Despite the passage of two federal mental health parity laws, the Mental Health Parity Act in 1996 under Bill Clinton and the Mental Health Parity and Addictions Equity Act in 2008 under George W. Bush, and despite a major 60 Minutes piece devoted to this issue in 2014, there remains little effective parity between psychiatry and the rest of medicine.
Unlike “medical” hospitalizations, all hospitalizations in psychiatry must go through an emergency room, or “emergency-room equivalent” (an acute care walk-in clinic with admitting privileges to an approved hospital), and must be “pre-approved” by insurance companies. This is a long-standing dictate from Big Insura, and the government has never dared put any teeth behind its parity laws. In practical terms this means a random representative of The Company, typically a nurse, typically somewhere in the Deep South, makes a decision at her whim — with powerful financial incentive to repeatedly declare, “NO!” — whether to approve of a hospitalization, or not, based on a case made, over the telephone, by those who have actually evaluated the patient.
(Imagine calling a “time-out” in the ED in order to make a series of phone calls in order to obtain insurance pre-authorization before transfer to the cath lab. And more, imagine the “cardiology piece” of your insurance has been “carved out,” in tiny print, to a different, even more cut-rate insurance company, with its own very limited contracts and very limited network for “cardiology-related issues,” likely a very different network than the rest of your insurance. A very common cost-cutting practice with regard to the “behavioral piece” of your insurance, not usually discovered until it’s too late.)
For those unfamiliar with psychiatric hospitalizations, these are generally considered to be the equivalent of intensive care units for the mentally ill. And it is well to keep in mind that safety standards are very different for psychiatry. Consider that patients with medical illness, despite heroic efforts, at times do die. And this is expected. But when a patient dies of psychiatric illness there are all manner of investigations, not least of which are often investigative reports by the media.
This is part of the backdrop of our efforts in crisis situations.
If a hospitalization, i.e. an intensive care stay, is not approved by Insura, the hospital will be reimbursed nothing if the patient is admitted. In fact, they will effectively lose money as they are losing a bed that could go to a paying customer (in addition to the money lost by occupying a bed in the emergency room for hours, sometimes days, sometimes weeks).