Obamacare for Mental Health

Under the new health-care legislation mental health and substance use disorder benefits must be offered on a parity with other medical and surgical benefits for all insurance plans. There can be no annual or lifetime limits or denial of benefits based on pre-existing conditions. There will be special support for the delivery of services, education and research for depression. The increased Medicaid eligibility will provide more mental health services and there will be some special demonstration projects under Medicaid. There is a 5% increase scheduled for psychotherapy services under Medicare. However there are some complicated issues concerning Medicare rates which need to be worked out including the feasibility of psychotherapy being provided under the prevailing fee schedule.

ObamaAt the end of last month President Obama signed into law  comprehensive health-care reform. Thanks to the analysis of the government relations people at the APA, I can distill some of the meaning to patients who require mental health care and to the professionals who provide it for them

Coverage For All Includes Mental Health

Virtually all Americans will have comprehensive health insurance coverage that includes coverage for treatment of mental illness including substance use disorders.The provision that  individuals may not be excluded due to pre-existing conditions or dropped because of their health status will also pertain to theses condition. Mental Health and Substance Use Disorders benefits must be offered at “parity” with other medical and surgical benefits for all insurance plans sold within the health insurance exchanges that are created under the new law. There will be no annual limit or life time limits. Private insurance costs will be subsidized for those with lower incomes.

Special Support for Delivery of Services, Education and Research  for Depression

The new legislation directs the Administrator of the Substance Abuse and Mental Health Services to award grants to centers of excellence in the treatment of depressive disorders starting in 2011. This provision is in recognition of the need to develop better methods of care for this condition. This is in addition to the funding which will continue to come from the NIH & NIMH for research.

There is also  a mandate that supports screening for women suffering from post partum depression and psychosis as well as education for mothers and their families about these conditions. There will be funding for research into the  causes, diagnosis and treatment of post partum depression and psychosis. This latter support is really the culmination of the efforts of so many people including the families of women who have died from post partum depression and led to the proposed Melanie Stokes legislation.

The overall direction of increased funding for depression, in my opinion,  confirms the recognition of depression being a systemic condition which goes beyond it simply being an important mental disorder. This is one of the many advantages and benefits of another provision which authorizes $50 million in grants for coordinated and integrated services through the co-location of primary and specialty care in community based mental and behavioral health settings. The interaction of mind and body is well established and the delivery of health care is always going to be better when there is facilitated communication and access between primary and mental health services.

MedicaidMedicaid and Other State Program by Other Names

In many places the success or failure of this legislation will determine how the poorest and least advantaged are able to receive mental health benefits. Much of the action here will be on the state level and until the economy turns around this will be perhaps the most difficult part to achieve.

Medicaid eligibility will be increased 133% of poverty with 100% of federal funding to all states for newly eligible Medicaid recipients for three years. Starting in 2014, former foster children will be covered by Medicaid. Also, benzodiazepines and smoking cessation drugs will be removed from  the Medicaid exclusion drug list.

Even though benzodiazepines are amongst the most addictive medications out there, the health program of the government will be removing them from the list of drugs excluded from Medicaid coverage.

There will be the Medicaid Emergency Psychiatric Demonstration Project which requires the establishment of  a Medicaid project in up to eight states requiring  reimbursement of  certain institutions for mental diseases for services provided to Medicaid beneficiaries between the ages of 21 and to stabilize an emergency psychiatric condition under the hospital anti–dumping law known as EMTALA.

Another demonstration project would be established in up to eight states to study the use of bundled payments for hospital and physicians services under Medicaid.

A third program provides options for health homes for enrollees with chronic conditions such as serious mental illness. They would be composed of a team of health professionals providing comprehensive medical services including care coordination.

There also would be increased funding for Community Mental Health Centers which traditionally provide low cost care for recipients on Medicaid ( as well as others ).

If these programs prove to be effective, they will encourage the development of similar programs in other states.

Medicare-1Medicare- The Most Complicated of ALL

The Medicare Part D Coverage Gap (doughnut hote) is scheduled to be closed which of course will make it easier for seniors to get all medications which they need including psychotropic drugs.

