Beyond Parity: Primary Care Physicians’ Perspectives On Access to Mental Health Care, an article featured in health policy journal Health Affairs, explores accessing mental health care from a different point of view. According to Peter Cunningham, a senior fellow at the Center for Studying Health System Change, found that in 2004-2005, more than 60% of primary care physicians were unable to obtain out-patient services for their patients seeking mental health care, a rate that is twice as high as barriers to other health related services. The report concludes that since the 1990’s, a little over 30% of patients in need of mental health care actually receive it. Among those providers that reported difficulty in accessing mental health care for patients were pediatricians. Problems also stemmed from the fact that there are shortages of mental health providers in the community.
The recession has left virtually no one unaffected, and those with chronic ailments are definitely no exception. The New York Daily News reports that diabetics are cutting back on visits to the doctor, insulin and blood sugar testing, actions that could have lethal repercussions. Adding to the severity of the situation, more individuals are being diagnosed with diabetes each year, with 1.6 million new cases in 2007. Without insurance, the cost of care for diabetics can range from $350 to $900 each month. Furthermore, the medications and treatments for the condition have declined.
The New York Times recently published an article detailing the case of a man whose insurance company paid for the removal of his brain tumor, but not complete cost of the cancer pills that his doctor prescribed for his treatment. The pills, Temodar, cost $5,500 for the first 42-day, then $1,700 each month thereafter. In cases of cancer, oral drugs are quickly replacing IV treatments as the most successful options, but insurance companies and prescription drug plans often do not cover the treatment. Only providing minimal coverage, these plan often leave patients to pay the majority of the bill. As result, some patients are not able to receive the medications that they desperately need. Medicare Part D’s “doughnut hole” is another factor contributing to the lack of access to health care and prescription drugs. Not only do oral cancer drugs require a 25% co-pay, the doughnut hole ceases to provide coverage when health care costs reach $2,700; coverage is reinstated after beneficiaries pay health costs totaling more than $3000 out-of-pocket.
Last month, insurance executives announced a willingness to stop charging higher premiums–or denying coverage altogether–for those with pre-existing conditions or other health problems. However, it was made clear that this practice would be dependent on Congress requiring everyone in the US to carry health insurance, which is still many months away. Karen Pollitz, project director at the Health Policy Institute at Georgetown University, laments, “Under the current system, the people who need insurance most can’t afford or can’t get coverage.”
In the meantime, the New York Times outlines some guidelines for what to do when you are already sick:
1) Keep your employer’s coverage (if possible). Under the Health Insurance Portability and Accountability Act (HIPAA), employers cannot charge more for your coverage if you have a pre-existing condition. Be aware that new employees may be denied coverage for treatment related to pre-existing conditions for up to 12 months. But if, under an alternative group plan, you have had continuing coverage, this may be applied to the 12-month period. If you have had a gap of 63 days or more, you can be denied a full 18 months, after which you are entitled to full coverage.
2) Learn your state’s rules. Federal law mandates that each state offer an individual option that cannot deny anyone coverage, as many individual plans deny those with pre-existing conditions. Find out what’s available at your state at the National Association of Insurance Commissioners. Unfortunately, the government does not regulate premiums, and cost can be somewhat of a problem. You can appeal your denial from a cheaper individual policy with the help of a doctor.
3) Seek alternate group coverage. Small business owners may be able to receive insurance through the chamber of commerce. Or several small businesses may come together for group purchasing alliances.
4) Be aware that insurance companies can rescind coverage. If applying for individual coverage, companies can rescind based on your failure to provide accurate information. Especially if you wind up getting serious treatment, even citing treatment for a canker sore months prior to developing mouth cancer as evidence of a pre-existing condition. Be ready to appeal with your doctor if necessary.
5) Watch out for temporary coverage. Temporary coverage, anywhere from a few months to a year long, seems like a good alternative, especially for those out of school or between jobs. But if you become sick, you will likely have trouble renewing because you will then have a pre-existing condition.
On March 17 Sen. John D. Rockefeller IV (D-W.Va.), chairman of the Senate Committee on Commerce, Science and Transportation, and Rep. Joe Courtney (D-Conn.), member of the House Education and Labor Committee, announced their intention to introduce The Pre-Existing Condition Patient Protection Act. The bill will aid the 133 million Americans living with at least one chronic condition, and would require the secretary of Health and Human Services to submit a report to Congress on the extent of adverse selection. The bill has been endorsed by over 22 organizaitons.
In 44 states, insurance companies are legally allowed to deny coverage, or charge more, to individuals with pre-existing conditions. Today, most Americans receive health insurance through an employer’s group rate, which cannot deny or charge more to those with pre-existing conditions. However, with the climbing unemployment rate, the number of Americans who get their coverage in individual or family rates will climb, as well. This will leave many with pre-existing conditions either untreated or in debt because of the higher rates.
Adding an infant or another medically expensive individual to a group rate can cause premiums to rise for all employees. So when her employee Kathy Fisher had a son, Nicholas, Shelly Yanoff of Philadelphia Citizens for Children and Youth (an organization that, ironically, works to get health insurance for children) decided to put Nicholas on an individual plan assuming it would be cheaper. Because of a jaundice at 5 days old, Aetna rejected him, claiming, “We couldn’t price a policy in a range that anybody could actually pay for. If we can’t price affordably, we don’t accept”.
The rejection of a five-day-old highlights the problems, specifically involving pre-exisiting conditions, with our health system. As President Obama said at Tuesday’s joint session, we need “quality affordable health care for every American”. To achieve this, we must end rules that allow insurance companies to exclude inviduals based on pre-existing conditions. A costly decision, but a necessary one.
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The American Cancer Society and Kaiser Family Foundation issued a report yesterday on 20 patients who have been diagnosed with cancer or other serious illnesses and the difficulties they have had in accessing affordable health care. The report, Spending to Survive: Cancer Patients Confront Holes in the Health Insurance System, identifies 5 major gaps that cancer patients experience after they have been diagnosed.
First, caps on benefits can lead to high out-of-pocket expenses. Second, employer-based health coverage may not cover catastrophically high health costs. Third, finding an adequate individual plan can be difficult, both for those recently diagnosed and for those in remission. Fourth, high-risk pools are either not available in some states or not affordable. Finally, the waiting periods and eligibility restrictions leave many patients in a period of limbo, in which they are without affordable coverage while waiting to be access public programs.
Amerigroup on Tuesday said it will enter a $225 million settlement agreement with Illinois and the federal government over allegations that it denied coverage to eligible pregnant women, the Baltimore Sun reports (Baltimore Sun, 7/23).
Cleveland Tyson, former vice president of government relations at Amerigroup’s Illinois subsidiary, in 2002 filed a whistle-blower lawsuit that claimed the company cherry-picked the healthiest patients to reduce spending. The U.S. attorney in Chicago and the Illinois attorney general later joined the lawsuit as plaintiffs. Illinois paid Amerigroup a flat fee per beneficiary that took into account that some people require more costly treatment than others. In March 2007, a federal judge in Chicago ruled against Amerigroup and awarded $334 million in the lawsuit.