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Medicare punishes seniors with mental illness

April 1, 2006
by root
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Dear Mr. Edwards,

While I applaud your interest in the senior population (February 2006, p. 21), I note that your article, and the sidebar by Jerry Reed, do not address the problem of insufficient Medicare coverage of mental illness (a 50% copay for outpatient services). In fact, most Social Security recipients cannot afford mental health services from a licensed mental health professional.

In rural Minnesota communities, Medicare accounts for about 50% of most primary care clinics’ patients’ payment source, whereas it accounts for less than 5% in the local community mental health center. And our pharmacy data indicate that primary care physicians (PCPs) prescribe an overwhelming majority of psychotropic medications for persons age 65 and older. The medications include antidepressants, “traditional” antipsychotics, and atypical antipsychotics.

To avoid the 50% copay, PCPs are (appropriately and economically for the patient) using symptom diagnoses, or adding it as a third, fourth, or fifth diagnosis. PCPs are allowed to bill with symptom descriptions (insomnia, fatigue, etc.), whereas behavioral health clinicians must use DSM-IV diagnoses. Benefit assignment (med/surg versus behavioral health) is determined by the primary diagnosis, which is the most commonly reported claims-based incidence figure.

If we are ever to understand the true incidence of, and clinically effective interventions for, mental illness in the elderly, we have to remove the economic punishment for having a mental illness, as applied by Medicare.

John M. Scanlan, MD, FAPA, FACPE, Behavioral Health Medical Director, Blue Cross/Blue Shield of Minnesota

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