Knocking Down the Barriers to Care

As I noted in my speech at APA’s annual meeting in May, we need to advocate for our patients and our profession. Among the more important tools for the protection of our patients and our professional judgment is the Mental Health Parity Addiction and Equity Act—MHPAEA, or simply the parity act—whose final rule applies for plan or policy years that began on or after July 1.

Barriers to psychiatric inpatient and outpatient care impermissibly impede the health of a significant percentage of Americans and violate the law. It is no secret that psychiatric patients and those who care for them are subject to inordinate rules, controls, economic pressures, and restrictive insurance models. The forms that these take are manifold: limited benefits; poor reimbursement; and highly, indeed uniquely, intrusive requirements for prior approval and review of care. While all of health care has been impacted by some form of these barriers, no medical specialty has experienced the intense disruption of the doctor-patient relationship to the same extent as psychiatry.

Consider for a moment the patient who arrives in an emergency room with a severe depression or obvious psychosis after making a recent significant suicide attempt or experiencing command auditory hallucinations. While some may doubt the reality of psychiatric illness, one night in an emergency room in any city in this country should convince all but the most ideological of the disabling impact and mortality risk associated with these conditions. Moreover, patients with psychiatric illness have increased medical illness burdens and shorter lifespans than their age-matched peers.

Under the best of circumstances, even if a patient is evaluated by an emergency room physician and a psychiatrist, with rare exceptions, those physicians will not be able to admit a patient with commercial insurance or Medicaid whom they deem in need of emergency admission—as defined in the Emergency Medical Treatment and Active Labor Act (EMTALA)—without first obtaining prior authorization. This is not only a clear violation of EMTALA, which forbids even asking about the insurance status of patients who need emergency inpatient care, but is also different from the process followed for all other emergency conditions. The patient with a heart attack, a pneumonia, or injuries requiring general medical care after a suicide attempt will simply be admitted—no questions asked, no hoops to jump through, no release of someone’s intimate medical history to an insurer.

In my own state of Massachusetts, despite 20 years of joint advocacy by the Massachusetts Psychiatric Society and the Massachusetts College of Emergency Physicians, the Massachusetts Medicaid program requires a second-level ER evaluation by an outside social worker before the insurance company can be called for prior authorization, all the while denying payment to the psychiatrist in contravention of state and federal laws. And this occurs even after patients are seen by emergency room and psychiatric physicians.

Perhaps as problematic as these discriminatory and intrusive forms of review is the distinct insurance industry that has grown up around psychiatric care. Variously known as carveouts or fourth-party insurers, these are used by so-called third-party payors—standard commercial or public insurers—to manage and assume risk for the coverage of psychiatric illness, including substance abuse. As the work of many groups in APA and elsewhere has shown, the reality of how this model works is far from ideal. Not only do carveouts subject patients, their physicians, and families to barriers to care, but also these separate payment streams are built upon a demonstrable fiction: that general medical and psychiatric care are not deeply interrelated and do not need to be part of both integrated systems of care and integrated financing streams.

APA must continue to have among its most important missions advocacy for our patients and the profession. This takes many forms, including supporting increased investment in our public mental health infrastructure and demanding additional support for critically needed research by both the federal government and private sources. In addition, we are working closely with both parties in Congress and the administration to pass much-needed mental health legislation that will support the ability of patients to get the care they need and enable families to assist them in those efforts.

While we do that, we are monitoring the implementation of parity at the federal and state levels and pushing for expanded parity rules to cover Medicaid and disclosure of discriminatory insurance rules that lead to delayed and denied care. When needed, we are taking legal action in concert with patients and our members to enforce the law. Our patients and our profession need our continued vigilance and advocacy. ■