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Medicare beneficiaries struggle with drug plans

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Medicare beneficiaries struggle with drug plans

Medicare beneficiaries struggling with prescription drug coverage

By Julian Pecquet
The Hill, July 25, 2011

Five years after the launch of Medicare prescription drug coverage, many beneficiaries are still struggling to sign up, according to a new report from the Medicare Rights Center.

The report highlights how hard it is for beneficiaries to choose among “a multitude of plans that have different benefit structures, pharmacy networks, formularies and rules for accessing benefits.”

“This report reinforces what we hear time and again on our helpline,” center President Joe Baker said in a statement. “The Part D plan selection process is enough to make many beneficiaries and their loved ones throw up their arms in surrender. People simply want to be able to find and enroll in the drug plan that is right for them, without getting stuck in a morass of indistinguishable plan options.”

http://thehill.com/blogs/healthwatch/medicare/173345-medicare-beneficiaries-struggle-with-prescription-drug-coverage

Comment: 

By Don McCanne, MD

“People simply want to be able to find and enroll in the drug plan that is right for them, without getting stuck in a morass of indistinguishable plan options.” No. People simply want to have the drugs that they need when they need them.

The Part D drug plan should have been created as a straightforward benefit of Medicare. The program should have been funded equitably through the tax system, and the benefit should have been simply to be able to obtain necessary drugs whenever prescribed. But no.

Congress decided to interject a separate, expensive, administratively complex industry into the picture – a market of competing drug plans. Not only do these entities waste resources, they establish even more barriers to access to the drugs patients need – barriers such as formulary exclusions, tiering of drugs, prior authorization requirements, exclusion of pharmacies from the plan networks, not to mention the complexities of trying to select from a hodgepodge of plans with widely different characteristics.

The obvious solution would be to establish a single payer national health program in which pharmaceuticals are a full, unencumbered benefit. That’s as obvious as, say, when you need the debt limit raised, you simply vote to raise the debt limit. But Congress doesn’t seem to be capable of making obvious choices.

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In praise of Medicare

By Samuel Metz, M.D.
The Oregonian, July 26, 2011

Medicare turns 46 this week and there is much to celebrate. Medicare assures health care for seniors who might otherwise find health care inaccessible. It saves our government money. It makes the lives of our seniors better.

Two concepts inspired Medicare. First, seniors require more care than younger Americans. Second, seniors usually live on less income; many survive only on Social Security. This combination renders seniors extremely vulnerable to losing their savings, homes or lives from easily treatable diseases.

And Medicare provides good care. American life expectancy at birth ranks 30th in the world. We remain 30th for the rest of our lives — until we reach 65. Then, our rank rises until we reach 14th at 80. We can thank the remarkable access to health care provided by Medicare.

Every industrialized nation guarantees health care for seniors. Indeed, we are unhappily distinctive in being the only industrialized nation that does not guarantee care for everyone else, as well. Medicare restores us to a civilized status.

Before Medicare, only 40 percent of nonworking seniors had health insurance, and of those with coverage, private insurance paid for less than 10 percent of their hospital bills. The principle of insuring only the healthy who consume little care and avoiding the sick has always driven our private insurance industry. No insurance company can make money by offering the same comprehensive, affordable coverage to seniors as Medicare, so they don’t offer it. Our experience with Medicare Advantage, an effort to privatize parts of Medicare, resulted in our government spending $17 billion more for the same benefits available through Medicare. Our private insurance industry was in no hurry to insure seniors before Medicare started. They are in no hurry now. Medicare revolutionized health care access for seniors.

Why is Medicare expensive? Simply, health care for seniors will always cost more than that of healthier, younger Americans. And costs are rising in every health care system around the world, not just Medicare. The United States is doubly cursed because our costs are rising faster and are already twice as expensive as other countries. Though hard to believe, Medicare is a leader in fighting cost increases. Private insurance industry costs are rising nearly twice as fast as those of Medicare. And when it comes to administrative expenses, private insurance is 10 times higher than Medicare. In fact, if the single payer financing of Medicare were applied to citizens of all ages, we would save $350 billion annually, more than enough to provide comprehensive health care to every American.

Medicare is good for our seniors and good for our country. It provides health care far more affordably and efficiently than our private insurance industry. It saves our country hundreds of billions of dollars in administrative overhead. And if we expand Medicare to cover younger, healthier Americans, we would all get more care at less cost.

