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Peace of Mind Difficult to Find

Posted on: Sunday, 25 September 2005, 18:00 CDT

Sep. 25--Your adopted daughter suffers from bipolar disease and the lingering effects of her biological mother's drug and alcohol abuse. She's in and out of the hospital, with stays cut short by insurance limitations. By the time she is 16, her $100,000 lifetime insurance benefit for mental health has maxed out. After a violent incident, you have her charged with assault so she can be placed under state supervision and continue to receive psychiatric care.

And then, while trying to live on her own, she attempts suicide -- for the 11th time.

That is the reality faced by an Overland Park couple who are exhausted by a 15-year fight to get their daughter, now 20, the care she needs.

"The doctors are under great pressure to get the patients out of the hospital," the father said. "Without a doubt, insurance coverage for psychiatric patients is very limited."

Welcome to the ongoing battle for care that confronts more than 44 million Americans who suffer from diagnosable mental disorders. It is a health-care crisis that prompted six Cabinet-level federal departments this summer to launch an agenda to "transform" mental health care in America.

For decades, this complex, often frustrating, system has thrown up obstacles to recovery, critics say. Patients seeking treatment and their families can face a tortuous path through a mazelike bureaucracy, hospital and doctor shortages, insurance problems and social stigma.

And the patients must navigate this system while coping with disorders that often cripple their ability to think clearly.

"It's very, very bad," said Frederick Mittleman of Prairie Village, who has practiced psychiatry for more than 30 years. "The general attitude now is that people have to fend for themselves."

The New Freedom Commission on Mental Health, a panel established by President Bush, says the U.S. mental health system is "fragmented and in disarray ... lead(ing) to unnecessary and costly disability, homelessness, school failure and incarceration."

And chances are it is affecting someone you know.

Critics say the barriers to mental health care come in many forms and challenge the insured and uninsured.

For example, patients with the most serious illnesses face a basic challenge of finding beds.

Despite some recent improvements, such as Shawnee Mission Medical Center's renovation of its mental health and addiction recovery units, the local bed situation alarms many mental health providers and advocates.

Sybil Noble, founder of the Ark of Friends, a local mental health support group, said there's "such a shortage of beds right now that people ... are having trouble accessing a place where they can go to the hospital."

According to data compiled by Research Psychiatric Center, one of the oldest psychiatric hospitals in the Kansas City area, the number of acute inpatient psychiatric beds in the region declined from 1,283 in 1991 to around 500 today -- a drop of more than 60 percent.

"Managed-care rates for inpatient psychiatric care were cut so much that that it just made it real difficult to maintain financially viable programs," said Bruce Johnson, director of therapeutic services with Research Psychiatric Center.

Johnson told of a local family with good health insurance, in which a teenage boy with severe depression needed long-term psychiatric care.

Even though the boy had sexually molested a younger sibling at home, hospitals refused to admit him because they lacked space.

"It was horrible," Johnson said. "The boy couldn't be kept at home, so dad stayed with him in a hotel" until the boy could be placed in a residential care facility.

Johnson said local patients often go as far as Wichita, Springfield and Topeka in search of beds. Such distances make it difficult for doctors to follow up with their patients and for families to play active roles in that care.

Overland Park health-care consultant John Leifer said that "mental health is high on the list of services to cut" as hospitals face increasing competition and reduced reimbursements.

The search for beds is only part of the problem, said Guyla Stidmon, executive director of the National Alliance for the Mentally Ill of Greater Kansas City. Stidmon said it can take three or four months to get outpatient treatment -- insurance or no insurance.

The number of psychiatrists is not keeping up with demand, said Stuart Munro, assistant medical director of Western Missouri Mental Health Center. He said the field has been underserved for at least 40 years.

For patients who find beds and doctors, insurance benefits may be another hurdle.

Psychiatrist Mittleman said he is fed up with trying to convince insurance companies that patients should be admitted to hospitals.

"Then once they get in, they want them out immediately," Mittleman said. "And oftentimes that would mean that they would try to get you to discharge patients before you felt comfortable."

That was an issue for the Overland Park couple whose daughter has bipolar disease, which characteristically involves cycles of depression and elation or mania. They recalled when their daughter, then 16, rolled into a ball and could not stop crying. She was admitted to Research Psychiatric Center.

"They got her stabilized on medication, and the insurance company said eight or 10 days would be enough," the mother said.

She said the doctors at Research argued unsuccessfully that the girl was being discharged too soon.

"When you have a psychotic event, you've had an assault to the brain," said the mother, who is a psychologist. "These individuals have to have some time to recover."

Mohit Ghose, spokesman for America's Health Insurance Plans, an insurance industry trade group, said insurers must balance providing needed care and keeping it affordable.

