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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).

The approval process is less challenging than it is tedious. Occasionally it will escalate to aggravating, like when, as Boyd illustrates, a representative is struggling to pronounce a medication name such as bu-pro-pi-on while a doctor waits on the other end of the line, and more importantly, a patient waits for desperately needed care.

Boyd also points out that because this is an emergency setting, the doctors making these calls are more often than not overworked psychiatry residents working on very little sleep.

"There's a constant flow of patients coming in through our emergency rooms, and you can imagine if you are the on-call psychiatrist, you're going to think twice before letting someone in. Because once you make that decision, you know that you or one of your colleagues is going to need to be on the phone."

And that's a problem. He continues:

"Colleagues of mine have pressed me to make sure its known that a lot of psychiatrists will do what they can to not hospitalize someone even if it's needed, especially if they are in a busy practice, because 40 minutes to an hour is time they simply don't have."

(Boyd assures me that neither he nor the residents who participated in this study ever let a patient leave who they determined needed to stay.)

The study's lead author, Amy Funkenstein, MD, offers a broader takeaway:

"Massachusetts is considered a model for health reform, yet we found that seriously ill patients routinely spent hours stranded in the ED [emergency department] due to insurance bureaucracy. The hours psychiatrists spend obtaining those authorizations could be far better spent treating our patients."

It might be easy to dismiss this as a niche issue. But when 26% of Americans are afflicted by varying types of mental illness each year, inadequate mental health care is clearly not an insignificant problem.

Projecting this small pilot sample across a population of 1.6 million psychiatric admissions among people with private insurance in the United States annually, an average 38 minutes of phone time to secure insurer approval equates to roughly 1 million hours of "wasted psychiatric time."

Unfortunately, however, Boyd doesn't see a change coming anytime soon.

"In order to stay afloat, hospitals have to play ball with the insurance companies. I'm sure if a hospital wanted to take the lead in the fight against this issue, they might end up being punished by the insurance companies next time contracts were being negotiated."

In addition, there isn't the same kind of public outcry for mental health care infringement like there was, for example, when insurers were pushing for rapid postpartum discharge in the early '90s.

Boyd recalls the very public backlash against what were then dubbed "drive through deliveries," so labeled for the 48-hour limit insurers put on paying for post-birth hospital stays. The American Academy of Pediatrics, the American College of Obstetrics and Gynecology, and the American Medical Association all publicly denounced the practice. A number of highly-publicized commentaries were published, one such titled: "Early Discharge in the End: Maternal Abuse, Child Neglect, and Physician Harassment." When the issue reached Congress the next year, sentiment quickly shifted out of managed health care's favor, and by 1997, national law mandated that 48 hours was the minimum amount of postnatal care insurers were required to pay for.

"Because of the stigma surrounding mental health issues, you don't have the same public reaction. People aren't willing to stand up and say how dare you for not allowing me full access to what I need immediately if I have depression, or am suicidal, or have schizophrenia, or my loved one does."

With the nation's attention recently tuned to mental illness, and the role it has played in mass shootings and other domestic acts of aggression, it's hard not to find what appears to be an unnecessary barrier to treatment difficult to stomach.

For now, we can only hope that the individuals who do require emergency care are at least Medicare recipients -- Medicare requires no prior authorization for emergency room visits -- or have no insurance at all, because that's 40 minutes less they'll have to wait to receive the much needed medical attention.

Twitter: @brokawbrokaw

(Photo by Rosser321)
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