There is 5% increase for psychotherapy services scheduled to go into effect for 2010. This is an extension of the increases scheduled for part of 2008 -09 which expired in 2010. HOWEVER, Congress has not acted to prevent the 21% reduction in the Medicare Sustainable Growth Rate which is suppose to go into effect now. They have postponed this vote twice . The establishment of an equitable Medicare fee schedule for mental health services is essential for the success of the new healthcare legislation. This is especially true if psychiatrists are able to continue to participate in the Medicare program in large numbers. Psychiatric consultation and the delivery of most effective psychotherapy is a time intensive service. While it may be possible to deliver psychopharmacology in a high quality manner in brief follow-up visits, that is usually not the case with psychotherapy. If psychiatrists have to opt out of the Medicare program in order to treat senior citizen at anywhere near their usual fee for psychotherapy they will not be able to provide psychopharmacology treatment which creates a dilemma for the patients, providers and our health care system. I have discussed this issue in a previous blog.

There are also two provisions in the new legislation pertaining to Medicare which may cause further complication in the delivery of Medicare. There would be a Payment Advisory Board which may be able to recommend reductions in Medicare payment if spending exceeds certain limits. While cost cutting could be necessary, directing it at our senior citizens, when the payment fees are borderline at best, could further limit mental health care. A second provision requires all physicians participating in Medicare to report on performance measures with failure to report bringing about a 1.5% penalty.  I think this is  a good idea once it is fairly set up but premature enforcing of this provision could discourage participation in the Medicare program.

Work Force

There appears to be some wording the legislation which allows repayment of loans to doctors who are providers of mental health services to children or will be working in under-served areas.  There also will be funding for the National Health Services Corps and for mental health education as well as training grants for  social work, graduate psychology  and child psychiatry. We need to make efforts to encourage the best students to go into professions which provide mental health services.

We need to examine the new program  and try to make it work. If it needs fixing we should advocate for changes.

Mental Health & The Developmentally Disabled

Tierra del Sol is a non profit organization serving people who are developmentally disabled. It has a small campus in Sunland, California where each day 250 adults are bussed in to participate is an individually designed curriculum. The programs include farm work, computer learning, art classes and kitchen training. People with developmental disabilities have a high prevalence of mental health problems, which can be difficult to diagnose. Mental health services for this group are more time consuming and therefore more expensive. As we are reevaluation our health care system in the U.S., this is the time to be sure that adequate mental health care for this is group is included in our health care program.

Tierra del Sol art

computer_lab_01aAre the Mental Health Needs of the Developmentally Disabled Being Met?

Tierra del Sol – Model Center for People with Developmental Disabilities

I recently met Steve Miller, the Executive Director of Tierra del Sol a non profit organization that works with developmentally disabled adults in order to train and help them function better in the workplace and in life. I accepted his offer to visit their beautiful campus in Sunland, California just outside of Los Angeles.

The atmosphere seemed to me to be a mixture of a small tranquil estate and a community college. I learned that one of the  beautiful buildings was once a training school for Catholic nuns that had its origin in the 1900s. In the last 15 years it has evolved into a productive training program where people with significant disabilities pursue a range of interests and training which will expand their options for participating in their local communities.

Personalized Curriculumequestrian_01a

Each day about 250 of adults with moderate to severe disabilities are bussed to the campus. Each of them has their own specifically designed curriculum. I walked through a barnyard area with farm animals where some of the people will tend the animals, learning skills, which can be useful in the still vibrant farm industry in California.

