Parity laws seek balance for mental health coverage
Legislators look for equality with insurance for physical ailments
From the October ACP Hospitalist, copyright © 2007 by the American College of Physicians
By Jessica Berthold
Hospitalists know what it's like to care for patients with mental illness.
Take William Ford, MD, Cogent Healthcare medical director for the section of hospital medicine at Temple University in Philadelphia. He estimates that 5% to 10% of people who come through Temple's emergency department door have bipolar disorder or schizophrenia. Add those with a history of anxiety or depression, and the figure jumps to well over 50%, he said.
"In many institutions, particularly those like Temple that are in inner-city areas, a large portion of patients have a comorbid mental disease," Dr. Ford said. "They tend to get admitted more often than those without a mental illness."
The issue
Nearly a quarter of hospital stays involve mental illness or substance abuse, the Agency for Healthcare Research and Quality recently reported. Yet a sizable number of patients wouldn't have to be in the hospital at all if their insurance made it easier to get help, said Victor Pinkes, MD, chairman of emergency medicine at Landmark Medical Center in Woonsocket, R.I.
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"Insured patients often have unusually strict mental health treatment limits and high copays. That makes it difficult to access care regularly, so these patients go into crisis and end up in the ED." —Victor Pinkes, MD |
"Insured patients often have unusually strict mental health treatment limits and high copays," Dr. Pinkes said. "That makes it difficult to access care regularly, so these patients go into crisis and end up in the ED."
Almost 90% of group health plans impose stricter financial and treatment limits on mental health and addiction care than other medical care, according to a 2002 Government Accountability Office report. A plan that pays 80% of services and covers unlimited outpatient and hospital visits for a medical illness may allow just 30 hospital days and 20 outpatient visits per year for a mental illness, and pay only half of covered services.
The coverage imbalance hasn't gone unnoticed on Capitol Hill, where several bills have been introduced to institute "parity"—insurance benefits for mental illnesses that are equal to those of other physical ailments. Physicians hope that, if passed, the bills will improve care for patients and make it easier for them to do their jobs.
A ripple effect
Distressed patients who wind up in the emergency department aren't just troubling because their mental health may have been neglected, Dr. Pinkes said. They also put a strain on overburdened emergency workers.
Depressed patients are three times as likely as nondepressed patients to be noncompliant with medical treatment regimens for ailments like end-stage renal disease, cancer and rheumatoid arthritis. Photo by Comstock Complete.
"They can be very disruptive to the care of all patients in the ED if they are violent or loud or verbally abusive. They may need to be restrained with chemical or physical restraints. They strain the functioning of the department because they are there for three to four times as long as anybody else," Dr. Pinkes said.
Mentally ill persons may wind up in the hospital, or have a prolonged stay, because they engage in behaviors that lead to medical problems, noted Daniel Brotman, FACP, director of the hospitalist program at Johns Hopkins Hospital in Baltimore.
"Often folks with mental illness go on to have bad health behaviors that give them disease like HIV or hepatitis C. You see a lot of substance abuse issues with the mentally ill," Dr. Brotman said.
A mentally ill person is also less apt to comply with a treatment regimen after he or she has become sick with another medical illness, which can lead to worsening health and repeat hospital stays, said Dr. Ford.
"Once we treat a mentally ill patient in the hospital for a baseline illness, whether it is hypertension, diabetes or cancer, it's unlikely he will follow up with the primary care physician," Dr. Ford said. "I find a good portion of mentally ill patients end up back in the hospital, and their comorbidities are much worse."
Depressed patients are three times as likely as nondepressed patients to be noncompliant with medical treatment regimens for ailments like end-stage renal disease, cancer and rheumatoid arthritis, according to a July 2000 meta-analysis in the Archives of Internal Medicine. Depressed diabetics are also significantly less likely to adhere to medication than diabetics who aren't depressed, according to a March 2005 review in the Journal of Diabetes and Complications.
"A person's health affects his psychology, and his psychology affects his health, in very real ways, and you often need to deal with both at the same time," Dr. Brotman said. "It's a mistake to try to separate physical conditions from mental conditions because they are so often entwined."
Admission barriers
Lack of parity stems from a long-held attitude that mental illness is less serious, and more in a patient's power, than physical illness, experts said. It's apparent in the skepticism internists said they face when trying to get insurers to approve a hospital admission for mental illness.
"There are a lot more hoops to jump through than there are for any other medical thing," said Judith Walsh, FACP, an associate professor of medicine who sees patients at the Women's Health Resource Center at the University of California, San Francisco. "It takes hours and hours of talking to people to make it happen. You constantly have to justify why a patient needs to be admitted instead of treated on an outpatient basis."
