Psychiatr News February 2, 2007
Volume 42, Number 3, page 16
© 2007 American Psychiatric Association
Calif. Physicians See Perils in Insurance Reform Plan
Rich Daly
Many psychiatrists are not convinced that the benefits of universal health
insurance will outweigh the costs to clinicians and to mental health care
quality.
A universal-insurance proposal for California that Gov. Arnold
Schwarzenegger (R) unveiled in January has raised concerns among psychiatrists
about the potential threat it poses to maintaining mental health care parity
and its call for scope-of-practice expansions for psychiatric nurse
practitioners.
Schwarzenegger's sweeping plan, which would require all Californians to
obtain insurance and would subsidize the poorest state residents, could,
however, have a beneficial impact on all state residents, especially the 6.5
million who lack health insurance. Many in this category are likely to have
untreated mental illness and could benefit from the access to care that the
proposal would provide.
"To the extent that people who don't have access" gain such
access through a reformed system, then the proposal "is a good
thing," said Randall Hagar, director of government affairs for the
California Psychiatric Association (CPA).
Like many health care proposals, however, the California plan has devils
lurking in its details, some of which trouble physicians in general and
psychiatrists in particular.
Scope-of-Practice Battle Could Erupt
Chief among concerns raised by the CPA is the portion of the proposal that
calls for expansion of "lower-cost models of health care
delivery," such as retail-based medical clinics, and scope of practice
for nurse practitioners and physician assistants.
Hagar doubts physician assistants will clamor for scope-of-practice changes
since few of them are mental health clinicians, but there are indications that
psychiatric nurse practitioners may want more independence from physician
oversight.
"We want competent nurse practitioners to help with the delivery of
quality mental health care, but it's a whole other kettle of fish if they
become independent practitioners," Hagar said.
Psychiatric nurse practitioners are now required to practice in
collaboration with physicians. Standardized procedures specify the
circumstances in which physician consultation is necessary.
Another area of concern is that business groups critical of the state's
mental health insurance parity law will use the insurance expansion to argue
for limiting the scope of parity coverage for mental health care. In recent
years some business groups have attacked the current requirement for coverage
for anorexia and bulimia, for instance.
The governor's plan calls for a review of "health/plan benefit,
provider, and procedural mandates in order to reduce the cost of health
care," which could apply to parity requirements. State law requires
health care service plans and disability insurance policies to provide
coverage for the diagnosis and "medically necessary" treatment of
severe mental illnesses of a person of any age, and of serious emotional
disturbances of a child, under the same terms and conditions applied to other
medical conditions. California law defines "severe mental
illnesses" as schizophrenia, schizoaffective disorder, bipolar disorder,
major depressive disorders, panic disorder, obsessive-compulsive disorder,
pervasive developmental disorder or autism, anorexia nervosa, and bulimia
nervosa.
Hagar emphasized that there have been no specific indications that either
concern will arise during consideration of legislation to implement the
governor's proposal, but the CPA and the California Coalition for Mental
Health plan to follow the legislation carefully in case moves to limit parity
are introduced.
Costs Worry Physicians
The proposal has drawn opposition from physicians because they would bear
part of the cost of the program through a 2 percent tax on their gross
revenues. The California Medical Association described the 2 percent charge as
a tax on patients because the cost would likely be passed along to them.
"Physicians are going to be subsidizing care, and that includes
psychiatrists," Hagar said.
The governor justified the added expense, arguing that the existing health
care system, which already covers the health care expenses of the uninsured,
amounts to a "hidden tax" on California health premiums that
drives up their cost by 10 percent. He cited a recent report by the New
America Foundation that estimated the "hidden tax" adds $1,186 to
family health insurance policies and $455 to individual policies.
Hagar said psychiatrists have raised questions about the new physician
levies but focused their concerns on whether it would result in improved
patient care.
One improvement the governor touted for physicians under the proposal is a
"significant" increase in Medi-Cal rates, which is designed to
encourage greater clinician participation in the state's Medicaid program.
Although details of the program's potential rate increase were limited, state
and federal funding for the increase would total about $4 billion, according
to the governor's proposal.
Hagar said that the additional 2 percent charge on physician income likely
would wipe out the proposed financial incentive aimed at encouraging more
physicians to participate in Medi-Cal.
"There's a lot of concern that the good won't outweigh the bad with
this proposal," he said.
Numerous alternative coverage options have been proposed in California in
recent years that range from regulation-tightening measures on insurance
companies to a bill that would provide universal, affordable, comprehensive
health insurance for all Californians, which the legislature passed and the
governor vetoed last year.
The California governor's proposal is posted at
<http://gov.ca.gov/pdf/press/Governors_HC_Proposal.pdf>.
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