At 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.

Medicaid 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.

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- 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.

Tomorrow: Will Psychiatrists do Psychotherapy?

The Happy 65^th Birthday Conversation

I remember the first time I had the “Happy 65^th 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 65^th 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 this. 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.