This week I had lunch with Dr. Martin Johnson, a Honolulu psychologist in private practice, who educated me to more ramifications of the new U.S. health care reform bill for mentalhealth care. As of July 1, 2010, he told me, insurance companies must cover mental health diagnoses on par with their coverage for medical diagnoses. Thus, if no cap exists for the number of covered visits for diabetes, no cap can exist for the number of visits a person can have for major depression or for schizophrenia, so long as the insurance company provides any mental ill coverage at all.
Immediately I asked, "won't all the companies just drop their mental health coverage?"
"No," Dr. Johnson answered, because the largest consumer of insurance plans are the large companies and they care that their employees have coverage for substance abuse treatment and for mental health, since these are the main reasons for losing good employees. Untreated employees do not return to work and must be replaced. Replacing employees is a complany's biggest expense." Dr. Johnson had earned an M.B.A. degree prior to becoming a psychologist and was well informed about the business view of mental health coverage. "Employers are not going to buy insurance products that lack mental health and substance abuse coverage. To be competitive, insurers must cover these services."
Though this made sense, it reminded me of an item in a newsletter to which I subscribe, Silicon India." This newsletter reported to its largely Indian audience that U.S. companies had decided that employees were readily replaceable and were therefore disposable commodities. This fit my impression of business in the U.S. better than Dr. Johnson's statement that recruitment and retention are a company's biggest costs. "But who will they credential to provide the coverage?" I asked.
"That's the question," agreed Dr. Johnson. "Clearly psychiatrists and licensed psychologists will be covered, but what about the many other mental health care providers?" He didn't know. These include marriage and family therapists (who paradoxically, mostly see individuals), licensed clinical social workers, certified counselors, certified drug and alcohol counselors, school psychologists, educational psychologists, and more. Whether insurance companies will reimburse any or all of these providers remains to be seen.
Despite this very good news, insurance companies have other tricks to reduce coverage. They can limit the number of credentialed providers. If they credential only a small number of providers in a given speciality or field, then access is limited. Only providers approved by the insurance companies are eligible to bill them. If this number is kept low, access is reduced, and utilization decreased. I observed this in action in the 1980s when I worked for an HMO in California. One of my duties was to provide acupuncture in the Pain Clinic. The HMO widely advertised how progressive they were to provide acupuncture. However, given that only two physicians provided acupuncture and only a part of their time, access was limited. Patients waited six months and could only be seen every six to eight weeks. This is rarely enough for most acupuncture protocols to be effective, especially for more serious and chronic pain syndromes. I challenged our policy, suggesting that we limit access so that people who began acupuncture could be seen once or twice per week until they finished a course of treatment that would be sufficiently intense as to have a chance of being effective. My suggestion was vetoed. The point was advertising coverage, not providing effective treatment programs. Upper management did not even believe that acupuncture worked. The intent was more about marketing than efficacy.
