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Unlikely Bedfellows: The integrity of diagnosis and the PPACA

By Dr. Julia Frank

As a psychiatrist who must apply diagnostic criteria based on clinical history, without benefit of objective tests, I often feel like someone riding in the basket of an untethered hot air balloon. While the DSM shows me the contours of the landscape, I cannot pull in closer to resolve uncertainty: Is that a cluster of cows down there, or a hayrick? Does this patient have simple sadness or bipolar depression?

A patient with ambiguous symptoms—a woman who describes “mood swings” but denies they last long or are associated with a disruption of sleep, a man who says “I hear voices” but denies they disrupt his ability to work—poses problems of both  validity and consequences. Many of the conditions I diagnose are chronic, by definition. If I record my suspicion that this woman has a form of bipolar disorder, or this man is in the prodromal phase of schizophrenia, it can prevent the patient from obtaining future insurance coverage because of a pre-existing condition.  In my effort to do no harm, I may under diagnose serious conditions, or use treatments that are not strictly justified by the label I apply in the chart or on the patient’s bill.

My colleagues in other fields face similar problems. The under diagnosis and undertreatment of depression, anxiety disorders and substance abuse in primary care is a persistent, well-documented and discouraging fact of medical care (1), especially in the US. For the general physician, the documentation of a pre-existing condition may be only one of many internal barriers to applying a diagnosis with prejudicial connotations. It is, however, a reflection of a more common underlying problem: stigma against anyone who has a chronic disease, stigma intensified if the condition is psychiatric. Insurance discrimination against pre-existing conditions and “behavioral health carve outs” are forms of institutionalized stigma that compromise care across the board.

In interpreting the PPACA, HHS issued regulations specifying which preventive medical services insurance must cover without patient “cost sharing” (aka co-pays). Depression screening is included, for both men and women (though substance abuse screening, unfortunately, is not) (2). Without fanfare, a psychiatric procedure now ranks with such well accepted activities as screening for gestational diabetes, childhood immunizations, PAP smears and smoking cessation counseling. In addition, the PPACA requires parity for the coverage of behavioral health services in essential benefits packages (3).  A clinician who uncovers a psychiatric disorder will now know that the patient’s insurance plan is obligated to cover a mental health referral. How real and usable that coverage is remains an unsolved problem, but at least it is there on paper.


Mental health screening requires asking the right questions and taking the time to deal with the answers.  Removing barriers to this process helps doctors communicate openly with patients and fosters trust, improving both diagnostic integrity and the outcome of care.


Conservative critics of health care reform explicitly seek to undermine open communication between doctors and patients, by attacking the effort to support discussions of end of life care, for example, or by allowing some medical institutions to forbid their staff to discuss contraception or abortion.  For a psychiatrist whose professional integrity and ability to make sound diagnoses depends on patients’ willingness to disclose sensitive information, any effort to facilitate such openness, towards me or some other health care professional, is a major step forward. More widespread screening will provide more reliable information about what kinds of mental health problems patients have in non psychiatric settings, how much care they need or don’t need, and what the impact of treatment will be on the bottom lines of both patient suffering and health care costs. I will someday be able to drop an anchor from my floating basket and clearly see the ground below.


1 Wittchen,HU, Muhlig S, Beesdo, K Mental Disorders in Primary Care Dialogues Clin Neurosci, 2003 Jun ;5(2):115-28


 2 Sommers, BD and Wilson,L, Fifty Four Million Additional Americans are Receiving Preventive Services Coverage without Cost-Sharing under the Affordable Care Act


3  Moving beyond Parity — Mental Health and Addiction Care under the ACA

Colleen L. Barry, Ph.D., and Haiden A. Huskamp, Ph.D.

N Engl J Med 2011; 365:973-975September 15, 2011

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