Ill Effects of Nickel and Dime Mental Health Care

It’s been a week since the U.S. surgeon general issued a landmark acknowledgment that--drum roll, please--”mental health is fundamental to health.” Given the rates of suicide, homicide, domestic abuse, drug addiction, alcoholism, anorexia, obesity, school violence, workplace violence, etc., you wouldn’t think we’d need the nation’s highest-ranking doctor to clue us in on that connection. Still, the report was welcome medicine.

Particularly in Southern California. Because even as Dr. David Satcher warned of a coming crisis in mental health care--especially among the elderly--the Medicare carriers who are entrusted with delivering it here were merrily making good counseling as hard as possible for the region’s senior citizens to get. For four years now, a once reasonable and now harmful crackdown on Medicare billings for therapy in Southern California has wrought havoc on the care of the very people the surgeon general singled out for concern.

At issue is a campaign that started--as such things will--with the best intentions. Concerned about a then-high volume of claims for psychotherapy in the southern half of the state, the government did an audit five or six years ago. As it turned out, Southern California, with 5% or less of the nation’s Medicare population, was generating about 20% of the program’s mental health care bills.

These bills were not for hospitalization. They came out of Medicare’s “Part B” pocket, which deals with doctor bills. Part of the 20% statistic could be chalked up to a higher acceptance here of mental health care as--well, health care. But a suspicious proportion was for severely mentally ill people and for seniors in nursing homes.

Such patients usually get seen at the behest of the facilities where they’re staying, by private therapists who get called in. The need is enormous. Depression is rampant in nursing homes, and medication is only half the cure for a person suffering from, say, schizophrenia (though drugs treat the disease’s symptoms, it takes human contact to treat the sufferer’s underlying psychological problems). That demand--plus Medicare’s own past laxity--had attracted fraud.

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So the Health Care Financing Administration, which runs Medicare, and Transamerica Occidental Life Insurance Co., which handles its claims here, cracked down in early 1996. By the end of that year, that 20% share of billings had plummeted to 12.7%, and the bulk of the fraud had been winnowed, but the squeeze continued. The share fell to 10.9%, then 8.3% and, as of this year, was still falling. Yippee, right?

Wrong.

Because--though you’d never gather this from the gung-ho way these crackdowns always get reported--it’s actually possible for these things to go too far. It’s one thing to stop quacks from swinging by nursing homes to say good day to people in comas, only to bill the taxpayers for “therapy.” It’s something else when an elderly resident degenerates to the point of suicide because her care has been cut off.

This actually happened. It was reported by a local therapist when the American Psychological Assn. surveyed the aftermath of the crackdown last year. There was also the psychotic who’d been kept alive for 18 years by his therapist, only to throw himself from a window after Medicare cut off his treatment. And the schizophrenic who periodically would go into a suicidal spiral, requiring weekly visits from a psychologist. When Medicare refused to pay for anything more than twice a month, she tried to kill herself--as predicted. The government ended up footing the bill, courtesy of Medicare’s “Part A” pocket, for her monthlong, $1,000-a-day stay in a psychiatric hospital. The extra session would have cost taxpayers $29.99 weekly for, maybe, three weeks.

So many caregivers were so fed up, the survey found, that fewer than half were willing to treat Medicare patients anymore, and of those who were, two-thirds reported that care was being chronically and inappropriately denied. Appeals were so arduous that one in 10 was seeing patients with no hope of payment. One therapist reported “15-20 people whom it costs me money to see.”

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At least four local congressmen have complained to HCFA about this, and in October, U.S. Rep. Ed Royce (R-Fullerton) petitioned Rep. Bill Thomas (R-Bakersfield), who heads the House Ways and Means health subcommittee, for a formal inquiry. So far, scant action has ensued from the bureaucracy.

And action is needed. Without mental health, a life is just an existence. With it, there is nothing--loss, pain, even life’s imminent ending--that can’t be borne. This long nickeling and diming of the weak has been, at best, pound foolish and at worst, a scandal. Morality shouldn’t require a prescription from the surgeon general.

Shawn Hubler’s column appears Mondays and Thursdays. Her e-mail address is shawn.hubler@latimes.com.