Insurance companies’ ‘prior authorization’ endangers psychiatric care
Despite federal and state mental health parity laws – like New York’s “Timothy’s Law” – that require insurance companies to offer the same coverage for mental health problems as they do for other medical conditions, mental health patients are routinely forced to overcome additional hurdles from insurers to get approval for prescribed treatments.
As Congress rehashes comprehensive healthcare reform, lawmakers should examine how insurers’ prior authorization rules endanger patients suffering from mental illness and violate the spirit, if not the letter, of mental health parity laws.
Prior authorization rules are not unique to mental health care. In all areas of medicine, insurance companies sometimes require doctors to obtain pre-approval before a patient is permitted to receive a certain medication or treatment.
But surveys have found that prior authorization denials are particularly common for psychiatric patients, with insurers denying coverage for psychiatric treatments at a higher rate than other medical and surgical services. The difficulty of dealing with insurers is one of the reasons psychiatrists accept private insurance at a much lower rate than doctors in other medical specialties.
Psychiatric medications can be denied through prior authorization if a doctor prescribes a drug for a different purpose than it was originally intended, even when this secondary use is proven effective.
For example, the sleep disorder drug Modanifil has been shown to be an effective treatment for depression. The anti-depressant Wellbutrin is licensed for use as an aid for quitting smoking. Under certain prior authorization rules, patients could be denied coverage for both prescriptions because they were not originally developed to treat a sleep disorder or depression.
Even when a treatment is not denied outright, an insurance company may request that a patient receive a cheaper alternative medication or a lower dose rather than the one originally prescribed. For patients with mental illness, a slightly different drug or dose can have a very different effect. It often takes years for a psychiatrist and a patient to find the right balance of medications. For a patient to suddenly find his or her treatment has been altered can be disastrous.
Waiting for an insurance company to approve treatment can be particularly damaging for those suffering from mental health problems. For my patients suffering acute mental health episodes, waiting to know whether they can see a mental health professional cannot only be excruciating, it can be life threatening.
Insurers justify prior authorization as a cost cutting measure that helps weed out medications they deem unnecessary. But there is little reason to believe that the requirement creates overall health care savings even if it helps insurance companies protect their bottom lines.
Whatever savings accrue to the insurance company come at the expense of practitioners, who must spend more of their time arguing for insurers to cover the treatment a doctor deems necessary. One study found interactions with insurance companies cost the average American medical practice an estimated $82,975 per physician per year. These costs that are either absorbed by the provider or passed on to the consumer.
I have devoted years of my life to protecting the mental health of my patients. Their well-being is my responsibility. That responsibility is threatened when insurers withhold coverage for mental health services or dictate which drugs they will allow.
The insurance company may hold the purse strings, but only trained medical professionals should determine treatment.
Laura Young is a New York City therapist and licensed social worker in private practice and co-author of “Making Contact: The Therapist’s Guide to Conducting a Successful First Interview.”