Sunday, October 12, 2008
When you weren't looking: "Mental parity" becomes law
The TARP is going to be a boon to... psychiatrists!
In the (fiscal) conservative outrage over all the pork stuffed in to the "bailout" bill, I seem to have missed this turd in the punchbowl:
Group health plans soon will have to provide the same coverage for mental disorders as they do for other medical illnesses, under a new benefits parity law.
President Bush last Friday signed the parity legislation as part of a massive financial services bailout bill that Congress approved last week...
The measure, H.R. 1424, will force most health care plans to change their coverage terms. For example, plans no longer will be allowed to limit the number of annual outpatient visits for treatment of mental disorders, while not imposing a comparable limit on the number of outpatient visits for other medical problems. Many plans currently use that approach.
"We are ushering in a new era of health care for those with mental illnesses. No longer will we allow mental health to be treated as a stepchild in the health care system," Sen. Pete Domenici, R-N.M., said in a statement following House passage of the legislation.
While the plan changes would be extensive, the cost impact is expected to be modest. The Congressional Budget Office last year estimated that enactment of a similar bill would boost health insurance premiums by an average of about 0.2% a year.
Group plans impose annual limits on mental health care for a reason. While very few people enjoy going to the doctor and do so only to treat a demonstrable ailment, there are many people who enjoy psychological therapy and will consume much more of it if it is free or very inexpensive to them. I predict that the aforementioned estimated increase in "health insurance premiums" will turn out to be much less than the actual increase in costs to employers. Indeed, if employers actually believed that they could confer this benefit at such a small increase in cost, many of them would have done so without having to be ordered by the federal government.
11 Comments:
By 
, at
Sun Oct 12, 09:02:00 PM:
Tigerhawk,
I think you may underestimate how many persons go to doctors and talk about physical pains as a substitute for talking about the emotional pains that aren't 'legitimate' subjects for medical attention. Surveys of general practitioners have estimated this number to be 30 to 40 percent.
Thus, saved general medical and laboratory expenses may off-set some of the increased psychiatric expenses.
Jim Nicholas
By 
TigerHawk, at
Sun Oct 12, 09:57:00 PM:
Interesting. But if that is true, why haven't insurance company actuaries figured that out? Put differently, I have sat through any number of very learned presentations by insurance experts on how to tweak health benefits to give employees stuff they value and at the same time keep costs under control, and I have never heard this proposal. I suspect that it is tough to model both the savings you suggest and the extent to which mental health utilization would increase if the benefits are capped at the same level as medical benefits.
By , at
Sun Oct 12, 10:05:00 PM:
I once sat in a class where the professor stated (as part of a lecture on how the US needed to spend more on mental issues) that 75% of people suffer from depression.
Being an engineer I naturally raised my hand, and when called on asked "What is depression?" Thinking there must be some sort of metric to measure such things, hence a 75% stat.
I was met with a blank stare, followed by a slightly incorrent answer about "knowing it when you see it".
I'm sure this will have almost no effect on insurance. Yep, none at all.
By Noocyte, at
Sun Oct 12, 10:20:00 PM:
Full disclosure: I am a clinical psychologist, and this legislation would impact directly on my clients and my practice.
That said, I can say that there are two converging threads here. The first was already stated by JimNicholas. A non-trivial number of my referrals come from GPs who see patients whose chronic but diffuse physical complaints defy conventional medical diagnosis and treatment. As work proceeds, it has often emerged that these complaints are at least partly psychogenic, and respond to treatment modalities which address the emotional and lifestyle issues which have previously gone unexamined.
The second thread is essentially the reverse: people whose emotional/psychological concerns are not being addressed will very frequently suffer from an increased vulnerability to more traditional medical ailments via stress, eroded immunological functioning, sleep deprivation (which all by itself leads to a host of problems ranging from reduced resistance to disease, to degraded concentration and thus increased risk of accident and injury). The costs of treating these medical issues after they arise has to be factored into the assessment of investment in psychological services.
I have all-too often had to work with clients whose on-going anxiety about having their sessions curtailed, and/or having to jump through the most arcane administrative hoops to continue their coverage have undermined their ability to devote their full attention to the work of therapy, and/or who are not able to commit fully to the work for fear that they will get to a given level of depth, only to have the rug yanked from under them.
While I do acknowledge that there are practitioners who may abuse their clients' coverage and unethically hyper-extend therapy beyond the useful, I also have had enough personal experience with the cavalier attitude toward mental health services which has been shown by insurance companies to feel that some variant of this idea is long overdue.
My $.02
By Andrewdb, at
Sun Oct 12, 10:47:00 PM:
Forgive me, but I don't know what you mean when you say "treatment modalities which address the emotional and lifestyle issues" - can you give me an example or two?
Part of the problem with the "parity" issue, I think, is that for mental treatments to be effective can take some time, which equals "high" cost, and the insurance company would prefer something that is resolved in 6 visits.