Upon entering the school building, I saw a series of comfortable class rooms humming with busy interested students although this was obviously not your typical college population. There was a computer class with older but functioning computers recently donated, which connected to the Internet. There was a knowledgeable instructor called “coach” and the activities ranged from doing the simple task  of connecting words with pictures to a very bright but dyslexic women who was trying to learn to write poetry. The art class which included ceramic making was an eye opener as among the busy diligent students using various media were some who were producing some outstanding drawings and paintings. The coach told me that most prefer to copy various pictures or images rather than draw from live models although they clearly bring in their own interpretations. There was one pencil drawing of an American Indian that I thought showed sensitivity and great depth of felling.  I learned that Tierra del Sol maintains a renowned gallery in the community called First Street which has earned some of these artists tens of thousands of dollars in commissions.food_service_01a-2

We detoured to the kitchen which reassembled a commercial set up of a moderate size restaurant. The students under the supervision of the coach were learning the workings of the kitchen at the same time that they were preparing meals to be used at the center. Many of them would be learning relatively simple tasks but along with their diligent work ethic, this would allow them to do work and make contributions to the community.

Students Provide Volunteer Service to the Community

As I chatted with Mr. Miller and his staff I learned that nearly everyone currently served on the  campus is engaged in community service – or “service learning” as colleges and universities refer to it. They will assist others to distribute food and clothing for impoverished seniors and children; care for abandoned pets, maintain community parks and assist understaffed hospitals, daycare centers, museum, libraries etc.

Many of the students move from volunteer service to wage paying employment at more than 35 private employers throughout the San Fernando Valley.  Additionally their newest program, NEXUS, is currently serving more than 50 young adults by supporting their enrollment in community colleges and other mainstream post-secondary education venues. In total they serve about 500 hundred people split about 50/50 between campus based preparatory programs and actual mainstream community life endeavors.

What are the Mental Health Issues?

I was particularly interested in how the mental health needs of this population were being addressed. I was not surprised to find out that it was not easy to arrange mental health and psychiatric care for those who needed it.

People with developmental disabilities have a high prevalence of mental health problems often at 30% in many studies and can be as high as 60-67% if aggressive and disruptive challenging behavior is included.

When we consider the autism spectrum disorder, the current thinking conceptualizes it as brain dysfunction with many underlying etiologies. Mental retardation is present in 65% -85% of this group. The onset of mental illness as a secondary disorder  is also a relative frequently. It is also known that persons with mental retardation, autism and other pervasive developmental disorders may exhibit co-morbid anxiety disorders, such as generalized anxiety disorder, obsessive-compulsive disorder, phobia and other anxiety symptoms at much higher rates than in the general population

Persons with developmental disabilities are more likely than the average person to have experienced abuse in their childhood which is known to contribute and complicate psychiatric disorders. There are often co-morbid medical problems which can lead to psychiatric symptoms. Furthermore medication taken for epilepsy as well as other medical conditions can cause psychiatric symptoms and complications.

Problems in Diagnosing Psychiatric Conditions in Persons

with Developmental Disabilities

Due to the nature of many developmental disabilities, there are inherent difficulties in diagnosing psychiatric disorders in this group. There are many reasons for this problem. Cognitive and communication difficulties can lead to unique modes of coping which can be mistaken for a psychiatric disorder. For example a person with such a condition might “self sooth” by talking to themselves which could easily be mistaken for a psychosis.

A person with a limited ability to communicate would not be able to provide information which would allow a mental health professional to easily make a diagnosis of a psychiatric disorder such as depression. Information such as changes in weight, sleep, feelings of sadness or even suicidal thoughts is necessary information for diagnosis and treatment. However a person with developmental disability might not be able to communicate these things. Similarly such information is required for follow-up in order to change medication or therapeutic techniques i.e. behavioral therapies could not be readily provided.

In order to make a psychiatric diagnosis in this population, develop a proper treatment plan and follow up it often requires close consultation with family, teachers and other care takers. In an environment of a program such as Tierra del Sol, the staff is often in the best position to facilitate the meetings which are necessary. They also can provide information needed for diagnosis and follow-up as well as be part of any behavioral treatment plan since they are people in the patient’s environment for most of the day.

