Health Care, National Health Insurance, and Psychology.

The role of psychologists as health care providers and the parameters of reimbursement for health care services are timely and controversial issues. A landmark decision was reached in this controversy in the 1980 appeal of a Virginia suit by clinical psychologists in which the court ruled that Blue Shield's refusal to directly reimburse psychologists was a violation of antitrust law. Thus, the requirement that psychologists bill through physicians was not upheld. In recent years a specific aspect of this controversy involved psychologists' roles in potential national health insurance programs. A limited study (appearing in the "National Register of Health Services Providers in Psychology" 1976-1978) of clinical psychologists' attitudes toward national health insurance suggests that Congress and psychologists may have disparate views. In addition to favoring national health insurance, over 85% of psychologists surveyed responded that consumers would benefit from such a program with mental health coverage. Only 16% agreed that such a program would constitute a subsidy of the rich by the poor (Albee, 1977). Several areas of conflicting or confusing responses in this study may reflect legitimate reasons for concern by Congress regarding institution of national health insurance. Belief that providers would benefit from mental health coverage in a national health insurance program was shared by 80% of respondents. Ninety-five percent of respondents identified the inclusion or exclusion of clinical psychologists in such a national health insurance as affecting the future of the profession. Curiously, over 50% of respondents agreed that primary care physicians should be reimbursed for mental health services, although such physicians have received no formal training in psychological services. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Health care reform: The 1993–1994 evolution.

Health care costs in the US continue to increase, as does the number of individuals who lack health care coverage. The magnitude of these critical problems assures that reform of the health care system will continue to be debated over the next decade. Increasing health care costs are associated with increased complexity of services and a greater number of health care providers. As health costs increase and the number of individuals covered by private insurance decreases, states will face increasing pressure to develop effective methods of providing coverage for those without health insurance. Employer mandates will be viewed as one method of extending health coverage. Psychologists must be involved in policy issues so as to ensure the utilization of psychological knowledge and attention to psychological and behavioral health needs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Emerging trends in mental health policy and practice

The continuing deinstitutionalization of patients in public mental hospitals and the growth of managed care are fundamentally altering mental health practice. Managed care provides opportunities for achieving parity of insurance coverage between mental and physical illness, but serious problems persist in integrating mental health, substance abuse, and general medical care and assuring an appropriate range of services and programs for persons with serious mental illness residing in community settings. Hospital and community care are poorly coordinated, and hospital care needs to be integrated into a more balanced system of services. Important new roles are emerging for purchasers, patient advocates, and mental health authorities.     

Psychiatric care and health insurance reform

Concerns about cost, access, and quality of health care in the United States have led to a variety of legislative proposals that would reform our health care system and its financing. Health insurance benefits for mental illness, including substance abuse, are treated differently from medical/surgical benefits, with stricter limits on outpatient visits and hospital days. Medicare, Medicaid, and most private health insurance plans contain this historic disparity of coverage for mental illness compared to general medical illness. Psychiatric services are also distinguishable because of the large public sector reimbursement for mental illness treatment and support. Principles for a more equitable design of mental health benefits include a non-discriminatory approach; payment on the basis of service rather than diagnosis; application of cost containment for care of mental illness on the same basis as care of general medical illness; retention of the public sector as a backup system for high-cost, long-term care; encouragement of lower-cost alternatives to the hospital through the development of a continuum of care; and a recognition of the distinction between psychotherapy and medical management. All current approaches to universal health care fall short of these principles. A research agenda is needed now more than ever in order to articulate the case for complete coverage of mental illness and substance abuse.     

Mental health care benefits and perceptions of health insurance agents.

Many professionals play a role in evaluating and defining health service coverage in the current marketplace. It is useful to professional psychologists to understand how their perceptions of the current coverage of mental health services are similar to or different from those of other professionals. The authors examined the views of health insurance agents. Both psychologists and insurance agents agreed that, mental health benefits were adequate to effectively treat mild mental health problems, coverage was inadequate to treat major mental illness. Psychologists and insurance agents differed in their perceptions of whether patients and therapists used benefits unnecessarily. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Taxing health.

