MENTAL HEALTH: HMOs Pose Access Barrier, Advocates Say

      Patients who are prevented by managed care policies from direct access to a mental health specialist could be receiving inadequate treatment for depression, mental health advocates said Friday. To counteract the "epidemic of undiagnosed and under-treated depression in the managed care setting," primary care doctors must learn to recognize and treat depression, according to doctors at a media round table convened by the National Mental Health Association and the National Alliance for the Mentally Ill (NMHA/NAMI release, 5/15). "Primary care physicians can no longer overlook their role in diagnosing and treating mental illness because patients simply no longer have access to trained mental health specialists," said Dr. David Brody, of Philadelphia's Allegheny University Hospital Systems (Reuters/Boston Globe, 5/16). Managed care policies on specialist referral often mean primary care doctors are left to shoulder the task of treating mental illness, but NAMI and NMHA note that "the majority of practicing physicians completed medical school at least a decade ago, when the only exposure to the treatment of mental illness was a brief psychiatric rotation."

Reliance On Medication
      Mental health experts said primary care physicians' limited knowledge of treatments for mental illness may lead to an "over-reliance" on new pharmacological treatments without the necessary follow-up by physicians. "All too often, patients will begin to feel better after six weeks on treatment, and drop off treatment because they believe that depression responds quickly to pharmacological treatment and that drug therapy should be stopped as soon as possible," said National Institute of Mental Health researcher Gabrielle Leverich. She noted that it often takes months to find a proper drug treatment and that "without proper guidelines, proper guidelines for medication use, proper compliance is often overlooked in the primary care setting" (NMHA/NAMI release, 5/15).

Leading the Charge
      Allegheny's Brody said managed care organizations can lead the charge to correct the underdiagnosis and undertreatment of depression. "While managed care is blocking progress right now, it also has a unique opportunity to lead in the reorganization and improvement of the delivery of mental health care in the primary care setting," the Reuters/Globe reported (5/16). NAMI and NMHA note that the National Committee for Quality Assurance, a major managed care accreditation organization, has included mental health measures in its draft 1999 accreditation guidelines (NMHA/NAMI release, 5/15).

Offering Less To More
      As mental health advocates blamed undertreated depression on managed care policies, a study in the latest issue of Health Affairs found "the level of mental health coverage that employees have access to is ... shrinking." Even though the number of insured workers with mental health benefits increased from 84% to 93% between 1991 and 1995, "more workers faced multiple limits on their benefits", including day and visit limits, separate coinsurance and separate copayments. The study further found that "HMO enrollees were more likely than conventional and preferred provider organization (PPO) plan enrollees to be subject to coverage limits." In addition, the study concludes that "the recently enacted Mental Health Parity Act of 1996 is not likely to alter [the] trend of offering less to more." Under the law, "employer health plans that cover mental health care are to provide the same annual and lifetime reimbursement ceilings for such care that they provide for other ailments." Researcher Gail Jensen, who led the study, said employers are concerned about costs as they attempt to more comprehensive benefits packages to workers. "[M]any of them may try to counteract these costs by imposing limits, such as restricting the number of inpatient days or outpatient days covered, or by requiring employees to pay higher deductibles," Jensen said.

Added Costs?
      The Health Affairs study also "notes that there is evidence that state mandates enacted prior to the [1996] parity law carried their own costs, including: discouraging some small firms from offering coverage altogether, causing some employers to reduce their coverage for other services ... and encouraging some mid-size to large firms to self-insure." Accordingly, the study authors "findings suggest that the parity law may indeed lead employers to add more restrictions to their present coverage" (Health Affairs release, 5/18).