1 Boring Old Man

Parity Enforcement: A Top Priority

PsychiatricNews

by Paul Summergrad

President of the American Psychiatric Association

December 2014

Many laws can be difficult to enforce effectively, or in some cases, to enforce at all. That’s long been the case with environmental and human-rights laws, often because violations are committed by many and the government’s ability to inspect and monitor is limited. As psychiatrists, we are already keenly aware of the challenges in enforcing the Mental Health Parity and Addiction Equity Act [MHPAEA]. Yet the violations are all too real and are ones our patients and we experience frequently. APA remains committed to ensuring that parity is much more than a symbolic law. President George W. Bush signed parity into law in October 2008. And it was only last year, in November 2013, that the departments of Health and Human Services, Labor, and Treasury jointly issued the final rule implementing parity. Together the law and the regulations make it clear that patients with a mental illness, including a substance use disorder, should no longer be discriminated against by insurers. But how many patients know specifically what a parity violation looks like? How many of us? We know what it feels like. But it takes education and awareness to help patients be able to identify practices that make coverage for mental health treatment more restrictive than for other medical care. Patients who know their rights are better equipped to protect their rights.

That’s why I am pleased to provide you with a new tool to support parity enforcement. It’s a poster, developed by APA, titled “Fair Insurance Coverage: It’s the Law” and can be downloaded here…

No, this post isn’t about insurance. I don’t know anything about that, having practiced "off the grid." If my patients used insurance, I was an "out of network provider" and they did their own filing and collecting. This post is about something else…

When I was a medical house officer in the 1960s, there was a widely used term, "supratentorial". The Tentorium is membrane that supports the Occipital Lobe, separating the Cerebum from the Cerebellum [the Cerebrum being the "thinking" part of the brain]. It was a slang, a code word that patients didn’t understand that sounded medical. So in a bedside presentation, the presenter might say, "or this could be a supratentorial problem" – meaning, "it’s in his head" – meaning, a psychological rather than a physical problem – meaning, "there’s nothing really wrong". There were a lot of dismissive terms around like that for people who had what were then called "neurotic" symptoms. And that’s where things usually stopped. We were heroically occupying the front lines, locked in holy battle with "real" life-threatening physical illnesses and had little time or patience for "neurotic" problems. Patients with the major psychiatric illnesses like Schizophrenia or Melancholia who showed up un the medical wards were different – more like "hot potatoes." Psychiatrists were called and speedy transfer was the name of the game.

My own interest came later – in practice. At first, I was awed at how many of the patients who were referred to me as an Internist who turned out to have "neurotic" or "psychosomatic" symptoms [75% – I counted]. Then I started asking them some questions and doing some exploring, and I discovered a whole new world of things were just too interesting not to pursue. But the point here is about legitimacy. In training, physical diseases were the legitimate domain of Medicine proper. And many patients feel the exact same way, feeling discounted by suggestions that their symptoms might not have some physical basis. And if physicians and their patients tend to see a biological basis as the sine qua non of legitimate medical illnesses, the insurance companies paying for medical care are absolutely adamant on that point. It’s not at all hard to see why that is.

A century ago, these matters were less clear. Many of the patients of the day presented much more dramatic symptoms that those seen now – paralyses, anesthesias, blindess. In fact, the term "neurotic" originally meant something akin to "neurology-like," psychologically derived symptoms that looked like brain or nerve problems. Much of what the early psychoanalysts had to say about such cases has been assimilated by our culture, and those "neurology-like" syndromes are rarely seen. The psychoanalysts and other psychotherapists turned their attention in a different direction – personality problems, post-traumatic syndromes, etc. And so about the insurance companies of the 1970s. Since most of us have our glitches or "baggage" from the past, the boundaries between normal and abnormal begin to fade, then disappear. So any given person and any given psychiatrist or psychotherapist could decide on any given day that a long course of psychotherapy was indicated [and frequently did] – aided and abetted by the DSM-II [1968-1980] that legitimized its vaguely psychoanalytic criteria for the "Neuroses."

