New York, NY – We often find that stress and anxiety manifest in physical symptoms. It has been shown that an individual’s immune system will not be as effective if they are under severe emotional stress. We also see symptoms such as inhibited digestion, ulcers, increased heart rate, increased blood cholesterol levels, lack of sleep and more. Additionally, individuals tend to navigate many mental health factors through coping mechanisms such as stress-based binge eating, excessive alcohol consumption, etc. Despite how much of an effect that stress, anxiety and other mental health factors play in our overall health, consideration towards it from a needs perspective has been limited.
Only in recent years have insurance companies been mandated to provide equal benefits for mental health as they do for general medical care. But here’s the challenge: Mental health care coverage is limited. While doing a search on your insurance provider’s website may result in a long list of names, you may notice that those names are often attached to licensed clinical social workers (LCSW), counselors, and some psychologists, but not many psychiatrists. This is an important delineation because, as defined by the American Psychiatric Association (APA), psychiatry “ is the branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional and behavioral disorders.”
As we think about healthcare in general, there are many specialties, each focusing clinically on an aspect of the body. The difference with mental health care is that there are layers or levels of care. There will be people that simply need coping strategies to deal with every day factors. Then there are those that have clinical disorders that need a specific-types of attention and care, beyond coping mechanics.
As the APA states, “Because they are physicians, psychiatrists can order or perform a full range of medical laboratory and psychological tests which, combined with discussions with patients, help provide a picture of a patient's physical and mental state. Their education and clinical training equip them to understand the complex relationship between emotional and other medical illnesses and the relationships with genetics and family history, to evaluate medical and psychological data, to make a diagnosis, and to work with patients to develop treatment plans.”
This makes an important case in favor of psychiatry with regards to holistic care. If our emotional state is intrinsically linked to the functions of our body, both physical and chemical, naturally a specialist who understands and is trained in understanding these facets is important.
So why is this relevant? Remember when I mentioned that the likely results of your insurance provider’s website? Well, you’ll often find that someone to help you with coping strategies, such as an LCSW, is covered with their services typically costing anywhere from $75 - $150. But, many psychiatrists often charge similar rates as other specialists, ranging upwards of $200 or more. Insurance companies often try to negotiate with providers to reduce their rates, but psychiatrists, given the range of provider options (LCSW, psychologists, etc.), face even more scrutiny. For an insurance company reimbursing ongoing appointments, the $75 fee combined with patient co-payment is significantly more appealing versus paying the higher costs of the medical specialist. As noted in the Journal of the American Medical Association (JAMA) article “Acceptance of insurance by psychiatrists and the implications for access to mental health care” from 2016:
“Because psychotherapy can also be provided by other professionals such as Master's level therapists, reimbursement rates for psychotherapy visits are lower relative to medication management visits. The relative difference between these reimbursement rates incentivizes psychiatrists who accept health insurance to focus on medication management visits. For many psychiatrists, however, a practice consisting only of time-limited medication management visits may be personally unfulfilling and at odds with their values about how to practice good psychiatry.”
Furthermore, the JAMA article highlights that often times psychiatrists have small or solo practices, which makes it even more difficult to work with insurance providers. To deal with insurance paperwork, administrative costs and negotiate rates, they would likely need supporting staff, which would increase overhead for their practice, while accepting lower value payments for their services. In essence, while insurance companies provide mental health coverage, often times, they can get away with not covering a psychiatrist or medically-trained mental healthcare provider by creating the perception of a full list of providers, most often who are not medically trained doctors.
RECENT INITIATIVES -
Factors such as these make initiatives like Mental Health SF so newsworthy and important. Since 2017, the homeless population has risen by 17%. There’s also been a direct link to homelessness and mental health issues, prompting a call to act. According to one site, 25% of the homeless population in America has suffered from serious mental illness, while 45% of the population contends with mental illness in any form.
Through Mental Health SF, the city of San Francisco would create a universal mental health treatment system, offering psychiatric and substance abuse services, as well as medication to any city resident. It would also provide for 24/7 treatment, counseling and crisis management. Interestingly, while the homeless population will be served, the city also acknowledges the challenges that insured patients have had (as previously stated) and will offer coverage to them, as well.
The initiative is the first of its kind and has immense potential; however, it again brings to light the ongoing crisis of mental health care coverage in the US. Private claims for such issues like PTSD, major depressive disorder and more, rose 65% from 2007 to 2017. And as we see from the reasons discussed above, people may not necessarily receive holistic mental health care due to their coverage issues. While San Francisco’s acknowledgement of all of these factors is an incredible step in the right direction, the initiative still awaits approval. Time will tell if the program will be implemented sustainably in an effort to provide long-term benefits to the people of San Francisco and if so, perhaps it can be a model for other cities in the future.