Does anyone else find it paradoxical that society stigmatizes mental illness AND expects them to reveal it to others? Our culture screams out its distaste. A person is “a schizophrenic,” not a person with schizophrenia. They are wacko, crazy, schizoid or bonkers. Oh, and by the way, it wouldn’t be a problem if you just take your medicine.
If our society wants people to enter treatment and adhere to it we are obligated to provide a clear path to that goal. This is not just about affordable health care. This is about access and availability of effective care.
We have made advances. After years of advocacy insurance companies have a mandate to add parity in coverage. Parity means that they had to include a comparable plan for mental health care to what they offered for physical care. In late 2008 President Bush signed a compromise bill that improved parity standards. The Affordable Care Act also sets standards for parity. There is a loophole in both bills – insurance plans can reduce benefits for physical illness instead of raising benefits for mental illness. They are still in compliance with the law, if not its spirit.
There are more barriers to access to effective medicines. Insurers have introduced Step Therapy for all medications. This protocol dictates that health care providers deliver the least expensive option first. Generally that means the lowest cost medicine available. For example, if Drug A and Drug B both treat your medical condition, a plan may require your doctor to prescribe Drug A first. If Drug A does not work for you, then the plan will cover Drug B.
This doesn’t sound like a bad idea. It can be an effective tool to provide care and hold down health care costs. But Step Therapy does not operate in a vacuum. It has to mesh with other insurance practices. There’s a reason the Step Therapy protocol is also called the Fail First requirement. The drug has to fail in delivering symptom relief before the insurer will authorize something more expensive. Imagine if you broke a bone but your insurer required you to try aspirin before giving you a stronger pain reliever.
Of course, determining whether a treatment is working means the doctor and patient need time together. This is particularly true with mental illness. A blood pressure monitor provides concrete information in diagnosing high blood pressure. Diagnosing mental illness relies on the doctor having a trust-based discussion wherein the patient describes feelings and behaviors . This takes time. The doctor and patient must meet again to assess how well the medicine is working.
Even with parity insurers limit how many visits a patient with mental illness can make to the doctor. As with any treatment for a serious illness the doctor must do a follow up to assess the drug’s efficacy. With Fail First the patient may need a series of visits to find the right medication. But insurance companies also limit the number of visits in a given time frame.
Stigma comes from a lack of understanding and empathy. Obtaining medications is not at all a simple process. If those who hold stigma would call on society to do what’s necessary to break down the barriers, then perhaps more people would, and could, take their medicine.
As Isaac Asimov said, “Your assumptions are your windows on the world. Scrub them off every once in a while, or the light won’t come in.”