How Managed Care Discriminates Against Women

by Judith Antrobus, PhD

A number of years ago when I was still engaged with health maintenance organizations (HMOs), I experienced the anxieties that everyone feels. I dreaded the calls I had to make to request additional sessions and feared I wouldn’t be able to cough up the ‘right’ answers. At the same time, of course, I had no respect for the ‘voice’ who was telling me how, and for how long I was to treat my patients. Over time, my fears diminished and my anger increased. I began a process of dealing with these people, a process that evolved slowly and was different from the attitudes I had previously felt. The process turned out to be successful – I always received the extra sessions I requested.

Backing up a bit, the turning point was a conversation with a woman from an HMO who called to send me a referral. She described a young woman who had been sexually abused by her father from about the age of eight through fourteen. Apparently, the HMO worker had heard that I specialized in ‘women’s issues” and thought I would be an appropriate therapist for this patient. I asked how many sessions I would be given. “Six,” she said, “but of course you can request more.” I was silent for a moment. Then I said, “If you can find a psychotherapist in New York who will see this woman for six sessions, let me know. In the meantime, how about six years?”

Shortly after, I quit all the HMOs. I’ve never looked back. I’ll describe in more detail my particular situation and how I have survived without managed care later in this article. But first I want to describe the way I handle a call to an HMO today.

One of my current patients has a health insurance plan which involves an HMO. Now and then, even though I am “out of network,” I have to make that same call to request extra sessions. This is how I handled the latest “clinical interview.”

As soon as the “worker” asked about my approach to this patient’s problems, I said I used feminist therapy techniques, and then, responding to the silence at the other end of the phone, I launched into a long and wildly over-simplified account of what that means. I stressed “context” and said that I was interested in gender differences in context. By and large, I explained, women and men live in different worlds and face different problems: women have babies and the care of children is primarily women’s responsibility, and, despite rhetoric from some contemporary anti-feminists, cultural attitudes still place women in a secondary position. As I spoke, the worker became interested. I elaborated on gender differences in approaches to psychotherapy, in diagnoses, in the incidence of various mental and emotional disturbances, and in the manner in which psychotherapy is used by women and men.

Occasionally the worker interrupted to ask a question, one that was clearly on her list. “Medical necessity?” she asked. That one really got to me. I assured her that the term was meaningless since we were talking about psychological stressors, not medical ones, and, furthermore, the HMO had never defined medical necessity. I discussed the ‘male medical model’ which has been elaborated by T. M. Luhrmann in her book Of Two Minds: The Growing Disorder in American Psychiatry, (Knopf, New York, 2000) which I have just reviewed for The Women’s Review of Books. According to Luhrmann, the male medical model, as it is practiced in hospitals today, is a biological (drug therapy) model, with severely limited interest in psychotherapy; since patients today are usually discharged within a week or less, there’s no time to get involved in psychotherapy. To apply this approach to outpatient psychotherapy is clearly a disaster, just as it is with an inpatient population.

I continued to elaborate on gender differences: more women than men seek out psychotherapy and women continue in treatment longer than most men do. * Women, in contrast to men, do not consider being in therapy a “one down” position but rather an opportunity to grow and improve their own lives and that of those around them, as well as to solve serious emotional problems. As a matter of fact, I said, I can and have “treated” the entire family through the woman who is willing to be in therapy. Psychotherapy is something women need and use well. In medicine, sex differences are being studied at long last and differences are emerging, e.g., in response to medications. Yet in psychotherapy, where gender as well as sex differences have been demonstrated for decades, women and men are treated alike by HMOs: six sessions and you’re out. Thus, in addition to all the other grievances I had against HMOs, here was another significant failing: HMOs clearly discriminate against women. Surely, the worker didn’t want to be put in the position of discriminating against a class of people.

One point of the above discussion is that I took control of the interview. I did not answer questions that made no sense to me. I was not afraid of the “clinical worker,” but rather tried to interest and educate her. I spoke almost non-stop but was not rude. Actually, I was rather friendly, on the assumption that, of course, I knew what I was talking about, and, of course, she would agree with me. I also gave her an “out” by declaring that I would continue to see this patient as long as she needed me, whether or not her company paid for the sessions. (I also increased my fee to $120 per session–which is lower than my usual fee these days – after I figured out that the HMO pays half no matter what I bill!) The fact is I have been seeing this patient for about five years, and all of her sessions have been covered.

I appreciate that not everyone who is a practicing psychotherapist is in a similarly independent position. I think age works in my favor. I have been around so long that I receive referrals from patients I saw 30 years ago. And my patients are also older than when I first began a private practice; thus, they are further along in their careers and are earning substantial amounts of money so that they can afford a very high fee. Also, they do not go through HMOs - money is not an object but privacy is. In addition, some of my former patients return now and again for a few months. Many of them have achieved extraordinary success. I like to think that the work they did with me in those early years played a part, but it could be I’m just lucky.

Whatever the reasons, I hope that there are some ideas in this brief article that will be helpful in dealing with, i.e., educating, HMO workers. If you are seen as someone to reckon with, the HMO worker should figure out that it is not worth the fight to deny your request for additional sessions, in which case she would be right.

*Statistics on the incidence of various mental disorders in women and men are available; for example, twice as many women as men are diagnosed with clinical depression. But statistics on the proportion of women vs. men who seek out psychotherapy and the duration of time spent in treatment are very hard to come by. No agency or institution seems to have compiled this information. Nevertheless, virtually every therapist I’ve asked over the past ten years has replied that, yes, of course, most of their patients are women, and, yes, most women tend to stay in therapy longer than men. If anyone has statistics on this issue, I’d be most grateful for the reference. Alternatively, I will probably draw up a brief questionnaire and send it out to various list-serves and see if I can obtain the data myself.

Judith Antrobus, Ph.D. is a Clinical Psychologist in New York City where she has a private practice in feminist psychotherapy.  She is the founder of the Division of Women’s Issue of the New York State Psychological Association, and is the recipient of the Margaret Floy Washburn Award for outstanding contributions in the field of psychology.

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