In With the Old, Out With the New

January 21, 2015
Allan Tasman, MD
Volume 32, Issue 1

Everyone who has ever billed a third party for psychiatric care knows that lack of “medical necessity” is the catch phrase used throughout the insurance industry to deny care that the clinician who has actually evaluated the patient has determined is needed.

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Allan Tasman, MD | Editor in Chief

When the Wellstone-Domenici mental health reimbursement parity bill was passed at the start of this millennium, there was tremendous excitement because psychiatrists felt that the end of discrimination in reimbursement for psychiatric care was on the horizon. This excitement was tempered by reality over the succeeding years but was revived again when President Bush signed the renewal of the law in 2008. Again, reality tempered enthusiasm as the final regulatory rules allowing full implementation of the law were delayed until the end of 2013.

But hope springs eternal, and spirits rose again when the Affordable Care Act implementation began in 2014, with new expectations for integrated care and real parity in reimbursement for psychiatric illnesses, now to include substance abuse and addiction. But, true parity and integrated care still remain a vision for the future, to the great detriment of our patients and their families.

Why start the new year with a brief recounting of this somewhat dismal historical record? Because near the end of last year, we had a reminder of just how far we still need to go and why it is still essential for all those hoping for change to continue to make our voices heard. What was the reminder? It was a Sixty Minutes segment broadcast on December 14, 2014, on CBS. We learned about a situation that is repeated thousands of times a day across the country in which a patient and her family suffered needlessly because of a denial for payment by an insurer of prescribed psychiatric care. And what was the response of the insurer to the story told by the patient’s family? A retired medical director based in California for a large insurance company said that sometimes insurance companies can’t approve services because psychiatrists may be exaggerating the severity of a patient’s condition to justify reimbursement for care.

His responses suggested a view that the insurance company was essentially serving as the watchdog for the public trust to be certain that there was no unneeded care being reimbursed. The interviewer responded that this sounded like an adversarial approach. Rather than disputing this was the case, the former medical director said that it was similar to a court proceeding where the truth and justice emerge from an adversarial process. The implication was that such an approach was needed because you just can’t trust these psychiatrists who are trying to get paid for unnecessary care. I won’t waste space here enumerating all the reasons why the response to evaluating a patient and prescribing needed psychiatric care is not appropriately an adversarial process. It was, though, a disheartening conclusion to yet another sad and regrettable story about a mother and daughter suffering needlessly.

Everyone who has ever billed a third party for psychiatric care knows that lack of “medical necessity” is the catch phrase used throughout the insurance industry to deny care that the clinician who has actually evaluated the patient has determined is needed. The implicit message is that psychiatrists don’t have the knowledge or skill to determine needed treatment, or worse, don’t really have enough work so that we need to pad our bills and mislead insurers for our personal gain. Ask the patients who call my university clinic why we have more than a 3-month wait for an initial evaluation if anyone thinks we are not completely overwhelmed with requests for service.

This broadcast reminded me of an experience I had back in 1988. Dr Paul Fink, then APA president, called and asked me to organize a meeting with the CEOs of all the major health care insurers based in Connecticut. Since I was working at the University of Connecticut Medical School, located in a suburb of Hartford, the insurance capital of the universe, he thought I’d be in a good position to arrange this meeting. As a tireless fighter for the end to stigma toward those with psychiatric illnesses and those who treat them, he wanted to make a presentation to the CEOs about why they should stop discriminating in their reimbursement policies. It was no surprise that not a single CEO attended, but I was pleasantly surprised that about 15 corporate medical directors said they’d attend.

Those of you who knew Paul, who, sadly, passed away in early 2014, will not be shocked to learn that he made an impassioned, thoughtful, data-driven presentation that emphasized the needless suffering of psychiatric patients due primarily to irrational and dehumanizing stigma. He appealed to the highest moral and ethical standards in his assertion that such discriminatory practices should end. Paul gave a brilliant and heartfelt conclusion showing that the result would not only be beneficial for the individuals affected but also for the social, health, and economic welfare of the country.

What was the response? One medical director said it would be impossible to change the policies because of a psychiatrist in Texas who had billed the company for 30 hours of care a day. Similar anecdotes about individual psychiatrists followed from several other medical directors. When Dr Fink asked them why they weren’t responding to his policy recommendations rather than reciting these individual stories, the answer was that there were just too many billing abuses to change the existing review policies. Sound familiar? You can see why I thought of this meeting when I watched the Sixty Minutes interview.

I’m not suggesting that insurers have any nefarious intent, such as was portrayed in The Rainmaker, the 1997 Francis Ford Coppola movie starring Matt Damon. Some of you will recall that Mr Damon portrayed a just out of law school attorney who was suing an insurance company on behalf of the family of a young man who had died of leukemia after approval for a potentially lifesaving bone marrow transplant was repeatedly denied because it was “experimental.” It turned out that the company CEO, played by Roy Scheider, had instituted an across the board denial of benefits policy with the expectation that the family of any insured would just give up after repeated appeals were denied.

But, I guess we might surmise there could be a financial motive for widespread denials of care by companies that are given fixed premium dollars, often by companies overwhelmed by rising health care costs, and who must still turn a profit for their stockholders. There has to be some reason why payment for health care services is called “medical loss” by insurers. And there has to be some reason, which my extremely knowledgeable billing staff could never understand, why a number of years ago nearly every one of our department’s billings for services to children were denied for months, only to be paid after re-filing the claims in an appeal process. It wasn’t because we had changed any information in the re-filing-because we hadn’t.

So, what do we tell the parents of those children whose disabling psychiatric problems cannot be treated because the treatments prescribed just aren’t “medically necessary”? I don’t know, but maybe some corporate or government leaders have a good answer. Yes, we have limited financial resources to care for an entire population, but I don’t hear too many stories about denials of care for diabetes or cancer or heart disease like we hear for psychiatric illnesses. And we know that just one of the illnesses we treat-depression-is deemed by the World Bank to be one of the top global economic burdens of any illness, not to mention the personal, familial, and societal costs. It seems to me this is just good old-fashioned stigma in not even new, but still fairly shabby, clothing.