There are too few hospital beds and child psychiatrists for people seeking mental health and substance abuse treatment in Connecticut.
There are too many barriers to getting services that could prevent crises.
There’s too much pushback from insurers over covering inpatient care even after a patient attempts suicide. And people with private health insurance often face some of the biggest challenges to getting treatment, according to a report issued Wednesday by the state Office of the Healthcare Advocate.
“The assumption has been that those who are insured through their employer or individually will have access to the mental health and substance use services they need. This is not the case,” according to the report, which cited the state’s fragmented system of care for mental health and substance abuse and the existence of multiple tiers of services depending on a person’s insurance.
The report, based in part on testimony from an October public hearing, came out a week before the start of a legislative session likely to include a significant focus on mental health care, prompted by the shootings last month at Newtown’s Sandy Hook Elementary School.
“If you talk to advocates, providers, consumers, there’s a lot of people out there who have felt for a long time that we needed to address this issue,” state Healthcare Advocate Victoria Veltri said. “It’s taken on a new level of urgency given what happened in Newtown. And we have enough information to start acting, and we should.”
The report calls for a single entity to coordinate the state’s mental health and substance abuse delivery system, more access to community-based services for people covered by private insurance, and better enforcement of federal and state laws that require equal coverage for mental and physical health care services.
“It’s really a public health crisis more than anything else,” Veltri said. “Mental health has always been treated differently, and it should not be. In fact, legally, it’s not allowed to be anymore under federal law. But we have a long way to go to achieve that goal.”
Private insurance problems
The report cited several problems with private insurance coverage, including inadequate provider networks, low reimbursement, lack of coverage for evidence-based services, and questionable criteria for denying coverage of potentially life-saving services.
Veltri said that in some cases, insurers cited the guidelines of medical professional groups in their criteria for determining whether certain services were medically necessary, but that the insurers’ criteria didn’t match the guidelines.
Several personal stories were included in the report.
Dr. Paul Rao, a child psychiatrist, said insurance companies routinely deny coverage for hospitalization, even for patients with severe mental illness who recently attempted suicide or injured themselves.
“After a few days — sometimes as little as 2-3 days, rarely more than week — the insurer denies coverage of further inpatient treatment,” he said, according to the report. “Appealing their decisions requires numerous calls up an administrative phone chain whose sole purpose seems to be to deny any rational or even compassionate argument for keeping a high-risk patient in the hospital.”
Some insurance company administrators have told him that if a patient hasn’t demonstrated self-harm behaviors or said they have suicidal thinking after five days, they no longer meet the criteria for hospitalization, Rao said.
In one case described by Dr. Mirela Loftus, a child and adolescent psychiatrist at the Institute of Living in Hartford, an insurance company refused to pay for more than four days of inpatient care for a 13-year-old girl with schizoaffective disorder who had been found walking on the side of I-84 in Cheshire to find her imaginary in-laws, who she believed had kidnapped her imaginary triplets. Loftus said the insurer’s medical director told the hospital that “walking on the side of the highway may be illegal but not dangerous,” according to the report.
Greg Williams, co-founder of Connecticut Turning to Youth and Families, which advocates for substance abuse prevention and treatment services, said the criteria used by insurers to determine if services were medically necessary were not transparent or consistent.
“As a result, we have ‘fail first’ stipulations of lower levels of care that promote young people to continue to use,” he said. “And they end up dying, getting locked up, bankrupting families who need to pay cash for treatment, and cost-shifting to the public sector.”
An estimated 60 percent of the denials related to substance abuse and co-occurring disorders that Veltri’s office takes to appeal are overturned, the report said.
“This trend casts grave doubt on the efficacy of the insurer’s internal mechanisms to adequately review and determine appropriate treatment protocols for their members,” the report said.
Keith Stover, a lobbyist for the Connecticut Association of Health Plans, said nobody in the industry is unwilling to look at best practices. But he said there’s not always consensus about the right type of care for certain conditions.
“We continue, in I think a positive way for the system, to move as close as we can get to evidence-based approaches and standards, and this is an area where there is not always widespread agreement about what the best and most appropriate type of care is for particular conditions,” he said. “That’s just a fact. That’s not a criticism of the delivery system or defense of coverage decisions.”
“I think it’s a challenge for providers, I think it’s a challenge for payers, I think it’s a challenge for families, I think it’s a challenge for the state’s own infrastructure to do the right thing in the right setting with the right amount of care that generates the best possible outcome,” he added.
Stover said the industry is happy to work with anybody on mental health issues generally, “where we are actually talking about moving forward toward a system that is based in evidence and rational analysis” and not anecdotal.
As for the concern about how insurers determine what is medically necessary, Stover said decisions are based on what the medical literature indicates is the current state of the art.
“Now people may not like the state of the literature or may disagree with the state of the literature,” he said. “But that’s a bit of an old retread, kind of anti-insurance company assertion that isn’t going to move the ball forward on this stuff, I don’t think.”
Emergency rooms overtaxed
If you want to see the flaws of the mental health care system, look at emergency rooms.
Many patients with behavioral health problems show up there, even though they could be treated more effectively, and less expensively, in outpatient settings. But that doesn’t happen because of multiple barriers to accessing appropriate services, according to the report.
Private insurers limit how long psychiatric patients can stay in hospitals, leading to relapses and emergency room visits. The decrease in state-operated beds for adults and residential care beds for children leads to an “extreme burden” on emergency departments, the report said, citing a report by the state Office of Health Care Access. And for patients new to the mental health or substance use treatment system, it can be hard to schedule appointments with community-based providers.
While many people believe there aren’t enough inpatient beds for mental health or substance abuse treatment, some of those in psychiatric hospitals can’t get out because of a lack of suitable places for them to go. The report cited a study that showed patients who stayed more than six weeks at the Yale-New Haven Psychiatric Hospital were there more than seven months longer than necessary to provide acute care treatment. The hospital is now working with a community partner to arrange for temporary housing so patients can move back to their communities, it said.
Cost-shift to the state
The report cited multiple evidence-based treatments offered outside of hospitals that are frequently not covered by private insurance plans, and said that leads to increased costs for the state. In some cases, young people receive services through the state Department of Children and Families’ voluntary services program, even if they have private insurance. Last year, the program spent approximately $16.4 million on mental health and substance abuse services for children who also had private insurance, the report said.
DCF and the healthcare advocate’s office are working to get private insurers to cover services in those cases, and that process has yielded savings so far, according to the report.
While patients in Medicaid often have a harder time than those with private insurance getting appointments with doctors for medical services, the opposite is often true when it comes to mental health and substance abuse services, according to the report.
“Our current ‘system’ is premised upon factors such as income, geographic location, age, employment and insurance status,” it said.
“The publicly funded system in Connecticut is one that involves all stakeholders, is person-centered and recovery oriented. The insurance system is designed merely as a funding mechanism. It does not incorporate the principles of prevention and recovery that our publicly funded system does. In that sense, insurance coverage falls far behind the comprehensive view of mental health and substance use treatment adopted by [the Department of Mental Health and Addiction Services], DCF and [the Department of Social Services].”