Said John W. Kennedy, executive vice president and chief operating officer at Blue Cross and Blue Shield of Kansas City: "We want appropriate treatment in the appropriate location for the appropriate period of time. We're trying to improve the health of the community we're serving here," Kennedy said of his company, which is the area's largest health insurer.

Critics say that mental illnesses are not allowed the same level of coverage as physical illnesses.

Parity laws, which seek to limit disparities with other medical coverage, have been passed in nearly every state, including Missouri and Kansas. These laws cover state-regulated insurance plans, generally those offered by small and midsize businesses.

The Missouri parity law states that mental health benefits "shall include at least two sessions per year" from a licensed psychiatrist or other mental health professional.

"That's a joke to me," said Stidmon of the alliance for the mentally ill. "I know people who have that many visits with psychiatrists in a week. Mental illness is not something that can be stabilized that quickly."

Kansas' parity law says coverage shall include, on an annual basis, up to 45 days of inpatient care and/or 45 visits for outpatient care.

But Topeka psychologist Ira Stamm said the 45 days/45 visits clause does not apply to all forms of mental illness or emotional distress. He added that health insurance companies frequently rule that 45 days of inpatient care and/or 45 outpatient visits are not medically necessary.

Graham Bailey, spokesman for Topeka-based Blue Cross and Blue Shield of Kansas, countered that "the mandated benefits don't mean that you just pay for those carte blanche." For services to be covered under a Blue Cross and Blue Shield of Kansas contract, the services must be deemed medically necessary, he said.

State parity laws also do not apply to consumers covered by federally regulated health plans, generally those provided by large employers.

To address those plans, Congress in 1996 passed the Mental Health Parity Act, which requires annual or lifetime limits on mental health benefits be no lower than those for medical and surgical benefits.

But the National Mental Health Association says that "many employers have been able to skirt the spirit of the law" by imposing new restrictions on the number of covered inpatient days or outpatient visits. What's more, the law does not require group health plans to include mental health coverage in their benefits package.

Even so, health-care statistics suggest disparities persist.

In 2001, about 63 percent of mental health expenses were covered by public sources versus 45 percent of health care expenses overall, according to the Substance Abuse and Mental Health Services Administration. The agency noted that mental health expenditures are falling more to public funders such as Medicaid, the financially struggling health insurance program for the poor that has been cutting back.

That rankles providers.

"It is quite clear ... that private insurance has cut back dramatically on paying for the treatment of our patients," psychiatrist Steven Sharfstein, president of the American Psychiatric Association, wrote in the July 1 issue of Psychiatric News. "With Medicaid cuts projected at $10 billion over the next five years, people with mental illness are more at risk than ever."

On a more basic level, mental health patients also must overcome the widespread stigma attached to their illness.

Jennifer Martin, a 28-year-old Kansas City attorney who is battling depression, said that when she started receiving treatment in November 2003, she never said a word about it to the senior partners of the firm where she was working.

"I was afraid they would think I couldn't handle my job," she said. "I was told, 'Never let them know how stressed you are, because then you won't get the good assignments.' Even though stress is not the same thing as depression, I didn't think they could understand that difference."

One local patient, who requested anonymity, said that for years he has paid for all his mental health treatments out of his own pocket. The total: more than $200,000.

"I was paranoid about putting it on my health insurance for fear of job implications and career implications," he said.

There also can be more long-term insurance implications.

Martin lost her group insurance when she left her last job to start her own practice. She said health insurance companies rejected her for nongroup, individual coverage because of her illness.

"It's an outrage," she said. "They don't make you stop taking allergy medicine or birth control medicine or asthma medicine to get insurance. But they want me to stop being treated for depression."

The system can be fixed, say mental health-care advocates.

William L. Bruning, president of the Mid-America Coalition on Health Care, said it will take a major coordinated national effort to bring appropriate treatment to the millions of Americans who need it.

"You start by recognizing that mental illness is a disease which, left untreated, can be fatal," he said. "Therefore, it must be addressed as we would any other similarly serious disease."

The issue is getting more attention, in large part because of the president's New Freedom Commission on Mental Health, which outlined problems in a 2003 report.

In response to the report, six Cabinet-level departments this summer unveiled "Transforming Mental Health Care in America. The Federal Action Agenda."

Among 70 specific "first steps," the plan calls for protecting the rights of people with mental illness, launching a consumer Web site and public education campaign, and working with employers on approaches to paying for mental health services.

In addition, the Campaign for Mental Health Reform, which represents 16 national groups, has proposed a similar "road map" for change.

But in these days of rising health-care costs, these ideas face their own obstacles.

Psychiatrist Mittleman clings to the hope that the public will simply acknowledge that mental health patients have legitimate needs that require substantive action.

"These people are not going to go away," he said. "If they're underserved in the mental health arena, they show up somewhere else."

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Copyright (c) 2005, The Kansas City Star, Mo.

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Source: The Kansas City Star (Kansas City, Missouri)

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