John M. Talmadge, M.D.

A Blog Covering Many Topics

60 Minutes: Managed Care & Mental Health

[Note: I am on no insurance company panels and have not been for over 15 years. I have no ties to the managed care industry. This post explains, in part, why I have taken that stance regarding insurance plans.]

CBS and 60 Minutes produced a chilling and dramatic segment on mental health and managed care.

Three years ago, we were reeling from the shock of the murders of 20 first graders and six educators at Sandy Hook Elementary School. Since then, we've learned that the killer suffered profound mental illness. His parents sought treatment but, at least once, their health insurance provider denied payment.

Because of recurring tragedies and an epidemic of suicides, 60 Minutes investigated the battles that parents fight for psychiatric care. CBS found that the vast majority of claims are routine but the insurance industry aggressively reviews the cost of chronic cases. Long-term care is often denied by insurance company doctors who never see the patient. As a result, some seriously ill patients are discharged from hospitals over the objections of psychiatrists who warn that someone may die.

An article in one of the academic journals, Administration Policy and Mental Health, states: "A diverse array of managed care techniques have been introduced into the profession of psychiatry in an effort to alter treatment patterns. One commonly used tool, utilization review, can alter treatment patterns by restricting access to treatment alternatives and providing incentives to practitioners to meet managed care goals. Other managed care tools are the determination of "medical necessity" and the use of triage and treatment guidelines among insured enrollees requesting services. These guidelines serve as selection criteria to help determine not only which members of the insured population receive treatment for mental health care, but also to determine the allocation of enrollees to staff members and to prescribe the starting point for the types of services received. Managed care psychiatrists may find changes not only in their client populations and treatment alternatives, but in many other aspects of their practice."

The 60 Minutes segment focuses on Anthem, an insurance company said to have a 90% denial rate. One of the many lawsuits filed against Anthem is detailed here. Many consumer complaints about Anthem are listed here.

To see this dramatic report from 60 Minutes and CBS News, click here.

Back from Vacation...

Just returned from vacation…and I can tell the difference in strategic attention, motivation, and general well-being. Here is an article from Forbes that explains why.

Not taking vacation time is a bad idea, as it harms productivity and the economy. Those are key findings of a new study released earlier this month.

More than forty percent of American workers who received paid time off did not take all of their allotted time last year, despite the obvious personal benefits, according to “An Assessment of Paid Time Off in the U.S.” commissioned by the U.S. Travel Association, a trade group, and completed by Oxford Economics.

Americans left an average of 3.2 paid time off days unused in 2013, totaling 429 million unused days for U.S. workers.

According to the study, most managers recognize the benefits taking time off from work provide to employees: higher productivity, stronger workplace morale, greater employee retention, and significant health benefits. But nearly 34 percent of employees surveyed indicated that their employer neither encouraged nor discouraged leave, and 17 percent of managers considered employees who take all of their leave to be less dedicated, according to the survey’s findings.

And four in ten American workers said their employer supported time off, but their heavy workload kept them from using their earned days.

“Despite the myriad benefits of taking time off, American workers succumb to various pressures-some self-imposed and some from management-to not take the time off to which they are entitled,” Adam Sacks, president of the Tourism Economics division of Oxford Economics, said in a statement. “Leaving earned days on the table harms, not helps, employers by creating a less productive and less loyal employee.

“Further, it is a misconception that employers are ahead of the game when workers don’t use the time they’ve earned,” he added. “In fact, stockpiled time off creates considerable financial liability for companies and governments when employees ‘cash out’ upon departure.”

The primary research for the study was based on an online survey conducted between September and October 2013. The sample included 971 employees, 700 of whom receive paid time off as part of their benefits package.

Mindfulness and PTSD

Among veterans with PTSD, mindfulness-based stress reduction therapy, compared with present-centered group therapy, resulted in a greater decrease in PTSD symptom severity. The results of the study were modest, but those of us familiar with mindfulness practice are encouraged that we are on the right track. The August 4, 2015 issue of the Journal of the American Medical Association includes an article describing the research. A summary of the article is available here. I discovered the article through a link through Dr. Ian Ellis-Jones and his excellent website devoted to mindfulness practice.

Mindfulness is the intentional, accepting and non-judgemental focus of one's attention on the emotions, thoughts and sensations occurring in the present moment, which can be trained by meditational practices. Although linked to Buddhism and eastern philosophies, many Christians practice mindfulness. It is not a religious practice, nor is it tied to a specific set of religious beliefs. An excellent article on Christianity and mindfulness by Dr. Scott Symington can be found in the Journal of Psychology and Christianity if you click here.

