Pitfalls of Using Health Insurance For Mental Health Care

Because of the unfortunate stigma still attached to mental health conditions, people should think twice before using their health insurance to pay for visits to a mental health professional, such a marriage and family therapist, a psychologist or psychiatrist.

If you do have health insurance coverage, your first reaction might be to think, “Well, if I’ve got insurance, why shouldn’t I use it? That’s what it’s there for.” And, most of the time, that’s true. I know I’m certainly grateful for my health insurance when I go to the doctor or dentist.

But it gets more complicated when it comes to mental health care because of negative associations attached to psychological disorders. For example, people probably think differently about an individual who has a physical condition such as a thyroid disorder versus someone who has a psychological condition such as major depression.

The reality is, if you want to get your insurance company to pay for your mental health care, the mental health care provider has to give you a serious psychological diagnosis or the insurance company won’t pay for the treatment.

For instance, many insurance companies won’t pay for someone seeing a therapist for couples counseling or for “normal bereavement” following a loved one’s death. So your mental health care provider needs to find a serious diagnosis that legitimately describes your situation and that will be acceptable to your insurance company. But, once you have that diagnosis, the big issue becomes confidentiality.

Here’s how that works. When you’re seeing a therapist and paying for it yourself, the information you discuss in session stays in the room for the most part. The therapist doesn’t share the information with anyone else, except when they’re required to report child abuse or elder abuse or a handful of other situations covered by law or their profession’s code of ethics. So the vast majority of the time, the information you share with your therapist stays just between the two of you, and you can feel completely free to share all the deep problems that brought you to the therapist’s office in the first place.

However, your sessions won’t be so private any more if your insurance company is paying for all or part of your mental health care, because your diagnosis then becomes part of your health record and it’s no longer confidential. That could be detrimental to you in the future.

For example, let’s say your therapist diagnoses you with major depressive disorder, which is a very common diagnosis. Think about how people view other people who are seriously depressed. They generally have certain expectations of how depressed people behave.

So having that diagnosis in your health record could affect your ability to get a job in the future. It could be an issue in a child custody battle or other legal problems, especially since law enforcement agencies can access your insurance information at any time. A serious mental health diagnosis could cause problems if you tried to obtain other health insurance or life insurance in the future. Those are just a few examples of situations to think about.

The other issue with using insurance benefits for mental health care is that the insurance company might place limitations on the number of sessions you can obtain or require that you get pre-approval from your primary care physician. Some insurance companies are very generous and allow weekly sessions until your problem is resolved, and they don’t interfere very much in the therapeutic process. But some companies place a limit on the number of sessions they’ll cover in a given year, and that frankly might not be enough to resolve some serious or longstanding problems.

But, to me at least, those pragmatic challenges of trying to get your insurance company to provide adequate mental health coverage pale in comparison to the confidentiality issue I was talking about earlier. Confidentiality really is the Number One thing you should consider when you’re deciding whether you want to use your health insurance to cover mental health care.

Suicide Prevention Through Better Mental Health Care

Better mental health care and ease of access :

We need to find ways to make life less difficult for people who struggle with mental illness. No one should have to choose between needed medicine and food or shelter.
We all deserve to have our basic needs met with respect and acceptance. Mental illness is not the person’s fault any more than cancer or heart disease is. This is hard for most of us to understand.
What we see of mental illness is just the tip of the iceberg.

Many more people suffer silently. We can’t see mental illness, it comes to our attention when it is not treated effectively. Sometimes that makes us uncomfortable, and forces us to look at the results of our personal priorities.
Mental health care and suicide prevention should be obvious public health goals. Medicines are getting better and better at keeping depression controlled, but the enjoyment and satisfaction of everyday life is more than just “getting by” emotionally. Suicide means ending your life on purpose. Suicide prevention means making living look better than dying.

Lots of people with depression, and other mental health problems, find new lives with the right mental health care. Others don’t have the same opportunities.
Suicide looks like the best or only choice for them. We can’t stop all of the hardships of their lives, but suicide prevention has to include making better mental health care more available.

How to help yourself and your loved ones get better mental health care:

Learn the warning signs of depression.