Discusses a federal proposal that would limit the amount of health insurance an employer could provide tax free to employees. This could lead to the elimination of cost-effective health benefits such as mental health coverage, drug and alcohol abuse programs, and other preventive care services. The proposal threatens health security and is unlikely to provide additional tax revenues for the government. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A summary of the Colorado Clinical Psychology/Expanded Mental Health Benefits Experiment.

Conducted an experiment to test 2 alterations in the Medicare program: (1) increasing the proportion of allowable charges for outpatient mental health services that Medicare will reimburse and raising the annual limit of reimbursement, and (2) reimbursing psychologists directly, rather than through a supervising physician, for providing mental health services. The experiment was conducted by Blue Cross/Blue Shield of Colorado from October 1976 to December 1978. All Medicare beneficiaries in that state were randomly assigned to 4 groups, each having a different combination of the 2 variables: coverage and practitioner status. The evaluation consisted of 2 primary components: assessing how successfully the operational aspects of the experiment functioned and determining the impact of the experimental changes on the use, cost, and delivery of mental health and medical services reimbursed by Medicare. There appeared to be no administrative barriers to implementing the changes necessary to select eligible psychologists to participate, select the services to be covered, or implement reimbursement procedures for clinical psychologists. However, the case-by-case peer review system developed for the experiment experienced administrative problems and was costly. There were no significant effects on the utilization of Medicare services, overall program costs, or the delivery of care. (4 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

How expensive is unlimited mental health care coverage under managed care?

OBJECTIVES: To study costs, access, and intensity of mental health care under managed care carve-out plans with generous coverage; compare with assumptions used in policy debates; and simulate the consequences of removing coverage limits for mental health care as required by the Mental Health Parity Act. DESIGN: Claims data from 1995 and 1996 for 24 managed care carve-out plans; all plans offered unlimited mental health coverage with minimal co-payments. OUTCOME MEASURES: Probability of care, intensity of care, and total costs broken down by service type and type of enrollee. RESULTS: Assumptions used in last year's policy debate overstate actual managed care costs by a factor of 4 to 8. In the plans studied, costs are lower owing to reduced hospitalization rates, a relative shift to outpatient care, and reduced payments per service. However, access to mental health specialty care increased (7.0% of enrollees) compared with the preceding fee-for-service plans (6.5%) or free care in the RAND Health Insurance Experiment (5.0%). Removing an annual limit of $25000 for mental health care, which is the average among plans currently imposing limits, will increase insurance payments only by about $1 per enrollee per year. Children are the main beneficiaries of expanded benefits. CONCLUSIONS: Concerns about costs have stifled many health system reform proposals. However, policy decisions were often based on incorrect assumptions and outdated data that led to dramatic overestimates. For mental health care, the cost consequences of improved coverage under managed care, which by now accounts for most private insurance, are relatively minor.     

Federal involvement in mental health care for the aged: Past and future directions.

Reviews federal legislative trends in mental health services for the elderly under the Reagan administration. The consolidation of 21 health programs into 4 block grants is considered for its impact on elderly mental health care, and Congress's support of important programs such as clinical training, social research, and research on Alzheimer's disease is discussed. Severe limitations for reimbursement of mental health care under Medicare are considered. It is concluded that Community Mental Health Centers under the Reagan administration will further limit non-revenue-producing services such as prevention, consultation, and education as they exhaust their 8-yr federal funding support, and it is unlikely that Medicaid will increase its coverage of services for the mentally ill. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Insurance coverage, physician recommendations, and access to emerging treatments: growth hormone therapy for childhood short stature

