By Alisha Wyman
Medicare coverage for outpatient mental health care is now in line with medical coverage, thanks to a law that closed the gap as of Jan. 1.
Experts say it’s a step in dispelling long-standing disparities between the two, but the change addresses only one of many hurdles in providing seniors with adequate mental health care.
The number of psychiatrists who accept insurance still falls well below their counterparts who treat physical ailments, according to a Weill Cornell Medical College study published in February.
Compounding this is a shortage of doctors with special training in treating the mental health issues in an older population, particularly in rural areas, some say.
But the increased coverage will lower one hurdle for older adults on Medicare seeking mental health treatment, said Alfred Chiplin, a senior policy attorney for the Center for Medicare Advocacy.
“I don’t know that will be the full driver towards people using more mental health treatment,” he said. “It certainly will remove an important part of the barrier.”
Congress passed the Medicare Improvements for Patients and Providers Act in 2008. Among a host of other provisions, it ramped up payments for mental health coverage in increments starting in 2010 from 50 percent to now 80 percent – the same level at which Medicare covers other medical treatment.
Medical and mental health issues for seniors are complex and inter-related, Chiplin said. A mental health condition itself could prevent an older adult from seeking treatment, and the stigma surrounding mental health conditions lingers.
The disparity in coverage long strengthened that stigma, said Steve Koh, assistant professor of the Department of Psychiatry at the University of California, San Diego and a sub-specialist in geriatric psychiatry. It also burdened primary care physicians, who have been left caring for mental health issues alongside diabetes, heart disease and other illnesses.
The changes the act provides is leveling the playing field, he said.
“Strictly from the patient access perspective, I think this is a good thing,” said Koh, who is also president of the San Diego Psychiatric Society. “I think it is a long time coming.”
Mental health services should be treated the same way as cancer or other medical conditions, said Ken Palinkas, a program manager at Senior Advocacy Services in Sonoma County.
”That’s a matter of treating the mind as well as the body. That should be a no-brainer,” he said. “There is a mind-body connection that is undeniable.”
With the percentage of psychiatrists that accept Medicare falling well below other doctors, maintaining the mental health side of the equation becomes more difficult.
The Weill Cornel Medical College study found that in 2009 and 2010, 86.1 percent of doctors nationwide accepted Medicare. In comparison, only 54.8 percent of psychiatrists did. Those numbers are similar to levels of private insurance acceptance.
Tara Bishop, assistant professor of health care policy at the college and the study’s lead author, said the next step of her research is to look closer into the reasons for this gap between fields. Anecdotally, she has heard that low insurance reimbursement rates and the hassles of the paperwork discourage doctors from taking insurance, she said.
The low-income are the ones who lose out, she said.
“There are many patients that don’t have that ability to pay out-of-pocket for medical care, and so it makes you worry that patients are not getting the care that they need,” she said.
Chiplin hopes the new changes the act put in place will influence these numbers, and the Affordable Care Act has its own implications on mental health.
“Those things all together give maybe a little boost to physician participation of Medicare,” he said. “We’ll have to see how that plays out over time.”
There are still rules that keep mental health coverage behind medical coverage, Koh said. For example, Medicare has lifetime limits hospitalization for mental health issues, while there is no limit for physical health issues.
It’s essential to treat a patient’s mental and physical health side by side, since the two are intertwined, Koh said. Doctors are starting to see through brain studies and other evidence that mental illness is a biological condition.
“To relegate mental health care as if it’s not part of an overall medical care for the individual is just wrong,” he said. “I personally don’t think it has any place in how we take care of patients in this day and age.”
Seniors’ responses and susceptibility to mental health issues changes as they age, he said. Geriatric patients might be more susceptible to conditions such as depression and anxiety because their spouse has died or they become isolated when they are unable to drive.
Specialized training to treat this population is important, but there is a shortage of doctors with this sub-specialty, he said. Only a handful of geriatric fellowships exist statewide, each of which only takes two to three fellows each year.
On top of that, the baby boomers are aging, and the doctors are aging with them, Koh said. By 2030, the number of people ages 55 and older will account for 30 percent of the population, according to the U.S. Census Bureau.
“We have our work cut out for us, and so in that sort of environment if you have payment system set up where it forces people to pay more to get good care, it works against us,” he said. “And that’s why some of these laws and changes that are coming are extremely important.”
Koh understands why some doctors are hesitant to take insurance. They can only bill for the time they spend with patients, not the time it takes to navigate the bureaucracy, he said.
“I think we need to find a better way to do that,” Koh said. “We need our docs to actually be seeing patients, not just sitting in front of a computer and filling out paperwork.”
Bishop said understanding the reasons why doctors are not taking insurance will help in forming ideas for solutions. If reimbursement levels are too low, we should work toward increasing them, she said. If the paperwork is burdensome, efforts should be made to simplify it.
Doctor supply is harder to address, she said. But there are ways to encourage students who are interested in the field to go into psychiatry.
One of the reasons the field isn’t drawing the numbers of students it needs is because of the heavy debt students will acquire by graduation, Koh said. A medical school student graduates from a public institute with an average of $150,000 to $200,000 in debt. It is far higher for private schools.
“You do not want the economic factors to influence how young students are choosing their career pathway,” he said.
An increase in the variety and scope of services available to seniors is an important part of providing better care, Chiplin said. And a vigorous education campaign about how mental health plays a role in overall health could help.
“None of these things should be viewed in isolation, but they’re all part of a broader tapestry of services and needs,” he said.