Randall A. Scott, MD, a hospitalist and medical director of adult psychiatry at Virginia Baptist Hospital in Lynchburg, agreed that insurance plans tend to emphasize outpatient care for mental illness. Yet inpatient care may be more beneficial for some patients.
"An anxious patient may return to the hospital, or her family doctor, repeatedly. But if you can bring her into the hospital for two to three days, you can coordinate the whole treatment plan—make an accurate diagnosis, educate the patient and outline the proper medicine, psychotherapy and follow-up care," Dr. Scott said. "You could get the patient on the right track for improvement, whereas if she is going from doctor to doctor and ER to ER, she will never get on that track."
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"It's not unusual to see someone who seems to have reasonably good medical coverage be transferred to our [psychiatry] unit, and. . .the insurance nurse says they have a $10,000 lifetime maximum for mental health." —Randall A. Scott, MD |
Neither is a mentally ill patient necessarily home-free once admitted. Though the Mental Health Parity Act of 1996 is supposed to ensure that annual and lifetime dollar limits for mental illness match those for other medical illnesses, there are loopholes to the law, Dr. Scott said.
"It's not unusual to see someone who seems to have reasonably good medical coverage be transferred to our unit, and all of a sudden the insurance review nurse says they have a $10,000 lifetime maximum for mental health," Dr. Scott said.
Indeed, after examining insurance denials from 1998 to 2001, one hospital found that psychiatry had more cases and patient days denied by insurers than did the departments of oncology, neurology and family practice, a study in the July 2004 Journal of Behavioral Health Services & Research found. Further, psychiatric patients were four to eight times as likely as family practice patients to have their care reviewed by insurers, the study found.
Parity bills could help
Forty-six states have laws on mental health benefits, according to the National Conference of State Legislatures, a bipartisan group that provides research for state legislators and their staff. However, state parity laws vary widely in scope and don't cover everyone. An estimated 82 million Americans enrolled in self-insured health plans are exempt from them, according to the National Alliance for the Mentally Ill (NAMI), an advocacy group.
At least four bills in Congress are looking to change the way mental illness is covered by insurance.
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The Medicare Mental Health Modernization Act of 2007 (H.R. 1663), sponsored by Rep. Pete Stark, D-Calif., would eliminate Medicare's 190-day lifetime limit on inpatient services at psychiatric hospitals, as well as reduce the 50% copayment for outpatient psychotherapy to the 20% that's charged for most other Part B medical services. The bill would also ensure that more outpatient facilities and services are covered, especially in rural and underserved areas.
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A provision in the Children's Health and Medicare Protection Act (H.R. 3162), co-sponsored by Rep. Stark, would reduce Medicare's 50% copayment for outpatient psychotherapy to 20%, and add more mental health providers to Medicare so services would be more widely available.
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Like a similar bill in the House, Senate Bill 558, sponsored by Senators Pete V. Domenici, R-N.M., and Edward M. Kennedy, D-Mass., seeks parity in terms of inpatient day limits and outpatient visit limits, as well as deductibles, copayments and cost sharing. Also like the House bill, it doesn't mandate that mental illness be covered, only that coverage be equal to other kinds of illness if it exists at all. This bill passed the Senate unanimously on Sept. 18.
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House Bill 1424, sponsored by Reps. Patrick J. Kennedy, D-R.I., and Jim Ramstad, R-Minn., seeks parity in terms of services and out-of-pocket costs but differs from the Senate bill on several points. For example, the Senate bill would let employers decide which diagnoses are covered or excluded, but the House bill says private plans must cover the same conditions that are covered by the health plan with the highest enrollment of federal workers. The House bill (also called the Paul Wellstone Mental Health and Addiction Equity Act) also mandates that group health plans provide an out-of-network benefit for mental health if there is an out-of-network benefit on the medical-surgical side. The Senate bill states that parity must exist only if there are already out-of-network mental health benefits in place.
A federal parity law won't solve every glitch in the mental health care system, said Andrew Sperling, JD, director of federal legislative advocacy at the National Alliance on Mental Illness, an advocacy group. States that already have strong parity laws, like Massachusetts and Maryland, still experience trouble, like reimbursement snags and a shortage of psychiatrists. Such issues run too deep for a single fix, but instituting parity is a step in the right direction, Mr. Sperling said.
"We're not trying to fix every problem in the health insurance system. We're not even trying to mandate that mental health be covered. We're just saying that if you do cover it, you can't discriminate. You have to do things on equal terms," Mr. Sperling said.
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