According to recent estimates, chronic medical conditions account for 7 of every 10 deaths in the United States and have been found to severely limit daily functioning in more than 1 of 10 Americans, or 25 million people.1 This tremendous disease burden accounts for most of the dollars spent on health care annually in the United States.1 Patients with chronic medical diseases represent a population at particularly high risk for mental disorders.2 There is abundant evidence that patients with chronic illnesses, including cardiovascular disease, cancer, and diabetes mellitus, experience high rates of psychiatric disorders, which range from 20% to 67%, depending on the medical illness. In addition, depression and other mental disorders significantly impact quality of life and the ability of patients to adhere to treatment regimens.3
However, access to and reimbursement of psychiatric and other mental health services are severely limited for these doubly burdened, comorbidly ill patients, despite abundant evidence that psychiatric and psychosocial interventions have positive economic and clinical outcomes. Furthermore, several federal commissions and boards, including the President’s New Freedom Commission on Mental Health, the Institute of Medicine (IOM), and the President’s Cancer Panel, and a national organization, the National Comprehensive Cancer Network4-9 (NCCN) have recently called attention to the evidence and the need to deliver mental health care to this population.
Why, then, is access to this care so limited? The reasons for the lack of recognition, diagnosis, and application of appropriate treatments are many: the stigma of mental illness; the busy clinics that reduce the physicians’ time to inquire about psychiatric or psychological symptoms; the reluctance of patients to bother the physician and distract him or her from the primary clinical problem; and the fact that mental health services are the first to be eliminated in budget crises and, hence, are often unavailable.
However, leading the list of obstacles— and resulting in a cascade of barriers that prevent the deliverance of these services—is the absence of an appropriate and well-articulated insurance benefit for patients with co-occurring mental and physical illnesses. The absence of an insurance benefit and the presence of carved-out mental health care have led to payment as an exception only and very low reimbursement for psychological, psychiatric, and social services by both private and public payers. When there is some reimbursement for mental health services, it is usually administered through a mental health carve-out that separates reimbursement for these services from the medical care reimbursement— resulting in patients being unable to receive care in the medical setting and not having access to experienced professionals capable of treating complex medical and psychiatric conditions.
Medical benefit plans vary, but most private insurance plans cover only limited psychiatric consultations and treatment. Mental health (behavioral) benefits are far more limited than benefits for other medical conditions. The Mental Health Parity Act, designed to provide mental health benefits equal to those for other medical conditions, did not affect many self-insured and small employers.
Some employee assistance program benefits fill gaps for psychosocial and family support. State Medicaid programs cover acute care consultations, ambulatory visits, and some psychosocial needs of patients who have serious medical conditions as well as mental illnesses. The federal Medicare program covers psychiatric consultations and psychosocial visits with clearly delineated diagnostic and billing codes. However, Medicare pays 80% for physical health care services but only 50% for mental health services. Gaps exist in free care programs unless delivered in emergency or hospital settings.
To compound the problem, the administration of claims under both private and public insurance programs frequently imposes a substantial documentation burden on physicians who seek payment for psychosocial services. Many nonpsychiatric physicians (eg, oncologists) who have attempted to provide a mental-health professional in their practice group have found that the time and paperwork required to request reimbursement for psychosocial services far exceed the moneys paid, and hence, they cannot afford to provide these services.
While, strictly speaking, mental health services may be covered in an insurance benefit program, use of behavioral health benefits is controlled by managed care organizations. To limit use of benefits, these organizations typically apply a number of utilization management tools, including strict medical necessity criteria, outpatientvisit capitation, prior authorization for psychiatric consultations (where no prior authorization may be required for other medical consultations), copayment by patient (often greater than for medical illness), and prescription prior authorization or preferred drug list restrictions. Public insurance programs may add other restrictions: behavioral benefits limited to priority populations, medical and social necessity criteria, outpatient-visit limits for patients without chronic mental illness, and physician- consultation limits. These tools, in short, make it difficult to obtain benefits without a sustained effort to challenge the application of the rules, at the very time when an ill person is most vulnerable and least able to do so.
Public health initiatives
Several key public health initiatives have provided some focus to this issue. The NCCN, a group of National Cancer Institute–designated cancer centers, in its 2003 standards of care,9 addressed the need to assess and treat distress for all patients throughout and beyond their cancer illness and, furthermore, to use evidence-based interventions when interventions are indicated. In 2 reports,6,8 the IOM has affirmed that practice guidelines are available that should dictate the standard of care for both physical and psychosocial symptoms. Care systems, payers, standard settings, and accreditation bodies should strongly encourage the guidelines’ expedited development, validation, and use.
The President’s New Freedom Commission on Mental Health4 clearly states that mental health must be addressed as aggressively as physical health and that meeting the mental health needs of individuals with primary medical conditions is an unfulfilled critical issue. Furthermore, on June 4, 2004, the President’s Cancer Panel, stated, The federal government should implement comprehensive health care reform, whose provisions should include coverage for psychosocial services both during and after treatment and reimbursement for a range of follow-up care, including that provided by nonphysicians.5 Most recently, the US Congress appropriated funds for a report to be developed that reviews the delivery of psychosocial services to cancer patients, with a special focus on barriers to access.