Medicare: Celebrate it, protect it, improve it, and expand it. We need more Medicare, not less.
 
Portland physician Samuel Metz is a member of Physicians for a National Health Program and a founding member of Mad As Hell Doctors.

http://www.oregonlive.com/opinion/index.ssf/2011/07/medicare_at_46.html

Impact of single payer on physician income in Canada

The Impact of Single-Payer Health Care on Physician Income in Canada, 1850–2005

By Jacalyn Duffin, MD, PhD
American Journal of Public Health, July 2011

Over nearly 60 years, into the 21st century, physician income grew at a rate of increase that outpaced that of other Canadians. Since 1958 through the advent of medicare, until at least 1992 and probably into the present, physicians, as a professional category, were the top earners in the country.

In 2005, US doctors earned about five-and-a-half times the US GDP per capita; Canadian doctors earned about four times their country’s GDP per capita.

The observation that Canadian physicians are paid less than their American counterparts invites us to ask, what do Canadians “get” in exchange for paying their physicians less than their American counterparts? A 1990 study showed that, although per capita expenditures on health in the United States were higher than those in Canada, the actual number of services was fewer. In other words, Canadian citizens were getting more and spending less.

From this research, we observe that even when the readjustments resulting from various policy and payment alterations are taken into account, Canadian medicare did not lead to a loss in physician income. Rather, physician incomes grew more quickly than those of other Canadians and are considerably greater. In short, the medical-income argument against moving toward a Canadian-style system is feeble.

The universal, single-payer system has been good not only for Canadians but also for their doctors.

http://ajph.aphapublications.org/cgi/content/abstract/101/7/1198

Comment: 

By Don McCanne, MD

The experience with single payer in Canada has revealed that not only were physicians’ incomes not harmed, physicians remain the top earners in the country. This article should allay the fears of U.S. physicians who would like to see us achieve a health care system that ensures quality health care for all but who remain apprehensive that their incomes might be adversely affected. As this report states, “The universal, single-payer system has been good not only for Canadians but also for their doctors.”

Messing With Medicare

By PAUL KRUGMAN
New York Times, July 24, 2011

At the time of writing, President Obama’s hoped-for “Grand Bargain” with Republicans is apparently dead. And I say good riddance. I’m no more eager than other rational people (a category that fails to include many Congressional Republicans) to see what happens if the debt limit isn’t raised. But what the president was offering to the G.O.P., especially on Medicare, was a very bad deal for America.

Specifically, according to many reports, the president offered both means-testing of Medicare benefits and a rise in the age of Medicare eligibility. The first would be bad policy; the second would be terrible policy. And it would almost surely be terrible politics, too.

The crucial thing to remember, when we talk about Medicare, is that our goal isn’t, or at least shouldn’t be, defined in terms of some arbitrary number. Our goal should be, instead, to give Americans the health care they need at a price the country can afford. And throwing Americans in their mid-60s off Medicare moves us away from that goal, not toward it.

For Medicare, with all its flaws, works better than private insurance. It has less bureaucracy and, hence, lower administrative costs than private insurers. It has been more successful in controlling costs. While Medicare expenses per beneficiary have soared over the past 40 years, they’ve risen significantly less than private insurance premiums. And since Medicare-type systems in other advanced countries have much lower costs than the uniquely privatized U.S. system, there’s good reason to believe that Medicare reform can do a lot to control costs in the future.

In that case, you may ask, why didn’t the 2010 health care reform simply extend Medicare to cover everyone? The answer, of course, is political realism. Most health reformers I know would have supported Medicare for all if they had considered it politically feasible. But given the power of the insurance lobby and the knee-jerk opposition of many politicians to any expansion of government, they settled for what they thought they could actually get: near-universal coverage through a system of regulation and subsidies.

It is, however, one thing to accept a second-best system insuring those who currently lack coverage. Throwing millions of Americans off Medicare and pushing them into the arms of private insurers is another story.

Also, did I mention that Republicans are doing all they can to undermine health care reform — they even tried to undermine it as part of the debt negotiations — and may eventually succeed? If they do, many of those losing Medicare coverage would find themselves unable to replace it.

So raising the Medicare age is a terrible idea. Means-testing — reducing benefits for wealthier Americans — isn’t equally bad, but it’s still poor policy.

It’s true that Medicare expenses could be reduced by requiring high-income Americans to pay higher premiums, higher co-payments, etc. But why not simply raise taxes on high incomes instead? This would have the great virtue of not adding another layer of bureaucracy by requiring that Medicare establish financial status before paying medical bills.

