July 27, 2007

Why I Am Against Mental Health Parity

The U.S. Senate is poised to vote on the Mental Health Parity Act of 2007, a cleverly named piece of legislature which conveys the warming sentiment of equality and progressiveness. But the Act is fatally flawed; not only does it not necessarily help patients, but it will likely worsen an already broken system.  It should not be passed.


There are two broad reasons to be against this Act, economic and social.

First, the economic.  Looked at generally, it makes no sense to provide equal coverage for something that exists in and of itself-- diabetes, tumors, hypertension, etc-- with something that, whether or not it exists, can be called into existence by the force of a single  person's voice.   If 50 psychiatrists say you do not have depression, but I say you do, who is right?  But my voice has immediately entitled you to substantial benefits.

It is a fairly simple matter to see how extra hospital days may or may not benefit an acute hyperglycemic crisis; it is entirely subjective whether they help someone with depression.  Nor am I being heartless: a psychiatrist may be tempted, out of kindness, sympathy, or expediency ("well, it's Friday, let's just discharge him Monday")  to keep a person in the hospital longer if there is no impetus to limit inpatient days.  Not only is it not obvious that this is beneficial, but a strong case can be made that it may be detrimental, fostering dependence, confirming a "sick role," etc.  To be clear: it may be true that extra days are beneficial, but there is nothing to go on but the judgment of the psychiatrist. 

The mistake is providing extra resources with no additional accountability.  To improve care, it is necessary to justify the expenditures.  I know it seems like we should trust the judgment of the noble doctors, but, well, we can't.   Simply having a deeper well from which to draw does not promote better care, and likely leads to waste. This follows from the most important flaw of the U.S. healthcare system: the user of the money-- the doctor-- has no accountability for the use of the money. In no other business does this uncoupling exist.  Why keep hospital days short or use fewer medications at better doses, etc?  Why not prescribe two antipsychotics at once, or keep them a few extra days?  It's so much easier...

The single solution to this is to remedy the flaw: make doctors in charge of the budget. "Here's how much you can spend per patient. Go."

Simply put, this Act does not guarantee improved care for patients; it guarantees improved payments to psychiatrists.  While I am all for getting paid more, we should probably focus on the stated purpose of the Act. 

The second, social, problem is more nuanced, but arguably more important.  The substantial problem with the bill is that, while it asks for parity in coverage for mental illness, it does not actually define a mental illness.  That is left to the individual insurers.  Thus, they can choose to cover schizophrenia and not depression; bipolar but not ADHD, etc.  Better than nothing, you say?  Observe:

If most insurers choose to cover bipolar disorder, but not "straight depression," there is the very real likelihood that psychiatrists will simply diagnose bipolar.  This already happens, especially to justify inpatient admission.  While numerous "reliable and valid" tools exist to make diagnoses, these are rarely used in everyday practice.  In most cases, diagnoses are based on clinician bias, feeling, medication justification, and expediency.  So many of the psychiatric disorders end up being treated with the same medications anyway-- antidepressants and antipsychotics-- so why fight a diagnosis?

But the social ramifications of an overdiagnosis of "bipolar disorder"-- or any psychiatric diagnosis-- cannot be overstated.  I've mentioned how psychiatry becomes an instrument of social change.   I hardly need repeat the legal ramifications of mis/overdiagnosis;  but medicalizing what might otherwise have been labeled and handled as social ills also means that these issues will be handled by people-- doctors-- who have the least resources available to make significant changes.  How do you reduce  poverty and domestic abuse with Zyprexa?

The current state of insurance coverage for patients is not great by any means; but this Act will not offer any improvements and will cost more.  A better Act would be one which ties benefits to outcomes.

I am hardly insensitive to the plight of the mentally ill and their need for psychiatric services.  However, the goal should be, specifically, better care for patients, not more money for psychiatry.  The two are easily conflated, but they are not necessarily the same.  At some point, you have to stop buying people's silence.


Stay tuned for Part 3 of The Most Important Article On Psychiatry You Will Ever Read (here's Part I)


Excellent article! My frus... (Below threshold)

July 28, 2007 6:12 AM | Posted by JC: | Reply

Excellent article! My frustrations with mental health are reaching a boiling point and I am uncertain if I will continue in the field. It is good to know that there is at least one other colleague who sees some of the absurdities.

