Second-class treatment: Care for the mentally ill lags Caution greets calls for parity HEALTH CARE -- COSTS & CHOICES

THE BALTIMORE SUN

In early editions of The Sun yesterday, an article erroneously stated insurance plans' co-payment for psychiatrists compared with that for other kinds of doctors. It is typically 50 percent or 65 percent compared with 20 percent for other physicians.

The Sun regrets the error.

Six years after Douglas Marquis won the Maryland Distinguished Scholar Award, he bought a hank of rope at a convenience store and hanged himself from a tree in front of his father's home in Ohio.

The cause of this 24-year-old artist's suicide was no mystery: He had suffered from a severe mental illness for at least six years. His sickness was the given, the inalterable. But there also was an "if only," component that will never cease to torment his mother. "If only he had been taken back in the hospital when he asked," says Linda Crane, "he wouldn't have died."

The staff at the Columbus hospital had told Ms. Crane, who was then living in Ellicott City and working on a Ph.D. in psychology, that Douglas didn't require hospitalization. In hindsight, of course, it was a great miscalculation of a medical necessity. But Ms. Crane is convinced that other factors having nothing to do with medical concerns were also at work.

Under his insurance plan, Douglas was entitled to 30 days of psychiatric hospitalization each year. But he had already used up almost all of that time, which is why, his mother believes, the hospital wouldn't admit him.

Three years after her son's death, Ms. Crane says Douglas was the victim of a peculiar kind of bias in U.S. health insurance, one that has consigned mental illness to secondary significance in the spectrum of disease. Had he suffered from heart disease or cancer, the limits of his medical care might have seemed boundless. Because he was a schizophrenic, he was very

quickly on his own.

Although the mentally ill and their advocates had hoped comprehensive health-care reform would bring an end to disparities in health benefits, the word from Washington has been deflating. While Hillary Rodham Clinton's task force has expressed unhappiness over the way mental illness is treated by American insurance plans, Mrs. Clinton herself conceded last week that the disparities cannot be eliminated at once.

"The goal is to achieve full parity," says Richard Frank, a staff member of the task force and an expert on the economics of mental illness. "Whether we can get all the way there from where we are now is what has to be thrashed out."

A misunderstood illness

It is, everyone concedes, a rather wide expanse to traverse. "Psychiatric illness is not understood in this country," says Ms. Crane. "It's thought of as hypochondria or malingering or misbehaving. It's not seen as a physical illness. As a result, there isn't seen a perceived need to take care of it in the way that other illness is. It's seen as coddling.

"But my son," she says, slowly enunciating each word, "was tragically, catastrophically ill."

Douglas Marquis suffered from a stigma that has been institutionalized by America's health insurance industry. The vast majority of insurance plans today offer two tiers of benefits: one level of coverage for mental illness and a second, much higher level of coverage for everything else.

So, for example, most private insurance plans in the United States limit the number of days psychiatric patients can stay in a hospital -- usually 30 or 60 days -- but place no restrictions on other kinds of patients.

Most plans require a much higher co-payment for psychiatrists compared with other kinds of doctors -- typically 50 percent or 35 percent compared with 80 percent. And most place ceilings on the total expenditures for mental health services.

Health maintenance organizations are generally even more neglectful of psychiatric patients. Many plans provide for no psychiatric hospitalizations at all and limit outpatient doctor visits to 20 a year. Many will authorize outpatient visits only if a life is at stake.

The federal reimbursement plans aren't much better. Medicare pays less for psychiatric outpatient care than for other medical treatment. Even Medicaid, which in Maryland generally pays for full psychiatric treatment, will not cover most patients at state mental hospitals. Medicaid also is accepted by few private practitioners.

Affording therapy

The way mental health is treated by most plans turns the notion of insurance on its head. It covers people for those expenses they could afford to pay on their own but not for those they can't.

"The limits start to kick in when you get into catastrophic losses," says Mr. Frank, a professor at the Johns Hopkins School of

Public Health.

To mental health organizations, the current debate is about nothing short of civil rights. "Any time part of the body is singled out and treated differently, that is discrimination," says Bette Stewart, executive director of the Alliance of the Mentally Ill of Maryland, an organization of the families of mentally ill patients. "If I have a thyroid condition, Blue Cross Blue Shield pays 80 percent of my costs. But if I go to a psychiatrist, my insurance pays only 50 percent. Now I didn't ask for my thyroid condition, and I certainly didn't ask for depression and in neither case did my lifestyle cause it."

Mrs. Stewart, who lives in the Lake Falls section of Baltimore County, has first-hand experience. Her husband, Cary, is a manic-depressive and the couple regularly receive dunning notices from the state for a $50,000 debt covering some of his 15 stays in psychiatric wards. A hospital administrator once suggested that Mrs. Stewart divorce Cary to protect herself financially. "I didn't think it was a fair thing to do, to leave someone who was sick," she says.

Mr. Stewart, once on track for a medical career, is far from the vibrant, energetic man she married, but he has been out of a hospital for six years.