By TigerHawk, at
Sun Oct 12, 10:54:00 PM:
Thank you, Noocyte. All of that makes perfect sense to me. I have two remaining questions. First, your points about the intersection between the psychological and the physical is well-taken, but it seemed to point toward higher utilization. Setting aside the question of whether there ought to be greater utilization, does the 0.2% cost increase strike you as plausible?
Second, the effect of this legislation will be to lower the out-of-pocket cost to patients for mental health therapy. When the price of something goes down, demand for that thing goes up. Do you foresee increasing demand for your services as coverage becomes more available?
By Noocyte, at
Mon Oct 13, 01:05:00 AM:
Andrewdb: Good question. One example which leaps to mind is a young fellow (I specialize in working with adolescents and young adults) who presented with excessive alcohol and marijuana use. In fairly short order, it became apparent that he was "treating" an underlying social anxiety issue with these agents, with only modest success, and at the cost of his academic and occupational functioning, as well as strife and stress within his family (and chronic sleep deprivation to boot). I've been working with him to address some of the tacit assumptions with which he enters social situations (I always have to be "on my game;" "I only need to slip up a little bit and I might as well leave," etc., etc.), as well as making a referral for concurrent Psychiatric care (and prescription of a certain class of anti-depressants which have also shown themselves to be effective for social anxiety). His substance use has begun to throttle back, and he has shown an increasing willingness to take social risks which would have been too scary for him (including participation in class discussion, and asking questions of his professors...which has in turn improved his academic performance). As he continues to gather mastery experiences which disconfirm his perfectionistic expectations and fears, the need for medication (and for me) will drop away, all other things being equal.
The presenting problem is, as often as not, the occasion to drill down to the non-obvious factors which give rise to and act to perpetuate that problem. As I like to say to my more tech-savvy clients (which, given the age group I work with, is most of them!), "The link is not the server." Unfortunately, these oblique relationships among phenomena do not always have time to rise to the surface when only a smattering of sessions can get approved during any given calendar year...especially if you factor in the time it takes for folks to overcome the perfectly natural reluctance to open themselves up to some strange dude in an office!
TigerHawk: I operate out-of-network (in solo practice, and just thinking about the amount of paperwork which being empaneled would entail makes me sleepy. Plus, I take a hard line on confidentiality, so submitting sensitive client data to bean-counters is not something I relish), so I don't know if I can speak to the larger-scale actuarial phenomena underlying that 0.2% figure (it does seem a mite low to me, just off the cuff...but then again, there is the unknown unknown of the savings in terms of other medical services which successful therapy might well offset, not to mention the increased employee productivity which it could enable).
The question of supply and demand is rather a complicated one in this instance, I think. While the availability of more coverage for services will surely lower the threshold at which people will seek services, there will still be the countervailing factors of stigmatization (less than in the past, but still pesky), and the reluctance to confront painful personal matters by making That Call. Most folk will still try everything in their personal and social repertoires before calling on the likes of me (which is fitting and proper, IMHO).
Somewhat less intuitively, there is the possibility that lowered cost will increase demand...but may also decrease perceived value. I have a very small N here, but I have observed at previous gigs that the folks who would come in, pay a small co-pay, and never directly experience the real cost of the services tended to attend more erratically, drop out more precipitately, and generally invest themselves more shallowly than those who would pay out of pocket (even on a sliding scale). When the insurance folks stuck around, I found [or at least felt...which is a whole 'nuther question ;-) ]that I had to work harder to get them on board. The private pay folks tended to put me (and themselves!) through markedly more demanding paces.
I can imagine a scenario in which people whose insurance picks up more of the tab might stick around just long enough to master a few key skills, get past a crisis, and generally achieve noticeable symptom relief. This might be a more intermittent model of intervention, versus the more thoroughgoing personality change which the private pay people in my experience have sought.
It's a very complex matter, which I look forward to watching evolve over time. In general, though, I should point out that I'm not at all crazy about (pardon the expression) the idea of such weighty matters getting snuck in as some kind of porcine pimple on the flank of this behemoth bailout. I would just as soon it'd been handled separately and deliberately and transparently, as it can't help but be seen as sullied by the company of wooden arrows and such!
Waiting is...
By TigerHawk, at
Mon Oct 13, 07:04:00 AM:
Thanks, Noocyte. Excellent contribubtions. Maybe I'm wrong on this one.
By Noocyte, at
Mon Oct 13, 10:21:00 AM:
Thank you, TH...and likewise! Let's see how this shakes out...
By Andrewdb, at
Mon Oct 13, 02:53:00 PM:
Thank you, that is very helpful.
By Donna B., at
Mon Oct 13, 05:37:00 PM:
There's one small group of people that this is going to help tremendously -- longterm survivors of brain injuries.
Their problems are due to a physical injury and it would seem would therefore be medical, and covered as such.
This is true for physical rehabilitation, but not for mental problems. Depression is a very common side effect of a head injury, but insurance pays very little to treat that in a group of people who have far fewer resources to pay out of pocket for the prolonged treatment they need.
Sure, it's a small group that should have been covered anyway, but this is very good news for some.
