Sick, insured, and nowhere to turn

Editorial from The Oregonian, October 2, 2011

A study reveals that even those with insurance can’t get emergency psychiatric care

READ – well, we’d like to show you the Harvard study referred to in this editorial, but the author doesn’t cite and it’s not online.
READ – Doctors Sue Over ER Limits in Washington State,
READ – well, we’d like to show you the OHSU study referred to in this editorial, but the author doesn’t cite and only a poor paywalled abstract is online.

Recently we celebrated in this space an Oregon study that found that the state’s 2005 law requiring parity in mental health insurance did not result in the spike in overall medical costs predicted by opponents of the law. However, the findings of a recent study in Boston may offer one explanation — and strongly suggest that our celebration was premature.

Researchers at Harvard Medical School posed as patients insured by Blue Cross Blue Shield of Massachusetts, the largest insurer in that state. They phoned every Blue Cross-contracted mental health facility within a 10-mile radius of downtown Boston — 64 facilities — and stated that they had been evaluated in an emergency department for depression and told to obtain a psychiatric appointment within two weeks.

In other words, they made it clear that they had a serious mental illness and needed prompt care. But in all but a small number of cases, they couldn’t get it, even though they presumably had strong mental health coverage through Blue Cross. Only eight of the 84 facilities that were “preferred providers” of Blue Cross offered appointments, only four offered an appointment within two weeks. Even worse, almost one-quarter of the phone calls seeking appointments were never returned, even after a second attempt.

Remember, for all the medical offices knew, every one of these calls came from a patient suffering from severe depression, a mental health emergency. And still, a quarter of the offices dumped their phone calls and another quarter or so called back only to say that they wouldn’t see the patient unless he or she already was enrolled with a primary care doctor affiliated with their facility.

It’s obvious what was going on here: Blue Cross Blue Shield of Massachusetts, like other private insurers, aggressively constrains patients’ access to mental health care through several covert means, including by limiting provider networks. (Not surprisingly, Blue Cross Blue Shield responded to the Harvard study not with a promise to change, but with an attack on the researchers for not seeking prior authorization to use the insurance company’s name in its survey calls.)

This isn’t just a Boston problem. There’s no reason to believe that the study results would be particularly different in Portland, New York or Los Angeles. National studies have found that two-thirds of primary care physicians say they cannot obtain outpatient mental health services for patients who need them.

This is a huge failure in our health care system, one that leads directly to the myriad cases of untreated mental illness on the streets of cities, with sometimes fatal interactions with police. We’ve clearly seen that here in Portland.

The Harvard researchers say their study ought to prompt insurance companies to improve their reimbursements for psychiatric care, which would open up much more treatment options for patients. That’s surely the right first step, but the companies won’t act without financial incentives. There’s no shortcut here. The only long-term answer to the continued discrimination against persons who suffer from mental illness is a health insurance system that truly and fully covers mental health services.