Bernards Voices

In the March 5th, New York Times, Gardiner Harris, reports that insurance does not pay enough to justify a psychiatrist providing talk therapy.

Like many of the nation’s 48,000 psychiatrists, Dr. Levin, in large part because of changes in how much insurance will pay, no longer provides talk therapy, the form of psychiatry popularized by Sigmund Freud that dominated the profession for decades. Instead, he prescribes medication, usually after a brief consultation with each patient. So Dr. Levin sent the man away with a referral to a less costly therapist and a personal crisis unexplored and unresolved.

When Dr. Levin began his practice in 1972:

he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart.

The article seems to deal, first, with the impact on the doctor–the loss of intimacy and connection he feels with his patients. But that it is insignificant, I feel, compared to the loss to the patients. Many studies conclude that medications, when necessary, combined with talk therapy provide the best results.

I’m not implying that Dr. Levin isn’t recommending talk therapy, he is, but finding a second doctor, either in-network, or paying for it out of pocket, or the patient filling out his own paperwork to get partially reimbursed for the therapy, just adds more and more obstacles to getting care. And many people don’t follow through. If you are suffering, maybe you’re depressed, anxious … just how many hoops are you going to jump through?

“Medication is important,” [Dr. Louisa Lance] said, “but it’s the relationship that gets people better.”

Harris makes a tricky little point below by conflating social workers and psychologists. Psychologists with PhDs or PsyDs have invested quite a lot of money as well, and do more training than social workers. I doubt they are very happy, actually I know from experience, that they aren’t happy with the reimbursement rates from insurers either.

Competition from psychologists and social workers — who unlike psychiatrists do not attend medical school, so they can often afford to charge less — is the reason that talk therapy is priced at a lower rate. There is no evidence that psychiatrists provide higher quality talk therapy than psychologists or social workers.

Here is a related post, from March last year. And another post, from January last year.

For the upcoming HOP mental health awareness event, a topic that generates a great deal of conversation is “navigating the mental health system”, specifically regarding insurance. All agreed that, especially with the recent health care reform laws that will be enacted over the next few years, this is an area that we need to spend some time on during Mental Health Week, May 10th through 15th.

As it turns out, I opened the Science Times section of The New York Times this morning — it is entirely devoted to helping consumers decipher the new health care legislation from both a policy and clinical standpoint; I highly recommend checking the whole section out on line if you can’t pick up a copy. And, lo and behold, there’s an excellent article entitled “Mental Health Experts Applaud Focus on Parity”. The focus is two-fold: the mental health care parity laws that will go into effect this July, providing that coverage for mental health treatments can be no more restrictive than for medical and surgical treatment; and how health reform will amplify these new parity laws to the benefit of those who need treatment for mental illnesses.

See related post on Obama administration rules for a single deductible.

The Obama administration issued new rules which will go into effect July 2010, that calls for parity coverage for the treatment of mental illness through employer and group insurance plans.  The rules carry out a law passed in 2008 sponsored by Wellstone and Domenici … what’s really amazing is that this legislation received bi-partisan support when it was originated — now that’s different!

Robert Pear in the January 30, 2010 The New York Times reported:

Insurers cannot set higher co-payments and deductibles or stricter limits on treatment for mental illness and addiction disorders. Nor can they establish separate deductibles for mental health care and for the treatment of physical illnesses.

The administration said the new requirements could increase premiums by four-tenths of 1 percent, or $25.6 billion over 10 years. Businesses with 50 or fewer employees are exempt.

The government said the rules would benefit 111 million people in 446,400 group health plans offered by private employers, and 29 million people in 20,000 plans sponsored by state and local governments.