High demand for health services and limited access paves a troubled path
By Joan Trossman Bien 01/23/2014
Now that the deadline has come for the Affordable Care Act’s requirement that insurance cover mental health just as it covers physical health, you might think that mental health treatment is readily available.
You also might be wrong. During the past few years, there has been a major shift in how psychiatrists and mental health therapists operate financially. Also, there are now fewer psychiatrists, and their role in talk therapy has been sharply curtailed. The amount of funding and the number of beds available for residential mental health treatment has been drastically cut for the entire state. More young people are displaying symptoms of attention deficit disorders. A congressional bill that would fund essential mental health services for veterans, inmates, police training, and other groups was recently stopped by two Republican senators who say they prefer that these services be provided by states and not by the federal government.
If you think that mental illness is the problem of a small number of people, you should know that, according to the National Institute of Mental Health (NIMH), it is estimated that more than one quarter of Americans age 18 and older suffer from a diagnosable mental illness at some point during any given year. Mental disorders are the leading cause of disability in the U.S. and in Canada. Almost half of those with severe mental illness, 45 percent, suffer from two severe illnesses, “with severity strongly related to comorbidity.” The average age of severe mental illness onset is the early 30s.
Insurance can be a barrier
Additionally, insurance has become anathema to many in the mental health community, with barely more than half of the therapists accepting either private insurance or Medicare for payment. If they do accept insurance, the payment is far less than if the patient pays cash at the going rate. Sometimes, the payment is two-thirds less than a cash payment.
Dr. Kerry O’Reilly is the director of Beachside Therapy in Ventura, a new mental health umbrella organization that has been designed to put the patient front and center. She said it isn’t that the therapists are unwilling to reduce their rates; it is the uncertainty that is created by the system.
Dr. Kerry O’Reilly
“The amount paid to the therapist is determined by the insurance program,” O’Reilly said. “They have different rates of reimbursement. If the patient or the therapist tries to find out what that rate of reimbursement is, they tell you that they don’t know and until you file the claim they can’t tell you. It can be as low now as $50. That is why so many therapists simply cannot afford to be part of an insurance panel.”
So who is covered under the new ACA rules for mental health? O’Reilly said the rules cover specific diagnoses.
“Although there are rules now that require insurance companies to offer mental health treatment in the same manner as medical care, there are only five diagnoses that fall under the parity law. They are severe anxiety disorder, major depressive disorder, schizophrenia, bipolar disorder and anorexia nervosa. That does not include any other eating disorders.”
The plan you choose ultimately determines the quality of mental health treatment that is covered.
“There is no standard; all of the plans are different from each other and within the insurance plan,” O’Reilly said. “In the big picture, treatment is geared toward whatever plan you sign up for and all the doctrines and rules that are within that plan. You really have to read what is covered.”
There is a shortage of psychiatrists who will accept insurance and there is nothing in the Affordable Care Act that requires any doctor to accept insurance, though Beachside Therapy does do so. According to a recent study conducted by Cornell Medical College and published in the Journal of the American Medical Association, 53 percent of psychiatrists accept private insurance and 54.8 percent of psychiatrists refused to accept Medicare.
That leaves a lot of patients who need mental health treatment, some desperately, unable to obtain it in a timely way.
“Generally, they can have a six-week to three-month waiting list,” O’Reilly said. “About a third of the psychiatrists were not even taking new patients.”
Medical doctors have not followed the exodus of psychiatrists from any form of insurance. The study noted that although only slightly more than half of psychiatrists accepted insurance between 2009 and 2010, 89 percent of all other physicians accepted insurance and most physicians accepted Medicare.
Cutbacks create dire situations
Young people are often considered to be less in need of medical treatment. Yet they face difficulties when pursuing mental health treatment.
The number of young people needing mental health treatment is significant. About one in five teenage boys has ADHD (attention-deficit hyperactivity disorder) along with about one in 11 high school girls, according to the Centers for Disease Control. The number of medical visits with mental disorders as the primary diagnosis: 63.3 million. Some 1.5 million patients at the point of discharge had psychoses as the first-listed diagnosis. And 12.4 people out of every 100,000 of the general population commit suicide, according to statistics from the National Institute of Mental Health.
California has slashed the number of beds for inpatient treatment. The state has been on a binge of eliminating those beds, removing some 4,000 beds since 1998, leaving many areas of the state without a single inpatient hospital bed. This action of pulling so many beds has left the entire state with only 100 slots for children in emergency situations. This lack of facilities affects paramedics who must travel great distances to find beds for patients as well as affecting law enforcement officers who must accompany the paramedics if patients are potentially dangerous.
This is the result of years of political turmoil and budget cuts. But even if the funding were to be restored, things have changed in how treatment is gauged and paid for.
Meloney Roy, director of the Ventura County Department of Behavioral Health, said the sickest patients are the first to get treatment.
“They have to have an impairment in functioning,” Roy said. “They are unable to work, unable to go to school, unable to maintain relationships, they are homeless.”
Treatment is not just about medications, although that is usually the front line of treatment because primary care physicians often handle the initial diagnosis and they are comfortable with prescription medications. But those doctors are not trained in therapy.
“Sometimes medication only is not the right treatment core, not the right option,” Roy said. “Sometimes, in fact, it is even better to try therapy and other interventions before trying medication. That applies particularly for kids.”
Roy said the older model of entering psychotherapy with an eye toward long-term treatment no longer exists.
“The wisdom is catch things early, intervene early, resolve the issues rather than let them fester,” Roy said.
