Pay­ment headaches hin­der progress on men­tal health ac­cess

Modern Healthcare - - Q&A - By Steven Ross John­son

Dr. David Reiss has seen a lot of changes in his field dur­ing 32 years as a psy­chi­a­trist. He has a pri­vate prac­tice in South­ern Cal­i­for­nia but re­cently be­gan com­mut­ing to work as a locum tenens physi­cian in New York City to off­set de­clines in re­im­burse­ment.

“Ev­ery­thing these days is driven by com­pen­sa­tion,” Reiss said. “Whether it be Med­i­caid, Medi­care or pri­vate in­sur­ance, ev­ery­thing is cut to the bone.”

Seven years ago, Reiss stopped ac­cept­ing new pa­tients with pri­vate in­sur­ance at his pri­vate prac­tice. He’d had enough of fill­ing out pa­per­work and fight­ing with health plans to con­vince them that the treat­ment he pre­scribed was ap­pro­pri­ate.

“You pre­scribe some­thing but it takes some­one three weeks for it to go through pre-au­tho­riza­tion to get the pre­scrip­tion,” Reiss said. “It’s just un­work­able.”

Reiss ac­knowl­edges his de­ci­sion to limit the types of pa­tients he sees may con­trib­ute to the short­age of men­tal health providers in this coun­try. About 55% of U.S. coun­ties, all ru­ral, have no prac­tic­ing psy­chi­a­trists, psy­chol­o­gists or so­cial work­ers, ac­cord­ing to a 2013 re­port to Congress from the Sub­stance Abuse and Men­tal Health Ser­vices Ad­min­is­tra­tion.

Just 55% of psy­chi­a­trists ac­cepted pri­vate in­sur­ance as pay­ment in 2010 (com­pared with 89% of doc­tors in other med­i­cal spe­cial­ties) and the per­cent­age had de­clined 17% since 2005, ac­cord­ing to a 2014 study pub­lished in JAMA Psy­chi­a­try. Medi­care and Med­i­caid ac­cep­tance rates among psy­chi­a­trists were also lower com­pared with the rates of other physi­cians. The same study found 55% of psy­chi­a­trists ac­cepted Medi­care re­im­burse­ment, com­pared with 86% of physi­cians in other spe­cial­ties, while 43% ac­cepted Med­i­caid, com­pared with 73% of other doc­tors.

The de­clin­ing will­ing­ness to ac­cept third-party re­im­burse­ment comes down to dol­lars and sense. Rates for some of the most com­mon be­hav­ioral health ser­vices, such as out­pa­tient ther­apy, di­ag­nos­tic eval­u­a­tions and med­i­ca­tion man­age­ment, have not changed sig­nif­i­cantly in more than a decade.

Many men­tal health providers and pa­tient ad­vo­cates hoped the Af­ford­able Care Act and the 2008 Men­tal Health

Par­ity and Ad­dic­tion Eq­uity Act would im­prove ac­cess to men­tal health and sub­stance abuse treat­ment for mil­lions of Amer­i­cans. In­deed, the ex­pan­sion of health cov­er­age along with the pro­tec­tions pro­vided in both the ACA and men­tal health par­ity leg­is­la­tion have in­creased ac­cess.

But the bar­ri­ers that re­main could lead to a men­tal health sys­tem that lim­its many ser­vices to peo­ple with the means to pay out of pocket.

“It’s just part of the job in an out­pa­tient prac­tice, know­ing that you’ll have to fight with in­sur­ance com­pa­nies,” said Dr. Bobbi Weg­ner, a Bos­ton-based clin­i­cal psy­chol­o­gist.

Weg­ner said she never thought about in­sur­ance cov­er­age or re­im­burse­ment dur­ing her first few years as a clin­i­cal psy­chol­o­gist in­tern at Mount Si­nai School of Medicine in New York City. It was only af­ter she joined the clin­i­cal staff at Bos­ton Be­hav­ioral Medicine eight years ago that she be­came aware of the re­la­tion­ship be­tween hav­ing the right cov­er­age and ac­cess to care.

“We con­stantly have a wait­ing list,” Weg­ner said. “But of­ten­times it’s hard to find a match in terms of peo­ple who have in­sur­ance that I can take and a match in terms of time and avail­abil­ity.”

In her first three years at Bos­ton Be­hav­ioral Medicine, Weg­ner han­dled her own billing—the clin­i­cians at the prac­tice are in­de­pen­dent providers rather than em­ploy­ees. The hours she spent talk­ing with in­sur­ers cut into her time to see pa­tients, tempt­ing her to forgo ac­cept­ing in­sur­ance at all.

“In­sur­ance is just no­to­ri­ously dif­fi­cult to work with,” Weg­ner said. “They will try to deny a claim with­out any real rea­son, just hop­ing that you’re not go­ing to fight it.”

Weg­ner ul­ti­mately opted to con­tinue to ac­cept in­sur­ance, she said, for the sake of mak­ing men­tal health­care ac­ces­si­ble to a wide range of pa­tients.

Although Reiss reached the op­po­site con­clu­sion, he says it wasn’t easy. Still, he con­tends that health plans and govern­ment pro­grams im­plic­itly en­cour­age men­tal health pro­fes­sion­als to fo­cus on vol­ume to come out ahead, de­tract­ing from the qual­ity of care. “Yes there are go­ing to be peo­ple who can’t get ac­cess, but there are more peo­ple be­ing hurt by the ac­cess they’re given where they re­ceive lousy treat­ment.”

