Two decades ago, physicians could make direct referrals to psychiatric facilities, but the practice became problematic due to lack of protocols. In fact, many people think that the reason managed care took hold in the behavioral health arena is because of abuses in which young people were placed in long-term psychiatric treatment that may not have been medically necessary. The generous insurance policies covering that care disappeared.
Now much has changed and healthcare is moving towards an approach in which medical/surgical and behavioral are more integrated. However, notes Mark Covall, president and CEO of the National Association of Psychiatric Health Systems (NAPHS), “We’re seeing the domination of management in the mental health and addiction side, and it’s very restrictive. That’s what the non-quantitative treatment limitations (NQTL) are about.” The reality is that insurance companies aren’t making changes in the NQTL area. So the question for is the behavioral healthcare field is, ‘How can the plans be held accountable, as the regulations stipulate?’
The thought of young children in psychiatric facilities is distasteful to most people, but it is what many inpatient facilities are now seeing. Covall reports children as young as six years old living in such facilities. But only the most difficult children get admitted—those who have acted out in extreme degrees by attacking their families or themselves, for example.
Children who need help, but have not demonstrated that they are a danger to themselves or others, often have great difficulty getting it. “The insurance company criteria for the threshold for admission is very high, some would say too high,” Covall said. And it’s become commonplace in the insurance industry to say that unless a patient is a danger to himself or others, a higher level of care isn’t necessary.
Time to do a clinical assessment on a child in need of treatment is also a factor. This is especially true for those admitted for the first time. And time is also a criterion that insurance companies try to limit. , “The hospitals are always fighting for extra days.” Covall notes.
Another problem is lack of capacity and services for young psychiatric patients. There aren’t enough beds, and there aren’t enough child psychiatrists. “Sometimes these patients stay in the emergency room for days or weeks,” reports Covall. “This is terrible enough for an adult who has a mental illness, but you can imagine what it would be like for a child.”
Finally, there is the Medicaid problem – the parity law applies to managed Medicaid and to Medicaid expansion, but not to regular Medicaid. “We’re pushing CMS to issue some regulations on how Medicaid works in terms of parity,” says Covall, who has assurances from the Centers for Medicare and Medicaid Services (CMS) Senior Policy Advisor John O’Brien that those regulations are being developed. “Until we get a regulation out of CMS specifically on how Medicaid MCOs and parity interface,” Covall continues, “we’re not where we need to be. That is something that is very high on our list, and there are a lot of those kids are on the Medicaid program. Until we get some further regulatory clarification, there is a big segment of the population that is not protected.”