O’Reilly said the general practitioners or family doctors who are usually the first medical professionals to see a patient are uncomfortable with the role of psychologist.
“The general practitioners would much rather send their patients to a psychiatrist because that’s all the psychiatrist does. They specialize in brain chemistry; they don’t specialize in therapy,” he said.
There are two basic types of need that prompt people to seek out talk therapy. First, there are those with a severe mental illness that is in the group of diagnoses that fall under the parity law. Then there are the rest who just need some help navigating the larger roadblocks in life. Normal, healthy people sometimes need professional help to untangle their problems and find solutions that actually work. This usually involves a relatively short period of talk therapy focused on coping skills for that particular person. This type of therapy seems as though it would be easily accessible. But it is not always readily available, and having insurance pay for those services is often unnecessarily complicated.
In fact, the mental health industry has created a de facto bifurcation of treatment: psychiatrists generally do not do talk therapy but instead prescribe psychotropic drugs while therapists of every stripe offer a wide variety of talk therapy options but do not have the authority to prescribe medication.
Why do so many therapists refuse to accept insurance? There are two reasons. The therapist loses a lot of the treatment control and is paid far less than if they had billed outside the insurance structure. Many insurance companies reimburse doctors at a rate comparable to Medicaid; in California that would be Medi-Cal, which is even lower than what the government pays for Medicare.
There are complaints that insurance companies insist on controlling the treatment, despite the fact that their interests are quite different from those of the patients. They impose insurance industry reasons for cutting off treatment before it is complete, or they fail to recognize actual improvement based on the current treatment.
Cash is the only alternative. Unless you can afford to spend $600 or more per month for relatively modest treatment, you should find out the details of your insurance plan.
Nicole Kasabian Evans is the vice president of communications for the California Association of Health Plans and she said the industry is moving toward managed care and away from fee for service. Patients need to understand the differences.
Nicole Kasabian Evans
“The whole concept about managed care, by promising a provider a guaranteed group of patients, the plan can negotiate based on a kind of bulk rate. The concept is to help control health care costs and that’s where the country is headed if you look at the Affordable Care Act. Mental health is new to this concept. Now you are seeing this large group of people come in and use their health care benefits to try to get their mental health care treatment, but it is not as ingrained in the system.”
Evans noted that most physicians work in an office that includes support staff whereas therapists usually are solo practitioners without any employees. She said it will take some time for mental health treatment to adjust to the model of managed care.
Nevertheless, Evans said, patients should make an effort to use their insurance. “People should go through their health plan first by contacting their health provider for recommendations and the list that the plan offers. After deciding on a provider, you have to decide what is more important, financially what you can afford to do, and personally what you prefer to do. You have benefits. Take advantage of those benefits.”
Are the therapists who accept insurance less skilled or less experienced than those who only accept cash?
Evans says the opposite could be true. “With health plans, doctors have to go through a certification process so you actually have a little more protection than if you are on your own. They’ve gone through a screening process before the plan ever contracts with them. So you know if that doctor is in the health plan, they have got the proper credentials.”
It’s all about the political money
California is continuing to struggle with the massive debt that swept state government during the past several years. Gov. Jerry Brown has loosened his grip on some state funding and proposed a new budget. It includes $670 million tagged for expanded Medi-Cal benefits with some of those funds being for mental health and substance use disorder.
That’s good news for people who need the services. But hidden inside those new funds are new payment cuts of 10 percent to the doctors who accept patients with Medi-Cal.
The executive director of the consumer group Health Access, Anthony Wright, said those cuts should be rescinded, especially in light of the $15 billion in cuts over the past several years.
“The level of services for California should not be set at the level of resources available during the worst recession since the Great Depression,” Wright wrote. “There needs to be some balance between frugality and needed investments for the future.”
This month, a congressional bill that would have increased funding for mental health services for inmates was suddenly derailed by two Republican senators, Tom Coburn of Oklahoma, and Mike Lee of Utah. They said they are preventing a vote on the Justice and Mental Health Collaboration Act because they believe that the states should be solely in charge of mental health programs. A 2006 study by the Bureau of Justice and Statistics found that more than half of all inmates are in need of mental health treatment. The bill would also provide military veterans with more access to treatment. According to the Veteran’s Administration, 22 veterans commit suicide daily amidst a common treatment delay of several weeks.
Perhaps the biggest logistical problem with the ACA is convincing enough healthy young people to sign up for insurance. Without a substantial base of young people signing up, there may be no easy way to stabilize this new system.
According to the White House, only 24 percent of those age 18 to 34 years old have enrolled. To make this set-up work, however, the target goal hovers around 38 percent.
Government officials as well as insurance officials said they believe that by the next deadline in March, many more young people will have decided to avoid the penalty and sign up. One official at Kaiser Family Foundation said he thinks enough people will be in the program to avoid a calamity but not enough to fully fund the system. He suggested that underenrollment may cause insurance companies to raise their premiums by about 2.4 percent.
Although there are no specific ceilings on what insurance companies can charge in the ACA, there are strict limits on profit margins and even stricter limits on reasons for rejecting a client. The “pre-existing conditions” that the insurance industry relied on as a way to boost profits and simplify its own patient load is now prohibited by the ACA.
You have probably seen television ads for Covered California but you don’t know who can join. Roy said it depends on your income.
“Covered California is for people at higher income levels. If you don’t qualify for Medicaid, you don’t qualify for Medi-Cal, as it is called in California, then you would go on the exchange and search the exchange for other levels of insurance coverage.”
Roy admitted, “I’ve been deep in the weeds for months. It is confusing for the public.”