Men­tal health providers have strug­gled for years to gain more eq­ui­table com­pen­sa­tion and recog­ni­tion that they pro­vide valu­able ser­vices. And they say the re­cent progress hasn’t been fast enough to meet in­creases in de­mand.

The men­tal health work­force, mean­while, could shrink as providers re­tire from the field. The me­dian age for psy­chi­a­trists is over 55, with 46% age 65 and older, ac­cord­ing to SAMHSA.

Those num­bers are par­tic­u­larly stark when one con­sid­ers that more than half of Amer­i­cans with a men­tal ill­ness do not re­ceive care. And as fewer providers are will­ing see all pa­tients, other providers are asked to take on more vis­its while pa­tients ex­pe­ri­ence longer de­lays for care.

Such lim­its on provider ac­cess are more likely to af­fect low-in­come pa­tients. While more low-in­come in­di­vid­u­als have gained ac­cess to men­tal health ser­vices through the ACA’s Med­i­caid ex­pan­sion and by gain­ing cov­er­age through the in­sur­ance ex­changes, a short­age of men­tal health pro­fes­sion­als will­ing to see pa­tients with public or pri­vate in­sur­ance makes ac­cess to care in­creas­ingly dif­fi­cult for low-in­come pa­tients, who are often un­able to af­ford their out-of-pocket obli­ga­tions.

High de­ductibles and cost-shar­ing in the most af­ford­able ACA plans often dis­cour­age the newly insured with men­tal health needs from seek­ing care. Though men­tal health ser­vices are con­sid­ered one of the ACA’s 10 es­sen­tial ben­e­fits, the law only en­sures first-dol­lar cov­er­age for de­pres­sion screen­ing. Men­tal health coun­sel­ing and psy­chother­apy are granted par­ity with med­i­cal ser­vices but re­main sub­ject de­ductibles and cost-shar-

ing. The av­er­age an­nual de­ductible for an in­di­vid­ual bronze-level plan (the most af­ford­able tier) in the ACA ex­changes was about $5,700 in 2013.

“I think what we’ve gained in the last cou­ple of years is greater un­der­stand­ing of what some of the gaps are and what we need to do to mov­ing for­ward to get these things im­ple­mented prop­erly,” said Paul Gion­friddo, CEO of the pa­tient ad­vo­cacy or­ga­ni­za­tion Men­tal Health Amer­ica. “But in terms of get­ting a lot more providers into the mix, get­ting a lot more providers into the net­works, and get­ting a lot more ac­cess for in­di­vid­u­als, I think we still have a long way to go.”

One of the larger road­blocks has been the his­tor­i­cally low rates psy­chi­a­trists re­ceive com­pared with rates paid in other spe­cial­ties, ac­cord­ing to Gion­friddo. “Pay­ing men­tal health providers less than a skilled trades­per­son is not par­ity,” Gion­friddo said, re­gard­ing the av­er­age salary of men­tal health coun­selors and so­cial work­ers. In Mod­ern Health­care’s 2016 physi­cian com­pen­sa­tion sur­vey, psy­chi­a­trists were among the five low­est paid spe­cial­ties at $250,000 a year, less than half the av­er­age salary of the high­est paid spe­cial­ists, ortho­pe­dic sur­geons.

“Be­hav­ioral health providers ap­pear to be dis­pro­por­tion­ately low in terms of their re­im­burse­ment rates that they re­ceive from in­sur­ers, and even from Med­i­caid and Medi­care,” said An­gela Kim­ball, na­tional direc- tor for ad­vo­cacy and public pol­icy for the Na­tional Al­liance on Men­tal Ill­ness.

One of the most com­mon men­tal health ser­vices pro­vided is a 45-minute out­pa­tient psy­chother­apy ses­sion. Ac­cord­ing to a list of Med­i­caid rates for men­tal health ser­vices for the state of Mary­land, physi­cians get paid $83 for such a ses­sion.

Medi­care, mean­while, paid an av­er­age rate of $102 for 45 min­utes of psy­chother­apy in 2001, ac­cord­ing to the ad­vo­cacy arm of the Amer­i­can Psychological As­so­ci­a­tion, a rate that has since dropped by 35% to $86 a ses­sion. The or­ga­ni­za­tion es­ti­mates Medi­care pay­ments are about 17% lower than pri­vate mar­ket in­sur­ance rates.

Some blame the rise of man­aged-care or­ga­ni­za­tions for the de­cline in re­im­burse­ment be­cause they cut costs by re­duc­ing uti­liza­tion of ser­vices. The strate­gies have re­sulted in uti­liza­tion re­view pro­grams that judge the med­i­cal ne­ces­sity of care that providers pro­pose.

An­other chal­lenge is earn­ing in­clu­sion on in­sur­ance pan­els.

“There is a high bur­den of pa­per­work on men­tal health providers com­pared to other forms of care, and in­creas­ingly there are chal­lenges with cre­den­tial­ing and get­ting into the provider net­works of health in­sur­ance plans or Med­i­caid pro­grams,” Kim­ball said. “So given all of the vari­ables that can make one’s pro­fes­sion more chal­leng­ing, I would say the odds are not stacked in fa­vor of men­tal health providers.”

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Source: JAMA Psy­chi­a­try

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