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Further Arguments for Eliminating the Private U.S. Health Insurance Industry

August 2011

Sidney M. Wolfe, M.D.

A study by Harvard medical researchers, published last month in the journal Archives of Emergency Medicine, documented the extraordinary difficulty insured patients with an acute psychiatric emergency had in obtaining an appointment for follow-up with Boston-area psychiatrists.

Study personnel posed as patients insured by BlueCross BlueShield of Massachusetts (BCBSMA) PPO, the largest insurer in that state. They called every BCBSMA-contracted mental health facility within a 10-mile radius of downtown Boston, stating they had been evaluated in an emergency department for depression and discharged with instructions to obtain a psychiatric appointment within two weeks — that is, they signaled they needed urgent psychiatric care.

Only eight of the 64 facilities (12.5 percent) listed by BlueCross as preferred providers offered appointments; only 4 (6.3 percent) offered an appointment within two weeks.

The authors of the study stated:

“This result confirms our suspicion that even for patients with private insurance, mental health services in the Boston area are severely limited, which is in line with national data showing limited availability; for example, two thirds of primary care physicians report that they cannot obtain outpatient mental health services for patients who need them.

“Our inadequate mental health system has widespread social effects. A third of the homeless and more than half of all prison and jail inmates have mental illness. The nation’s Emergency Departments are de facto psychiatric wards, with 79 percent of emergency physicians reporting that their hospitals board psychiatric patients for whom appropriate treatment resources could not be found, sometimes for days.

“Although there are many contributors to the inadequacy of our mental health system, managed care has hit psychiatric services hard. Private insurers aggressively constrain patients’ access to services by stringently limiting provider networks.

“As our study shows, this is often covert; insurers provide lists of in-network providers, but most are unavailable. Reimbursements for psychiatric services are far lower than for other types of care, so institutions frequently restrict access as stringently as possible, often, as in our study, by requiring that a patient have an in-system primary care provider (even though the insurer requires no referral). Many private practitioners refuse to accept insurance payments altogether. Improved reimbursements for psychiatric care will be an important step in reducing the barriers to care experienced by patients with severe depression.”

Rather than admitting to these serious access problems, a BCBSMA official tried to intimidate the researchers. I sent the following e-mail to BCBSMA objecting to this attempted harassment:

“I have just received a copy of an e-mail you sent Wednesday objecting to a study published July 21st in the Annals of Emergency Medicine, concerning extremely limited access to Blue Cross Blue Shield psychiatrists in the metropolitan Boston area.

“Your response to this study is intemperate and heavy-handed. You [BCBSMA] stated that:

‘We are VERY concerned about the use of BCBSMA’s name and brand in a published study without BCBSMA authorization. We’d like to talk with you about that.’

“It is absurd for BCBSMA to require authorization to either do a study of physicians with whom it contracts or in order to use BCBSMA’s name and brand in conjunction with this study.

“Please send me a copy of the BCBSMA policy manual that specifies the need for such censorship.”

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