If the depression is mild and not upsetting sleep, appetite, concentration or irritability, look for a licensed counselor, social worker or psychologist.
If there are any of the following,
frequent crying or anger outbursts, or crying for no reason, or loss of temper at little things
unusual irritability, snappiness, impatience, criticism of others
poor concentration, follow through, or are more easily distracted
avoiding family and friends, saying ‘no’ to most invitations or suggestions
trouble falling asleep, (longer than 20″-30″), staying asleep (should be getting usual sleep or 6-8 hours a night), or sleeping too much ( more than 2 hours longer than usual), or waking up and not getting back to sleep
panic attacks, with physical signs like fast heart beat, shortness of breath, shaking, sweating, dizziness, nausea, chest tightness or chest pain, numbness or tingling in hands or feet
thoughts of death or suicide
new or increased use of alcohol or recreational or prescription drugs
All of the above persons can do counseling, but a person will probably also need someone who can prescribe medication.

Choosing the right Mental Health Professional assures better mental health care for everyone.
Learning more about depression helps you to get better mental health care for yourself and your loved ones. You will pick up on it sooner, and do something about it before it gets disabling.
Thoughts of suicide don’t usually come on suddenly, so noticing depression early and getting help can stop a lot of suffering. Spread the word, help stop the epidemic of suicide.
Of course, suicidal thoughts or attempts always deserve immediate attention.

Looking for Light in the Mental Health Care Wilderness

Paul Raeburn writes poignantly of his experiences as a father helping raise three children, two of whom suffer from mental illness-a son with bipolar disorder and a daughter with depression. His account will elicit a shudder of recognition from clinicians with institutional or agency experience and will resonate with the many parents struggling to get help for distressed children from managed care and the medical profession.

Raeburn’s son Alex, a fifth grader, “detonated” one day upon learning that his art lesson had been cancelled. Screaming in fury, he ran through the halls at school, smashing the glass on a clock with his fist, barreling through the front door, and leading the school staff and police officers on a chase through the neighborhood. The cops wrestled him down, yelling, punching, and kicking, packed him into a squad car, and drove away.

The accounts of this incident and of the many that follow are replete with details familiar to those who work with bipolar children:

seizurelike rages that give way to exhaustion, sleep, and a subsequent total lack of recall
agitated or rambunctious behavior in class
oppositionality and reckless defiance
risky and rebellious impulsivity
threats to kill
a mysterious decline in academic abilities despite superior intelligence
dark, brooding malevolence interspersed with creativity, brilliance, and sweetness

With the skepticism of a veteran observer, Raeburn traces the family’s journey through a maze of hospitals, physicians, therapists, and medication cocktails. Just as age, maturity, and possibly blind luck seem finally to be allowing Alex to regroup, the Raeburns’ daughter, Alicia, then in sixth grade, becomes symptomatic and is found to be swallowing handfuls of pills and cutting herself. Once again the family is driven back to the hospitals and practitioners who worked with Alex.

Through the years the Raeburns continue to find the results of treatment frustrating and at best mixed-a pharmacological cornucopia, substance abuse, involvement with the juvenile justice system, and therapists who blame parenting skills, intramarital conflict, and, in Alicia’s case, the trauma of rape rather than brain chemistry. Perhaps inevitably, given the severity of the stressors, the Raeburns’ marriage dissolves. The parents go their separate ways. Raeburn writes unflinchingly about the loss of his marriage and his own experience of psychotherapy.

Formerly a senior writer and editor at Business Week with years of experience covering science and medicine, Raeburn is no stranger to research. He has mined his family’s medical records and has interviewed-and quotes-not only Alex and Alicia but also their brother, Matt, and other parents and children. He writes:

New Trends in Mental Health Care

I’ve been writing about the hurdles that the mental health care system has been facing since the recession struck the country. What I haven’t written about is where this whole thing is going and which trends are surfacing.

The trend these days is to shift from “monster units” that house 20 or more people to Community Based and Teaching Family Programs.

On one hand, having smaller case loads makes programming easier and the number of behavioral incidents get substantially reduced by having less crowded buildings. If it’s hard to live with just one person under the same roof, imagine living with 20 (with psychological issues). Moreover, staffing big units is not always an easy task and supply of qualified staff has surprisingly shrunk during the past months. We were expecting a surge in demand due to the recession but for some reason (unknown to me) this hasn’t happened.

Another advantage of having smaller units is that the stress levels that staff are subject to are greatly reduced (which helps decrease turn-over rates) as a consequence of having fewer incidents and a slower paced environment.

Even though the legal client to staff ratio is 8:1 big units need to have at least a 5:1 ratio to ensure proper coverage during crisis situations and daily programming. This greatly impacts budgets and is one of the main problems that service providers are having across the country. Unfortunately there’s no way of reducing FTEs without affecting service quality, the latter being often the loser in this battle since budgets are the priority. I think this is mainly why funding agencies are pushing towards more home-like settings.

