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With Mental Health Emergency Care, Insurers Bank on Hassle Factor


One million hours of doctors' time is being wasted annually getting pre-approval for the hospitalization of the mentally ill.

We all know that a hospital emergency room can't turn you away if you're in need of care. That's been law since the Emergency Medical Treatment and Active Labor Act was passed in 1986. But, there is a case when an attending doctor might think twice before deciding whether or not you need to be admitted: if you've passed through those sliding doors with a mental health issue, and -- here's the kicker -- are privately insured.

A study published Tuesday in Annals of Emergency Medicine has found prolonged wait times in Boston-area emergency rooms for severely ill psychiatric patients. The study's 53 insured subjects were each deemed in need of immediate hospitalization. So, why then did a sample population whose primary reason for admission was suicidal ideation -- with select cases exhibiting homicidal intent -- spend on average 8.5 hours waiting in the ER?

Overburdened hospital staffs and restricted facilities for mental health patients are a leading cause of this wait time. But, at least part of the blame falls on prior authorization requirements put in place by insurance companies.

"This is an issue psychiatrists know all too well," says J. Wesley Boyd, MD, PhD, a staff psychiatrist at Cambridge Health Alliance (one of Harvard Medical School's teaching hospital) and the supervising author of the study. "Lots of other medical specialties need to get authorization for drugs, and certainly for procedures. But, prior insurer authorization for [emergency room] admission is unique to psychiatry."

"Could you imagine if a pregnant woman came into an emergency room in labor," says Boyd, "and they said, 'we have to hop on the phone with your insurance company and get this prior authorized'?"

Over the course of the three-month study, psychiatrists spent an average of 38 minutes on the phone with insurers getting emergency patients authorized for admission, with 10% taking more than an hour. In one case, a psychiatrist spent over five hours obtaining authorization. But, with all this time spent chasing insurance provider approval -- delaying care and taking away from psychiatrists' duties -- only one of the 53 requests for authorization was denied.

"Essentially, the forgone conclusion is if you jump through the hoops, stay on the phone long enough, and answer all the questions, your patient will ultimately be admitted," says Boyd.

Then why all the fuss?

People in Boyd's field call it "rationing health care by a hassle factor." The idea is that when a doctor calls up a provider like Aetna (NYSE:AET), Cigna (NYSE:CI), or UnitedHealth Group (NYSE:UNH), the process will be so laborious, so time-consuming, he or she will be deterred from seeking approval for patient admission in the first place.

Health-care providers' reasoning behind this, Boyd explains, is quite simple: "The less service [private health insurers] agree to pay for, the more money they get to keep in their pockets."

Insurance companies certainly aren't inept at making money. The top-10 US health insurers, which, along with the names above, include WellPoint (NYSE:WLP), Humana (NYSE:HUM), and others, drove a 250% increase in profits last decade.

The approval process usually goes something like this.

A doctor will place a call to the insurance company and be put on hold for an inordinate amount of time. Or, Boyd recalls from his own experiences, he or she will be kicked around from department to department until finally connecting with the appropriate representative. Once a representative is reached, the process is relatively straightforward: a list of questions confirming a patient's condition is administered by someone who, Boyd says, is almost never a doctor. (Very rarely, he says, will a claim be so contentious that a call will get passed up high enough on an insurance provider's hotline to become a doctor-to-doctor issue).
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