Correspondence
Will Parity in Coverage Result in Better Mental Health Care?
N Engl J Med 2002; 346:1030March 28, 2002
- Article
To the Editor:
Frank et al. (Dec. 6 issue)1 make the case that managed care enhances the affordability and feasibility of parity in coverage for mental health care because of controls implemented by managed-care organizations on the utilization and costs of psychiatric treatment. The authors point out, however, that parity with managed care will not cover many cost-effective services, such as day hospitals, psychosocial rehabilitation, case management, or residential treatment programs. It is this model of acute care in the event of “medical necessity” that has led, in my view, to a downside of managed care that requires attention.
Managed care for behavioral health that is “carved out” of the health benefits provided by an employer — a practice that is ubiquitous — has led to psychiatric hospital stays of ever decreasing duration, so that stays of three, four, or five days are commonplace and multiple readmissions are standard practice. Managed behavioral health care has shifted many people from private insurance to the public sector for care. Parity with managed care has done nothing to reduce the number of mentally ill persons who are homeless or of those who are incarcerated; this situation represents a public health crisis and a failure of public policy.2 Before we think that we have solved the problem of financial discrimination against the mentally ill and the problems associated with their treatment through parity with managed care, we must evaluate more carefully the effects of managed mental health care.
2 ReferencesSteven S. Sharfstein, M.D.
Sheppard Pratt Health System, Baltimore, MD 21204
ssharfstein@sheppardpratt.org 1
Frank RG ,Goldman HH ,McGuire TG . Will parity in coverage result in better mental health care? N Engl J Med 2001;345:1701-1704
Full Text | Web of Science | Medline2
Hall LL, Edgar ER, Flynn LM. Stand and deliver: action call to a failing industry. Arlington, Va.: National Alliance for the Mentally Ill, 1997.
To the Editor:
As a pediatrician in a community with abundant resources for mental health care, I am appalled by the inaccessibility of mental health care providers to my patients. Psychiatrists and psychologists have opted out of insurance panels, simply because they cannot afford to stay on them. When one of my patients with severe learning disabilities and behavioral problems required neuropsychological testing, the health plan covering the patient reimbursed the psychologist $53 per hour for the appropriate consultations, testing, and follow-up.
To improve access to appropriate mental health care services, we need to do more than improve insurance coverage. We have to address the problem of inadequate reimbursement for mental health care providers.
Jonathan A. Benjamin, M.D.
1400 Centre St., Suite 203, Newton Centre, MA 02459Author/Editor Response
The authors reply:
To the Editor: Drs. Sharfstein and Benjamin highlight two points. First, parity is necessary but not sufficient to ensure access to high-quality mental health care services. Second, parity does not provide for many services that are needed to support patients with severe and persistent mental disorders.
Dr. Benjamin is frustrated by the difficulty of finding a child psychiatrist who will accept referrals, despite the fact that he practices in one of the most psychiatrist-rich areas of the country — upper-income communities in suburban Boston. In spite of a seemingly generous supply of therapists, networks can be organized and reimbursed in such a fashion as to create barriers to access that are every bit as substantial as those created by limits on coverage and high levels of cost sharing.
Dr. Sharfstein notes that even in the presence of a benefit providing parity in mental health coverage, the focus of health insurance on acute care limits coverage for cost-effective services such as psychosocial rehabilitation. He also claims that parity and managed care have resulted in a shifting of costs to the public mental health system. Although this effect is plausible, at this point his argument is speculative.
Richard G. Frank, Ph.D.
Harvard Medical School, Boston, MA 02115
frank@hcp.med. harvard. edu Howard H. Goldman, M.D., Ph.D.
University of Maryland School of Medicine, Baltimore, MD 21201Thomas G. McGuire, Ph.D.
Harvard Medical School, Boston, MA 02115
