With the recent 10-year anniversary of the Mental Health Parity Act being signed into law, comes the reminder that we still have so much work to be done. Unfortunately, blatant discrimination in health insurance coverage for mental health and substance abuse has continued despite this legislation. The Parity Act required that dollar limits on mental health benefits be no lower than the dollar limits for medical and surgical benefits offered by insurers. But what has this really done for patients seeking mental health care?
I work in both the inpatient and outpatient setting in rural Mississippi. My perspective is unique because I see both Medicare patients and privately insured patients. I can honestly say that although the Parity Act guidelines are awash with great intentions, the enforcement has been abysmal.
As the medical director of an inpatient geriatric unit where we only take Medicare, both Humana and Windsor not only make getting a patient admitted difficult, but make getting days approved for full, effective treatment is virtually impossible. I have to speak, or should I say plead, with a physician who is miles away on a phone, who has never evaluated nor met the patient so that he or she can determine whether the days will be approved. I plea. I yell. I cry.
Yet 9 times out of 10, the days are denied. They dictate the course of treatment yet assume no liability for it. This does not go on in the inpatient medical setting. Patients stay until their medical treatment is deemed complete.
I have also recently opened a private practice in a rural, underserved part of Mississippi. My clinic is one of the few mental health clinics that will even accept private insurance. However, most patients are struggling to get their treatment covered or are having to struggle to pay high copays. Because no one is enforcing parity, insurance companies can set their own “industry standards” for the care they choose to cover. Insurers will agree to provide mental health coverage as they are required by law but what exactly they agree to cover is vague. The devil is in the details. Insurers have a set of guidelines in which clinics must follow to approve treatment, however, they are elusive and often open to interpretation. Therefore, health insurance companies often deny claims for mental health care after these guidelines are not followed.
If a patient is ever able to obtain an evaluation, they are also at the whim of the insurance companies to decide what treatment will be covered. This includes what medications they are willing to cover and if they are willing to provide therapy. We all know that the gold standard of psychiatric care is a combination of therapy and medications, but it is often not covered under mental health plans.
It is even worse for addiction treatment despite our ongoing opioid epidemic and need for good addiction treatment. I am married to an addiction psychiatrist who comes home frustrated with insurers daily. Insurers deny patients after he spends hours doing peer reviews saying patients aren’t meeting “appropriate guidelines for treatment.” Yet, no one can cite these guidelines. Their newest tactic is to shorten detox days from the standard 7 to 10 days to 3 to 4 despite the severity of the addiction and clinical presentation. Insurers once again, without proper evaluation of their own, dictate treatment course yet assume no liability.
Since there is no one truly enforcing the parity law, it is left to the patient to fight for their own parity which means fighting huge corporations. How can we expect patients who are battling mental illness to have to fight parity battles as well?
This lack of parity only further emphasizes the stigma surrounding mental health care. Mental health care is essential for total health and treatment is effective. There are numerous studies showing that the real cost lies not in the treatment of mental illness but in the lack of treatment. So, I am left asking the question: Is there parity in mental health coverage or are we still dealing with a paucity?
Katherine Gantz Pannel is a psychiatrist.
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