By Mickey Skidmore, ACSW

Contrary to popular misconception and misinformation, private pay is affordable and preferable to many people — especially when it comes to the delivery of behavioral/mental health services. Despite the doom-sayers who predicted that managed care is the way of the future and that fee-for-service providers will eventually disappear, “Turning Points” takes the view that at least in the delivery of mental health services, that private fee-for-service maintains many advantages over insurance-based and/or managed care approaches. This “perspective” briefly examines some of the disadvantages of the current trend.

Insurance Companies

In general, insurance companies have been slow and sometimes resistant to providing adequate coverage for behavioral/mental health services. Often, insurance policies will reimburse for acute inpatient psychiatric treatment only, with minimal, inadequate, or no outpatient coverage. Moreover, many are unaware that the standard requirements of most insurance carriers that do reimburse for outpatient treatments include: assessment of mental condition and diagnosis of mental illness as conditions for reimbursement. The “diagnosis” or social label(s) then essentially become part of your permanent insurance and health records [can you say “pre-existing condition!?”]. This is especially alarming when parents seek out mental health services for their children, who in all likelihood will have these social labels follow them throughout their lives. Furthermore, many health care consumers are becoming increasing aware of the compromises associated with advanced technology and risks to their privacy and confidentiality as well. It is simply naive to think that confidentiality is limited to you and your provider if you have authorized an insurance carrier to reimburse for treatment services.

Managed Care

It has been estimated that managed care now provides 80-90% of health care coverage in some areas of the country. Despite this however, it is the subject of great public confusion and distrust. For some, managed care represents access and stability of care; yet for others, limitations and restriction of choice. From a providers standpoint, many health care professionals have voiced concerns over the erosion of clinical judgment in determining the best care to provide. In their zeal to contain costs, managed care companies may have accountants and business managers making clinical decisions. Another disadvantage of managed care in my view is the increasing push to pharmacological solutions (drugs). Managed Care companies are big on prescriptions; they are easy to track and pay for. Furthermore, using general practice physicians as gatekeepers also biases to medical/biological approaches rather than psychological or psychosocial solutions.

Insurance-Based/Managed Care Summary

Many insurance plans who offer behavioral/mental health coverage focus primarily on acute care or crisis psychiatric care provided via inpatient hospitalization. Often, the outpatient coverage to divert costly psychiatric hospitalization is woefully inadequate or unavailable. Managed Care plans stressing brief therapy approaches recognizes the value of addressing problems before they escalate. However, while professing “prevention” and “wellness”, their policies sometimes interfere with or even dictate treatment protocols and clinical decision making — thus making the phrase “Managed Cost” perhaps a more accurate description of this type of delivery system. Moreover, managed care companies generally discourage innovation. Remember, managed care emerged de facto when government sponsored health care reform failed. Managed care programs are simply another vehicle of insurance companies designed to contain the rising cost of health care (while subsequently increasing profits). Both insurance and/or managed care programs compromise the confidentiality between patient and provider. And increasing numbers of people are less than satisfied with plans which contain cost by:

    1. 1)limiting choice of physicians or other health care providers;


    1. 2)declines coverage for an increasing list of medical conditions or procedures; or


    1. 3) utilizes “pre-existing condition” clauses to reduce, limit, or deny claims; and


    increases risks to confidentiality by creating another layer of beauracracy to “manage” the plan.

One of my personal concerns is the growing confusion between managed care’s efforts of time limited therapy and brief therapy in general. Many see brief therapy and managed care as synonymous, which is simply not true. The primary values of brief therapy approaches include:

    1. 1) An emphasis on parsimony, and the least intrusive interventions possible.


    1. 2) A recognition that most change occurs outside therapy.Therapy just sparks the change.


    1. The client’s outside life is more important than therapy.3) Expensive therapy is not always helpful.


    4) Therapy is not timeless, or eternal. This is a drain on resources and time, and the therapist needs to be sensitive to that.

In short, I believe insurance and managed care companies are not paying attention to quality, but to the bottom line. While this may work in the short-term (and yield increasing profits), many are expressing concerns about the long-term.

In contrast, I believe brief therapy is oriented towards quality. Brief therapy approaches are client oriented and oriented towards an immediate beginning to therapy. Clear definitions and understanding of the problem and the solution help. These features in my view offer the best “managed care system”.


Regardless of current trends, “Turning Points” takes the position that there will always be a market where (potential) clients will seek quality professional services, who insist on discretion, privacy, and confidentiality, who do not wish to be labeled or otherwise identified with the “Mental Health System”, and who do not wish to involve insurance companies or managed care programs.

When sufficient numbers of both practitioners and consumers complain, this will eventually engender change. In fact, some have even predicted that managed care companies per se will disappear, with less micro-management, in favor of health care delivery systems favoring more management outcomes on long term averages. Challenge the system where possible and necessary!


1) Cayner, Jay J. “Rights Under Managed Care”, NASW News, February 1997, Vol. 42, No.2.

2) O’Hanlon, William. “The Perils and Possibilities of Brief Therapy in the Era of Managed Care”. 4th Eastern Conference on Ericksonian Hypnosis & Psychotherapy Keynote Address. July 7th, 1995.