Wednesday, March 09, 2011

Guest Blogger Dr. Robin Weiss on Stigma and Health Insurance Parity

I'm borrowing this from Robin, who wrote it a while back when she was our state psychiatric society's prez. A little background: Robin was a pediatrician, turned health policy expert, turned psychiatrist. I'm guessing that she didn't do her second residency training in psychiatry so that she could write prescriptions for 40 patients a day, but I could be wrong. Except that I'm not.


Psychiatry has always seemed to me to be the most fundamental and inclusive medical specialty. What psychiatrists understand is this: Human illness is a dynamic function of genetics and environment, and genetics and environment are further influenced and changed by each other. So we understand that existential angst, psychodynamics, family structure, goodness of fit between parent and child, inborn temperament, neurotransmitters, brain structure and function, and more, are all part of the illness mix -- just as true listening, various forms of psychotherapy, and psychopharmacology are all part of the treatment. It is this understanding that elevates psychiatry to a model for all medical specialties. Furthermore, mental illness disrupts and damages those very human capacities that we value most -- our thinking, our emotional lives, and our behavior. I don’t mean to create a competition among the organs (pancreas, liver, kidney vs. mind/brain), but certainly those functions executed by the brain underlie all else. In light of all this, what could possibly account for psychiatric treatment’s peripheral, holding-on -by-the-skin-of-our-teeth insurance coverage status?

Dr. Myrna Weissman, in JAMA, wrote an editorial titled Stigma. She describes the experience of her friend’s fourteen year old son as he struggled with first, serious mental illness, and later, leukemia. What his mother encountered first was her insurance company’s refusal to authorize a comprehensive evaluation; a useless three day hospitalization leading to an episode with the legal system; blame for her son’s behavior; and more care provided by the education system than by the medical care system. What she encountered when he developed symptoms of leukemia was prompt diagnosis and full treatment; an expectation that there would be relapses; compassion and support; and full insurance coverage for hospitalizations, partial hospitalizations, and home care. Dr. Weissman concludes that the stigma associated with mental illness leads to lack of insurance parity, which leads to heartbreakingly bad care -- this, at a time when each week brings breathtaking new research findings about the etiologies of mental illnesses and their treatment.


So what do you think? This paper was written in 2001. Has much changed? We hear a lot about psychiatry being under-funded because the research and the proof aren't there. It seems it can always be done with less (less time, less therapy, less hospital beds --okay, fewer hospital beds--, less expensive medications, less education) or so we're told. I personally think the insurance companies simply want to part with as little money as possible, and that certain illnesses garner more sympathy than others. Can you imagine the uproar if an insurance company refused to pay for a child's treatment for leukemia? And with all the push for parity, is it getting any better for psychiatry? Or is just getting worse for the other specialties?


moviedoc said...

How much would you be willing to add to your monthly insurance premium to get the kind of parity you want. Remember that everyone else would have their premiums increase by the same amount. Give us a number.

Robin Weiss said...

You are asking a valid question in the context of an irrational system. "Parity" is, I am trying to say, a concept that should never have been - there is no biological basis for distinguishing between mental and physical illnesses. Furthermore, the insurance industry's overhead costs are an artifact of a chaotic, broken construct, which will eventually crumble under its own costly weight. So giving a "number" is a distraction, only reinforcing how we have come to accept the insanity of our "health care" system's language.

SidewaysShrink said...

Study after study in managed care and PPO insurance reimbursement structures have demonstrated that when patients have delimited access to mental health services--a therapist of their very own and a specialist for psych meds whether the same provider or not--the patients who increased their utilization of psychiatric care had a marked, cost saving decrease in visits to other medical providers. Ask primary care how often certain of their patients come in for attention to emotional needs, psychiatric problems and somatic preoccupations. Factor in the savings from a decrease of psych hospitalizations. Then consider all hidden the medical costs associated with untreated or under treated mental illness, particularly depression: the cost of medical complications due to substance abuse and the cost of the failure to adhere to treatment plans for diabetes, obesity and other chronic diseases. And consider that the biggest 2 causes of lost days of work are 1) substance abuse and 2) depression.
These costs are hidden in the current system. Mental health parity not only makes clinical sense for the health of patients, it would not increase costs for the incredibly wealthy insurance companies who pay us shrinks like sh*t and it is ethically right.

moviedoc said...

Robin Weiss: We're on the same page regarding the current insurance industry. I say the sooner it crumbles the better, and I try to help it along every day. But don't delude yourself that just crying "parity" will get us what we want. We will have to fight for it in any new system, and to do that we will need to place a value on it. A dollar value.

Anonymous said...

I have no doubt the description in the letter is still completely accurate. Agreed there should be parity. That said, and a little to play devil's advocate, but a little because I think there may be truth to it, is that mental illness does not really have an objective measurement. Both in therms of diagnosis and treatment, there is not always consensus. Psychiatrist 1 diagnoses MDD, psychiatrist 2 diagnoses bipolar, psychiatrist 2 diagnoses ADD + OCD, and to begin to list the range of treatment options - would take forever. This is obviously not ideal, but it is reality.
Not to mention the other side of subjective - depression is a scale. Should insurance pay for months and months of unending treatment under the label of depression for someone who's unhappy in his marriage and wants a career change? That may well be depression, but it's not mental illness.

