Grand Rounds

Why we do the things we do

Mad as Hell and Worried I'm Going to Have to Take It

Mental Health Parity can feel delusional.

Let me go over a few maddeningly unchanging facts, with a few opinions thrown in for good color commentary. Much of this many of you will already know, but, as with all political issues, sometimes it is helpful to restate the obvious in order to accentuate the corresponding lack of progress.

1. We are the only developed country to carve out psychiatric care to for-profit insurers. Thus, although much of our health insurance payers are non-profit (Blue Cross, for example) we see fit as a culture to allow for-profit, private companies to "manage" a significant portion of our health.

2. These for-profit companies have a major obligation to their board to deliver the most "cost efficient" - read, "cheapest" - care possible. By definition (i.e., "for-profit") these companies must make the most money possible in the least amount of time. I don' think this is necessarily immoral. If you are "for-profit," then your job is to profit. I need to make more than I spend to take care of my family; that's how you make a living. I just find the juxtaposition of these payers with my work at best tacky, impersonal, and inconsistent, and at worse, down-right horrific.

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3. Folks are tied to their insurers through their work. As work changes, so changes their insurance for health care. With every change in insurance, there are corresponding changes in mental health insurance as well.

4. Since folks are changing jobs a lot these days, they are also changing insurance. This means that in order to turn a profit, the for-profit mental health payers can make the most money by, to put it bluntly, stalling. Every little barrier to care saves money, and believe me, the barriers have increased dramatically over the last few months. People move onto to other insurers, and if the companies can create enough barriers, people whose very suffering makes them more prone to give up will go on suffering and cost a given mental health carve-out less money than if services were more readily available.

Thankfully, some of these ongoing circumstances lead to the long-awaited passage of Federal Mental Health Parity in this country. This development was loudly applauded at a recent meeting I attended in England discussing international approaches to reducing stigma in public and professional perceptions of mental health.

Part of the reason a bunch of international academics who study stigma were interested involves current research that psychiatric insurance carve-outs have a significant attitudinal consequence among medical students and other current and future health care providers. Many have gotten the impression that because our culture has deemed it legitimate to carve out psychiatric care and thus make it more difficult to receive needed services, then there must be some validity to the prejudice and short shrift that psychiatric suffering itself receives in our country. This has been studied and documented.

All of this is akin to shopping at Whole Foods for all of your medical care and then bopping into 7-11 for some beef jerky and a soda when feeding your psychiatric needs.

And, boy, am I worried that things are going to get worse. Things will certainly look economically bleaker before they get better, and these very stressors that lead to increased psychiatric illness are likely also to lead our enlightened policy makers, once again, to cut costs in the psychiatric arena in an effort to save a few bucks.

If you're lucky, you haven't had to directly confront these issues. However, given the amount of psychiatric and psychological suffering, the odds are that if you haven't been down this Byzantine path, someone you care about has. They just haven't told you, potentially because the very barriers to care that they've encountered make them feel ashamed of needing the care in the first place. This reaction has also been documented.

I have watched, over the last two months alone, the amount of regulatory oversight into my work mushroom to new heights. Although I prefer my posts to be more light-hearted, I find it hard to scrape levity from the increasingly nasty practice of telling people I don't know all about patients for whom I care deeply and then having the people I don't know read off a series of questions, like Stepford reviewers, and then at first deny care.

It is a game. They know they'll approve care. I know they'll approve care. There's a script we follow, like actors in a failing Kabuki theater heading down an inevitable path while the audience chuckles sadly at our seeming inability to just arrive at the last scene without all the drama in between.

"I'll have to have you talk to our doctor on call," they say eventually. "Thanks," I say back. (My script allows for little more here, though the language of my unspoken affect is more colorful if not fit for all audiences...). The doctor-on-call comes on the phone, sitting someplace, I imagine, or perhaps working out on the stair-master. Maybe he or she is wearing a bathrobe. I don't have any idea who I am talking to, how they can assess my patient whom they've never met, and how they determine proper care from their kingdom of pre-approval. Usually things go OK and treatment is approved, except it can take as long as a few days, and by the end of all that, I feel pretty beat up and genuinely saddened. What a message to convey to our culture, that all of this is necessary to validate a certain kind of suffering.

I am all for cost oversight. I just think we can do it better and more humanely.

At the end of the day, this is stigma, formally defined as an explicitly visible sign, a stigmata, that confirms shame on those who show it. We have sanctioned this stigma for way too long, and the stage is now set, as we rebuild our increasingly dysfunctional health care system, to get this right. It is our ethical as well as our economical imperative, and I would put the priorities in exactly that order.

Steven Schlozman, M.D., is an Associate Director of Medical Student Education in Psychiatry for Harvard Medical School.

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