Dr. Denial = Death

Katherine West was a 14 year old with an eating disorder. Her condition was serious enough that her physician and psychiatrist ordered a 12-week stay of residential treatment, to which she was promptly admitted. Six weeks into therapy, the largest insurer in the United States (Anthem) decided that Katherine had gained “enough” weight and could be safely discharged from the hospital. Her treatment team vehemently disagreed with this assessment. The insurance company overruled the hospital and West was sent home for outpatient care. Less than a week later, the teen was discovered dead by her mother from heart failure caused by continued purging. Clearly, Katherine was not an appropriate candidate for the shortened stay determined by Anthem.

Despite passage of the Mental Health Parity Act in 2009, inequalities in healthcare coverage persist. Psychiatric treatment continues to be denied by insurance companies in unprecedented ratios compared with other health conditions. The implications of this disparity are particularly relevant to the recovery community. Addictions, including alcohol, drugs and eating disorders often require more time in treatment than insurance companies are willing to bear. The result is that treatment gets cut short, often with deadly consequences. The deeper issue at hand is the lingering perception of mental health concerns as moral failures. Voices for change are being raised, by former Congressman Patrick Kennedy and in mainstream media outlets, like 60 Minutes, where a December 14 story raised ire across the country.

Kennedy said, “It’s an all too familiar tragedy that mental health is not treated the same as the rest of physical health. It’s in the detail of how medical utilization reviews are made.” Health care companies are currently opaque in regard to their processes for denial. The former congressman has founded a non-profit organization called “One Mind.” The organization’s intent is to lead efforts in research, funding and public awareness of mental illness and brain injury. Kennedy’s vision is to bring government, corporate, scientific, and philanthropic communities together in a push to reduce the social and economic effects of mental illness and brain injury.

The statistics from the National Alliance on Mental Illness are telling: 9.2 million adults have co-occurring mental health and substance abuse conditions. One in four adults experiences mental illness every year and 13.6 million Americans live with chronic conditions such as schizophrenia, bipolar disorder and depression. To the extent that stigmas about mental illness and addiction can be removed, so goes our ability to manage the practices of health care companies.

The type of review that resulted in the death of Katherine West works like this: After a patient is admitted into a treatment center, doctors begin receiving daily calls from a representative of the insurance company. If that representative decides the patient is ready for a lower level of care, the case is referred to an insurance company physician. This doctor, who has not met and will never meet the patient, reads the file, talks to the treatment team on the phone and renders a decision.

Evaluations that change the course of care are done with alarming frequency in psychiatric and behavioral treatment. Insurance companies refer to the practice as as “managed care” but it is clearly about managing costs. Doctors are forced into dialogue with insurance companies on a daily basis to justify approval for patients to continuepreviously approved treatment. Questions are asked, like, “Is the patient acutely homicidal or suicidal?”  The questions are worded just so to ensure a doctor’s response of “no.” In a supervised setting and without a weapon, the patient is not in what is considered to be an acute condition.

The doctors providing assessments for insurance companies are generally not full-time employees. They are hired on a fee-per-review basis. This results in the contracted doctor working through cases at a rapid pace. In a recent incident documented by the show 60 Minutes it took a total of 55 minutes for a patient to be released to outpatient care, without one conversation occurring between the insurance provider and the hospital. The physicians contracted by Anthem have denial rates of 90% and above for behavioral treatment. While it sounds ludicrous, it is business as usual when it comes to managing the cost of treating psychiatric issues.