Health care roundtable

Virginia Business
May 2006

Virginia Business asked health insurers, physicians, hospital administrators and businesspeople: “Should all mental health illnesses have the same coverage as other illnesses?”

Dr. Martin N. Buxton,
Service chief of psychiatry, CJW Medical Center and president, Insight Physicians PC
Richmond

Yes, absolutely. The mental health patient population, by and large, is a population without self advocacy. The higher-functioning psychiatric patients do not want to be identified and can often afford to pay for their treatment out of pocket. By the nature of chronic mental illness, patients so afflicted often do not have the capacity to represent themselves, organize and lobby.

If insurance companies are allowed to capriciously “cherry pick” the illnesses that they will cover, clearly their for-profit motivation will result in financial decisions driving which illnesses are covered and which illnesses are not. Recent benefit utilization and cost analyses for federal government employees who do have health-care coverage parity for all illnesses including mental health have challenged the ubiquitous belief that parity would bankrupt health care. With lifetime prevalences for mental health disorders as high as 25 percent and increasing, how do you not treat? To use a computer metaphor, how could you benefit from having the component parts of a computer system if you weren’t allowed to have a screen?

I apologize for my negative drift on this subject, but the paradox of people finding out that they have the illusion of insurance coverage (which is shattered when they get ill and read the fine print) is juxtaposed to the reality of various insurance companies declaring all time profits for their stockholders. From the clinical trenches where I gain my perspective, capricious and selective science is often used by the insurance companies to justify the withholding of coverage that people have paid for. What happened to the concept of holism?

Joe R. Wilson
CEO, PermaTreat Inc. and chairman of the board of MediCorp Health System
Fredericksburg

I guess the first thing that comes to my mind is: What is the real definition of parity? Wearing my MediCorp hat, I see parity as meaning that reimbursements for providers would be paid at the same level as other reimbursements, instead of the very low reimbursement rates currently in place.

The state is downsizing mental health facilities (Western State, Central State, Eastern State, etc.) and private hospitals have closed their mental health facilities (Culpeper and Potomac General, for example) due to low reimbursement rates and the fact that they lost money on these services.
Reimbursement parity for mental health services is a must. At our own Snowden Psychiatric Hospital (34 beds), we regularly lose money. The only reason we keep it open is because we're a community hospital, and we consider it a part of our mission.

One of the big issues I see with our mental health coverage at PermaTreat Pest Control (107 employees) is that the number of days that our plan provides for in-patient mental health services, in some cases, is not enough to really solve a problem of this nature.

I suppose the real issue for the small business person (real or imagined) is that expanded mental health coverage would mean higher health care costs. The New England Journal of Medicine, in its March 30, 2006 Abstract, cites a study of federal employees that says costs do not increase. It is difficult for me to accept this analysis, but I have no basis on which to defend my position.

I do know this much...every year, when faced with double-digit increases in health care costs, I am faced with having to pare down benefits or increase co-pays in order to bring what was a 43 percent increase in premium down to a 29 percent increase. My guess is that my employees would be more interested in coverage for physical illnesses, realizing that there will be a minority of employees needing coverage for mental health services.

Most group plans have some provision for inpatient mental health stays. Most plans have a cap on the number of inpatient days one can use. The payers usually dose these days out (in PermaTreat's case) starting at 7 days. Should the patient need more time (as in the case with most substance abuse situations) the provider has to call the insurance company and in most cases beg for more days. If the extension is granted it's usually for only a couple days more and then it's back to begging. With the physical health side you are usually pushed out of the hospital on the tail end of your stay because the insurance company says you are well enough to go home.

Maybe parity is more a change in attitude (and reimbursement) as opposed to a system change?

William L. (Chip) Sharkey Jr.
Senior vice president, human resources, Direct Holdings Worldwide LLC
Virginia Beach

I believe any expansion of the existing state law amounts to adding mandated benefits by the commonwealth. Virginia law already differentiates between "biologically based mental illness" and other types of mental illness and substance abuse. The law currently provides that these "biologically based mental illnesses" be covered the same as other physical illnesses.

I do not believe Virginia should be expanding mandated benefits. The commonwealth already has more mandated benefits and required procedures than all other states but one.

Adding mandated benefits directly increases health care costs. Increasing health care costs makes health care less affordable for both employees and employers. The question is: who is going to pay for this additional coverage?
Individuals, as well as employers, will have to bear a significant part of these increasing health care costs. And these increases make health insurance less affordable for some people. I do not believe we should be adding even more costs that must be passed along to individuals in our insurance plans.

Dr. Matthew M. Keats
Senior medical director, Sentara Behavioral Health Services
Hampton Roads

Like most issues in health care, this depends on the perspective of the stakeholder:

• For the consumer, this would clearly be positive, since psychiatric illness is common, chronic and debilitating and psychiatric treatments are as effective as for other medical illnesses.

• For the insurer, many studies show there is a very small increase in the cost of care due to the decrease in the patient’s out of pocket expense (but not through any increase in utilization).

• For the employer, increased productivity associated with treating psychiatric illness has to be weighed against the possibility the very slight increase in insurer costs may be passed on.

Mental health and substance disorders have a profound impact on the personal and work lives of millions of Americans. It is estimated that in our country, one in five Americans are affected with mental illness and substance abuse and that one in 10 children suffer from serious emotional problems.

As the number of people struggling with mental and substance illness rises so does the burden on health, family, productivity and safety in the workplace. Restrictions and lack of mental health coverage often leads consumers to less than adequate treatments that temporarily place a band aid on the symptoms but fail to provide comprehensive care. Not only does inadequate coverage affect the population critically needing it, but providers of mental health care and substance abuse services are seriously challenged every day with providing highest quality care with ever decreasing reimbursements. Those patients who require services are never turned away although a huge number of persons in our community are uninsured and underinsured.

We must not turn our heads to the needs of those who are in need of mental health services, otherwise those who suffer from broad ranges of illness will have no place to turn. Facilities are faced with closing and streamlining services as they struggle to continue commitment to those needing care in our communities.

A vicious cycle of depression, isolation, addiction, job and family loss, jail and even death can occur without adequate mental health and substance abuse treatment. Providing a broader range of mental and substance abuse coverage will improve health outcomes, family life, job productivity and enhance quality of life.

Dr. Norris Royston
President, The Medical Society of Virginia

The Medical Society of Virginia supports parity coverage – by this I mean we look forward to the day depression and mood disorders will be covered the same as would a routine medical condition.”

Doug Gray
Executive Director
Virginia Association of Health Plans

Virginia law already mandates minimum coverage amounts for mental health services and additional coverage for ‘biologically based mental illnesses’ like schizophrenia and bipolar disorder. Some health plans exceed the state mandates while others do it. Insurers can offer additional mental health benefits if employers demand it and can afford the cost.