““Parity’’ for mental-health care is still far from certain. The House version of the bill contains no such language, so a conference committee must resolve the differences, a contentious closed-door process that could take weeks. Business and insurance companies are lobbying strenuously against the measure, fearing exploding costs. Mental-health-care advocates are lobbying just as intensely to keep it. They cite estimates that parity for mental illnesses could raise insurance premiums by as little as $40 a year per family, particularly if those benefits are tightly controlled by managed care.
But therein lies an even bigger battle. Psychotherapists are at war with managed care. The same system that has helped cut medical costs in recent years – by limiting access to doctors and cutting ““unnecessary care’’ – has come to mental-health care at an even faster pace. A staggering 125 million Americans now have ““managed’’ mental-health-care benefits, as specialized ““behavioral-health-care companies’’ woo employers with promises to cut their costs by as much as 30 percent. Therapists charge that those savings come from denying needed care, while some managed-care companies keep as much as 40 percent of premiums as ““administrative costs’’ and profits. ““This system grabbed hold in the marketplace before people understood the powerful incentive to undertreat,’’ says Bryant Welch, a former director of the American Psychological Association, now an attorney filing suits over inadequate care.
Most Americans with managed-mental-health benefits have no idea how their policies work until they actually seek treatment. Typically, they have to call the company’s 800 number and tell an anonymous caseworker what’s troubling them before they can even see a therapist. The reviewer will give them a short list of approved providers for a single consultation. If the therapist thinks more sessions are needed, he must get prior approval, usually by disclosing intimate details of the sessions. Often, patients are told all they need is a prescription for antidepressants.
Mark Hudson, a former ““referral assistant’’ for Blue Cross/Blue Shield of Massachusetts, gave a rare inside glimpse of the process when he testified in a lawsuit against the company last summer. Hudson, who had no experience in counseling, says he fielded calls from paranoid schizophrenics, people going through bitter divorces and people contemplating suicide. Once he had to put a caller on hold while he told his supervisor, ““I’ve got a guy who’s raping his 12-year-old daughter. What category do I put him in?’’ ““I had people screaming, crying, pleading, threatening,’’ Hudson told NEWSWEEK. One man said, ““I’m going to come and blow your brains out if you don’t get my wife some help.’’ Many people gave up and paid for care on their own. And if a therapist argued that a patient needed more sessions, he says, he could be barred from more referrals.
Susan Leahy, a spokeswoman for Blue Cross/Blue Shield, insists that Hudson’s allegations are ““not true.’’ He was fired two days after he signed the affidavit, despite a court order barring retaliatory action. (Leahy says he was sacked for absenteeism.) She also denies the lawsuit’s charge that Blue Cross advertised a higher level of benefits than it provided patients. ““If the treatment was medically necessary,’’ she says, ““they got the treatment.''
Managed-care companies say the medically necessary standard not only helps control costs, but brings needed accountability to psychotherapy. Without it, they say, patients could seek reimbursement for years of Woody Allen-style sessions on the couch, with no discernible progress. ““No one can afford to deliver free access to unrestricted mental-health care. We need an objective measure,’’ says Peter Brill, CEO of Compass Information Services, which sells a system for tracking a patient’s progress against a database of 15,000 others, allowing therapists to adjust the care if necessary.
Critics contend that human beings with complex emotions don’t fit neatly onto computer grids. And James Wrich, who audits managed-benefit plans for employers, says that scrimping on mental-health and substance-abuse programs can cost employers more in future medical bills. ““One auto accident involving alcohol or one suicide attempt can wipe out all the savings,’’ he says. ““One day in the emergency room can cost $4,000.''
Therapists also worry that the intimate details of patients’ lives they must disclose to case reviewers will end up in computer banks as data to be sold. Medical Information Bureau, a national clearinghouse in Westwood, Mass., collects information on the health status and hazardous hobbies of some 15 million Americans, and shares it with member insurance firms trying to detect applicant fraud. MIB insists it strictly limits access to the records, but in these days of computer hackers and software glitches, who knows where they could go? A ““Medical Records Confidentiality Act’’ is pending in Congress, but critics say it would do more harm than good, creating even more information lending libraries. And provisions in the House health-reform bill would create a vast central data bank in the Department of Health and Human Services, giving the government new access to medical records. Big Brother, it seems, could be watching, and he just wants to know how long you’ve been feeling this way.
Two thirds of insured Americans have mental-health coverage through managed-care firms. Critics charge they withhold treatment to save money.
Managed-care plans rely heavily on social workers who get more than 50% of referrals.
Only 10% of people with managed behavioral health care use their benefits.
The average outpatient treatment ranges from 3 to 7 sessions (not counting long-term illness).
Average fee per outpatient visit to a psychologist under managed care is $75, compared with $100 in other plans.
1993: 86 1994: 92 1995: 107 1996: 125
Source: Open Minds
