"Managed Care" policies, it has been argued, often fail to ensure patients' rights to appropriate treatment, with a provider of their choice, for a duration sufficient to fully address the presenting problem.
The law now provides Consumer protections such as
disclosure requirements, grievance procedures for patients, and an end to the "gag rule" which punished health care providers for being honest with their patients about the quality of care within an HMO.
However, legislators failed to enact safeguards which would ensure "point-of-service" options for patients seeking treatment with a doctor of their choice, outside a Managed Care network.
Throughout 1997-1998, despite a booming economy and record corporate earnings, standard fees to health providers plummeted, causing many to leave Managed Care panels, and denying consumers choice of qualified providers. Where psychotherapy is still available under Managed Care, it has become severely restricted in terms of allowing the doctor rather than the telephone clerk to determine what is in the patient's best interest, both short-term and for the long-term.
1998 In Review
New York State became eligible for $256 Million in additional money for the Child Health Plus program which,
in theory, allows for up to 60 outpatient visits per year, but in practice only allows 20 for treatment. There are efforts underway to make these benefits "convertable", and this is seen as an excellent area in which individuals and organizations might be pro-active.
Who is eligible for Child Health Plus? Dr. Frank Goldberg explains: "Any child NOT eligible for Medicaid, not insured, and with a family income up to 222% of the poverty level". Bringing the floor up to 300% would, if this could be attained, provide "near universal" mental health coverage for children.
The proposed law would have allowed the growth of several bachelor's and masters-level professions, with both appropriate scope and limitations to protect the consumer. It was also very clear in its definitions of both psychological and medical treatment, so that unless one profession feels the need to defend against the other, there should have been no ensuing "turf" wars in the immediate future...which would have been good for everyone-- professionals, consumers, and MCO's too. However, the Medical Society of NY waged a massive financial and political crusade to defeat the entire bill. The bill was next re-introduced in the Year 2000 legislative session.
The Mental Health Parity Act of 1996 (P.L.104-204) was signed into law by President Clinton on September 26, 1997. Passed with broad bipartisan support, the legislation was hailed by the National Alliance for the Mentally Ill as the beginning of movement toward " the process of ending the long-held practice of providing less insurance coverage for mental illnesses, or brain disorders, than is provided for equally serious physical disorders".
The Mental Health Parity Act of 1996 took effect on January 1, 1998.
Key Provisions Of The Law
- The law equates aggregate lifetime limits and annual limits for mental health benefits with aggregate lifetime limits and annual limits for medical and surgical benefits. The yearly and lifetime caps, however, are unequal.
- The law covers "mental health services" but NOT substance abuse or chemical dependency treatment.
- The Federal Law does NOT preempt State "parity" laws, and allows for States to legislate more comprehensive coverage than the minimum prescribed Federally.
- The law applies only to employers in large companies with health plans which include mental health coverage. Such coverage is not mandated.
- The law allows for cost shifting, hardship exemptions for employers, raising deductibles, raising co-insurance, limiting number of outpatient visits, and limits on coverage for prescription medications.
What’s Not Covered
In accordance with this new Federal Law, many individual States have been enacting Legislation of their own since 1997 to protect consumers beyond the provisions of the the parity amendment. In New York State, several coalitions representing consumers and health care providers has been formed to "fight to end health insurance discrimination against persons living with mental illness and chemical dependency."
- There is no mandate for mental health benefits in insurance plans.
- Coverage is not provided for treatment of substance abuse and chemical dependency
- There are no rules or guidelines governing out-of-pocket limits, copayments, arbitrary treatment termination, or quality of care for patients.
- The law does not apply to businesses with less than 50 employees.
- An employer can also be exempt if it can be shown that mental health parity would raise costs more than 1%.
The task still remains to remind employers, employees, legislators and mental health professionals alike, that mentally healthy workers are more "productive" workers,with better morale, lowered sick days, etc. Consumers already know that the fabric of society is shaped by the mental health of our friends, family, neighbors and political leadership. The fight for true mental health "parity" continues. A list of national organizations and resources is provided below.