CONTEXT: There is concern in both the medical community and the general public about mechanisms of medical decision making and the interplay of physician and insurer decisions in determining access to care. OBJECTIVE: To examine the medical process influencing access to growth hormone (GH) therapy for childhood short stature by comparing coverage policies of US insurers with the treatment recommendations of US physicians. DESIGN AND PARTICIPANTS: Independent national representative surveys were mailed to insurers (private, Blue Cross/Blue Shield, health maintenance organizations, programs for Children with Special Health Care Needs, and Medicaid programs, n=113), primary care physicians (n=1504), and pediatric endocrinologists (n=534) with response rates of 75%, 60%, and 81%, respectively. Each survey included identical case scenarios. Primary care physicians were asked decisions about referrals to pediatric endocrinologists. Endocrinologists were asked GH treatment recommendations. Insurers were asked coverage decisions for GH therapy. MAIN OUTCOME MEASURES: Insurer coverage decisions for GH in specific case scenarios were compared with the recommendations of primary care physicians and pediatric endocrinologists. RESULTS: Physician recommendations and insurance coverage decisions differed strikingly. For example, while 96% of pediatric endocrinologists recommended GH therapy for children with Turner syndrome, insurer policies covered GH therapy for only 52% of these children. Overall, referral and treatment decisions by physicians resulted in recommendations for GH therapy in 78% of children with GH deficiency, Turner syndrome, or renal failure; of those recommended for treatment, 28% were denied coverage by insurers. Similarly, GH therapy would be recommended by physicians for only 9% of children with idiopathic short stature, but insurers would not cover GH for the vast majority of these children. Furthermore, the data indicated considerable variation among insurers regarding coverage policies for GH (P<.01). CONCLUSIONS: Access to GH therapy differs depending on the type of insurance coverage. The deep discord between physician recommendations and insurance coverage decisions, exemplified by these findings, represents a major challenge to mechanisms of health care decision making, access, and costs.     

Comparative studies of specific acquired systemic tolerance induced by intrathymic inoculation of a single synthetic Wistar-Furth (RT1U) allo-MHC class I (RT1.AU) peptide or WAG (RT1U)-derived class I peptide

Research on public opinion has seldom been incorporated into the debate about appropriate coverage of mental health and substance abuse treatment services in health insurance plans. However, several surveys have been conducted to probe for voters' awareness of and attitudes toward persons with mental illness and insurance coverage of their treatment needs. Given the current debate over mandating parity for coverage of mental health and substance abuse treatment services, these data promise to be particularly useful to politicians and health policy analysts. The author reviews reports of survey research conducted between 1989 and 1994 to assess American voters' support for expansions of mental health and substance abuse treatment coverage, including their knowledge about the origins and implications of mental illness and their willingness to pay for more generous benefits. The results suggest widespread support for such benefit expansions, but voters express concern about potential increases in their taxes or in their health insurance premiums. To facilitate the passage of meaningful reforms for mental health and substance abuse treatment benefits, policy makers must present realistic estimates of the costs of such expansions and of the benefits to be delivered to those in need.     

Children's access to mental health care: does insurance matter?

Using data from a 1992 community survey of children and their parents (or guardians), we found major gaps in mental health insurance coverage. Interestingly, private insurance had no statistically significant effect on use of mental health services. Youth without insurance coverage and those with public insurance had higher rates of serious emotional disorder than did those with private insurance. The analysis is based on the National Institute of Mental Health's Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) study, conducted in three mainland U.S. sites and in Puerto Rico.     

National health insurance, psychotherapy, and the poor.

Debate on psychotherapy coverage under national health insurance has centered around perceived inequitable service to different income groups. It has been argued that national health insurance coverage for psychotherapy would represent a subsidy to the affluent by poorer citizens. Four pertinent hypotheses were examined in a series of studies of 5,967 patients in community mental health centers. It has been maintained that the poor would not seek psychotherapy, would receive fewer sessions, would receive either less prestigious treatments or less trained therapists, and would benefit less than the more affluent. None of these hypotheses were supported. The implications of these findings are discussed in terms of psychotherapy coverage under national health insurance and the role of psychologists in a national system of service delivery. (36 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Interview with Representative Cecil Heftel.