But, you may say, raising taxes would reduce incentives to work and create wealth. Well, so would means-testing: As conservative economists love to point out in other contexts — for example, when criticizing programs like food stamps — benefits that fall as your income rises in effect raise your marginal tax rate. It doesn’t matter whether the government raises your taxes by $1,000 when your income rises or cuts your benefits by the same amount; either way, it reduces the fraction of your additional earnings that you get to keep.

So what’s the difference between means-testing Medicare and raising taxes? Well, the truly rich would prefer means-testing, since they would end up sacrificing no more than the merely well-off. But everyone else should prefer a tax-based solution.

So why is the president embracing these bad policy ideas? In a forthcoming article in The New York Review of Books, the veteran journalist Elizabeth Drew suggests that members of the White House political team saw the 2010 election as a referendum on government spending and that they believe that cutting spending is the way to win next year.

If so, I would respectfully suggest that they are out of their minds. Remember death panels? The G.O.P.’s most potent political weapon last year — the weapon that caused a large swing in the votes of older Americans — was the claim that Mr. Obama was cutting Medicare. Why give Republicans a chance to do it all over again?

Of course, it’s possible that the reason the president is offering to undermine Medicare is that he genuinely believes that this would be a good idea. And that possibility, I have to say, is what really scares me.

http://www.nytimes.com/2011/07/25/opinion/25krugman.html

Single-payer system is the only answer

By David Moynahan, M.D.
Letters, Tallahassee Democrat, July 14, 2011

Re “Progressives have debt-reduction ideas, too” (Eugene Robinson, July 11).

I was heartened to see yet another article in support of single-payer health care. All the railing against “Obamacare” is just a distraction from our currently failing health care system, and “Obamacare” is hardly any better than the old system.

Those advocates of “Leave My Healthcare Alone” aren’t admitting to themselves that as “their” plan keeps getting more expensive or offering fewer benefits, they too might get squeezed out. Every day, more employers are opting out of providing health care, adding to the number of uninsured Americans. The uninsured seek only the most expensive health care (emergency room or catastrophic) for which they can’t pay, and the hospitals add those losses to their costs for everyone else.

So those with insurance pay for everyone else already. Single-payer systems around the world provide better (yes, better, by every measurable outcome) health care for half the cost. We need to wake up and demand true health care reform. Advocates of the status quo are like a ship’s passengers who demand that the captain stay on course and that the band keep playing instead of repairing a bad leak in the sinking USS Health Care.

David Moynahan, M.D., practices family medicine in Crawfordsville, Fla.

Why Medicare Is the Solution — Not the Problem

By Robert Reich
Robert Reich’s blog, July 22, 2011

Not only is Social Security on the chopping block in order to respond to Republican extortion. So is Medicare.

But Medicare isn’t the nation’s budgetary problems. It’s the solution. The real problem is the soaring costs of health care that lie beneath Medicare. They’re costs all of us are bearing in the form of soaring premiums, co-payments, and deductibles.

Medicare offers a means of reducing these costs — if Washington would let it.

Let me explain.

Americans spend more on health care per person than any other advanced nation and get less for our money. Yearly public and private healthcare spending is $7,538 per person. That’s almost two and a half times the average of other advanced nations.

Yet the typical American lives 77.9 years – less than the average 79.4 years in other advanced nations. And we have the highest rate of infant mortality of all advanced nations.

Medical costs are soaring because our health-care system is totally screwed up. Doctors and hospitals have every incentive to spend on unnecessary tests, drugs, and procedures.

You have lower back pain? Almost 95 percent of such cases are best relieved through physical therapy. But doctors and hospitals routinely do expensive MRI’s, and then refer patients to orthopedic surgeons who often do even more costly surgery. Why? There’s not much money in physical therapy.

Your diabetes, asthma, or heart condition is acting up? If you go to the hospital, 20 percent of the time you’re back there within a month. You wouldn’t be nearly as likely to return if a nurse visited you at home to make sure you were taking your medications. This is common practice in other advanced countries. So why don’t nurses do home visits to Americans with acute conditions? Hospitals aren’t paid for it.

America spends $30 billion a year fixing medical errors – the worst rate among advanced countries. Why? Among other reasons because we keep patient records on computers that can’t share the data. Patient records are continuously re-written on pieces of paper, and then re-entered into different computers. That spells error.