The Patient/Provider Perspective
Psychology's Future under Managed Care?
A provocative interview with Nicholas Cummings, pioneer advocate of industrialized managed behavioral healthcare, and former President of APA. Was he right?
Mental Health Bill of Rights
600,000 Mental Health Professionals issue this proclamation of basic healthcare rights. (3-97) Risk Management for Practitioners
An Interview with Bryant Welch, J.D., Ph.D. (11-2000)
Overview of legal and quality-of-care issues, ranging from liability insurance to nuances of online practice.Part of an excellent Professional Interview Series directed towards health professionals. (athealth.com) Suing Managed Care
Bryant Welch, J.D., Ph.D. (3-97)
A short list of compelling arguments when seeking redress from MCO's.
Large corporations are beginning to review the evidence of how managed care typically benefits the insurers more than either the companies or the employees. (In fact, as one company learned, the costs associated with managed care administration and fees often surpass the cost of uncapping mental health services, and letting morale and productivity improve as a result.) The story of one very successful corporate move away from managed care, follows, courtesy of Frank Goldberg, Ph.D., Alliance for Universal Access to Psychotherapy:
Motorola Rejects Managed Care
Because a behavioral managed care organization did not produce much savings in outpatient mental health costs (due to clerical, executive staff and overhead costs, and the expenditures necessary to sustain micro management controls) the Motorola Corporation, a large nationwide electronics firm based in Texas, decided to implement their own self-insured plan. In effect, since January, 1996, Motorola provides unlimited outpatient psychotherapy benefits to its employees with no yearly or lifetime cap. There is a panel of providers, but an employee can recommend a non-panel provider of their choice, who, if meeting the necessary professional credentials and submitting two sample treatment cases, will usually be accepted as a provider. There is no pre-certification. Fees vary depending on location.
There is a quality check case review after 20 sessions, with no impact on the continuation of treatment. Mr.Tom Schmitt, Regional Manager for Employee Benefits, explained that the program was initiated "to get away from the watchdog, paranoid attitude of managed care companies micro managing benefits, to a more collaborative relationship among the employer, the employee and the provider." The company realizes that most patients stay in treatment for a relatively short period of time (e.g., 5 to 8 sessions, or 12 to 20 sessions). Motorola does not want to erect barriers to treatment and is promulgating this model (with planned follow-up and outcome survey) to improve the mental health of their employees, which they believe has intangible positive morale consequences and translates to increased productivity.
APA Announces Legal
Actions To Protect Patients
The American Psychiatric Association is
going to court to protect the right of patients
to receive optimal care for their mental
illnesses, APA President Harold I. Eist, M.D.,
announced today. In a three-pronged attack,
the APA is:
From President Bill Clinton's State of the Union Address, January 27, 1998: "One hundred and sixty million Americans are in managed-care plans. These plans can save money and can improve care. But medical decisions should be made by medical doctors, not insurance company accountants. So I urge the Congress to write into law a Consumer Bill of Rights that says this: You have the right to know all your medical options, not just the cheapest. You have the right to choose the doctor you want for the care you need. You have the right to emergency room care, wherever and whenever you need it. You have the right to keep your medical records confidential. Traditional care or managed care, every American deserves quality care."
Congressional Testimony on the "Malpractice" of Managed CareTestimony of Congressman Ganske regarding Health Care Reform, from the Congressional Record, March 28, 2000. Poignant testimony from this former surgeon turned legislator.
Health Administration Responsibility Project (HARP)The Home Page of a large and activist group of doctors, lawyers and consumers, opposed to Managed Care. Many resources, articles, list-servs, and more.
New York State Bill to enact Single Payer Health Insurance:
(March 2001) Assembly Bill A04700: Summary | Full Text
Physicians for a National Health Plan (PNHP)Includes a Q&A about Single Payer National Health Insurance, information on alternatives to "Managed Care" and Why the U.S. Needs a Single Payer System.
Psychologists' Guide to AdvocacyFrom the American Psychological Association, features updates on important issues relating to national mental health policy.
Last Updated: Saturday, 06-Sep-2014 05:13:59 EDT