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Treating the Mind as Well as the Body

November 13, 2000|BOB ROSENBLATT

Mental health coverage has been the weak link in the health insurance system. Employers and insurance companies, always worried about controlling costs, often have been skeptical of the efficacy of treatments for mental health problems. Add to that the stigma and sometimes the self-inflicted shame faced by patients and their families struggling with mental illness.

The result is a daunting challenge for people seeking help. There is a world of difference in the ease of treatment if the sickness is of the body rather than the mind. For someone with high blood pressure and diabetes, for example, a typical health plan allows access to doctors and hospitals without restrictions. A young woman with an eating disorder who consults a therapist or must be hospitalized faces rigid insurance system rules: probably a strict limit of 30 days a year in an inpatient mental facility and 20 visits to a counselor.

California now has a chance to lead the way as a pioneer in offering equal treatment for both physical and mental ailments. A new state law requires parity of treatment for a specific list of mental health problems. The law applies to coverage for the 20 million California consumers who are enrolled in health insurance systems regulated by the Department of Managed Health Care. These include many health maintenance organizations (HMOs) and some preferred provider organizations (PPOs).

(The law does not apply to people in traditional indemnity insurance programs and to some PPOs regulated by the California Department of Insurance. Those plans are still permitted to have different rules for coverage of physical and mental ailments.)

The new law covers these ailments, as defined in the psychiatric profession's standard diagnostic manual:

* schizophrenia

* schizoaffective disorder

* bipolar disorder (manic-depressive illness)

* panic disorder

* obsessive-compulsive disorder

* pervasive developmental disorder or autism in children

* eating disorders, including anorexia nervosa and bulimia

* serious emotional disturbances in children (defined by the Diagnostic and Statistical Manual of Mental Disorders as a problem that results in "behavior inappropriate to the child's age according to expected developmental norms").

No longer can the health plans impose a limited number of patient visits or hospital days for these ailments. The duration of stay or the number of office visits is now prescribed by the professional who treats the patient, just as it would be for an appendectomy, a heart attack or a removal of cataracts.

The law was carefully written to cover certain conditions. But it specifically excludes treatments for alcoholism and drug addiction, which can be very costly.

The new law has the potential for helping thousands of patients and their families. By assuring parity--the same availability of coverage--the families no longer will be forced to spend thousands of dollars for vital treatments. A day in a mental health facility can easily cost $1,000, and a visit to a therapist might range from $50 to $150.

Daniel Zingale, director of the state's Department of Managed Health Care, said he will aggressively implement the law as a "commitment to preventive health" for consumers.

"We want treatment early to prevent more costly physical ailments down the road," he said in an interview. Untreated mental and emotional problems raise stress levels that can lead to heart disease and a host of other physical problems, according to Zingale. "Treating these conditions early will pay off for the whole system" by saving money in the long run.

Zingale's office has sent material to the health plans it regulates, and will hold a series of meetings with the organizations "to impress on them our vigilance, and our intention to keep focused on the mental health parity act," he said. He wants the health plans to make clear to all their members that the expanded coverage is available.

"It doesn't do any good to have the benefit unless people know exactly what is available to them," he said.

The law became effective July 1, with the renewal of health plan contracts. Since businesses typically sign one-year contracts with their plans, the law should be universally effective with all programs under Zingale's regulation by next summer.

"This is a very big thing," said Andrew Sperling, director of public policy for the National Institute of Mental Illness (NAMI), which represents 210,000 patients and family members. "It's much stronger than the federal law; it essentially addresses major gaps in the limited federal rule."

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