Publications/Articles Archives

September 02, 2006

Publications and Articles

Below you will find a listing of publications and articles which we feel are important or especially helpful to anyone seeking information about psychiatry. Some of these may be fully reviewed in our Media Reviews section as noted. Others are links to files or other websites which will open in a new window.

  1. BCMS Report — Spring 1998 HTML | PDF (Questions to Ask About Your Health Insurance), Baltimore City Medical Society Foundation
  2. Choosing Your Health Care Plan HTML | PDF, Medical and Chirurgical Faculty of Maryland
  3. Managed Care and Mental Health: Will your health plan meet your mental health needs? HTML | PDF, Maryland Psychiatric Society
  4. Managed Care and Your Mental Health: What You Need to Know about Your Managed Mental Illness Insurance Benefits HTML | PDF, American Psychiatric Association

Note: Files marked with a are in Acrobat PDF format. Acrobat files may be viewed on any type of computer system with the free Acrobat Reader. Acrobat Reader is provided on most computer systems now or can be downloaded from Adobe.

Bazelon Center Publications

Government and Organization Reports on Mental Health

Domestic Violence

9/11, National Disasters and Terrorism (including Biological and Chemical Terrorism)

Terrorism, Violence and Children

Terrorism, Violence and the Elderly

Posted by admin at 10:41 AM

March 20, 2003

Managed Care And Your Mental Health: What You Need to Know About Your Managed Mental Illness Insurance Benefits

The American Psychiatric Association
1400 K Street NW
Washington, DC 20005

Introduction

In survey after survey, the American people have said they believe in equal care for mental illnesses and that every person needing psychiatric care should have access to a psychiatrist of their choice.

Unfortunately, many employers, in the name of controlling costs, only offer their employees a choice among managed care plans such as Health Maintenance Organizations and Preferred Provider Organizations. These systems may limit your choice of psychiatrist or other physician, and provide less care for mental illnesses than for other medical illnesses. Some evidence indicates that certain population groups do not do well in managed care plans.

Patients who have a choice should opt for a health insurance plan offering free choice of physician, one in which all health decisions are the responsibility of the doctor and the patient. Health care today is big business. To get the best care, patients must be informed about their own health’s needs, must understand the details of their insurance plans, and must be willing to fight for what they deserve.

Harold I. Eist, M.D., President
American Psychiatric Association 1996- I997

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Your Benefits

Don’t assume that because you or a family member do not now have a mental illness that you don’t need good mental health coverage. One in four adults will suffer from a mental illness or substance use disorder in any year. The best plans provide the same coverage for mental illness as for other medical illness such as cancer or arthritis subject to the same deductibles, co-pay amount, annual limits, and lifetime maximums. Unfortunately, most health plans discriminate by providing less care for mental illness, and by requiring you to pay more out-of-pocket for the care you do receive. Make sure the plan offers emergency care, including psychiatric emergencies, and will allow you to go to the nearest emergency facility.

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Exclusions

Read the “fine print” in your own benefit plan and ask to see the contract between the plan and the employer. If you can't understand its legalese, have your employee benefits manager or attorney explain it in straightforward language. Some plans will discriminate by strictly limiting the number of psychotherapy visits and days in the hospital, and may limit the type of medications they will provide or pay for. If you are joining the plan for the first time, make sure it will cover illnesses you suffered in the past or are currently being treated for. Many plans require a waiting period for pre-existing illnesses.

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Choosing Your Psychiatrist

The American Psychiatric Association believes that all health plans should allow you to choose your own psychiatrist, even one outside the plan, although you may be required to pay a larger portion of the cost yourself. If your psychiatrist is not a “participating physician”, a second choice is to ask whether he or she would be allowed (or would be willing) to join the plan’s panel of physicians. The third choice, and least desirable, is to negotiate a transition period with the plan in which you remain in treatment with your current psychiatrist, but eventually transfer to the care of a “participating psychiatrist.” If you must switch to a plan psychiatrist, ask your treating psychiatrist to recommend one from the plan roster. Note: Not all may be accepting new patients or be convenient to you.

