for example, that long-term psychotherapy will be covered under most plans unless a much higher co-payment is assigned to the patient. It’s unclear how chronic mental health disorders--which are common--would be handled by insurers.

Says Honorof: “I think the mental health community, within itself, has to come to some sort of agreement on what should be covered. There is not going to be money to pay for everything.”