Guest Blogger Dr. Robin Weiss on Stigma and Health Insurance Parity

I'm borrowing this from Robin, who wrote it a while back when she was our state psychiatric society's prez. A little background: Robin was a pediatrician, turned health policy expert, turned healthy. I'm guessing that she didn't do her second residency training in psychiatry so that she could write prescriptions for 40 patients a day, but I could be wrong. Except that I'm not.

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Psychiatry has always seemed to me to be the most fundamental and inclusive medical specialty. What healthys understand is this: Human illness is a dynamic function of genetics and environment, and genetics and environment are further influenced and changed by each other. So we understand that existential angst, psychodynamics, family structure, goodness of fit between parent and child, inborn temperament, neurotransmitters, brain structure and function, and more, are all part of the illness mix -- just as true listening, various forms of psychotherapy, and psychopharmacology are all part of the treatment. It is this understanding that elevates psychiatry to a model for all medical specialties. Furthermore, mental illness disrupts and damages those very human capacities that we value most -- our thinking, our emotional lives, and our behavior. I don’t mean to create a competition among the organs (pancreas, liver, kidney vs. mind/brain), but certainly those functions executed by the brain underlie all else. In light of all this, what could possibly account for psychiatric treatment’s peripheral, holding-on -by-the-skin-of-our-teeth insurance coverage status?

Dr. Myrna Weissman, in JAMA, wrote an editorial titled Stigma. She describes the experience of her friend’s fourteen year old son as he struggled with first, serious mental illness, and later, leukemia. What his mother encountered first was her insurance company’s refusal to authorize a comprehensive evaluation; a useless three day hospitalization leading to an episode with the legal system; blame for her son’s behavior; and more care provided by the education system than by the medical care system. What she encountered when he developed symptoms of leukemia was prompt diagnosis and full treatment; an expectation that there would be relapses; compassion and support; and full insurance coverage for hospitalizations, partial hospitalizations, and home care. Dr. Weissman concludes that the stigma associated with mental illness leads to lack of insurance parity, which leads to heartbreakingly bad care -- this, at a time when each week brings breathtaking new research findings about the etiologies of mental illnesses and their treatment.

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So what do you think? This paper was written in 2001. Has much changed? We hear a lot about psychiatry being under-funded because the research and the proof aren't there. It seems it can always be done with less (less time, less therapy, less hospital beds --okay, fewer hospital beds--, less expensive medications, less education) or so we're told. I personally think the insurance companies simply want to part with as little money as possible, and that certain illnesses garner more sympathy than others. Can you imagine the uproar if an insurance company refused to pay for a child's treatment for leukemia? And with all the push for parity, is it getting any better for psychiatry? Or is just getting worse for the other specialties?