Psychiatr News August 1, 2008
Volume 43, Number 15, page 1
© 2008 American Psychiatric Association
Congress Ends Medicare's Mental Health Copay Bias
Rich Daly
The legislation, which also reverses an impending deep cut in Medicare
physician reimbursement, had more than enough backers to override a veto by
President George Bush.
Congress passed landmark mental health legislation on July 9 that will
provide equal coverage for outpatient psychiatric care as for other types of
care for the first time for the 44 million Medicare beneficiaries. Although
President Bush vetoed the measure a week after it passed, Congress overrode
the veto the same day.
The legislation also includes provisions that will affect health care
delivery, including replacing a planned 10.6 percent cut in physician
reimbursements with a small increase (see Threatened Medicare Cut Turns Into
Slight Boost).
The Medicare Improvements for Patients and Providers Act (HR 6331) also
will expand Medicare beneficiaries' access to needed psychiatric
medications.
"This legislation will put an end to a system that forces medically
vulnerable patients, including psychiatric patients, to pay two-and-one-half
times more out-of-pocket costs for mental health services than for any other
service under Medicare Part B," said APA President Nada Stotland, M.D.,
M.P.H., in a written statement.
"We could not have arrived at this extraordinary moment without the
coordinated efforts of our dedicated members, our devoted and skilled staff,
and the efforts of those legislators who were unwilling to tolerate this
unacceptable discrimination," she told Psychiatric News.
The measure, which passed with veto-proof majorities in both chambers of
Congress, was vetoed by Bush because, in part, it cut payments to Medicare
Advantage plans, which he favors because they were designed to cost
beneficiaries less than traditional fee-for-service Medicare.
The measure will phase out over six years the 50 percent coinsurance
payment beneficiaries face for outpatient mental health services. This
discriminatory copay requirement has been in effect since Medicare was
established in 1965. Medicare requires beneficiaries to pay only 20 percent of
the cost of outpatient services for problems not classified as related to the
treatment of most mental disorders.
The copay disparity between mental health and other types of medical care
has resulted in undertreatment of mental illness among the Medicare
population, which includes some demographic groups that have the highest
suicide rates in the nation, according to mental health advocates.
Research indicating high rates of mental illness among the Medicare
population included a 2006 study by researchers at George Washington
University that found that 26 percent have mental disorders, while only 21
percent of the general population has such conditions. The researchers found
that among the other population that Medicare serves—people with
disabilities—nearly 60 percent have a mental disorder, and 37 percent
have "severe" mental illness.
"Elderly people are particularly vulnerable with respect to
depression, anxiety, and alcohol use problems, each of which can be treated on
an outpatient basis," said Ron Manderscheid, M.D., an adjunct professor
in the Department of Mental Health at Johns Hopkins University, in
congressional testimony in March.
Proponents of the change also point out that Medicare's long-time
requirement for only a 20 percent copay for inpatient mental health care has
also led Medicare beneficiaries to overutilize those services, because the
copay makes them more affordable than outpatient care.
A 2002 analysis by the Substance Abuse and Mental Health Services
Administration of Medicare and Medicaid—the latter does not charge
proportionally more for outpatient mental health care—found that
Medicare beneficiaries are much more likely than Medicaid beneficiaries to
receive costly inpatient mental health and substance abuse care, if they
receive any such services. This has resulted in higher annual costs per
beneficiary for inpatient mental health care and substance abuse treatment in
Medicare than Medicaid.
The new law also requires coverage of benzodiazepines and barbiturates
under Medicare Part D, a change that goes into effect in 2013. The federal
prescription drug program excluded benzodiazepines when it was launched in
2006 due to concerns that it would expand the misuse of the medication in an
attempt to sedate nursing-home residents.
Statutory protections for certain classes of medications—including
ant idepressants and antipsychotics—under the new law will ensure that
medically vulnerable patients will have access to "all or substantially
all" such medications under Part D.
"This fixes significant problems in the Medicare program. This bill
will allow patients easier access to psychiatrists and treatments that can
relieve suffering and help patients live more fulfilling and productive
lives," Stotland said. "This bill is consequential and far
reaching."
APA and other physician groups, including the AMA, joined with AARP and
other advocacy groups to push strongly for final approval of the measure.
"Along with the AMA, many patient, physician, and military groups
called on Congress to pass this bipartisan bill," said Nancy Nielsen,
M.D., president of the AMA, in a statement shortly after Congress overrode the
veto. "The only group opposing the bill was the health insurance lobby,
which was eager to protect health plan subsidies and profits."
The text of the Medicare Improvements for Patients and Providers Act
can be accessed at
<http://thomas.loc.gov>
by searching on the bill number, HR 6331. 
Related Article:
-
Medicare Advantage Profits Far Exceed Projections
- Mark Moran
Psychiatr News 2008 43: 14-15.
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