Insurance Challenges for the Mentally Ill - An Ongoing Problem

Interview with Dr. Robert Dorwood, Chief of Psychiatry at
th Harvard- affiliated Cambridge Hospital in Boston.

Dr. Dorwood was principle investigator of a nationwide study of
hospitals and mental illness. He found that two-thirds of all
psychiatric hospitals and hospitals with psychiatric units
engage in the practice of transferring patients to public
facilities when their insurance runs out, regardless of whether
the patient has completely recovered mentally.

DANIEL ZWERDLING: If anybody in your family
or a friend has ever suffered a mental illness such as severe
depression or schizophrenia, then you know how hard it can
be to get insurance companies to cover all the treatment. And
now, a nationwide study shows how big that problem is.
Investigators at Harvard University surveyed virtually every
hospital in America that has a psychiatric ward: public
hospitals, private ones, community mental health clinics. And
according to the results, most of the hospitals -- two-thirds of
them -- kick out psychiatric patients if they haven't been cured
within roughly 30 or 40 days because the patients' insurance
companies say they won't pay for them any longer. In many
cases, the patients get transferred to state mental hospitals,
where they begin their treatment all over again.
The chief investigator, Harvard psychiatrist Robert Dorwood,
says the heart of the problem is the fact that there's still a huge
gap between the way the insurance companies handle physical
illnesses and emotional ones.
you were to look at your own insurance policy, you would
see there is some limit, but it's typically a dollar limit. For
example, $1 million would be the maximum that the insurance
would pay for your care in a given year. That might be the
And so if you have the open heart surgery and you have
complications, you might well be in for four, five or six weeks
of hospitalization. But you wouldn't reach your limit. And it
would all be paid for by the insurance company.
And no one would say, "Well, look. Your time's up. You're
not better. But you'll just have to leave and go home. " It
would be unthinkable.
ZWERDLING: And the mental health coverage?
DORWOOD: The mental health coverage is specified either
in days or in dollars but the dollar limit might be $50,000. And
it's perfectly legal to write that into the -- for an insurance
company to write that clause into the contract. You buy the
insurance. And it just turns out that the $50,000 will barely get
you a month in a hospital.
ZWERDLING: Obviously, most hospital administrators are
not evil people, right, who don't have, you know, any feelings
for emotionally disturbed patients.
ZWERDLING: Let's think from their point of view for a
moment. First of all, I can imagine many of them saying,
"Look. We are not being heartless. We are getting rid of the
patients when their insurance runs out. But we are sending
them to a state psychiatric institution where they will be
treated just as we were treating them. "
DORWOOD: Well, it is true that historically, there have
existed public mental health services for people without
insurance or for people with long-term catastrophic illness.
However, over the past decade or two, in most every state in
the country, the policy has been to deinstitutionalize those
facilities -- to downsize them, to close them in many cases.
So what that means is that to the extent that this behavior
continues of transferring uninsured patients to the public
facilities, typically what happens is the public hospital now is
forced to discharge somebody who is treated there. And
often that is a person who is going to end up on the streets, in
a homeless shelter or what have you, because they're filled up.

ZWERDLING: Well, let's go back to the hospital
administrator again who'd just gotten rid of this patient
because the insurance ran out. This administrator might also
say, "Look. Give us a break here. You can predict that when
a patient with a broken leg comes in, it will take X number of
days to fix it, right? But some people are depressed or, you
know, have psychotic breaks or whatever over a period of
months, sometimes years, sometimes their whole lives. You
can't expect us and the insurance companies to cover these
people forever. "
DORWOOD: Well, that's an interesting policy question. I
think that it is more fair today than it was in the past -- that is,
we have better treatments, for example, for depression now
than we had. We have multiple medications that can be used.
ZWERDLING: But what would you say to the insurance
company, then? I want you to cover John Jones with his
schizophrenia or his clinical depression. I want you to cover
him for two months, four months in the hospital, whatever it
takes to get him better and back at work. Is that what you
would say to them?
DORWOOD: That's what we'd say to them. For this small
proportion of people who have to have long stays, maybe the
financial burden should be and could be shared by state
government, say, and that those kind of innovations are being
ZWERDLING: This past year, of course, Congress -- with
President Clinton's urging -- passed a part of a bill saying to
insurance companies, "You can't discriminate against people
with mental health problems the way you have been. You
know, you've got to make your mental health coverage more
equal to the physical health coverage. "
And that law is just about to go into effect now, isn't it?
Will that clear up this problem?
DORWOOD: Yes, - Well, not entirely. It will for some people. But
the problem with the legislation is it only covers people who
have health insurance who are working for large employers.
Many insurance plans and many employers are exempt from
these regulations. They simply do not apply to everybody,
only to certain instances -- large employers, for example. So
it's a positive step.
But there is -- the safety net fabric is still full of holes, as far as
we can tell on this issue.
ZWERDLING: Robert Dorwood is chief of psychiatry at the
Harvard- affiliated Cambridge Hospital.



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