Access to insurance, YAY!!
Better coverage for substance related conditions, YAY!!
Access to care…?
We have much to cheer in the long awaited final federal regulations covering insurance for mental health and substance abuse care. The final rules declare mental health and substance abuse benefits to be part of the essential benefits package required by the exchanges. The regulations require the benefits to be real, that is, insurance companies may not apply different lifetime limits, pre-authorization requirements, or separate deductibles to mental health services. They also require insurers to maintain adequate networks of providers and to offer out-of-network benefits on the same terms as those offered for general medical care. Moreover, plans must now cover screening for depression and substance misuse/abuse without “cost sharing” (i.e., copayment) on the part of the patient. This provision will specially benefit generalists, who often see depressed or addicted people but cannot bill for identifying a problem and counseling a patient on what should be done about it.
Parity regulations also now clearly apply to partial hospitalization, which the insurance companies must treat the same way they treat other intermediate services (like rehabilitation and short term nursing care). Partial hospital programs provide intensive services to people who are not imminently dangerous, but still ill enough to need more than occasional outpatient visits. Partial hospitals and intensive outpatient programs have the potential to significantly reduce the discouraging (and costly) relapse and re-admission rates that occur when patients achieve remission of illness or abstinence from substance use in a tightly controlled setting, then return abruptly to the environment that induced and maintained their condition in the first place. Anything that helps disentangle the issues of providing care for people because they are ill, rather than controlling people because they might be dangerous, is cause for real celebration.
So why only two cheers? Access to insurance does not, unfortunately, equal access to care. The rules apply only to insurance companies. They do not reverse the trend of states draining mental health resources (inpatient or outpatient) from their budgets. Nor do they establish fee schedules or staffing patterns that would allow mental health professionals to be fairly reimbursed for their work. Currently, rates of reimbursement remain so low that mental health professionals outside of salary based systems like the VA often cannot afford to treat the patients who need them most, including those who have been the most responsible about buying insurance that should cover their care.
Many psychiatric conditions are chronic illnesses that require varying levels of intervention at different points in a person’s life. The draconian restriction of mental health care through intensive case management has been based on a model that that treatment must be time-limited, short term, and applied only to those who are imminently dangerous. Changing the terms of this oversight, though necessary, does not reset our priorities to create a system that provides appropriate care, at appropriate times, for disorders that may require lifetime intervention.
The recent atrocities perpetrated by mentally ill people expose the many weaknesses in our non system of mental health care. I rarely agree with Charles Krauthammer (a psychiatrist turned conservative pundit). He was, however, right on when he noted after the Navy Yard shooting that our ability to provide effective treatment is limited by overly restrictive commitment laws, huge gaps in the continuum of services, and lack of appropriate facilities and resources.
The resources that do exist are tragically mis-allocated. In 2006, 10 times as many mentally ill people were incarcerated than were in publically funded mental hospitals. Governments across the nation spend millions to house the disruptive mentally ill in jails and prisons, then starve the hospitals, clinics, and social programs that might help them resume productive lives. (Thanks to the sequester and the systematic erosion of funding for the agencies that collect this information, more current statistics about this and many other problems are simply unavailable.)
Discriminatory insurance coverage for mental health services is both a cause and an effect of the stigma and confusion that characterize society’s understanding of mental illness. Strengthening the regulations that combat insurance discrimination against the mentally ill (including many alcohol and drug users) is long overdue. Two cheers are certainly warranted. But correcting abuses in current forms of oversight will mean little if the facilities and services that patients need are unavailable, undervalued, and uncoordinated. Only when those problems are addressed, will I climb the pyramid, turn a cartwheel and shake my pom poms with mad enthusiasm.