When Blue Cross & Blue Shield of Rhode Island subscribers need to see a psychiatrist or psychologist, they can just call and make an appointment – no preauthorization needed.
They have up to 30 visits per year, and very soon, it may be 50, or as many as they need.
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William A. Hancur, the company’s associate director for behavioral health, is widely viewed as a leader in improving access to services. And President and CEO James E. Purcell says the interdependency of physical and behavioral health “cannot be disputed.”
The changes, mental health providers say, are huge – across the private health insurance system, but especially at Blue Cross. Yet unresolved issues and new problems, a discussion at Butler Hospital on Oct. 7 revealed, threaten to undermine the progress.
The event was billed as a way to “continue the dialogue” with Blue Cross. To set the tone, Dr. Patricia Ryan Recupero, president and CEO of Butler, presented statistics showing that nationwide the number of both state and private psychiatric hospital beds has been dropping rapidly and those that remain are heavily strained.
But demand for mental health services remains high, with one in four U.S. adults (59 million) getting some form of treatment in the past two years, and about 48 million taking medications. Increasingly, however, it’s not specialists, but primary-care doctors treating mental disorders, and those with severe problems are ending up in emergency rooms.
The “unmet need” for specialized services is high, Recupero said, yet fewer and fewer psychiatrists are practicing in the community, where they’re most needed.
While 68 percent of doctors are primarily in private practice, she said, citing a recent SHAPE Behavioral Health System Study, only 40 percent of adult psychiatrists and 24 percent of child psychiatrists are. And of the psychiatrists who graduated from Brown Medical School between 1994 and 2004 and stayed in the state, almost half went to hospitals.
The problem goes even deeper, others in the audience noted: The SHAPE study found only 57 percent of adult psychiatrists and 50 percent of child psychiatrists accept private insurance. And as much praise as Blue Cross gets for other policies, in this case it was singled out as doing worse than UnitedHealthcare of New England, CIGNA or Tufts.
Here’s why: Blue Cross pays about $100 for an hour of psychotherapy, half to two-thirds of the “going rate,” said Dr. Paul Lieberman, president of the Rhode Island Psychiatric Society. With United and other carriers, patients can still use the provider and pay the difference, but Blue Cross, like Medicare, holds psychiatrists to the same rule as other doctors – if you’re in the network, you have to accept the network fee, and that’s it.
“It’s a very significant difference,” said Lieberman. As a result, many psychiatrists forgo that area of their practice, even though “it’s a big part of our identity,” and they have a strong incentive to do medication checks instead, for example – at $60 apiece for a few minutes.
The Blue Cross rule has implications for Butler and for community mental health centers as well, several people said. Butler has been courting a child psychiatrist who specializes in severe illnesses such as schizophrenia and bipolar disorder, but if he went to the hospital, he’d have to join the Blue Cross network, and that would preclude him from refusing to take Blue Cross in his private practice, one Butler official said. The same applies to anyone who wanted to work a few hours a week, as a public service, at a community clinic.
Health Insurance Commissioner Christopher F. Koller, however, warned that trying to change the rules could undermine efforts to achieve parity with physical health.
“If we want parity for behavioral health,” he said, “then we have to have parity across the system.”
Dale K. Klatzker, president and CEO of The Providence Center, pointed out another major area for improvement: emergency room overuse. There’s too little money in the system for mental health, Klatzker said, but there’s also a lot of money “misspent” putting people in ERs who actually need a community health center or a mental hospital bed.
“It would be an enormous challenge” to change that, Klatzker said, “but I think it’s doable in a small state like this, if people committed to it. Right now we’re wasting a lot of money.”
Koller agreed, and he said buyers of health insurance – especially large employers – could make an impact by demanding such a change. The market pressure on Blue Cross now is to “get the hell out of the way” and let people access services as they wish, Koller said, “and that’s great until you run into problems like we have with the ERs.”
Hancur, of Blue Cross, made note of another market pressure that he said could be devastating to behavioral health: the push toward “consumer-driven” health care – specifically high-deductible plans combined with health savings accounts (HSAs), whose benefit structures are tightly governed by U.S. Treasury rules.
Such plans are “a huge threat to us,” Hancur said, because no behavioral health services are exempt from the deductibles. (To see a therapist once a week, a patient could pay $2,000 out of pocket in just two months.) “I don’t see how we can deal with this,” he said.
Even non-HSA plans are already creating problems, said Judy Hoffman, of the Rhode Island Employee Assistance Program. Many plans (such as some with health reimbursement accounts, or HRAs) cover the first, say, $1,000 in expenses, then force the employee to pay the next $500 or $1,000 out of pocket. Given how quickly costs can add up with mental health services, Hoffman said, some workers avoid therapy, saving their benefit for emergencies.
“They don’t want to dip into that pot of money that the employer sets up,” Hoffman said. “We’re very concerned about this plan design.”
