And When Reforming Insurance, Don't Forget Mental Illnesses

February 28, 1993|By STEVEN S. SHARFSTEIN

A 35-year old lawyer faces financial ruin due to a serious mental illness. Her health insurance policy only covers 30 inpatient days and 20 outpatient visits per year and has a $25,000 lifetime maximum.

This contrasts with coverage for all other general medical conditions with no limit on length of stay or office visits and a $1 million lifetime maximum. She suffers from severe depression, alternating with mania, which has been successfully stabilized over the years through a variety of medication strategies.

Unfortunately, she occasionally develops side effects to these medications that require rehospitalization. With her fourth episode requiring inpatient care, the family faces treatment costs approaching $20,000 per month -- and financial devastation.

A 32-year old homeless man has suffered from chronic schizophronia since age 21 and has been without health insurance benefits for eight years. Follow-up treatment through a community mental health center has proven to be inadequate and he drifts in and out of public hospitals when his condition worsens. He refuses to go to shelters and lives on the street suffering from exposure and continuously talking to imaginary voices. Most recently, he has been jailed for vagrancy.

These two patients are examples of a misunderstood and hidden problem in the health care crisis we face today. They are a subset of the millions of Americans who have no health insurance and face financial catastrophe or worse. Health insurance reform that does not specifically include these patients will be extremely costly for other sectors of our society, including the already overwhelmed criminal justice system and social services.

In addition to the 37 million Americans who have no health insurance, another 15 to 30 million have inadequate insurance for the treatment of mental illness. Public sector cutbacks have been combined with private sector rationing, which consists of bare-bones policies with little or no mental health care as well as extremely stringent limits on treatment.

Principles for coverage under national health reform for mental illness should include the following: nondiscriminatory coverage; encouragement of lower-cost alternatives to the hospital; and support from the public sector for high-cost, long-term care.

Psychiatric care remains misunderstood and stigmatized. Payers vacilate between extreme views that the mentally ill are hopelessly disabled or are among the "worried well." Mental illness, in its various forms, is a part of medicine, and with the increasing effectiveness of treatment, the traditional distinctions between "nervous and mental disorders" and general medical conditions are no longer valid.

National health reform should be nondiscriminatory with regard to psychiatric benefits. This entails having whatever limits or managed care restrictions that are placed on general medical benefits be equally applied to psychiatric benefits. Today, no other condition evokes day and visit limits, as well as lifetime maximums, the way mental illness benefits do.

Such nondiscriminatory benefits will encourage the continuum of care and lower-cost alternatives to the hospital. Insurers have not structured benefits to encourage the use of alternatives to hospitalization. While general medicine has made a strong move to alternative settings with surgi-centers, ambulatory care centers, convalesent care units, etc., psychiatric alternatives such as day treatment, residential care and intensive outpatient services are similarly cost-effective and substitute well for more expensive inpatient treatment. National health reform should provide for access to such alternatives.

Long-term care requires the shoring up of the public sector as well as care and support for persistent mental illness. If the money is made available, our strate sstems can provide that care and support in alternative settings.

These reforms would help reduce the inappropriate use of medical care and the criminal justice system. Health insurance reform is no reform unless mental illness benefits are made part of the core benefit package in a nondiscriminatry fashion.

Steven S. Sharfstein is president and medical director of The Sheppard and Enoch Pratt Health System, Inc. and secretary of the American Psychiatric Association.

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