Am J Psychiatry 1991; 148:318-323
Copyright © 1991 by American Psychiatric Association
A psychodynamic perspective on the clinical impact of insurance review
GO Gabbard, T Takahashi, J Davidson, M Bauman-Bork and K Ensroth
C.F. Menninger Memorial Hospital, Topeka, KS 66601-0829.
The rise of managed care and concurrent utilization review has had a
profound impact on the practice of inpatient psychiatry. Little has been
written, however, on the clinical impact of the review process itself. The
actions of insurance reviewers often result in their being incorporated
into the psychopathology of individual patients and into the dynamics of
families and institutional settings. The authors apply psychodynamic
understanding to a series of case examples to illustrate how concurrent
review may promote splitting, impede the patient's ability to separate from
the hospital, and paradoxically reinforce the patient's illness. They also
explore a number of typical responses of treatment staff and families to
the review process. A case vignette demonstrating a sincere effort at
mutual collaboration between payers and providers is also presented. This
spirit of compromise is proposed as the solution that best serves patient
care.