Heftel discusses (a) reasons for spiraling health care costs; (b) why cost-saving alternatives such as nonphysician practitioners (e.g., psychologists) have been excluded from Medicare coverage; (c) the Heftel and Inouye bill providing Medicare coverage of psychologists' services in health maintenance organizations; (d) the need to increase in general Medicare coverage of mental services for the elderly; (e) the high incidence of mental illness in the elderly; (f) lower usage of mental health services among the elderly compared to younger groups; (g) mental health services in Hawaii; (h) the issue of psychologists as independent practitioners within Medicare; (i) involvement of psychologists in political advocacy; and (j) use of media by behavioral sciences to promote their concerns. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Primary mental health care: A "find" for psychology?

Challenges within the emerging area of primary mental health care, in contrast with secondary or tertiary care, are discussed. A review including British and Canadian research in this area is provided. Some attention is given to employer-subsidized services that are available in the workplace. Special consideration is given to mental health services provided in pediatric and family medicine settings. Some suggestions are made in regard to organized psychology's response to these issues. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contrast-sensitivity testing with scanning-laser ophthalmoscope stimulation in normal, ocular hypertensive, and glaucomatous patients

This article reviews the history, growth, and evolution of managed care in mental health and substance abuse treatment. Specific issues described are stigma, the important social dimensions and chronicity of some types of mental illness and chemical dependency, and reliance on the public sector for care. Opportunities and challenges for occupational therapists in the rapidly changing mental health system are discussed, including the use of interdisciplinary teams, the importance of measuring functional outcomes of interventions, the need to develop clinical guidelines, the importance of the community setting and a continuum of services, ethical dilemmas, and the importance of assertive occupational therapy advocacy and involvement in health care reform.     

Health insurance reform legislation

The Health Insurance Portability and Accountability Act of 1996 (HIPAA), enacted on August 21, 1996 (Public Law 104-19), provides for improved access and renewability with respect to employment-related group health plans, to health insurance coverage sold in connection with group plans, and to the individual market (by amending the Public Health Service Act). The Act's provisions include improvements in portability and continuity of health insurance coverage; combatting waste, fraud, and abuse in health insurance and health care delivery; promoting the use of medical savings accounts; improving access to long-term care services and insurance coverage; administrative simplification; and addressing duplication and coordination of Medicare benefits.     

Mental disorders and access to medical care in the United States

OBJECTIVE: The authors examined the barriers to receipt of medical services among people reporting mental disorders in a representative sample of U.S. adults. METHOD: The sample was drawn from adults who responded to the 1994 National Health Interview Survey (N=77,183). The authors studied the association between report of a mental disorder and 1) access to health insurance and a primary provider, and 2) actual receipt of medical care. Multivariate techniques were used to model problems with access as a function of mental disorders, controlling for demographic, insurance, and health variables. RESULTS: While people who reported mental disorders showed no difference from those without mental disorders in likelihood of being uninsured or of having a primary care provider, they were twice as likely to report having been denied insurance because of a preexisting condition or having stayed in their job for fear of losing their health benefits. Among respondents with insurance, those who reported mental illness were no less likely to have a primary care provider but were about two times more likely to report having delayed seeking needed medical care because of cost or having been unable to obtain needed medical care. CONCLUSIONS: People who reported mental disorders experienced significant barriers to receipt of medical care. Efforts to measure and improve access to health care for this population may need to go beyond simply providing insurance benefits or access to general medical providers.     

Prospective payment and psychological services: What difference does it make? Psychologists aren't in Medicare anywayp.

Asserts that Medicare is important in health policy considerations because of the magnitude of the program itself and the nature of the population it serves. Reasons why professional psychology has traditionally expressed frustration and irritation toward the Medicare program, including coverage limitations on mental health services and restrictions on autonomous professional practice, are discussed. The advent of prospective payment for Medicare and the implications of these changes for the delivery of all health care services are addressed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The politics and economics of mental health 'parity' laws

The enactment of the Domenici-Wellstone amendment in September 1996, which calls for the elimination of certain limits on coverage for mental health care under private insurance, is being hailed as a major step forward in the quest for "parity" in mental health coverage. Parity legislation is being introduced in a number of state legislatures and is finding new enthusiasm in Congress. In this paper we consider the efficiency rationale for these laws and examine their likely impact in the era of managed care. We conclude that although such successes represent important political events, they may offer only small gains in the efficiency and fairness of insurance markets.