Mental Health Services for this Group Time Consuming and  Expensive

Psychiatric services are usually time sensitive. Fees are at least in part determined by the time spent with a patient. Obviously working with this population requires an enhanced time commitment. These are some of the most difficult patients to treat and often requires special expertise and as described above, the use of many collateral interactions which of course is time consuming  MediCal or Medicaid or some other state insurance are often the only insurance which many patients have available to them. It is not surprising that it is difficult to find psychiatrists and other mental health professionals to provide the needed services to this population if the fee imbursement turns out to be relatively low as compared to the non disabled populations.

Now is Time to be Sure that Mental Health Care for this Group is Included

in our Health Care Programs

We are at time in history where we are reevaluating our health care system. We need to be sure that the people who are at the table in formulating our new health care plan understand all aspects of health care including psychiatric care and the delivery of this care to special populations such as those with developmental disabilities. The decisions that are going to be made will be based on cost issues as well as what is ethically and morally right. It is hard to believe that anyone would disagree that it is only right to provide needed services for those who with no fault of their own are developmentally disabled. Our society has a tradition of providing medical care for this group but appears to balk and come up short when we have to come forth with the funding needed to meet the cost of necessary mental health care. The prevailing thought is often that we don’t have an unlimited source of funding. However, if you look at the big picture, providing sufficient funding for mental health care in this population may very well in the long run be a very good investment. The result of proper outpatient treatment will prevent costly inpatient care. Psychiatric treatment which can diminish disruptive behavior or incapacitating symptoms will allow people to better participate in the type of programs described above at Tierra del Sol. This will allow many of them to be productive people doing some work or volunteering in worthwhile service. The impact reverberates on families, schools and on our entire society in a very positive manner.

I welcome your thoughts and comments on this important issue.

Happy 65th Birthday-Your Psychotherapy Fee is Reduced.

The author describes his experience of wishing a patient in psychotherapy a happy 65th birthday and telling the patient that his fee is now reduced since he is now on Medicare. Opting out of Medicare is discussed as well as the implications of new healthcare changes which may discourage psychiatrists from doing psychotherapy.

Today: 65th Birthday While in Psychotherapy

Tomorrow: Will Psychiatrists do Psychotherapy?

The Happy 65th Birthday Conversation

I remember the first time I had the “Happy 65th birthday” conversation with a patient. He was a very successful businessman and financial investor whom I had first seen in my New York practice about 15 years previously at the time he was having some personal and business crises. He was in twice week  psychotherapy with me for about three years. When he was 62 his wife died and he came in for a few sessions during this difficult time but handled his grieving as well as could be expected. He came back to see me two years later related to conflicts within himself and with his children about a decision whether or not to get married to a women with whom he had a relationship for about 6 months. I saw him once per week and as I expected, he was working well in therapy.

Your Fee is Reduced

I knew his 65th birthday was coming up and when he came in and announced it was his birthday I replied, “Happy Birthday and your present from me will be that your fee will be reduced 150% to about $100/session”. I elaborated that this was the Medicare fee for 45-50 minute psychotherapy sessions.  He laughed and said, “Of course not, I am more than glad to pay your full fee and you know that I have no trouble affording it.” He was quite surprised when I told him that would be against the law and that I was mandated to charge him the Medicare fee. He offered to pay the difference and thought it was grossly unfair to me for him to pay me a reduced fee. I told him that I had no choice and that the only way that I would be able to see him was to charge him only the Medicare allowable fee. Obviously, this became a topic in the therapy with him but that is not the point that I am discussing here.

Impact on the Psychiatrist of Treating Patients on Medicare

Over subsequent years as many of my patients aged, I had similar conversations with them. I had previously treated a relatively small number of patients on Medicare and was comfortable in accepting the reduced fees. While the fee for psychotherapy was much lower than my customary fee, the Medicare fee for psycho-pharmacology was only slightly below my usual fee and the time of these visits were 20-30 minutes per session. When I would see patients who had private insurance, most of their policies allowed them to see a doctor “out of network” which usually meant that the patient was allowed to make up the difference in payment of what their policy allowed for treatment and that of my usual fee.  I also had a major academic position so overall the Medicare portion of my income was relatively small.

