“I’m not able to authorize payment.”
It’s a line I’ve heard many times in the five years I’ve been practicing psychiatry, so I was ready for it. I’d been on the phone for 45 minutes telling the insurance company representative how my patient came into the hospital emergency room so depressed he could hardly function. How he’d missed nearly every day of work for the last few weeks and was close to losing his job.
My patient was resilient and determined to beat his depression. He’d been looking for months for an outpatient psychiatrist who accepted his insurance. Unfortunately, many insurers pay mental health providers so poorly and make it so difficult to get compensated that nearly half of psychiatrists don’t accept insurance at all. Now he was on a six-week waiting list.
None of that mattered, though. A complex man dealing with complex issues had been reduced to a binary variable by his insurer: suicidal, or not suicidal. And because my patient fell into the latter category, he didn’t meet his insurance company’s “medical necessity” requirement. He could still come to the hospital for help, sure, but only if he were willing to pay thousands of dollars out of pocket for treatment.
My patient didn’t have that kind of money. He could barely make rent.
Before I decided to specialize in psychiatry, I assumed a person in need of mental health care would have the same access to treatment one has for medical conditions like kidney stones, pneumonia or seizures. Instead, mental health patients and their providers face a mountain of bureaucratic obstacles that other patients are spared.
Even when patients have just attempted suicide, most insurers still require prior authorization by phone before admission.
The look of disappointment on this man’s face when I explained he wasn’t considered depressed enough to be hospitalized was unmistakable. Had he shown up with a general medical condition, he would’ve been welcomed into the hospital almost immediately. But because he had a mental illness that hadn’t yet reached the most critical of states, and because he wasn’t a wealthy man, he couldn’t come in.
That night, like many others prior and since, I left work with a great sense of guilt for participating in a system that regularly fails people in need.
The bar is set incredibly high these days when it comes to insurance coverage for psychiatric admission. Even when patients have just attempted suicide, many insurers still require prior authorization by phone before admission. And until the insurance company agrees to pay, the patient must wait, usually in the emergency room. Each phone call eats up a psychiatrist’s time ― 38 minutes on average ― and makes delivering efficient care extremely difficult. Some nights, I make six or more of these calls, leaving patients waiting for hours.
When it comes to general medical hospitalizations, on the other hand, no phone calls are required. You simply tell the patient they are being admitted, and that’s that. No forms, no conversations, no questions. Insurers trust our judgment. Not the case with psychiatric hospitalizations. In the U.S., outright denials for mental health care occur twice as frequently as denials for general medical care.
The discrimination is obvious for anyone willing to see it.
Insurers reduce costs with this prior authorization strategy, not just by overt treatment denial but also by its ability to deter the offering of psychiatric hospitalizations as a treatment option in the first place. In busy emergency rooms, if a provider knows that a prior authorization call awaits, the decisional balance often moves toward less-comprehensive treatment options that don’t require a call.
In the U.S., outright denials for mental health care occur twice as frequently as denials for general medical care.
The public seems aware something is wrong with our mental health care system, but as someone who toils daily inside the opaque maze, I see how it’s designed to keep patients out and providers tied up. People dealing with mental illness and addiction flood hospitals, but insurer tactics, along with paltry government funding, have choked off delivery of care to a mere trickle.
Compounding matters, America is currently seeing a decrease in the number of psychiatric beds as government-funded psychiatric hospitals close and as other hospitals decide against adding beds due to poor insurer reimbursement. So even if insurers approve a hospitalization, patients often have to wait until a bed at a psychiatric facility opens up. A patient seeking medical admission usually waits about four hours in the emergency room; a patient seeking psychiatric admission waits about 22 hours if being transferred to an outside psychiatric facility. Some of my patients have waited for days.
To understand just how deeply the discrimination against the mentally ill is ingrained in our insurance system, flip over your own health insurance card. Most providers list a different phone contact for mental health and addiction services.
Why? Because these services are often “carved out” to other companies that work to reduce their use by creating labyrinths of prior authorization requirements for everything from medications to residential treatment. A call to that phone number means entering a separate insurance system where discrimination reigns.
Despite incredible profits, insurers won’t give us a break. This is a natural consequence of a poorly regulated, profit-driven industry paying for our health care. Those with mental illness ― and others who cannot advocate for themselves ― get excluded.
People dealing with mental illness and addiction flood hospitals, but insurer tactics, along with paltry government funding, have choked off delivery of care to a mere trickle.
Why have we allowed our mental health care system to reach this breaking point? We all know by now mental illness is common, and when it goes untreated it stifles not only our economy but also our society as a whole. The Mental Health Parity and Addiction Equity Act of 2008 and the Affordable Care Act were supposed to help end mental health discrimination, but their requirements don’t go far enough and are rarely enforced. Further parity requirements were passed in 2016, but government agencies didn’t give insurers any guidance on compliance until just last week, when they were finally pressed by the Senate Health Committee.
Our mental health insurance system needs serious reform. We’ve waited long enough for insurers to recognize that the brain — the organ that directs all the other ones — can malfunction just like the heart, the kidneys and the liver. The problems that arise when this occurs are extremely complex but largely treatable. Is it too much to ask that insurers allot a fair share of spending to tackle these challenges? I don’t think it is.
The effects of untreated mental illness ripple through generations, as any person who has grown up in a home with a parent suffering from depression, addiction or personality disorder can attest. A society that truly values the future of its children will not continue to defer its commitment to the task at hand.
A complex man dealing with complex issues had been reduced to a binary variable by his insurer: suicidal, or not suicidal.
Money is at the root of the issue. We need funding for more mental health providers and psychiatric beds, and much more equitable insurance practices so patients with mental illness can access the care they need when they need it ― before they’ve reached the point of suicide.
Accomplishing this will require political leaders who can break free from the trance of the current political sideshow in Washington, recognize the gravity of the situation and work in a bipartisan manner to relegate our shattered mental health care system to the tattered, yellow pages of history books. Because while we wait, emergency rooms and prisons overflow with the mentally ill, suicides continue to climb past record highs and overdose deaths soar.
Our nation’s psyche can’t bear separate but equal treatment for much longer.
If you or someone you know needs help, call 1-800-273-8255 for the National Suicide Prevention Lifeline. You can also text HOME to 741-741 for free, 24-hour support from the Crisis Text Line. Outside of the U.S., please visit the International Association for Suicide Prevention for a database of resources.
Brian Barnett is a fellow in the Partners HealthCare Addiction Psychiatry Fellowship and at Harvard Medical School. His research focuses on substance use disorders, as well as mental health services in the United States and Malawi. You can follow him on Twitter @BrianBarnettMD.