By now, mental illness was supposed to be taken as seriously as physical disease. California and several other states even created laws to that effect.
So-called parity laws require that insurance coverage for mental illness equals that for other diseases. Under California's law, passed four years ago, health plans can't require patients to pay higher co-payments for treatment, and they can't impose lower lifetime and annual caps on benefits. If the lifetime maximum benefit under a policy is, say, $2 million for physical illness, then it must be $2 million for mental illness as well. The number of days allowed for hospitalization also must be the same.
Such efforts to elevate the status of mental illness have made it to the federal level -- proposed federal legislation would require insurers in all states to provide equal benefits.
Though laudable, the laws have not remedied longtime inequities, mental health advocates say. "The parity law was intended to create an atmosphere where people would feel comfortable asking for service and erase the stigma associated with the disease," says Randall Hagar, director of governmental affairs for the California Psychiatric Assn. "It was supposed to provide access to treatment by providing higher benefits."
Californians who suffer from mental illness now receive equal reimbursement, but they may not be receiving high-quality care. In its most recent annual report card, the National Committee for Quality Assurance, a nonprofit group that accredits and evaluates health plans, said that although some plans improved care for patients with certain physical conditions in 2002, care did not improve for those with mental illness.
The committee noted that over the last four years there has been little improvement in treatment rates for depression. For example, generally accepted standards of medical practice call for people who receive a diagnosis of depression and a prescription to have at least three visits with their physician in the next 12 weeks. But only 19% saw their doctors that many times in 2002. Only 11% of patients on Medicare had the optimum number of visits.
When it came to proper follow-up treatment after a hospital stay for mental illness, only about half received care within seven days of leaving the hospital.
By contrast, more than 90% of heart attack patients received life-saving beta blocker treatment in 2002 and 80% of women were screened for cervical cancer.
Both patients and doctors share the blame for such low marks. "A lot of employees are hesitant to use mental health benefits provided by their employers," says Sue Davis, executive director of the Arizona chapter of the National Alliance for the Mentally Ill. "They are afraid of the stigma and that word will get back to their employers that they are ill-equipped to do a job."
Rhonda Robinson Beale, chief medical officer for Cigna Behavioral Health, says many doctors, particularly primary care physicians not trained in psychiatry, do not always know the standard of care. She says it takes about 17 years for medical research to make its way into accepted medical practice.
People with mental illness can't wait that long. A study reported earlier this year in the Journal of the American Medical Assn. found that major depression accounts for nearly half of all lost productive time at work (among workers with depression) and costs employers about $44 billion each year.
Some health plans are not waiting for medical knowledge to filter down to doctors. They are designing programs to raise their report card grades and benefit patients at the same time.
Cigna provides doctors with guidelines to help them identify patients with depression. HealthNet issues reports -- based on its own pharmacy records -- that show doctors which patients appear to have stopped taking antidepressant medicine. "We recognize there's room for improvement," says HealthNet spokesman Brad Kieffer.
Patients should not wait either. One way to improve care is to see how California health plans scored on treatment for mental illness. Although the National Committee for Quality Assurance does not make results available for individual health plans, California's Department of Managed Health Care has a Web site (www.opa.ca.gov) that shows how 10 health plans rank in providing care. If you're choosing a new health plan this fall and suffer from mental illness, these rankings might help you find an insurer that is trying to deliver good care.
Trudy Lieberman can be reached by e-mail at email@example.com. Health Matters appears on the third Monday of the month.