Second-class treatment: Care for the mentally ill lags Caution greets calls for parity HEALTH CARE -- COSTS & CHOICES

May 30, 1993|By Michael Ollove | Michael Ollove,Staff Writer

In early editions of The Sun yesterday, an article erroneously stated insurance plans' co-payment for psychiatrists compared with that for other kinds of doctors. It is typically 50 percent or 65 percent compared with 20 percent for other physicians.

The Sun regrets the error.

Six years after Douglas Marquis won the Maryland Distinguished Scholar Award, he bought a hank of rope at a convenience store and hanged himself from a tree in front of his father's home in Ohio.

The cause of this 24-year-old artist's suicide was no mystery: He had suffered from a severe mental illness for at least six years. His sickness was the given, the inalterable. But there also was an "if only," component that will never cease to torment his mother. "If only he had been taken back in the hospital when he asked," says Linda Crane, "he wouldn't have died."


The staff at the Columbus hospital had told Ms. Crane, who was then living in Ellicott City and working on a Ph.D. in psychology, that Douglas didn't require hospitalization. In hindsight, of course, it was a great miscalculation of a medical necessity. But Ms. Crane is convinced that other factors having nothing to do with medical concerns were also at work.

Under his insurance plan, Douglas was entitled to 30 days of psychiatric hospitalization each year. But he had already used up almost all of that time, which is why, his mother believes, the hospital wouldn't admit him.

Three years after her son's death, Ms. Crane says Douglas was the victim of a peculiar kind of bias in U.S. health insurance, one that has consigned mental illness to secondary significance in the spectrum of disease. Had he suffered from heart disease or cancer, the limits of his medical care might have seemed boundless. Because he was a schizophrenic, he was very

quickly on his own.

Although the mentally ill and their advocates had hoped comprehensive health-care reform would bring an end to disparities in health benefits, the word from Washington has been deflating. While Hillary Rodham Clinton's task force has expressed unhappiness over the way mental illness is treated by American insurance plans, Mrs. Clinton herself conceded last week that the disparities cannot be eliminated at once.

"The goal is to achieve full parity," says Richard Frank, a staff member of the task force and an expert on the economics of mental illness. "Whether we can get all the way there from where we are now is what has to be thrashed out."

A misunderstood illness

It is, everyone concedes, a rather wide expanse to traverse. "Psychiatric illness is not understood in this country," says Ms. Crane. "It's thought of as hypochondria or malingering or misbehaving. It's not seen as a physical illness. As a result, there isn't seen a perceived need to take care of it in the way that other illness is. It's seen as coddling.

"But my son," she says, slowly enunciating each word, "was tragically, catastrophically ill."

Douglas Marquis suffered from a stigma that has been institutionalized by America's health insurance industry. The vast majority of insurance plans today offer two tiers of benefits: one level of coverage for mental illness and a second, much higher level of coverage for everything else.

So, for example, most private insurance plans in the United States limit the number of days psychiatric patients can stay in a hospital -- usually 30 or 60 days -- but place no restrictions on other kinds of patients.

Most plans require a much higher co-payment for psychiatrists compared with other kinds of doctors -- typically 50 percent or 35 percent compared with 80 percent. And most place ceilings on the total expenditures for mental health services.

Health maintenance organizations are generally even more neglectful of psychiatric patients. Many plans provide for no psychiatric hospitalizations at all and limit outpatient doctor visits to 20 a year. Many will authorize outpatient visits only if a life is at stake.

The federal reimbursement plans aren't much better. Medicare pays less for psychiatric outpatient care than for other medical treatment. Even Medicaid, which in Maryland generally pays for full psychiatric treatment, will not cover most patients at state mental hospitals. Medicaid also is accepted by few private practitioners.

Affording therapy

The way mental health is treated by most plans turns the notion of insurance on its head. It covers people for those expenses they could afford to pay on their own but not for those they can't.

"The limits start to kick in when you get into catastrophic losses," says Mr. Frank, a professor at the Johns Hopkins School of

Public Health.

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