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Dear Doc,“…not onl... (Below threshold)

July 30, 2007 4:43 PM | Posted by Herb: | Reply

Dear Doc,

“…not only does it not necessarily help patients” --- The Last Psychiatrist

I shall have to strongly disagree with your position as I come to you from a different perspective as a very, very long time support person, care giver and mental health advocate and pro-activist.

How would you know “…not only does it not necessarily help patients?” The mental health patient has never had parity. What makes you automatically assume it won’t help a percentage of patients? I certainly hope this is not along the same lines of all the medications, therapies and treatments that your profession offers up that do not necessarily help patients or what I refer to as the “Trial and Error Approach to Wellness.” Well maybe its just time we tried another medication or therapy or treatment or we simply try thinking outside the box, like parity! Maybe like thinking about nurturing and preventative approaches before these mood disorders get seriously out of hand.

Maybe the first thing you should discuss is the medical profession cleaning up their own flawed acts and then address all the flaws and failed promises and acts of the HMO system that has done nothing more than the redistribution of monies to an intermediate bureaucracy lining their own pockets, removing medical decisions making from the patient and physician and adding nothing to the quality of health care in this country. Least I forget why not also address the flaws of $12 Billion a month or about $610 Billion since 2001 going to warring that could be better served caring for the citizens of this country.

Right, I agree with you there are flaws with just passing money legislation without accountability but I personally would rather piss away several billions in the hope it trickles down to a percentage of the population disenfranchised, long discriminated against as well as stigmatized and poorly cared for.

While you’re also at it discussing flaws how about also looking into the medical profession own stigmatization of your profession (Psychiatry). While you’re at it, take a moment if you haven’t done so to read the treatise rendered by CMS as it relates to VNS Therapy. Its one thing to deny coverage for an FDA approved therapy but it is also another to have denigrated Psychiatry as well as some of the leading researchers and thought leaders in your field who I also presume may be your colleagues.

Whatever flaws there maybe in the legislation, it is a very long overdue starting point. One can always fix the flaws later on but now is the time to “Overcome.”


Alone's Response: woah, this is a post in itself. But I agree with you, not disagree with you. Parity only provides more money, not better results. It is a subsidy to doctors. It is exactly like the government saying it will pay for half of the cost of gasoline. So for a year, that's great-- lower prices, more gas for everyone. But then there's no incentive to reduce pollution; no incentive for more fuel efficient cars; etc. AND, may I add, you'll get exactly what we have going on with university tuition: the cost will rise. If you were willing to pay $3 for gas, and now the govt. pays $1.50, you can be sure that in a little while, the cost of gas will be $4.50. People have already shown they would pay that much. So, too, with healthcare.


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I have to agree with you bo... (Below threshold)

July 31, 2007 2:35 PM | Posted by Ripley: | Reply

I have to agree with you both! As usual, the political policy making machine only half understands what we're really dealing with here so there are going to be issues with this bill.

A worse problem yet is that so many people need help and simply aren't getting it. I am troubled by any policy that is motivated by profit and yet as Herb suggests, if even a small percentage of these funds make their way to helping some that are seemingly overlooked right now, I'd rather implement the policy and troubleshoot than wait for congress to devise another flawed bill that may or may not pass.

If it's war we're funding, the deadlines for making decisions seem to come at rocket speed. If only a bill could be created by those that know best what is missing in the system instead of bureaucrats who vote themselves raises.

Having said this, accountability is a huge pink elephant that will surely bite us in the end (no pun intended). Someone has to be responsible since clearly the politicians typically aren't.

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Part of the problem is peop... (Below threshold)

August 25, 2007 10:09 PM | Posted by aquariancore: | Reply

Part of the problem is people circumventing proper mental health exams by having their hmo doctors just hand out perscriptions without patient mental health history as well. This take a pill and chill treatment is as good as no diagnosis at all.

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There's a reciprocal relati... (Below threshold)

September 23, 2010 11:00 AM | Posted by RC: | Reply

There's a reciprocal relationship between one's mental and physical health that has been apparent for centuries - this law is long overdue.

Any administrative or legal action that would make mental healthcare more efficient and affordable would also make non-mental healthcare more efficient and affordable. You make some great suggestions for this elsewhere in your blog, but I don't understand why you don't want to tweak BOTH systems to make them work better? You know, give them "parity" and all.

This law is hugely beneficial for those of us who have missed work for "headaches," "stomach aches," "colds," and "back pain," when the truth is we were just too depressed to get out of bed. If depression can be as debilitating as these other things or if it can in fact CAUSE all these physical ailments, why shouldn't it received equal coverage?

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