Meanwhile, administrative costs eat up 15 to 30 percent of all healthcare spending in the United States. That’s twice the rate of most other advanced nations. Where does this money go? Mainly into collecting money: Doctors collect from hospitals and insurers, hospitals collect from insurers, insurers collect from companies or from policy holders.

A major occupational category at most hospitals is “billing clerk.” A third of nursing hours are devoted to documenting what’s happened so insurers have proof.

Trying to slow the rise in Medicare costs doesn’t deal with any of this. It will just limit the amounts seniors can spend, which means less care. As a practical matter it means more political battles, as seniors – whose clout will grow as boomers are added to the ranks – demand the limits be increased. (If you thought the demagoguery over “death panels” was bad, you ain’t seen nothin’ yet.)

Paul Ryan’s plan – to give seniors vouchers they can cash in with private for-profit insurers — would be even worse. It would funnel money into the hands of for-profit insurers, whose administrative costs are far higher than Medicare.

So what’s the answer? For starters, allow anyone at any age to join Medicare. Medicare’s administrative costs are in the range of 3 percent. That’s well below the 5 to 10 percent costs borne by large companies that self-insure. It’s even further below the administrative costs of companies in the small-group market (amounting to 25 to 27 percent of premiums). And it’s way, way lower than the administrative costs of individual insurance (40 percent). It’s even far below the 11 percent costs of private plans under Medicare Advantage, the current private-insurance option under Medicare.

In addition, allow Medicare – and its poor cousin Medicaid – to use their huge bargaining leverage to negotiate lower rates with hospitals, doctors, and pharmaceutical companies. This would help move health care from a fee-for-the-most-costly-service system into one designed to get the highest-quality outcomes most cheaply.

Estimates of how much would be saved by extending Medicare to cover the entire population range from $58 billion to $400 billion a year. More Americans would get quality health care, and the long-term budget crisis would be sharply reduced.

Let me say it again: Medicare isn’t the problem. It’s the solution.

[This is drawn from a post I did in April, also before current imbroglio.]

http://robertreich.org/post/7941066493

When will the lights go out on fee-for-service?

By Robert B. Doherty, ACP’s Senior VP in Washington, DC
From the July/August ACP Internist

Physicians have been paid according to the number of visits or procedures they bill for a very long time, almost half a century for Medicare. Fee-for-service might have made sense originally, when everything was done on an episodic, acute care basis, but medicine has changed, and the payment system needs to change with it.

Today, we know that the best thing for the patient is to help prevent illnesses or complications that require more invasive tests or surgical procedures or hospital admissions.

Good medical care requires coordination among teams of health professionals and family caregivers, not just the interaction between the individual doctor and patient. Some of the most valuable things doctors do happen outside of the office visit, such as making arrangements over the phone with other clinicians or family caregivers. And the cognitive services provided by primary care physicians are at least as valuable to patients as doing a procedure, and outcomes and quality matter more to patients than how many procedures their doctor orders.

Yet doctors and patients are stuck with an out-of-date system that fails to pay for the things that we now know are essential to good medical care. Is it any wonder, then, that we get what we do pay for: rushed, inefficient, high-volume, invasive, and fragmented care that undervalues primary and preventive care, and is highly dissatisfying to doctors and their patients alike?

Despite all the flaws with fee-for-service, the medical profession has steadfastly clung to it. Year after year, physician membership organizations have devoted most of their attention to trying to change it at the margins: getting new CPT codes adopted, persuading Medicare to increase the relative value units, and of course, fighting the perennial battle to halt cuts to the sustainable growth rate (SGR) formula. Despite physicians’ concerns about the current system, they have been skeptical about proposals to replace it. There is increasing evidence, though, that fee-for-service, like a play gone stale that has been on Broadway way too long, is about to end its half-century run.

“Unless we begin the process of developing a long-term solution, we will once again be faced with the unwanted choice of extending a fundamentally broken payment system or jeopardizing access to care for Medicare beneficiaries,” wrote Rep. Henry A. Waxman, ranking Democrat on the House Energy and Commerce Committee, in a March 28 letter to ACP and about 50 other physician membership organizations. “We cannot let either happen.”

The letter went on to request that the physician organizations provide the committee with specific ideas “on how to reform the physician payment system and move to a system that reduces spending, pays providers fairly, and pays for services according to their value to the beneficiary.”

