Getting a prescription for medications is required for a patient to take them. So what happens when it’s increasingly difficult to find the right doctor for the right illness? Medical care is already a fee for service business.
Psychiatry is becoming a cash for service business. This practice goes beyond the issue of affordable insurance. When doctors will only accept cash payments only those with the means to pay in full at the time of care will have access to it. A recently published study in the journal JAMA Psychiatry revealed that only 55 percent of psychiatrists accept private insurance, compared with 89 percent of other doctors. As is so often the case, low-income patients have even less access. Only 43% of psychiatrists surveyed accept Medicaid.
For a person with mental illness it may feel like even psychiatrists stigmatize them. Obviously medical students who choose psychiatry for their specialty desire to help people with psychiatric disabilities. Thus stigma in its most literal sense is not the issue but it does resurrect the problems with payment disparities.
Policy makers have tried to eliminate disparities between what insurance will pay for mental health care compared to physical health care. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 was supposed to eliminate these disparities. It mandates that any health insurance plan that provides mental health or addiction coverage must not provide less coverage than it provides for medical and surgical benefits covered by the plan. This is the closest to actual parity that federal law has mandated to date
While it was an honest effort, the parity act has been less than successful. Understandably, mental health advocates and professional organizations have touted the victory of parity legislation after decades of work to get such legislation passed. Yet it’s time to re-evaluate.
Health care economists routinely cite the success that insurance companies have had in limiting mental health expenses as if the primary goal of health care policy were to keep funds away from the mentally ill.
Are payment disparities a form of stigma? Of course they are. It’s a simple business equation. When the customer will not pay what it costs to provide a service, the number of providers will decline. Falling mental health care reimbursements result in mental health becoming arguably the most underpaid area of health care.
Cause and effect are evident. If insurance pays less for psychiatric care then psychiatrists will not accept insurance payments as payments in full.
So let’s point out the obvious. To get adequate care from a psychiatrist the patient must:
1. Have the cash on to pay in full at each appointment
2. If they have insurance, they must do all the paperwork to file for reimbursement. For a person already struggling with mental illness this can be a daunting task.
3. They must be able to afford the difference between the doctor’s fee and what insurance will pay.
4. They are responsible for getting all pre-authorizations, which means getting the doctors’ statements that care is medically necessary and dealing with the claims managers when the insurer declines to pay the claim. This is never easy – imagine how it must be for a person dealing with paranoia or hallucinations.
Public calls for improving mental health care are loud after incidents such as the violence at Sandy Hook Elementary School and the Aurora movie theater. But has access improved in the real world? Not so much. The right psychiatric medication can make enormous improvements in recovery for patients. It can mean the difference between a life of pain and isolation and one with meaningful relationships and work. But if patients can’t find a psychiatrist to treat them, how are they going to have a chance at finding the right treatment?
If insanity is the belief that one can do the same thing over and over again and expect a different result, then how ironic is our mental health care system? Society is failing to pay what it costs for good psychiatric care and then asks, “Why don’t they just take their medications?”