Blue chip insurance no promise of psychiatric care

Prompt follow-up is key for patients who present to emergency rooms with acute depression. But getting psychiatric outpatient appointments, even for people with premier health plans, can be cumbersome and time consuming, requiring them to navigate tricky voicemail systems and to jump through insurers’ hoops, among other barriers. Both emergency room and primary care physicians report that it’s difficult to secure outpatient mental health services for their patients.

Recently, a team of clinicians at Cambridge Health Alliance (CHA) in greater Boston got so frustrated they staged a “simulated patient” exercise. They posed as patients enrolled in Blue Cross Blue Shield of Massachusetts’ flexible Preferred Provider Organization (PPO) plan and called every in-network mental health facility within a 10-mile radius of downtown Boston claiming to have been discharged from an emergency room with a diagnosis of depression and instructions to obtain a psychiatric appointment within two weeks.

Out of 64 clinics, four accommodated the two-week timetable and four offered appointments after two weeks. Fifteen clinics didn’t return calls after two attempts. Another 15 said they could not grant an appointment without an in-system primary care physician (PCP), even though Blue Cross’s PPO plan requires neither a referral nor a PCP. Blue Cross Blue Shield is the largest insurer in Massachusetts.

“For people in the field, this study didn’t tell them anything they didn’t know. For the public, the study was a wake-up call and appalling from a public health point of view,” says J. Wesley Boyd, M.D., Ph.D., whose letter to the editor (with three co-writers) describing the findings appeared in the August 2011 issue of Annals of Emergency Medicine.

Of the remaining 26 facilities, eight said no psychiatrist was available or there were cutbacks, six provided youth or specialty services only, six required more information, one didn’t accept insurance, one offered group therapy and four gave no reason.

These excuses are “covert” ways of rationing care, Boyd says. An insurer may soften plan requirements but reimburse so poorly that facilities have no choice but to restrict access.

“The roadblocks we had were set up by the facilities themselves because they are trying to limit their financial exposure,” Boyd says. “For highly reimbursed procedures, like imaging or titanium hip replacements, there are no roadblocks.”

Jerry Berger, M.S., media relations director at Beth Israel Deaconess Medical Center, says that because of low reimbursement rates, many clinics and providers opt out of joining insurers’ provider panels, which puts the squeeze on those, like Beth Israel, that do. At the same time, Beth Israel’s psychiatric outpatient clinic runs a “substantial” deficit and must be subsidized by the hospital.

“To keep our losses at a manageable level, we need to limit the size of our clinic and the programs we offer and are unable to accommodate all those seeking outpatient treatment,” Berger says. “The serious impact of low reimbursement for psychiatric services is a local and national problem that requires thoughtful and rapid attention.”

Health care payment reform is on the table in Massachusetts in the form of a bill filed this past February by Gov. Deval Patrick that would shift payment from the fee-for-service model to a lump-sum “global” or “bundled” model that would take outcomes into consideration.

It would de-emphasize specialties and high-tech interventions in favor of a system that rewards prevention, primary care and wellness, particularly mental health, says Brian Rosman, J.D., research director at Health Care for All, a consumer advocacy group.

“Simply talking to a patient is the least valued activity in the current payment system,” Rosman says. “So that’s why we think payment reform could go a long way toward making mental health care a more attractive source of revenue for providers and lead to greater supply.”

Catherine Pemberton, LICSW, works in the psychiatric emergency room at CHA Cambridge Hospital and spends hours helping patients with private and public insurance access outpatient psychiatry. She says that contrary to what the Blue Cross spokesman said in a Boston Globe story (July 21), getting an appointment is not assured by simply calling the toll-free number on an insurance card.

Customer service people tend to be overworked, might not have the clinical background to understand the type of provider a patient needs and can’t go beyond prescribed utilization criteria without higher authorization, she says. Plus, a provider might not be accepting new patients.

“It’s roulette,” Pemberton says.

Blue Cross would comment only with a statement: “Our focus is to ensure that our members have timely access to these important services should they need them. We would have concerns if a behavioral health clinician who is contracted with BCBSMA and is therefore obligated to see and accept our members were not able to do so and would want to understand why that is. On a regular basis, we track our members’ ability to access behavioral health services; our surveys continually show that our members are getting access to the care they need.”