The idea of paying for services according to their value to the beneficiary would be a fundamental departure from the current Medicare system. Fee-for-service is agnostic about value to the patient, because it only concerns itself with the number of procedures and visits generated, and the work and costs involved in delivering the services (the relative values), not how valuable they are to the patient. By comparison, value-based payments would mean paying physicians, at least in part, for achieving measurable improvements in the outcomes and efficiency of care provided.

Most proposals for value-based payments also change the unit of payment from a procedure code to a bundle of services, discreet episodes of care, or risk-adjusted payments per patient per month (capitation), with the opportunity to earn more or less depending on how well the physician or health care organization delivers care effectively and efficiently. Some proposals would maintain an element of fee-for-service with value-based payments layered on top.

Not only Congress has decided that the current payment system should be on its way out. ACP, the American Medical Association, the American College of Surgeons, the American Academy of Family Physicians, and the American Osteopathic Association responded to the Energy and Commerce Committee’s request by offering proposals to transition to new models aligned with value.

Although the details of their proposals varied, all called for a period of at least five years of stable payments with the annual updates guaranteed by statute instead of being set by the SGR. During this time, a variety of alternatives would be pilot-tested on a voluntary basis. Physicians who agreed to participate in the pilots could earn more for achieving better outcomes. Then, after the five-year period of stability and innovation, the models that were most effective in the pilots would be broadly adopted by Medicare. Physicians then would be given a clear timetable, another four or five years, to transition to the new models so that by the end of the decade, most practices would be paid, at least in part, on value to patients, not volume of services.

ACP recognizes that there will be many challenges in transitioning to new value-based payments, but the alternative is trying to defend a broken payment system that does not meet the needs of patients, the people who pay the bills (taxpayers and employers), and physicians themselves.

Copyright © 2011 by the American College of Physicians

http://www.acpinternist.org/archives/2011/07/washington.htm

Mark Weisbrot: U.S. health care problems are rooted in the private sector

Problems of U.S. Health Care Are Rooted in the Private Sector, Despite Right-Wing Claims

By Mark Weisbrot
McClatchy-Tribune Information Services, July 20, 2011

Right-wingers, insurance companies, and other opponents of health care reform in the United States are always looking for ways to blame the government for the failures of our health care system. But the simple truth is that they have it backwards: our problems with health care are firmly rooted in the private sector. That is why the average high-income country – where government is vastly more involved in health care – spends half as much per person on health care as we do, and has better health outcomes.

That is why even Medicare – which has to pay for health care services and drugs at costs inflated by our dysfunctional private health care sector – has still proven to be much more efficient than private insurance.

The most effective way to insure everyone and make our health care system affordable would have been to expand Medicare to everyone, while beginning the process of reducing costs through negotiation with, and restructuring incentives for, the private sector. The private insurance companies use up hundreds of billions annually on administrative costs, marketing, and other waste – which is what you would expect from companies who maximize profit by insuring the healthy and trying to avoid paying for the sick.

It remains to be seen whether the PPACA will be a step toward more comprehensive, effective reform that gives us Medicare for all. In the meantime, the right will try to blame the government and the legislation itself for rising health care costs and other failures of our health care system. But in fact these result from the legislation not having gone far enough to rein in the private sector.

(Mark Weisbrot is co-director of the Center for Economic and Policy Research, in Washington, D.C.)

http://www.cepr.net/index.php/op-eds-&-columns/op-eds-&-columns/problems-of-us-health-care-are-rooted-in-the-private-sector-despite-right-wing-claims

Comment: 

By Don McCanne, MD

When it seems that we are making so little progress on the reform front, it is reassuring to see that PNHP and our single payer colleagues are not alone in spreading the Medicare for all message.

Timely Treatment for Depression Hard to Get, Even for the Insured

By Maia Szalavitz
Time magazine, Healthland, July 21, 2011

Massachusetts requires health insurance for all, is second in the nation in the number of doctors per capita, and mandates equal coverage for mental and physical illnesses.  Yet when researchers there posed as well-insured patients seeking treatment for depression, only 6 percent of calls to mental health facilities resulted in an appointment within two weeks, according to a new study.

This was true even though the prospective “patients” claimed that they’d been told by an emergency room doctor to seek psychiatric care within that time period — so those who took the calls should have been alert to the possibility that the patients were suicidal or otherwise needed urgent care.