He is working again as a counselor in a home for mentally retarded and mentally ill patients. The family needs his income badly; their 16-year-old son has now been diagnosed with depression. Even though Mrs. Stewart has Blue Cross/Blue Shield, she can barely afford her co-payments -- 65 percent -- for the therapy sessions.

"I told my son's therapist I couldn't afford every week," Mrs. Stewart says. "His psychologist said, 'I don't think you can afford not to.'"

Relief in Maryland

For some mentally ill patients in Maryland, some relief is already on the way. This year, the General Assembly passed the "parity bill," which requires insurers to offer mental health coverage equal to that provided for other ailments. The legislation contained some disappointments to mental health organizations -- it applies to only certain types of insurance and it likely will mean much higher premiums for those opting for full mental health coverage -- but it was still seen as a major victory in the effort to win equity for the mentally ill.

Because health-care reform these days also means cost containment, the victory in Maryland is unlikely to be followed by another one on the national level. That is why interested groups are quibbling among themselves over the best direction of mental health reform. For example, the Alliance for the Mentally Ill is insisting that in any reforms, the severely mentally ill receive first priority over people who are troubled but functional.

"There is a distinction," says Laurie Flynn, executive director of the alliance, "between illness and unhappiness."

Illness affects many

Meanwhile, psychiatrists, psychologists and other therapists are sounding the alarm that the current reimbursement levels and limitations on office visits keep many who need counseling from seeking it. One solution that is gaining in popularity: Remove limitations on office visits but keep the reimbursement levels where they are for psychotherapy.

The debate that is now occurring would not have happened 30 or 40 years ago, because health insurance did not then make distinctions between mental health and other physical illness.

According to Mr. Frank, the disparity originated when the insurance companies broke out mental health coverage from the rest of their health plans. Those who knew they needed mental health services were offered special, more expensive coverage while the basic plans reduced their mental health benefits. Gradually, though, the special plans disappeared, leaving the mentally ill without comprehensive psychiatric coverage.

The states made it easier for health insurers to get out of mental health by providing the safety net of state psychiatric hospitals and community mental health services. Few would ever choose TTC the public system, though, if they had a choice.

"We have a very large public system . . . that is underfunded,

subject to enormous variation across states and, as the provider of last resort, is not always the highest caliber," says Mr. Frank.

The most important document to emerge is a good news-bad news report released in March by the National Institute of Mental Health (NIMH). The report suggests that mental illness may be far more prevalent than most believe. In any given year, nearly one quarter of Americans suffer from a mental disorder, about the same number as those with cardiovascular illness. About 5 million Americans, almost 3 percent, suffer from "severe mental illness," which is generally defined as an illness that seriously interferes with their daily lives.

Inaccessible treatment

Yet, the report notes, "Far too many Americans with severe mental illnesses and their families find that appropriate treatment is inaccessible because they lack any insurance coverage or the coverage they have for mental illness is inequitable and inadequate."

Only 60 percent of those with severe mental illness obtain treatment, the report says.

That was the bad news. The good news was that despite popular misconceptions, medicine can treat mental illnesses. "We can diagnose mental disorders much more reliably than ever before," says Steven S. Sharfstein, president of Sheppard Pratt Hospital. "We can treat these disorders, especially the most serious ones, much better than before, and we can predict the costs."

Thanks particularly to advances in drugs, the NIMH report says that severe mental illness can now be treated as successfully as other maladies. Patients with schizophrenia, manic-depressive disorders and major depression typically respond well to drug therapies, significantly lowering the need for hospitalizations, the report says.

Risk of suicide

Too often, though, because of lapses in insurance coverage, patients do not get the medication they need. Beverly Hlatky, a 49-year-old Dundalk woman diagnosed as manic-depressive, exemplifies the problem. Between 1980 and 1987, when her use of medication was only intermittent because she had no insurance coverage, she attempted to kill herself 15 times, each time with an overdose of pills.

Beginning in 1987, however, when she started going to the Southeastern Community Mental Health Center, she started receiving free prescription drugs and she has remained out of the hospital. She has also held down a part-time job. Now, however, because of budget cutbacks, the center can no longer afford to give her free medication. Mrs. Hlatky says she cannot afford the $350 a month it costs to purchase the medications. Once again, the danger of suicide looms. "My doctor says if I go off medication, there's a 99 percent chance I'll wind up in the hospital," she says.

Because of people such as Mrs. Hlatky and a growing appreciation of drug therapy, it is likely that the task force will make comprehensive coverage for psychiatric medications a top priority in the mental health reforms.

Eventual savings

While such steps would be expensive, the NIMH report says, they would actually lead to savings. It would cost $6.5 billion in direct health costs to provide comprehensive mental health coverage to the severely mentally ill, the report says. But, untreated mental illness now costs $8.7 billion in lost wages, police and criminal justice costs, social welfare expenses and avoidable medical care.

For those suffering from severe mental illness, those savings are not the primary reason to offer them full benefits. For people such as Susan Kadis, a 39-year-old manic-depressive in Owings Mills who has been forced to leave hospitals after running through her allotted days, comprehensive mental coverage could be the difference between life and death.

"Do you have to kill yourself to prove you need insurance?" she asks.

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