Third-Party Payers

By Fink, Paul J. | Clinical Psychiatry News, November 2004 | Go to article overview

Third-Party Payers


Fink, Paul J., Clinical Psychiatry News


Because of inequitable limits applied to mental health benefits, many patients fail to get the mental health care they need. What is the impact of third-party payments in doctor-patient relationships?

Psychiatry Is to Blame

The current inequitable limits applied to mental health benefits by third-party payers affect most profoundly the patients with severe psychiatric disorders. Imagine how you would feel, for example, if a family member with Parkinson's disease or multiple sclerosis was fully covered but another family member with schizophrenia or bipolar disorder was only partly covered. All four of these disorders are clearly established as brain diseases, you would correctly argue; why should there be differences in coverage?

The main source of such inequitable coverage is the psychiatric profession itself. By insisting that all categories of mental disorders (except drug and alcohol disorders) be covered equally, we are saying that treatment for a child with "mathematics disorder" is as important as that for schizophrenia and that treatment for "avoidant personality disorder" is as important as that for bipolar disorder or severe depression. Most laypersons, as well as insurance officials, find such a proposition absurd.

Second, we have allowed widespread abuse of insurance coverage. Individuals with problems such as lack of fulfillment or poor interpersonal relations are routinely labeled with dysthymia or another official diagnosis so that third-party payers will cover psychotherapy visits. Because of this widespread abuse, the credibility of the psychiatric profession among third-party payers is at an all-time low.

E. Fuller Torrey, M.D.

Bethesda, Md.

Most Needy Lack the Most Care

In a way, health insurance companies are the messengers, and the real entities limiting benefits are the employer purchasers. Four out of five health plans nationally have discriminatory coverage for mental health. Yet most people with health insurance are adequately treated under these limited mental health benefits. (The unscrupulous restriction of even these limited benefits is another matter.) Not many patients need more than 30 inpatient days per year. Long before managed care, the mean number of outpatient visits was 8-10.

In mental illnesses, like physical illnesses, the vast majority of people (80%) use a minority of health services (20%). The problem with existing mental health benefits is that they harm the 20% of our patients with chronic psychiatric illnesses. These chronically ill patients may use 80% of the resources, but it simply makes sense that sicker people need more services. The caps on visits and inpatient days, discriminatory copayments, etc., hurt the people who need treatment the most.

Thomas Carli, M.D.

Ann Arbor, Mich.

Glad to Have Left the U.S.

Now that I am working only in private practice with fee-for-service patients, I realize how difficult it was for me to work for many years with insured patients in America under managed care.

Now I see patients for a minimum of 50 minutes per session, and I have time to listen to and learn about them. When necessary, I increase the frequency of the sessions, and I can have meetings with patients' families based on clinical needs. I don't have to waste time filling up endless and repetitious treatment plans.

While working in America under managed care, I was always overwhelmed, even afraid, because I knew I was not doing as good a job as I knew I was able to do. Managed care very subtly undermined my work and my relationships with my patients. Insurers tried to reward me financially for doing four med checks an hour (15-minute sessions) and working with therapists who did not have my training. I fought back by trying to take care of the medication and psychotherapy with sessions that lasted 30-50 minutes, but I was discouraged to do so. …

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