“What this study says is that even with what is basically the best private insurance available in this state and [probably] in many others as well, help is very difficult to find and may be impossible to find for many,” says Steffie Woolhandler, visiting professor of medicine at Harvard Medical School and an author of the study.

The research, which was published in the Annals of Emergency Medicine, found that nearly a quarter of the calls made were never returned—even after the “patient” called again to follow up.  Another 23 percent of providers turned people away if they were not already patients of a primary care physician associated with their institution. Only 12 percent of the facilities actually offered appointments to the patients.

“I think a lot of systems are trying to cut back on psychiatric care, but they don’t want to cut back to zero, so they restrict access to the handful of appointments that they have to people who are already part of their system,” says Woolhandler.

Since depression itself can make help-seeking difficult because it reduces motivation and makes people feel hopeless, even small barriers to care can have a huge impact. “How many seriously depressed people are going to persevere through all of this to get an appointment?” Woolhandler asks.

The research was prompted by concerns raised by psychiatric residents, who were interested in access to mental health care. They had the sense that when they sent people home from the emergency room, they weren’t actually getting the follow-up care that had been recommended.

So for the study, researchers posed as patients in exactly that situation, saying they had Blue Cross/Blue Shield insurance, which is held by about half of all Massachusetts citizens and is considered to provide excellent coverage. All of the facilities they called were listed as preferred providers of care for BC/BS members, yet only 12 percent offered appointments.

“Having to suffer longer with depression is very painful and to expose people unnecessarily to prolonged suffer is really not acceptable when we have the resources to help people with this problem,” says Woolhandler.

Since this study only looked at what is basically the best-case scenario in the state that has an insurance system similar to the one that will be rolled out nationwide under President Obama’s Patient Protection and Affordable Care Act, it suggests that simply providing insurance will not be enough to make mental health care appropriately accessible to patients in need. Truly effective mental health care requires both coverage and ability to get services.

http://healthland.time.com/2011/07/21/timely-treatment-for-depression-hard-to-get-even-for-the-insured/#ixzz1SqLvoxm9

Even good health insurance doesn't ensure access to doctors

By David W. Freeman
CBS News, July 21, 2011

Just because you have health insurance doesn’t mean you can get a doctor. That’s the apparent take-away message of a shocking new study showing that even in Massachusetts – a model for the federal health legislation that President Obama signed into law in 2010  – access to medical care is severely limited.

And that’s true even in emergencies – and even for people who have top-drawer insurance coverage.

For the study, Harvard researchers posed as patients insured by Blue Cross Blue Shield of Massachusetts, the state’s largest insurer. They called every mental health facility within a 10-mile radius of downtown Boston, saying they had been diagnosed with depression and needed to see a psychiatrist within two weeks.

What happened? Only eight of the 64 facilities (12.5 percent) listed as preferred providers offered an appointment, and only four (6.2 percent) offered an appointment within two weeks.

Perhaps most shocking – given the urgency of the requests for appointments – one in four calls to providers were never returned.

Study author Dr. J. Wesley Boyd, an attending psychiatrist at the Harvard-affiliated Cambridge Health Alliance, blamed health insurers for having highly restrictive provider networks and low reimbursement rates for psychiatric care. They’ve “created a situation where a patient with a potentially life-threatening disorder, such as the severe depression portrayed in our callers’ scenario, is essentially abandoned at a time of great need,” he said in a written statement.

In the continuing debate over health care insurance, “we tend to fixate on getting people insurance,” study author Dr. Rachel Nardin, chief of neurology at the alliance, told CBS News. “But the real question is, “What happens if I get sick? Can I get the care I need?”

http://www.cbsnews.com/8301-504763_162-20081423-10391704.html

Psychiatric Care Hard To Get, Even For The Insured, Study Finds

By Rachel Zimmerman
WBUR, CommonHealth blog, July 21, 2011

It turns out a good shrink (or just about any shrink) is hard to find, even in the medical mecca of greater Boston.

According to a new study by Harvard researchers, access to outpatient psychiatric care is extremely limited here, and it doesn’t make much difference if the patient has top-notch health insurance or is suffering from a dire mental illness. As part of this “simulated patient” study, published Thursday as a letter in the Annals of Emergency Medicine, researchers posed as severely depressed patients with excellent health insurance and tried to get an appointment for psychiatric care at a facility in downtown Boston. But of the 64 facilities they called, they were only able to get 8 appointments, and only 4 of those were within two weeks.

