When patients are admitted to Butler Hospital, it’s because they’re in real distress. They may be having a psychotic episode. They may have uncontrolled bipolar disorder and be violent. Or they may be so severely depressed that they can’t function or are suicidal.
The doctors help them get back to a safe place, providing medication and behavioral therapies as appropriate for their condition. But just as a person who’s had a heart attack or a diabetic crisis needs follow-up care after being discharged from the hospital, so do they.
Yet for several reasons, many don’t get it.
Now a Brown University study published in the Dec. 24 issue of JAMA has documented the impact of one key factor: cost. When health plans have higher copays for mental-health services than for primary care, the study found, fewer patients get the follow-up care they need after a psychiatric hospitalization.
Specifically, the study found enrollees in plans with equal copays for mental health and primary care, 65 percent had a follow-up visit within 30 days, while only 52 percent of those in plans with higher mental-health copays did – even with only a $14 average cost difference.
“People who receive timely follow-up care after a psychiatric hospitalization are less likely to be re-admitted to the hospital, and have better outcomes,” said Dr. Amal N. Trivedi, lead author of the study and assistant professor of medical science in the Department of Community Health at The Warren Alpert Medical School of Brown University.
The study comes at what Trivedi called a “watershed” time in America: In July, Congress required Medicare – not including privately run “Advantage” plans – to cover outpatient mental-health services in the same way as medical services.
And in October, in a major coup for U.S. Rep. Patrick J. Kennedy, an impassioned advocate of mental-health parity, Congress included a mental-health parity provision in the $700 billion financial-industry bailout plan. Both laws go into effect in 2010.
In a statement about the Brown study, Kennedy said it “further validates the years of work and advocacy” to pass parity legislation.
Trivedi’s study notes that less than half of people with mental illness receive treatment, and for people who’ve been hospitalized, outpatient care is not only important to avoid a relapse, but also to help transition to community-based services and be healthier in the long run.
In fact, the measures Trivedi’s study used – follow-up care within seven and 30 days of a hospital discharge – are widely recognized quality indicators. He examined a large sample – nearly 44,000 patients in 302 Medicare plans that cover 79 percent of the Medicare population.
Not only does parity make a difference, he said, belying insurers’ longstanding claims to the contrary, but the study shows that “people are much more price-sensitive to mental-health services than what we found for other health services such as mammograms.”
Rhode Island has required parity for years, but most Americans face higher out-of-pocket costs for mental-health services, and some don’t get coverage at all. And even in Rhode Island, the copays typically mirror the cost of specialist visits, not the cheaper primary care copays, and there’s often a cap on allowed visits.
Trivedi said many insurers worry that if copays are too low, enrollees will “overuse” services they perceive as having “little value,” and they also worry that they’ll attract people who use a lot of mental-health services – what is known as “adverse selection.”
In reality, Trivedi said, “these concerns are probably overstated,” because after the Clinton administration required all of the Federal Employees Health Benefits Plans to institute mental-health parity, for example, there was no increase in mental-health spending or use.
Locally, Blue Cross & Blue Shield of Rhode Island has expanded its mental-health coverage in recent years, noting that a healthy mind and healthy behaviors are closely tied to physical health. Yet even Blue Cross scored only three stars out of five on follow-up care after mental- health hospitalizations in the latest health plan rankings by the National Committee for Quality Assurance and U.S. News & World Report. (UnitedHealthcare of New England also got three stars, while Tufts Health Plan got five.)
Dr. Steven A. Rasmussen, medical director at Butler Hospital, said he expects Rhode Islanders covered by Medicare to benefit greatly from this year’s legislation, because they now face “substantial” copays, and many providers don’t want to take Medicare patients at all.
For insurers and Medicare, Rasmussen noted, parity is likely to reduce costs, because people who get proper outpatient care are less prone to relapse and be re-hospitalized. •