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Gatekeepers

Many plans will not allow you to make an appointment directly with a psychiatrist. They require that you first be evaluated by a “gatekeeper” -- usually a family doctor, social worker, or plan service representative -- to determine whether specialist care is needed. Unfortunately, gatekeepers may not be adequately trained in the diagnosis of mental illness and may miss symptoms indicating the need for care by a psychiatrist. George Anders, in his book “Health Against Wealth” quotes the mother of a seriously ill child who was mistreated by a well-known managed care plan: "We don’t need a gatekeeper if the child is in an emergency; we need all the doors to be wide open.”

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Confidentiality

Your trust that confidential information discussed with your psychiatrist will not be shared with others is crucial to effective treatment. Ask how confidential information is protected and don't sign blanket medical record release forms; only sign time-limited requests for specific information. If the plan cannot assure you that information that would identify you will not be shared without your permission, investigate another plan, or consider contracting privately for care from a professional outside the plan who will protect your confidences.

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Quality of Care

It is nearly impossible for a consumer to judge the quality of care provided by a managed health plan, and the National Commission on Quality Assurance (NCQA) created by the managed care industry to accredit HMOs and other organizations -- at present offers limited help. The NCQA measures such things as the percentage of plan physicians who are “board certified.” It does not measure many indicators of quality -- for example, the number of participants treated for depression who resume normal functioning. To determine overall member satisfaction with the plan, request the plan’s “patient satisfaction data” from your benefits manager. However, this survey data is unreliable without knowing how the questions were asked, cannot be compared with other plans, and may not give you an indication of how seriously ill patients rate the plan. Also, ask how many member appeals were filed and how many were denied. A high denial rate may mean the plan is rationing care to save money.

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User Friendliness

Plan hospitals, clinics, and physicians should be conveniently located near your home or work place, with flexible hours of service. You should be able to get an appointment to see a psychiatrist or other professional within a reasonable period of time, and your waiting time to see the clinician once you have arrived should not be excessive. If you travel extensively make certain you are covered for care in other cities or countries.

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Open Consultation

Patients should be able to have a free and open conversation with their psychiatrist or other physician about their care. The psychiatrist should be free to tell you about all treatments that may help you; even those not covered by the plan. The physician should also be allowed to tell you about his or her financial arrangement with the plan-whether he or she benefits financially by limiting treatments and tests according to goals set by the plan. Over 95% of people responding to a recent survey said they wanted more information about financial incentives HMOs offer their physicians to reduce costs. Managed care plans can dismiss physicians who order more tests or hospital days beyond the plan’s norm. Some plans have “gag rules” prohibiting full communication between doctor and patient, or “antidisparagement” rules prohibiting any comments critical of the plan. (So far, 16 states have passed laws barring these practices.)

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When You are Dissatisfied with the Plan Offered You

Call the plan’s customer service department, and talk to your employer’s benefits manager or your union representative about your concerns. Remember: You don’t have to have mental illness in your family to be worried about the adequacy of the mental health benefit.

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When You are Dissatisfied with the Services Provided

First talk to your psychiatrist or other physician and ask him or her to appeal on your behalf. If you have been denied treatment in what you consider a life threatening situation, do not hesitate to get the care you need from outside the system, even if you have to pay the entire bill yourself. Otherwise, use the plan’s appeal process. File a formal written complaint with the plan, with a copy to your employer’s health benefits manager and to the state insurance commissioner. Write to your state and federal legislators. Seek advice from your local psychiatric society. If you have a very strong case, consider taking it to the local news media. Consider talking with an attorney about your rights. In ail cases, do everything in writing, and make as much noise as you can. In managed care, the squeaky wheel does get attention.

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For More Information About Managed Care

American Psychiatric Association
Office of Economic Affairs
1400 K Street NW
Washington, DC 20005

For Information About Mental Illnesses

American Psychiatric Association
Division of Public Affairs
Department HE
1400 K Street NW
Washington, DC 20005
e-mail PUBAFRS@psych.org
Or visit the APA Website http://www.psych.org

Posted by admin at 11:04 AM

Managed Care and Mental Health: Will your health plan meet your mental health needs?

Maryland Psychiatric Society


What is Managed Care?

Managed care is a form of health care delivery that currently covers about half of American workers, and is growing rapidly. It promises to reduce the cost of health-care coverage to employers by hiring managed care companies to review the treatment recommended by your physician and determine if it is medically necessary. In this way, managed care companies hope to eliminate “overtreatment”
of patients.