“The takeaway here is that having insurance is obviously important but it is not sufficient when it comes to access to psychiatric care,” says Dr. J. Wesley Boyd, an attending psychiatrist at the Harvard-affiliated Cambridge Health Alliance, and the study’s lead author. “What does it say when there’s a patient with a potentially life-threatening disorder, such as the severe depression portrayed in our callers’ scenario, who is is essentially abandoned at a time of great need?”

To test their hypothesis that the availability of psychiatric services has greatly diminished (due to a combination of paltry reimbursement rates and budget cutbacks) Boyd and his colleagues embarked on a stealth plan involving a little bit of dramatic play. A psychiatric resident, Andy Linsenmeyer, pretended to be a patient named Andrew Meyer suffering from severe depression and in need of psychiatric care.

Linsenmeyer and an undergraduate student researcher, both posing as patients, chose 64 medical centers listed on the Blue Cross Blue Shield of Massachusetts website all within a 10-mile radius of downtown Boston, and set out to call each one. (Blue Cross played no role in the study). This is what the “patient” said when he got someone on the phone: “I was seen in the emergency room last night for depression and discharged with instructions to get a followup psychiatric appointment in two weeks.” He said he was covered under a Blue Cross Preferred Provider Organization health plan.

Linsenmeyer, now a fourth year resident in the Harvard Longwood psychiatry program, didn’t do so well undercover as Andrew Meyer trying to get professional help.

Only 8 of the 64 medical facilities he and his student called offered appointments (12.5 percent); and only four of those offered an appointment within two weeks, researchers reported. Moreover, 15 providers (23 percent) never returned calls seeking an appointment, even after two detailed messages were left. Finally, 15 other providers (23 percent) flat out refused to offer an appointment due to requirements that all patients be enrolled with a primary care doctor affiliated with that particular psychiatric facility, researchers said.

Was anyone surprised by the results? Not really. “A big part of residency is trying to get care for people and I know how difficult it can be, so unfortunately, I wasn’t that surprised, ” Linsenmeyer said. “But I think the point here is that having health insurance does not equal access to care. Everyone here is like, ‘Oh, Massachusetts is so great because everyone has health insurance,’ but it’s really not great because people put up all these barriers to care, so it’s a little disingenuous. Everyone has health insurance but that doesn’t mean you can get care.”

The dearth of psychiatric care available in Massachusetts has larger national implications, the authors write:

“This result confirms our suspicion that even for patients with private insurance, mental health services in the Boston area are severely limited, which is in line with national data showing limited availability; for example, two thirds of primary care physicians report that they cannot obtain outpatient mental health services for patients who need them.

“Our inadequate mental health system has widespread social effects. A third of the homeless and more than half of all prison and jail inmates have mental illness. The nation’s EDs are de facto psychiatric wards, with 79% of emergency physicians reporting that their hospitals board psychiatric patients for whom appropriate treatment resources could not be found, sometimes for days.

“Although there are many contributors to the inadequacy of our mental health system, managed care has hit psychiatric services hard. Private insurers aggressively constrain patients’ access to services by stringently limiting provider networks.

“As our study shows, this is often covert; insurers provide lists of in-network providers, but most are unavailable. Reimbursements for psychiatric services are far lower than for other types of care, so institutions frequently restrict access as stringently as possible, often, as in our study, by requiring that a patient have an in-system primary care provider (even though the insurer requires no referral). Many private practitioners refuse to accept insurance payments altogether. Improved reimbursements for psychiatric care will be an important step in reducing the barriers to care experienced by patients with severe depression.”

The study was unfunded, Boyd said. However the group, Physicians for a National Health Program, an organization of physicians who advocate for single-payer national health insurance, helped publicize the research, as all of the authors are members of the group and two are co-founders.

Blue Cross Blue Shield was critical of the study, according to The Boston Globe:

“Blue Cross Blue Shield spokesman Jay McQuaide took issue with the study, describing the researchers as opponents of private insurers who were trying to extract higher reimbursement rates for themselves. McQuaide said the study was ‘an attempt to publicly pressure the state’s health plans, like Blue Cross, to pay these clinicians more money which, frankly, is disappointing.’ The authors dismissed that claim, saying that only two of the five authors are psychiatrists and the real goal of the study was to examine access to mental health care.”

http://commonhealth.wbur.org/2011/07/psychiatric-care-hard-to-get-even-for-the-insured-study-finds/