If our national dialogue is telling us anything about mental health, it is that we have to improve access to care.
Here are three suggestions for reform:
1. Increase funding for mental health services and maintain that increased funding so that the pathway to full recovery is open to everyone.
2. Require that insurers pay for the rehabilitation programs that are critical to full recovery for the mentally ill. Rehab is available for cardiac patients, why not for the mentally ill?
3. Shift the burden to prove "medical necessity" from the clinician and patient, and make the insurer disprove it. Require that all precertification and recertification denials by insurers are reviewed by an independent panel of clinicians, housed in the Office of the Health Care Advocate, and reimburse care during the review and any appeals.
Access to care has been a problem for the mentally ill from Colonial times, when there was essentially no care. In the early 1800s, mental disorder was recognized as illness worthy of humane treatment and asylums such as the Hartford Retreat for the Insane (now the Institute of Living) offered a glimmer of hope.
In the mid- to late 1800s, states opened public asylums. They were soon overwhelmed and transformed into the "snake pits" of the 20th century. Through the mid-1900s, state hospitals offered long-term institutionalization to the indigent while private practice psychotherapy was available to those who could pay. Those in the economic middle had little access to care.
With the evolution of private (commercial ) insurance and the enactment of the Medicare and Medicaid programs in the later 1900s, access shifted dramatically. The deinstitutionalization movement followed and led to massive downsizing and closing of state hospitals. The money was supposed to follow the patients into community programs, but in most states that promise was poorly kept. The chronically mentally ill wound up on the streets or, all too often, in prison.
Connecticut's mental health system is better than many. But nevertheless, funding for state mental health programs everywhere is inadequate. And now, as we appreciate the need for universal programs that promote early detection and intervention, the demand for better funding will grow.
Gov. Dannel P. Malloy addressed some of these needs with proposals to increase spending on mental health services, but $25 million in cuts to state grants for mental health and substance abuse clinics, applying to the current and next fisal years, are scheduled in July. These cuts assume that many of the patients served will be newly insured through the Affordable Care Act (Obamacare). But most will be insured under Medicaid, and these clinics can't run on insufficient Medicaid rates. Increased funding for mental health services demands real commitment for many years.
A pernicious problem is the denial of reimbursement even for programs that are ostensibly covered. A clinician attempting to initiate care for a patient must get it precertified by the insurer. That, for example, requires a phone call from the emergency department prior to hospitalization to get the cost approved. The patient may be suicidal, but if the insurance company's reviewer doesn't agree that the risk is great enough, care may be denied as not "medically necessary." If the patient is approved for admission, the care must be recertified every few days. If, on day three, the patient denies being suicidal, further care may be denied even if the hospital psychiatrist believes it is warranted.
Appeals are reviewed by clinicians on the insurer's payroll. They rarely decide in favor of care.
Access to care for the insured raises other issues. Private insurance pays for psychiatric hospitalization and traditional outpatient services. But full recovery from mental illness often requires much more: supportive housing, psychosocial and vocational rehabilitation programs, visiting nurses, assertive community treatment teams, access to peer counselors and more. These are available to individuals under the care of the state Department of Mental Health and Addiction Services. But if adult children are fortunate enough to be on their parents' insurance, they will not have access to these programs. Commercial insurers do not pay for them.
The path to full recovery is blocked by an antiquated approach to insurance for mental disorders that provides, at most, a once-a-week visit to a clinician and a short hospitalization when necessary. It is not enough.
Harold I. Schwartz is psychiatrist in chief and vice president of behavioral health at the Institute of Living/Hartford Hospital.