While some unnecessary treatment may exist, under the competitive pressure to reduce costs, managed care companies have an economic incentive to reduce all treatment. This can be a serious problem in the area of mental health where managed care may define adequate treatment as barely enough to release a patient from the hospital, but not enough to return him or her to normal functioning.

Mental illness afflicts a large part of the population. In any year, about 13 million Americans will experience major depression. Another 5 million will experience schizophrenia or bipolar disorder, and many more people will suffer from short term mental distress which can be treated by appropriately trained clinicians. How your health plan deals with mental illness is at least as important to you and your family as how it deals with cancer or diabetes.

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Health Coverage Under Maryland Law

The Maryland Psychiatric Society believes that mental illness should receive the same consideration as any other illness. Along with other mental health providers and consumer groups, it urged state legislators to pass a mental health parity bill that requires insurance companies to provide mental
health benefits equal to other medical benefits. This law became effective July 1994. It covers all insurance plans and HMOs except those for small businesses and self-insured companies, Medicare and Medicaid. It allows unlimited outpatient visits with an increasing copayment It allows inpatient
days equivalent to those allowed for other medical conditions. There is no separate limit on benefits for psychiatric care annually or over the lifetime.

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Will You Receive Sufficient Treatment?

Despite this law, managed care companies can limit the number of visits paid for by stating that treatment is no longer medically necessary even if your doctor recommends further treatment and you want to receive it. They can also recommend less intensive treatments such as every other week
appointments or short term group therapies even when your physician disagrees. Sometimes, managed care companies prefer one type of therapy and may be reluctant to approve of other therapies, especially if theyare more expensive. In this way, managed care companies influence and potentially restrict the choices consumers can make in seeking mental health care.

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Appealing Managed Care Decisions

Managed care companies are required to have a clear appeals process so that a patient and/or the doctor can appeal a decision to decrease or stop treatment. Currently, most appeals are handled within the same managed care company. This raises concern as to how objective reviewers of an appeal can be. For this reason, Maryland physicians favor laws that would require managed care companies to handle appeals through an independent review panel.

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Will Your Privacy Be Protected?

In the past anything that your doctor learned about you during a patient visit was strictly confidential by law. Now, the managed care company insists on knowing detailed information in order to assess the plan of treatment for which they will pay. Patients must be aware that physicians may be required to disclose private data to the managed care company. Under many managed care plans, privacy may not be fully protected. For example, in the course of conducting quality assurance reviews, an HMO can require doctors to allow inspection of their patients’ medical records by HMO representatives.

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Questions You Should Ask

The questions outlined below are designed to help you understand managed care and how your health plan may deal with mental illness. If you have a choice of plans, these questions may aid you in deciding among them. Answers can be obtained by reading the plan or asking your Human Resources Department. If you are already in treatment you may want to discuss different health plans and their mental health coverage with your therapist.

  • Does the plan cover mental illness?
  • Do the deductibles or co-payments for mental illness differ from those for other illnesses?
  • Is there a time or cost limit on services for mental illness?
  • What are the qualifications of the people who review or deny psychiatric treatment?
  • Are there written criteria for approval of proposed treatment?
  • What is the appeal process for an adverse review?
  • Does the plan publish a list of its providers?
  • Can you bring your current physician into the network?
  • Will the plan pay for a doctor outside the network of providers?
  • Is privacy for medical records assured?
  • Under what circumstances can your medical information be seen by someone other than your doctor, without your consent?

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What You Can Do

If you have concerns about managed care and its impact upon your mental health treatment you can write to your State Senators and your State Delegate(s). If you do not know their names, contact the State Administrative Board of Election Laws at l-800-222-VOTE for the number of your county board, or call the Maryland Psychiatric Society at (410) 625-0232 In addition you might wish to inquire and/or file written complaints with the following Maryland State agencies:

Attorney General’s Office
Health Education Advocacy Unit
Consumer Protection Division
200 Saint Paul Place
Baltimore, MD 21202
(410) 528-1840
Mediates complaints against health care providers and health plans.

Office of Licensing and Certification,
Department of Health and Mental Hygiene
4201 Patterson Avenue
Baltimore, MD 21215
(410) 764-4970
Certifies private utilization review agents to operate in Maryland. Regulates quality aspects of health care delivered by HMOs.