And then, in what seemed like the twinkling of an eye, the businessification of Medicine [Managed Care, HMOs, PPOs, Hospital Corporations] and the [re]medicalization of Psychiatry [DSM-III, biological treatment, PHARMA] turned everything upside-down. The DSM-III couldn’t achieve legitimacy in the usual medical way [biological markers, etiology], but it did produce a syndromatic symptom-oriented medicalesque classification that made no mention of matters psychological [etiologically neutral]. We all know the rest of that story. The DSM-III legitimized a biologically oriented psychiatry. The DSM-III legitimized the non-psychiatric mental health specialties’ access to medical insurance, albeit in a tightly managed way. It even legitimized the patients’ illnesses – having a named and numbered Disorder, "I have been diagnosed with Bipolar Disorder." It wasn’t "in your head" anymore, it was "in your brain". In practice, most psychiatrists did medication management using the new drugs that flowed steadily from the PHARMA pipeline. Our journals filled with Clinical Trials of those drugs and reports of the advances in biological brain science – genomics, proteinomics, neuroimaging, cognitive sciences, and the like. The mental-illness-as-manifestation-of-brain-disease meme increasingly crept into the discourse, and by 2002, the fledgling DSM-5 Task Force announced that the biology would be added to the next revision of the diagnostic manual.

Apparently, the medication management/therapist split with its managed care reimbursement was an adequate enough compromise, because things settled down and the wars of the 1970s abated. As I said in the last post, it became something of a "therapist"/"psychiatrist" symbiosis. And this was an outpatient oriented solution aimed at treating what the psychologist next door called the walking wounded – the not so very ill. Hospital Care for the more profoundly afflicted was radically trimmed – almost to zero. People were only hospitalized in the direst of circumstances based not so much on treatment needs or treatment plans, but because there were no alternatives [and discharge planning started in the admission office] – very short stays. Patients with psychotic illnesses like Schizophrenia or Mania were mainly treated in the dwindling public sector with service availability varying widely from place to place. If you saw a severely ill patient, getting them adequate treatment was a nightmare with or without their being insured.

This system may have been an adequate compromise for the reimbursement needs of mental health clinicians, but it wasn’t so hot for the patients who felt the constraints of its limitations – a feeling shared by many of the "providers" who felt as if they were doing First Aid rather that medical care. Patients referred to psychiatrists rarely left without a medication prescription. "Counseling" was often time limited or catch-as-catch-can.  Over the years, there has been an increasing disillusionment with the efficacy [and/or safety] of the ubiquitous psychiatric medications. While it’s true that all medical care has suffered under the system of Managed Care, mental health care has been the most closely watched, the most severely cut, the most vulnerable to being shaped by its control. We may have been declared legitimate, but apparently not all that legitimate. It feels like the whole medical system is run on cutting out everything they can get away with cutting, and in mental health, they can get away with cutting a whole lot. The disparity between medical coverage and mental health coverage was obvious to anyone that looked, and ultimately lead to the Mental Health Parity and Addiction Equity Act, signed in 2008. But, as Dr. Summergrad points out, it hasn’t really even been implemented – thus, this pdf APA poster. I guess it’s supposed to be stuck up on the office wall.

I started with the remembered attitudes towards matters mental from my medical house officer days – those "supratentorial" problems – because I actually think that attitude has controlled our fate [and by "our" I mean all of us – psychiatrists, psychologists, social workers, etc. and our patients with mental health problems]. The late-coming Mental Health Parity and Addiction Equity Act is an attempt to fix something that has largely shaped and contorted our specialties for forty years – another piece of legislation [see Managed Care]:

Richard Nixon … was the first mainstream political leader to take deliberate steps to change American health care from its longstanding not-for-profit business principles into a for-profit model that would be driven by the insurance industry. In 1973, Congress passed the Health Maintenance Organization Act, which encouraged rapid growth of Health Maintenance Organizations [HMOs], the first form of managed care.

…and vice versa. Psychiatry did everything in its power to fit into the new Managed Care system – "a for-profit model that would be driven by the insurance industry." It created a medical diagnostic system [DSM-III] and adopted the principles of evidence-based medicine. Out came the white coats, and our journals followed suit with the graphs and tables more familiar from the medical journals. Psychiatry accepted the abbreviated sessions of medical consultations and the closing of our non-cost-effective hospitals. The psychologists, social workers, counselors jumped on board and agreed to accept the mandates and control of managed care – happy to be included. PHARMA didn’t just jump into the mix, they dove in with wild abandon, passing out some of the fortune they reaped from the windfall along the way. Researchers began to search for the missing links, the biomarkers that would concretize full membership in the medical fraternity.

But try as we might, psychiatry and the other mental health disciplines never had the bargaining power of the rest of medicine. We just didn’t really fit, in spite of our claims and an inordinate amount of chest-beating. So we’ve been clay in the hands of the bean counters, and had to follow their lead rather than leading – all of us. Worse than that, our patients most in need were left out of the loop. It goes without saying that "a for-profit model that would be driven by the insurance industry" would hardly be expected to focus on a chronic, psychotic [largely uninsured] population – people who need ongoing care and where the goal is often to prevent deterioration rather than effect some measurable cure. So parity? legitimacy? not even close.