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)