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Parity for Effective Addiction and Mental Health Care: Not Just Treatment as Usual

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Wednesday, the New York Times published my op-ed arguing that while we need equal insurance coverage for mental health and addiction in line with the treatment of other diseases, if parity is not accompanied by the requirement of evidence-based treatment, it can do harm.

For space reasons, I was not able to explore in that article some of what I think are the best examples of the problems with parity without an evidence requirement -- so I thought I'd lay them out with the background information they require here.

In the late 80's, many insurers offered virtually unlimited inpatient addiction treatment benefits-- and some offered similarly generous coverage for psychiatric hospitalization. Both addiction and psychiatric disorders were then heavily stigmatized-- so when insurers had to actually pay out these benefits, the people being treated almost certainly needed some kind of care.

Then, however, came Betty Ford and celebrity rehab and a time when having an addiction was almost fashionable. A time when in the film "The Player," a Hollywood producer attended AA without having a drinking problem because "that's where the deals were being made." This kinder view of addictive disorders undoubtedly helped millions of people with addictions-- but it was not without its dark side.

Since AA and other 12-step programs and the rehabs based on them promoted the idea that people with addictions always denied the full extent of their problem, virtually everyone who was referred for inpatient treatment of addiction-- whether they had weekend marijuana habits or were heroin injecting freebasers-- was admitted for a full month-long course of hospitalization. And this cost about $15,000-30,000.

It was a catch-22 for anyone suspected of addiction. If you said you weren't drinking or using drugs, you were "in denial" and needed lots of treatment; if you admitted some use, you were "in denial" of the seriousness of the problem and needed just as much care.

This wasn't at first done cynically: but it resulted in a situation where virtually everyone who sought or was referred for evaluation for treatment, no matter how minor the problem, got the max inpatient stay for each treatment episode. The number of for-profit alcoholism treatment units skyrocketed from 295 in 1982 to 1401 in 1990.

And soon, providers took even greater advantage of the situation. In part of a pattern of medical fraud that resulted in the largest federal judgment against a health care organization in history, National Medical Enterprises actually kidnapped teenagers and children into treatment and held them-- sometimes against their parents' wills-- until their insurance ran out.

It worked like this. NME would pay "bounties" to high school guidance counselors and others who worked with youth to identify those with parental insurance who might "need" treatment. The child would then be picked up off the street or from school by security guards and held in the hospital. The parents were notified that if they didn't go along with the decision to institutionalize their children, child welfare authorities would be notified and custody might be jeopardized. Dozens of kids-- many of them in Texas-- were held for months. As soon as their insurance ran out, however, they were suddenly "cured."

Bruce D. Perry, MD, PhD (my co-author on The Boy Who Was Raised as a Dog and Other Stories from a Child Psychiatrist's Notebook: What Traumatized Children Can Teach Us About Loss, Love and Healing) later helped some of the once-perfectly normal children who had been traumatized by this "treatment." One boy had been prevented from going outdoors for two years-- he and others were repeatedly physically restrained and were often kept in isolation.

And NME wasn't some rogue or isolated operator-- it was one of the top chains of psychiatric facilities and rehabs in the country. The settlement was close to half a billion dollars.

In what is probably the most notorious case of fraudulent and quackish over-treatment, one woman and her children were held for years in Chicago's Rush-Presbyterian Hospital, diagnosed as having been victims of "Satanic Ritual Abuse." They were often tied to their beds and verbally abused until they took on their "alter" personalities, who would discuss Satanic ceremonies involving sexual abuse of children and cannibalism. This is the only story of which I am aware in which the managed care benefits administrator is a hero: apparently, the administrator worked out that such treatment was exactly correlated with the maximum of a person's hospitalization benefit. Generous benefits here benefited the provider, not the patient.

And shockingly, while these are extreme examples, damaging over-treatment in a time of generous benefits was not uncommon. A 1991 study found that a youth's time in a psychiatric or addiction rehab was not linked to the severity of his diagnosis-- but was directly correlated with the max of his insurance coverage. In other words, more insurance = more time locked up, not better care.

As a result of these abuses and their general cost-cutting mandate, insurers rapidly restricted mental health and addiction benefits during the 90's. Many of those rehabs opened during the boom days rapidly shut down.

Patients, once again, were the losers. These days, people who truly need treatment often cannot get it. In children's mental health, it has gotten so bad that in 2001 alone, according to research by the Government Accountability Office, parents of nearly 13,000 mentally ill teens went as far as relinquishing custody of their children to state agencies. It's the only way they were able to get needed care.

This is horrendous-- and so in order to get good treatment to those who need it most, I support parity for evidence-based treatment only. This should cut the costs of over-treatment and divert needed money into providing the best care for those in need. As I noted in the Times piece, much of what is practiced now isn't effective. Using monetary incentives, we can change this and simultaneously provide parity. We can't simply demand more money for treatment as usual-- what we want is more money for treatment that has been proven to work.

[Note: the full story of NME is well told in Joe Sharkey's Bedlam: Greed, Profiteering and Fraud in a Mental Health System Gone Crazy. Sharkey wrote the book after an 'evaluation' for rehab which used the "you're in denial" paradigm. After resolving his alcohol problem on his own, he began investigating further. The Satanic Ritual Abuse case and its HMO connection was explored in a brilliant 1995 Frontline, The Search for Satan by Ofra Bikel and Rachel Dretzin]