Many psychiatrists and psychologists have moved away from the labels of psychiatry—bearing in mind that diagnosis and traditional treatment are often very helpful—to incorporate mindfulness based practices in our work. Dr. Melissa Polusny from the Minneapolis VA Health Care System, and colleagues randomly assigned 116 veterans with PTSD to nine sessions of either mindfulness-based stress-reduction (MBSR) therapy or present-centered group therapy, which focused on current life problems.

Dr. Ellis-Jones comments on his blog: "The researchers found that during treatment and in the two months following, MBSR therapy improved PTSD symptoms more than did present-centered group therapy. In fact, those who had MBSR experienced a 49 per cent reduction in PTSD symptoms, compared with a 28 per cent reduction in symptoms among those who had present-centered group therapy."

News Flash! Interesting Articles...

Stages of Change: A Summary

Stages of Change
The Stages of Change, as described in the treatment of alcoholism and other addictions, can be summarized in five parts. The stages are best conceptualized as a cycle. Alcoholics and addicts cycle through the stages, sometimes three or four times, before they complete the cycle without a slip or a relapse. This can be very frustrating for all concerned. But that's the nature of the game.

The Stages of Change Poster Image


"It isn't that we can't see the solution. It's that we can't even see the problem for what it is."

Pre-contemplators usually show up in therapy because of pressures from others: spouses, employers, parents, and courts. They resist change. When their problem comes up, they change the topic of conversation. They place responsibility for their problems on factors such as genetic makeup, addition, family, society, destiny, the police. They explain how little they actually use or drink, and they complain that no one gives them credit when they cut down or even abstain for a short time. They feel hopeless and demoralized, and they are often defensive, angry, and frankly illogical in their thinking.


"I want to stop feeling so stuck. I am tired of all the hassles and of other people intruding in my life."

Contemplators admit that they have a problem and begin to think about solutions. Contemplators struggle to understand their problems, to see its causes, and wonder about possible solutions. Many contemplators have indefinite plans to take action within the next few months. They know where they want to do, and they have ideas (some good, some not so good) about how to get there.

"You know your destination, and maybe even how to get there, but you're not ready to go…yet."

Contemplators tell themselves that someday they are going to change. When contemplators are trying to reach the preparation stage of change, their thinking is clearly marked by two changes.

First, they begin to think more about the future than the past.

The end of contemplation stage is a time of anticipation and anxiety. Relapse is common when individuals reach this stage. They are fearful of what will happen next. Support from family and friends may be exhausted. Even though they have made considerable effort, things often don't get easier — not yet.

Between stage 2 and 3: A decision is made. People conclude that the negatives of their behavior outweigh the positives. They choose to change their behavior. They make a commitment to change. This decision represents an event, not a process.


Most people in the preparation stage are planning to take action and are making the final adjustments before they begin to change their behavior. Usually they have not resolved their ambivalence. A part of them wants to get well, but as the Zen saying puts it, "The mind is a barrel of wild monkeys," and they often go back and forth about taking action.


The time for action does not come on with a blinding flash of light. There is no burning bush. Gradually the person overtly modifies his or her behavior and his or her surroundings. At this point the make the move for which they have been preparing. This is a critical point, and it requires the greatest commitment of time and energy.

Change is visible to others. Others can see the difference in attitude, honesty and commitment. Small changes sometimes matter the most.


Change never ends with a single action. One old saying in Alcoholics Anonymous is that without a strong commitment to maintenance, there will surely be relapse, usually to the pre-contemplation or contemplation stage.


Processes are selected activities that are regularly initiated to effect change. There are nine important ones chosen by therapists as distinct areas of consideration and useful tools in personal transformation.

1. Consciousness-raising: Increasing knowledge about yourself and your problem.

2. Social liberation: Considerations in the external environment that can contribute to helping change, i.e.: no smoking areas, lo-cal menu items, advocacy groups.

3. Emotional arousal: Increased awareness through depth of feeling from natural events or dramatic intervention, psychodrama.

4, Self-reevaluation: A thoughtful and emotional reappraisal of yourself as regards your problem, weighing the pros and cons of changing.

5. Commitment: Acknowledging that you are the only one who can respond, speak and act for yourself.

6. Countering: Planning for and substituting healthy responses for unhealthy ones, action oriented.

7. Environmental control: Restructuring your personal environment so that the probability of a problem-causing event is reduced.

8. Rewards: Affirmation of desirable behavior by self or others as contrasted with and better than any type of punishment for problem behavior.

9. Helping relationships: Receiving care, support and assistance from significant people in your life.

For more information about the stages of change, see the book Changing for Good by James Prochaska.