“Mental health parity” has been widely welcomed in the US, while here in the UK things are very different…or are they?
I’m grateful to Dr. Deb for posting a quick summary: Mental Health Coverage in US is Law!
But wait a moment…coverage? Other commentators disagree that “those of us who live in the US will now have mandatory mental health coverage” is really what happened, and my reading of H.R. 6983 is in line with those other commentators. What really happened is that mental health coverage will in future be all-or-nothing. People will be able to choose cheaper health cover by opting out of mental health cover completely, and it seems to me that in a recession that’s what many people will do.
Here in the UK
All that is on the other side of the pond, though. Here in the UK we have a National Health Service that provides just what Dr. Deb would like to have in the US:
No one should be without medical or mental healthcare.
Last week I heard about a patient who has a life-threatening mental illness, and who was placed on a nine-month waiting list to be assessed for treatment. This was on condition that he stops seeing the very supportive GP who has been helping him until now, and registers with a new GP in a different district.
The excuse for this kind of thing is always “lack of resources”. During the nine months, though, this patient will need constant support for his untreated condition, and he can be expected to make frequent demands on primary care, A&E, the ambulance service and the police. Meanwhile he’s unemployable, living at the state’s expense and not contributing to the economy or paying taxes. Knock-on effects on family members (for whom this is like a nightmare) may well mean that they have greater healthcare needs, too.
And that’s assuming he survives the nine months. If he dies, there will be other costs in the courts, the complaints system, and the opportunity cost of a life allowed to go to waste.
A reasonable diagnosis of the system would be that “resources” are so plentiful they can freely be wasted on the hugely expensive business of maintaining illness, making actual treatment a kind of last resort.
Many people who can afford to pay for treatment outside the NHS do so to evade the erratic way the NHS rations care. They often do this by by purchasing insurance cover.
As in the US, some of this insurance does not cover mental health at all. Other plans impose per annum cash limits on mental health expenditure, and these limits can be restrictive.
So a common situation is that a patient has a number of sessions of CBT, and then the cash runs out for that year. If the patient cannot afford to continue with treatment, then a “therapy holiday” is needed. When treatment resumes in the next year of insurance cover, the break in treatment rarely turns out to have been harmful. It is almost always just an annoyance, rather than an obstacle to recovery. Some patients simply pay for the extra sessions themselves, of course.
What actuaries know
CBT is relatively cheap, so it’s perhaps surprising that this kind of thing happens often. Insurers know a way to make CBT much more expensive, though. Some of them require the involvement of a psychiatrist in addition to the CBT therapist. If the psychiatrist performs an initial assessment and regular reviews, this can easily double the cost of treatment, making that per annum cash limit pay for less actual therapy than you would think.
Why insurers do this is a mystery to me. One theory is that seeing a psychiatrist has a stigma attached to it, so the requirement to see a psychiatrist makes people avoid treatment, reducing the total cost of claims. Another theory is that insurers are effectively paid on percentage, so if they can raise the cost of treatment they make more money. A further theory is that there really is no reason, except that claims managers are dimwits. If there is a reason at all, only the actuaries know it.
Employee health schemes and other indirectly funded care are not always arranged through conventional insurers, and some of them impose a weird restriction. This is that the therapist is contractually prevented from providing treatment beyond the patient’s cover. For example, a patient is entitled to six sessions of CBT under the scheme, but his condition is complex and he needs ten sessions. The contract means he cannot pay for these four extra sessions out of his own pocket. Instead, he must start again with a different therapist. In my opinion these contracts are unethical, but I have not seen any criticism of them by therapists’ professional organizations.
There are no universal solutions to the problems of universal healthcare. Our NHS has chronic deficiencies that as a society we desperately need to address, even though to some extent those same deficiencies fuel a thriving private healthcare sector here. What’s needed is some kind of paradigm shift, seeing the whole issue from a different perspective — perhaps we will be able to learn from developments in the US in the coming years.