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Connecticut three-day
rule is history
(July 2008
Issue)
By Nan Shnitzler
Connecticut Gov. Jodi Rell on May 27 signed a bill that eliminates
the "three-day rule" that had been the bane of mental health care
clinicians, advocates, administrators and patients since the early
1990s. The rule says that group health insurance doesn't have to
pay for residential mental health care treatment for children and
adolescents unless the patient is hospitalized first for at least
three days.
Public Act 08-125, which takes effect Jan. 1, 2009, strikes the
three-day requirement, applies to all patients and includes provisions
for medical necessity and clinical assessment. Legislators had rejected
the bill until Kathryn Laudadio went public this past April in the
Hartford Courant.
After an anorexia-related collapse last summer, Laudadio, a high-school
student with a history of mental disorders, was taken to the emergency
room. Doctors wanted to hospitalize her before sending her to residential
treatment, but no psychiatric beds were available. Her mother, Lisa
Gfeller of Fairfield, fearing for her daughter's life, checked her
into a Philadelphia residential treatment center, despite learning
the day before about the three-day rule. She has been fighting Anthem
Blue Cross and Blue Shield for $13,400 in reimbursement ever since.
It's a Catch-22 situation when adolescents can't get the level
of care they need because they're not sick enough to satisfy the
inpatient hurdle, says Harold I. Schwartz, M.D., chief psychiatrist
at Hartford Hospital's Institute of Living.
"From our point of view, it was just the insurance industry's way
of ensuring diminished utilization of the benefit altogether to
force people into ambulatory or acute care with nothing in the middle,"
Schwartz says.
The Catch-22 often left families with no recourse except to dip
into their savings. Moreover, insurance companies applied the law
inconsistently and sometimes even ignored it.
A public hearing Feb. 26 in front of the legislative insurance
committee was an opportunity to educate lawmakers, says Kevin Lembo,
M.P.A., Connecticut's healthcare advocate. They didn't seem to understand
that a stay in a residential treatment center required professional
assessment and clinician sign off, that one couldn't just walk in
off the street.
"Their point was they liked the idea of the patient being in a
controlled clinical environment for a few days until a provider
could assess the total package of needs," Lembo says. "But we explained
that while some need an acute stage first, it wasn't necessary in
all cases nor was it appropriate or cost effective just as an entrance
ramp to residential care. So we had to get them over that hurdle."
The other half of the equation is the shortage of psychiatric beds,
especially for children and adolescents and particularly for eating
disorders, Lembo says, which, ironically, is being addressed via
residential programs. In fact, the Institute of Living became aware
of the three-day rule when it investigated setting up a residential
program. The three-day rule itself feeds into the shortage when
acute-care beds are occupied needlessly.
"It's hard to get a psychiatric bed in a hospital, especially if
you're a kid," Lembo says.
Despite impassioned testimony from Lembo, the state attorney general,
parents and advocates, the original bill never made it out of committee.
With only about two percent of mental health care in Connecticut
provided residentially, according to Lembo, some legislators didn't
consider it a problem.
But through the newspaper publicity, efforts of Gfeller's state
senator, John McKinney (R-Fairfield), and lobbyists for the Institute
for Living, the Connecticut Psychological Association, NAMI Connecticut
and others, legislators ultimately jumped on the bandwagon and passed
the measure in May.
"We were really happy to see it pass," says Alicia Woodsby, public
policy director for NAMI Connecticut, who testified last February.
"We thought it was an arbitrary requirement that created barriers
to access the right level of care. This is a step in the right direction
and a good law."
What is the takeaway for psychologists? Lembo encourages mental
health clinicians to refer patients denied insurance to his office
for assistance.
"It was always our goal and that of our allies in this fight to
make sure patients get the appropriate level of care with the appropriate
frequency in the appropriate setting," Lembo says.
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