Like I said, a little bit devil's advocate, but also valid. And no, I don't want to pay higher premiums for a guy who doesn't like his job to see a therapist. It sucks, he has my sympathy but...he's not mentally ill and I don't want my rates going up because "parity" doesn't have a way to make that distinction.

moviedoc said...

Devil's advocate's point is absolutely valid, leads me to another question for Dr. Weiss: I cringe every time I hear "pay for performance." Do we want that in psychiatry? If it's imposed on us, will anyone want to be a sporkiatrist then? That's where devil's advocate's comments will be huge: How will they (It won't be we.) measure our performance?

Sunny CA said...

It is certainly nice to read a more compassionate and hopeful post than the post about the 40-patients a day meds-only psychiatrist we read recently. Dr. Robin Weiss sounds like a terrific doctor.

Battle Weary said...

Anonymous said, "...I don't want to pay higher premiums for a guy who doesn't like his job to see a therapist. It sucks, he has my sympathy but...he's not mentally ill...) My question is, maybe he is mentally ill, maybe he's not, maybe he's a do you know? Would you rather pay higher premiums for him to get a little therapy or would you prefer higher taxes so he can be kept in prison if he goes into work and shoots everyone? Either way he ends up getting therapy of some prison he can see Clink, right! ;)

Anonymous said...

nope, I wouldn't. A sociopath is not going to be any "better" because he's had some therapy. Some talk therapy is not likely to prevent a "sociopath" from turning up at work or school and shooting people.

And no, I don't want to pay higher premiums for everyone having a bad day to get therapy. Let them pay out of pocket to docs in private practice. Leave my insurance premiums relevant to people who are mentally ill, not uncomfortable. (Yes, I know the two are not mutually exclusive.)

Battle Weary said...

Really anony, it's a rather ridiculous point. Parity laws are for major mental illness, not someone is "uncomfortable". Therefore the person you describe will end up paying out of pocket anyway.

Also, I only threw in Sociopath to appease those who would suggest those are the ones most likely to commit a crime such as I was suggesting. This is true, but certainly not the only possibility.

The bottom line for me is, what makes my Dissociative disorder less important than my diabetes? The Dissociative disorder effects my life more profoundly than my diabetes (as long as I take my insulin and monitor my bGl).

Fortunately CA has had parity laws in place for years already.

Battle Weary said...

Again to actually didn't answer my question. I gave an either/or, not a yes/no scenario.

Anonymous said...

your question is ridiculous because it's not either/or; there's no causation. it's apples and oranges in the sense that if i say yes, i want an apple, it has nothing whatsoever to do with whether or not i like oranges.

and you're absolutely wrong about the fictitious unhappy-at-his-job-guy having to pay privately. don't kid yourself. parity laws will cover any dsm diagnosis recorded, and sychiatrists and psychologists who accept insurance - or who don't, but provide bills for the patient to submit for out of network reimbursement - routinely write whichever diagnosis an insurance is likely to reimburse. a therapist is unlikely to turn away a patient who is looking for help, but again, like i said - treatment of mental illness unfortunately does not have an effective means of being measured. which means that unhappy-with-his-job guy comes away with a code for dysthymia or depression and his insurance pays without a second glance.

thinking otherwise is as absurd as your either/or scenario that some talk therapy could cure a sociopath.

Battle Weary said...

You are incorrect anony...parity laws do not cover any DSM code. What is covered is
* Major depression
* Bipolar (manic-depressive) disorder
* Panic disorder
* Anorexia
* Bulimia
* Obsessive-compulsive disorder
* Autism or Pervasive Developmental Disorder
* Schizophrenia
* Schizoaffective disorder
* Children's severe emotional disturbances

Dysthymia is not covered and depression must be major depression.

I never said a sociopath could be cured (or even helped) by talk therapy. A competent therapist may however, "discover" a previously undiagnosed sociopath and in a round-about way prevent a tragedy.

Anonymous said...

Mental health parity laws require that insurance benefits for mental health conditions are equal to those benefits for physical conditions. It doesn't require employers to provide mental health coverage, but if they do, the benefits can't be lesser then physical coverage. that's all that mental health parity laws are, no more, no less.

fyi - sociopathy doesn't exactly work that way.

not going to continue this conversation further.

Battle Weary said...

Anony...I don't particularly care how sociopathy works "exactly". If you reread my second comment you will note why sociopathy was brought up and that it was not intended as a focus of any discussion.

I have no argument on your definition of what the parity laws are. However, the list of covered mental illnesses I provided was copied and pasted directly from the website link I provided. If you can find a reputable source that states that ALL DSM codes will be covered without question, then I would be more than happy to check out the source. Since you state you will not continue the conversation I am sure no link will be forthcoming.