The Year of Moving Forward

The Year of Moving Forward
At our 4 person wedding reception in DC

Monday, December 29, 2008

Health Care Discussion...Mental Illness

The Obama-Biden Transition Team has asked individuals from across the country to host Community Health Care Discussions during the last two weeks of the year as a way to hear what everyday Americans are saying about Health Care in our country.

I hosted such a meeting last night, to which were invited several Bessemer neighbors as well as health professionals including a nurse manager in mental health, the Dean of the School of Public Health at UAB and a faculty member from the School of Health Professions at UAB. I purposely kept the number of people low to insure that everyone would have a chance to take part in the discussion.

I will be sending a report to the Transition Team which can be used in crafting policy for the new administration.

But here are a couple of things we learned. It's not news that the "system" is broken, but the degree to which it is broken and the ways in which this affects patient care was surprising.

One problem had to do with insurance coding and billing and how this affects a doctor's scheduling.

It boils down to: you make an appointment to see a doctor about problem A, and before your scheduled appointment time you develop problem B. When you arrive for your appointment the doctor refuses to address problem B and requires that you schedule another appointment, which may be two weeks or more down the road. What this does to the health of America is it keeps this person (or lots of people, assuming this is happening all over) sick or in pain for an additional two weeks. Or, of course, their condition could worsen.

In other words, the "Health system" is contributing to a "sick nation." It is contributing to people being off from work. It is costing Americans more.

And that is just one of the problems.

The other issue we discussed was mental illness and how stigma affects the treatment people receive. The stigma associated with mental illness can result in people ignoring symptoms or pretending they don't exist, and avoiding treatment.

Mental illness stigma exists for several reasons. One is that mental illness is thought by some to be the result of a choice or action of the individual and is perceived to be on a different level than physical illness. In reality, mental illnesses are complex and are due to physical changes in the brain, with or without a genetic component.

Mental illness should be treated with the same degree of recognition and respect as physical illnesses. The American Public should be educated about mental illnesses, and not from commercials on TV about drugs used to treat them. Doctors as well, should be educated and should focus on the mental health of their patients as well as their physical health.

Depression, for example, affects people's ability to work in a huge way, yet often physicians ignore or don't take the time to question patients in order to pick up signs that there may be a problem.

Then there is this: 1 in 5 young Americans have a personality disorder, according to a recent study. But less than 25% get treatment.

These disorders include obsessive or compulsive tendencies (different from OCD) and anti-social disorders (which can lead to violence) and paranoid behaviors, all of which can interfere with day to day functioning. That's 1 in 5 of our future leaders.

Mental health parity is the first step in reducing the stigma associated with mental illness.

Parity would require insurance plans to treat mental health patients on par with those who have physical ailments. No more higher copays or deductibles for the mental health treatments. No more limits on visits to the doctor that differ from the caps for other patients.

A mental health parity bill was tacked on to the big bailout passed in October, but that bill is not complete and parity involves more than just payments, it also involves doctor's attitudes and education. But...it's a start.

7 comments:

Jeff said...

Joe, I applaud your participating in the process. I have little experience with the provision of mental health care services in the current system, so I will seek to better understand that area before commenting. I would like clarity on your comment that "you make an appointment to see a doctor about problem A, and before your scheduled appointment time you develop problem B. When you arrive for your appointment the doctor refuses to address problem B and requires that you schedule another appointment, which may be two weeks or more down the road." I have almost 15 years of experience in our complex healthcare system, but I have never witnessed what you allude to. Who is this happening with? What member of your group brought this up?

While I agree that the system is made more cumbersome by coding and billing and reimbursement requirements of payors, I do not agree that this leads physicians to fail to address complaints during a patient's visit.

Joe Openshaw said...

Two people brought this up. One works for the Jefferson County Health Department, and in fact, said there is a "one complaint only" policy in her department. Unbelievable.

The other works for UAB and has heard this from other workers there.

The problem would have to be, it seems, cumbersome coding and billing, or certain physicians not wanting to miss charging an additional visit.

I brought up that as a veterinarian, I learned, and practiced, a complete physical exam on every visit. Not only is that better for the health of the animal, but it will help your bottom line also. Of course, we were not controlled by insurance companies and coding policies, etc.

Jeff said...

With regard to mental health parity, insurance companies do not make the decisions regarding what copays and deductibles will be or setting limits on visits. Those decisions are made by the employer (for the majority of Americans who have health insurance as an employment associated benefit) in securing the level of coverage for their workforce. Utilization of services by the group drives up costs associated with providing coverage for the group. Issues such as affordability of the plan, both for the employer and the employee, must be considered in choosing the "level" of coverage that is offered. It is misleading and I would disagree with the statement that "mental health parity is the first step in reducing the stigma associated with mental illness.

Jeff said...

I know of no physicians who are abrogating their ethical responsibility to do good simply to ensure that they capture charges for another office visit.

Joe Openshaw said...

Jeff,

"...insurance companies do not make the decisions regarding what copays and deductibles will be or setting limits on visits. Those decisions are made by the employer..."

I'm not sure this is entirely accurate, and does not apply to people like me who are self employed or buy private insurance policies.. But this statement is from the article that I linked to:

"Parity would require insurance plans to treat mental health patients on par with those who have physical ailments. No more higher copays or deductibles for the mental health treatments. No more limits on visits to the doctor that differ from the caps for other patients."

So, whether parity is directed at the insurance company or the employer, doesn't matter. It just needs to be.

And stigma aften relates to inequality. As long as parity does not exist in insurance coverage, then mental illness will be thought of as less important, and those who have it, as less worthy. That's just the way it is.

Of course education, both of the medical profession and the public, is also an important part of eliminating stigma. But education will be a lot easier when things are equal, when parity exists.

"I know of no physicians who are abrogating their ethical responsibility to do good simply to ensure that they capture charges for another office visit."

Of course this is entirely different from saying that none do it, it just says you don't know of any.

Joe Openshaw said...

A column in the New York Times about the parity bill on October 5, 2008, http://www.nytimes.com/2008/10/06/washington/06mental.html?_r=1, contained this paragraph:


"The requirement, included in the economic bailout bill that President Bush signed on Friday, is the result of 12 years of passionate advocacy by friends and relatives of people with mental illness and addiction disorders. They described the new law as a milestone in the quest for civil rights, an effort to end insurance discrimination and to reduce the stigma of mental illness."

In other words, the writer also believed that parity helps reduce stigma, and links the two.

Jeff said...

Joe, perhaps it would be a learning opportunity for you and your audience for you to explore what levels of coverage are available to you through your current carrier. I think you will find that if you are willing to absorb the increased cost you can obtain coverage with fewer of the restrictions that you mentioned. The question is then just a matter of budget.

Who is it specifically who alleged physician malpractice? The responsibility to report such a serious issue to the Board of Medical Examiners should not be overlooked.

I respectfully re-state that the intiail comments in and of themselves (i.e. standing alone in the intial posting) were misleading.

I am not opposed to advocacy work on behalf of those with addiction or mental illness. I fully agree that these are medical conditions just like diabetes and high blood pressure. I am just not so naive as to think that coverage restrictions can be eliminated without some way of covering the eventual increased costs associated with the expanded coverage.