Maryland Insurance Administration
Life and Health Section
Inquiries and Investigative Unit
501 Saint Paul Place
Baltimore, MD 21202
(410) 333-2793
Regulates insurance companies and financial aspects of HMOs

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Posted by admin at 11:02 AM

Choosing Your Health Care Plan

Medical and Chirurgical Faculty of Maryland
"Doctors dedicated to the health of our patients"

Ask yourself the following questions to see if the plan you’re considering meets your family’s health care needs"

  1. Can I continue to see the same doctor that I have seen in the past? How much will I have to pay if I want to see a doctor who is not in the plan?
  2. Are pre-existing conditions covered?
  3. Which hospitals are in the plan? Can I have outpatient surgery in a hospital or only in surgical
    centers?
  4. Are preventive care, immunizations, well-baby care, prenatal care, maternity care and fertility treatments covered? What types of care are excluded from the plan?
  5. Do I need a referral each time I see a specialist? Is there a limit on the number of referrals to specialists?
  6. If I have an emergency or need care after hours, where do I go? Do I need to get authorization to go to an emergency room? Do I have to pay if I’m taken by ambulance to a hospital that is not in the plan?
  7. How do I get a second opinion? Who chooses the doctor? Who pays?
  8. What limits does the plan place on payments for medical care?
  9. If I’m unhappy with the plan, how do I withdraw from it? Do I have to pay a penalty or meet new deductible requirements if I switch to another plan?

What you don’t know may cost you!

Posted by admin at 11:00 AM

Baltimore City Medical Society Foundation Report, Spring 1998

Questions to Ask About Your Health Insurance

Health insurance is confusing. At some point we are all faced with making decisions about our health insurance coverage. No one plan is right for everyone. The following questions may help you to choose the best coverage for you and your family.

  • May I be seen and treated by my current physician both in the office and in the hospital?

  • If I am ill after my doctor’s office is closed, may I call him or her directly or must I call the health plan first?

  • What if I go to an emergency room? Will care be paid for even if it proves not to be a life threatening condition? Will I have to call the plan before I can be cared for in an emergency room?

  • Will I always be seen by a physician or may some routine care be handled by a nurse practitioner, physician’s assistant, or other health care professional?

  • What is the plan’s policy if I want to be seen by a physician only?

  • What specialists are included in the plan?

  • What happens if I want to see a specialist without a referral from my primary care physician?

  • What happens if I want to see a specialist not affiliated with the plan?

  • How are complaints handled by the plan?

  • On average, how long will I have to wait to get an appointment with a physician?

  • Can I change primary care physicians if I choose to?

  • Are there restrictions on changing physicians?

  • Are there limits on how far I may be required to travel to see a physician in the plan?

  • What hospital(s) are affiliated with the plan?

  • What costs will I be responsible for under the plan?

  • What portion of the plan members dropped out during the past year?

  • Can my coverage be dropped by the plan?

  • How can I drop out of the plan?


Medicare patients thinking about joining an HMO should also ask the following questions:



  • If I am not happy with my plan, how can I drop out?

  • If I drop the plan, can I re-enroll in my Medicare supplemental insurance?

  • Will there be a waiting period before I can enroll in supplemental insurance?

  • Will I be rated differently if I drop my supplemental coverage and then re-enroll at a later time?


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Filing a Complaint about Your Health Insurance Company


There is help for you if you have a problem with your health insurance plan but it is difficult to find. Your first recourse is the insurance company itself. Every HMO in Maryland is required to have an internal system for handling complaints. For those people not satisfied with the insurance company’s decision, the Maryland Attorney General’s Office Consumer Protection Division handles some complaints, the Maryland State Health Department handles some types of complaints, and the Maryland Insurance Administration handles others.


Your physician is working to make this process much simpler for you. If the Maryland General Assembly passes HB 3 or SB 401, the Maryland Insurance Administration will have jurisdiction in handling complaints about health insurance coverage. You, or your physician on your behalf, will be able to file a complaint with your insurance company whenever a determination is made that care your physician recommends is denied. If the complaint is not resolved by the insurance company you may appeal to the Maryland Insurance Administration and the Attorney General’s Office will help you in preparing the appeal. If the Insurance Commissioner finds in your favor, he can order the health plan to pay for the service or treatment. You can help your physician make the process simpler for you by contacting your legislators to support HB3 and SB 401.


If you do not know your legislators call the Board of Election Supervision:


Baltimore City • 410-396-5550



Baltimore County • 410-887-5210


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Posted by admin at 10:57 AM




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