Psychiatrists Urged to Lead Push for Health System Reform

Psychiatrists have an obligation to lead the fight to overhaul the nation's health care financing system because patients and other individuals who need mental health care are among those with the least access to care under the current system, according to psychiatrists speaking last month at APA's 2008 annual meeting.

Among the starkest markers of the need for action by psychiatrists is the estimate that 68 million Americans have no insurance for psychiatric care—20 million more than the total number who are uninsured.

“Our patients are even more uninsured or underinsured than average Americans,” said Steven Sharfstein, M.D., former APA president and president and CEO of Sheppard Pratt Health System, at a symposium on financing reform.

Even insured patients are often unable to find a psychiatrist who accepts their insurance plan and who accepts new patients. In addition, patients who seek out-of-network care encounter even more barriers, because there is often little or no insurance reimbursement for those psychiatrist visits. Moreover, many insurers lower their psychotherapy reimbursement fees as a way to encourage almost exclusive use of brief medication-management visits.

Sharfstein noted that although psychiatrists have the treatments to address even the most acute cases of mental illness, insurance companies have reduced coverage for psychotherapy to such a short period of time that it is ineffective.

An additional problem is the widespread lack of coverage for substance use treatment.

Taken together, the impact of the ever-increasing private-insurance restrictions on the coverage of treatment for mental illness should serve to encourage psychiatrists to lead the push to reform the U.S. health care financing system, he said.

Where to Start

Psychiatrists hoping to push for change might first consider the health care plans of the leading presidential candidates. A financing overhaul may originate there, according to Harvey Fernbach, M.D., a psychiatrist who has studied their positions on the issue.

Although all of the candidates generally support incremental change, as opposed to a general financing overhaul, the financing proposal put forth by Republican Sen. John McCain concerns Fernbach the most. McCain's dependence on individual responsibility and market forces to address disparities in health care access inspired McCain's proposal to give tax credits to Americans to buy individual insurance plans on the open market. This change would be coupled with the loss of the tax deduction employers now receive for the insurance coverage they provide. Moreover, private insurers would not be required to open access to the tightly restricted individual insurance market. This would result in widespread loss of insurance as workers are unable to replace lost employer-provided insurance with individual coverage, he said.

“McCain's own history of malignant melanoma would prevent him from getting coverage under his own plan,” Fernbach said.

The health care proposals of Democratic candidates Sens. Barack Obama and Hillary Rodham Clinton are fairly similar. They are based on the view of health care access as a right for all Americans. Both would widely subsidize insurance premiums in an attempt to ensure universal health care access; however, neither would push for health insurance laws that, for example, would prohibit restrictive clauses denying coverage to individuals with preexisting conditions. Also, neither of the candidates' plans addresses the growing paperwork burden on physicians and hospitals or empowers patients to direct their own health care, Fernbach said.

“They would keep pumping money into the private health care system,” he said.

Other Options Available

More aggressive reform options will likely lead to the creation of a single-payer system in which the government pays for the health care of most Americans, according to Hawaii psychiatrist Leslie Gise, M.D., a leading proponent of such an approach. This system is not socialized medicine, Gise said, because all of the private hospitals, physicians, and other health care workers would not be salaried by the government but instead would be paid for their services as private entities.

This approach, which has drawn widespread criticism from Republicans, could provide at least the same number of health care services available now for less money, Gise noted. And the savings could be used to expand health care access.

The estimated annual saving of $300 billion under a single-payer financing system is based on the lower administrative costs incurred by a single-payer system like Medicare compared with the administrative costs of private insurers.

“Meaningful health care financing reform will cost less than incremental changes,” Gise said.

Although some dismiss a single-payer system as a health care reform option that the majority of Americans would never support, Gise said it is very achievable. Legislation to enact a single-payer system, the United States National Health Insurance Act (HR 676), was introduced in February 2007, although it has not yet advanced.

Such a system is similar to what has long been in place in Canada, said Jon Davine, M.D., a Canadian psychiatrist. under his country's financing system, all physicians provide fee-for-service care and are paid by the government at rates regularly negotiated by regional medical associations. The single-payer financing system covers all “medically required services” and allows Davine to base his patient selection solely on each patient's medical need.

The administrative burden also is small, with few forms and no need for preapproval or phone calls to insurance administrators. All billing work in Davine's office takes half an hour each week.

The only shortcomings he identified were that Canadians who are not elderly or poor must obtain private insurance for medication coverage.

“The system allows all access to treatment to be based on medical need and nothing else,” Davine said.

A broad-based financing system also allows physicians to try innovative approaches, such as a pilot program in his province, Ontario, that teams psychiatrists and primary care physicians for all of their patients. The approach allows each physician to assess and care for patients who might not come to them otherwise.

The financing reform bill can be accessed at<http://thomas.loc.gov> by searching on the bill number, HR 676. A comparison of the presidential candidates' health care proposals is posted at<www.health08.org/sidebyside.cfm>.▪