While I could theoretically limit the number of patients that I would see on Medicare, I was not comfortable in choosing individual patients to treat using that criterion. Once I would agree to see a patient, as I stated above, I would be obligated to charge them only the Medicare fee. So as I always did,  I continued to accept Medicare patients as they came to me if I felt I could help them.

However, as the years progressed I was increasingly involved with other professional activities mainly research, special projects as well as eventually becoming the Speaker of the Assembly of the American Psychiatric Association. This meant that I had less time for private practice and therefore seeing patients on Medicare would have a more significant impact on my income.  There happened to be a brief period where I was not treating any patients on Medicare. Since it would not impact any of my current patients, at that point, I made a decision to do something that I thought I would never do. It was something that I understood an increasing number of psychiatrists and other doctors in New York, Washington D.C. Texas and I am sure other locations were doing.

The Opting Out Solution

I opted out of Medicare! This is a legal process where a doctor files papers with Medicare which states that he or she is no longer part of the Medicare program and can no longer submit bills to Medicare nor could any of his or patients submit your psychiatric bills to Medicare for reimbursement. In fact, patients had to sign a statement that they understood that neither they nor their heirs could be reimbursed for any bills that you had given them for treatment. I, of course could see any patient of Medicare age but they could only pay me out of pocket or be reimbursed through insurance that they might have other than Medicare. This worked satisfactorily for me as I had a limited private practice, which I also continued when I recently relocated to Southern California. I will always tell patients when they first call me for a consultation that I am no longer part of the Medicare program and the implications of tIMG_0007his. Some find this O.K. and will see me while others will not.

I don’t believe that my particular decision to opt out or the decision of other psychiatrists to do likewise seriously impacted the availability of care in the two communities in New York and California where I practiced. As far as I could see, there still are sufficient psychiatrists accepting Medicare. Perhaps some were not offering psychotherapy to such patients but were there to do psycho-pharmacology, which is essential care for many conditions. Also, in these areas there are many psychologists and social workers who are trained in psychotherapy, many of whom have a fee schedule less than the prevailing psychiatric fees for psychotherapy. They often work in conjunction with a psychiatrist who prescribes medication. Such dual therapy, in my experience, usually works quite well. However, in some situations it is much more ideal that a psychiatrist should do the psychotherapy and prescribe the medication to an individual patient. If psychiatrists continue to opt out in these communities or in communities where there are limited psychiatrists, this could become a major problem.

Implications of New Changes in Our Healthcare System

We are on the verge of major changes in our healthcare system. Certainly I hope and expect that the coverage of mental illness will be on parity with other medical conditions. This should include inpatient treatment and outpatient follow-up care for serious mental illness, which includes substance abuse. It should also include psychiatric care for all designated mental conditions. It is possible that there will be limitations put on the number of sessions allowed for psychotherapy and on the fee schedules that are set up for this form of treatment. Ideally the fee schedule should be fair and equivalent to other medical care, based on the time that the psychiatrist spends administering psychotherapy for patients who need it. These are very complicated issues. While psychotherapy has been shown to be effective with evidence-based research, there may not be the same degree of established research as to the efficacy compared to some other medical conditions. This could lead to limitations or no reimbursement for psychotherapy of certain conditions. If the emerging system limits or  discourages psychiatrists from doing psychotherapy, this will be a great loss in providing mental health care in this country. The growth of psychotherapy has a history as coming from psychiatrists, along with our colleagues in the mental health field So many of the great therapists and teachers have been outstanding dedicated psychiatrists. If psychiatrists are forced to do less psychotherapy, there will be a diminution in training programs and psychotherapy research, which could be a great loss to the quality of care being delivered in this country.

I fervently hope that we make major changes in our healthcare system. I personally believe that there should be a public option even though I recognize the possible dilemma as I indicated above, that could occur for psychiatrists who wish to utilize their psychotherapy skills along with their other psychiatric treatment modalities. The best way to work this out is to continue to put a searchlight on all aspects of this issue. I hope that this piece will stimulate discussion that will allow us to continue to move forward and solve these problems.

Your comments are welcome.