Additionally, mental health care facilities have been reticent to expand their community based programs for a simple reason: less beds means less money. But empty beds are starting to pile up so it makes no sense keeping a big building fully operational if you are going to operate at half capacity. It’s a waste of resources. Furthermore, if you think about it, TFP and Community based programs give more flexibility and are better suited for growth. If you plan to expand your business it’s easier to buy a small house or sign in a family for a TFP than building a big facility from scratch. You are also not constricted to available (physical) space on your campus or center, thus there’s basically unlimited possibilities for expansion.

Having smaller units also means lower maintenance costs, and the opportunity to develop more and more diverse programs to fit the different populations.

Something that cannot be stressed enough is the importance of having a homogeneous population in each building. Usually, the bigger the unit the more diverse the conditions it serves. This can make daily activities a nightmare since clients’ preferences and needs greatly vary. By having small and homogeneous groups this can be avoided.

While some organizations have reacted faster to the new environment and are currently expanding at a frantic pace, others have been more skeptical and tried to stay on course, crashing into the reality wall. They have realized that the near future doesn’t look so bright and therefore, they have started to lay out plans to expand into the community. The fate of some will depend on how fast they can deploy. Other organizations, which enjoy a big enough financial cushion, will have time to make this transition in a tidy manner.

Fernando Tarnogol is an Argentinean psychologist, currently working as Program Coordinator at the Devereux Foundation in West Chester, Pennsylvania.

How State Budget Cuts Impact Continuity of Mental Health Care

Continuity of care between the inpatient and outpatient settings continues to be a challenge. Current hospital payments assume that hospitals are actively involved through discharge and the transition to outpatient settings and advocating for payments for outpatient providers to assist in this process is viewed as duplicative. This undermines mental health care providers’ ability to smoothly transition clients between service settings.

Meeting the credentialing requirements for program services and mental health professionals has posed new challenges. Community behavioral health organizations employ professionals that may not meet private insurers’ credentialing standards (for example, 3 years of post-licensure experience). Community providers have addressed this through contractual arrangements in which quality assurance and supervision requirements substitute for these credentialing standards. Services are billed under a supervisory protocol in which the supervising professional’s national provider identifier is used.

Additionally, some programs offer services that rely on a combination of funding sources such as county, state, and private insurers. In these situations, counties sometimes want to limit private insurance clients’ access to these programs because a portion of the overall program is covered by the county.

Impact of State Budget Cuts on Mental Health Care –

In a dramatic turnabout that may foreshadow dilemmas faced by other states, the governor of Minnesota vetoed funding for the state’s mental healthcare program. The legislature would have extended the program for several months, as a compromise was negotiated to retain elements of coverage for the state’s mental health population – a hospital uncompensated care fund, medication/pharmacy, and “coordinated care delivery systems.” In the system, an accountable hospital-centered program paid a fixed amount to cover about 40% of the state’s mental illness population who elected to participate. As there is no reimbursement for outpatient clinic and all non-hospital services, providers and consumers now are scrambling to seek disability determination or enroll in Medicare type coverage after the six month state mental illness coverage enrollment period ends.

While these cuts are only effective as of June 1, 2010, it is expected that they will result in increases to the uncompensated care burden on hospitals and community safety net providers.

How Do We Minimize The Impact of Budget Cuts on Mental Health Care?

Many not-for-profit membership organizations representing community mental health and other service provider agencies throughout Minnesota have been working in coalition with national mental health groups on advocacy related to the state’s mental health program changes. Initially, advocacy efforts were focused on encouraging the state legislature to vote in support of expanding the state Medicaid program early to receive additional federal funding (as provided for in the national healthcare reform bill). Unfortunately, this proved to be politically untenable in the immediate future; however, a measure was passed to allow the governor to use executive authority to expand Medicaid coverage for mental illness patients.

While being actively involved in this advocacy process is vitally important to the community behavioral health system, national mental health advocacy medicaid organizations and their members are also evaluating ways in which they can optimize their business practices to meet this changing budgetary reality. Among other strategies, community behavioral health providers are working to develop partnerships with community hospitals to reduce the number of avoidable emergency department admissions and ease the transition from the inpatient to outpatient settings, supporting clients through the disability determinations process so they may become eligible for Medicaid as quickly as possible, and raising funds that will help to cover the cost sharing requirements for state sponsored mental health care and the enrolled clients that are unable to pay.

Through this two-pronged approach that includes both advocacy and pragmatic business considerations, it is hoped that the community behavioral health system will be able to develop new cost-effective ways of delivering services that will be well-positioned to withstand funding changes while taking advantage of new opportunities made available through national and state health care reform initiatives.