Treating the Mind as Well as the Body

Mental health coverage has been the weak link in the health insurance system. Employers and insurance companies, always worried about controlling costs, often have been skeptical of the efficacy of treatments for mental health problems. Add to that the stigma and sometimes the self-inflicted shame faced by patients and their families struggling with mental illness.

The result is a daunting challenge for people seeking help. There is a world of difference in the ease of treatment if the sickness is of the body rather than the mind. For someone with high blood pressure and diabetes, for example, a typical health plan allows access to doctors and hospitals without restrictions. A young woman with an eating disorder who consults a therapist or must be hospitalized faces rigid insurance system rules: probably a strict limit of 30 days a year in an inpatient mental facility and 20 visits to a counselor.

California now has a chance to lead the way as a pioneer in offering equal treatment for both physical and mental ailments. A new state law requires parity of treatment for a specific list of mental health problems. The law applies to coverage for the 20 million California consumers who are enrolled in health insurance systems regulated by the Department of Managed Health Care. These include many health maintenance organizations (HMOs) and some preferred provider organizations (PPOs).

(The law does not apply to people in traditional indemnity insurance programs and to some PPOs regulated by the California Department of Insurance. Those plans are still permitted to have different rules for coverage of physical and mental ailments.)

The new law covers these ailments, as defined in the psychiatric profession’s standard diagnostic manual:

* schizophrenia

* schizoaffective disorder

* bipolar disorder (manic-depressive illness)

* panic disorder

* obsessive-compulsive disorder

* pervasive developmental disorder or autism in children

* eating disorders, including anorexia nervosa and bulimia

* serious emotional disturbances in children (defined by the Diagnostic and Statistical Manual of Mental Disorders as a problem that results in “behavior inappropriate to the child’s age according to expected developmental norms”).

No longer can the health plans impose a limited number of patient visits or hospital days for these ailments. The duration of stay or the number of office visits is now prescribed by the professional who treats the patient, just as it would be for an appendectomy, a heart attack or a removal of cataracts.

The law was carefully written to cover certain conditions. But it specifically excludes treatments for alcoholism and drug addiction, which can be very costly.

The new law has the potential for helping thousands of patients and their families. By assuring parity--the same availability of coverage--the families no longer will be forced to spend thousands of dollars for vital treatments. A day in a mental health facility can easily cost $1,000, and a visit to a therapist might range from $50 to $150.

Daniel Zingale, director of the state’s Department of Managed Health Care, said he will aggressively implement the law as a “commitment to preventive health” for consumers.

“We want treatment early to prevent more costly physical ailments down the road,” he said in an interview. Untreated mental and emotional problems raise stress levels that can lead to heart disease and a host of other physical problems, according to Zingale. “Treating these conditions early will pay off for the whole system” by saving money in the long run.

Zingale’s office has sent material to the health plans it regulates, and will hold a series of meetings with the organizations “to impress on them our vigilance, and our intention to keep focused on the mental health parity act,” he said. He wants the health plans to make clear to all their members that the expanded coverage is available.

“It doesn’t do any good to have the benefit unless people know exactly what is available to them,” he said.

The law became effective July 1, with the renewal of health plan contracts. Since businesses typically sign one-year contracts with their plans, the law should be universally effective with all programs under Zingale’s regulation by next summer.

“This is a very big thing,” said Andrew Sperling, director of public policy for the National Institute of Mental Illness (NAMI), which represents 210,000 patients and family members. “It’s much stronger than the federal law; it essentially addresses major gaps in the limited federal rule.”

Federal legislation mandates lifetime parity. For example, a policy that pays $1 million in benefits for physical illnesses must have the same limits for mental illness. But this attempt to equalize treatments still left the health plans with the leeway to impose high deductibles or co-payments for mental ailments, or sharply curtail the number of visits during a year. In California, at least, the insurance coverage provided by the health plan can no longer be written this way.

Rather than a “cookie cutter” approach, limited to 30 hospital days and 30 visits a year, California patients “can now get individualized treatments that should be more effective,” said Dr. Jerry Vaccaro, vice president and corporate medical director at PacifiCare Behavioral Health, the mental health division of the PacifiCare system.

“We know that in better than 80% of the cases, there are treatments that work,” he said. New medications have had tremendous success in dealing with mental ailments. “These are the ones where there is no doubt they are biologically based,” he said. “There are diseases of the brain just as diabetes is a disease of the pancreas.”

Many mental health advocates would have preferred general legislation, coverage that didn’t single out certain conditions. But this wasn’t politically workable.

“There was a perception problem, a fear of the ‘Woody Allen syndrome,’ where people are not very sick and do not have real problems but sit on the psychiatrist’s couch week after week and month after month,” said Rusty Selix, executive director of the Mental Health Assn. of California, an advocacy organization. In many movies, comic director and actor Woody Allen plays a worried character whose years of psychotherapy have made him hyper-articulate in discussing his problems but still unable to solve them.

Although there are specific illnesses mentioned in the law, ambiguity may be an issue for the category of serious emotional problems for children. Zingale acknowledged this is a gray area for both health plans and his own regulatory staff, but he is looking for what he calls an open-minded interpretation by the health plans. His department has an independent appeals process and expert advisors who will help interpret the law.

But Zingale said he is aiming for an expansive interpretation of the statute as part of a general pro-consumer policy. “I would hate to see the health plans walk away from treating a mental illness just because it may not fit neatly within the list,” he said.

Consumers with questions about the law should check with their health plans to find out about the coverage and whether the new law immediately applies to their health program. The Department of Managed Health Care also will provide information. Call (888) HMO-2219 (466-2219). The Web site is https://www.hmohelp.ca.gov.

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Questions about the finances of someone in a nursing home are among the most common problems facing our readers. Here is an example.

Question: Fifteen years ago my father put my name on his bank accounts and certificates of deposit. I have durable power of attorney and I pay his bills. Today he is an Alzheimer’s patient in a nursing home that charges about $4,200 per month, which means in about six years he will run out of money. Because my name has been on his bank accounts and CDs, does this mean that I am entitled to some of these assets and that not nearly everything has to be spent from our joint accounts (including mutual funds) before Medi-Cal will take over the financial burden of the nursing home?

Answer: Your name on the account does not necessarily mean you are entitled to any of the money. To get the funds legally, you need a clear direction. Either your father must be of sufficiently sound mind today to make a gift of money to you, or he must have spelled out specifically in the written power of attorney that you are allowed to transfer money from the account to yourself. If you are allowed to transfer money to yourself, there can be certain penalties before Medi-Cal coverage begins. Check with a lawyer who is familiar with both powers of attorney and the Medi-Cal rules. The National Academy of Elder Law Attorneys has a list of experienced practitioners. The Web site is https://www.naela.org.

But this letter raises a note useful to anyone (single or married) concerned about growing older and paying for a nursing home. Good planning includes giving to someone you trust both a health care power of attorney and a financial power of attorney. The documents should be carefully written and spell out what you would like to have done if you are unable to make decisions for yourself.

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Bob Rosenblatt welcomes your questions, suggestions and tips about coping with the changing world of health care. You can contact him by writing Bob Rosenblatt, Health, Los Angeles Times, 202 W. 1st St., Los Angeles, CA 90012, or by e-mailing bob.rosenblatt@latimes.com. Health Dollars & Sense runs the second Monday of each month.