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With Mental Health Emergency Care, Insurers Bank on Hassle Factor

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

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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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