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Firms put limits on mental therapy

New scrutiny may break federal law, opponents allege

By Kay Lazar
Globe Staff / May 17, 2010

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Spiraling medical costs have driven many employers to place new limits on coverage for mental health care, raising concerns that the rules may violate federal regulations intended to make it as easy for patients to see therapists as other doctors.

At issue is the growing practice of requiring therapists to undergo lengthy and repeated phone interviews about their patients’ progress before the insurance company will approve further treatment. According to patients and therapists interviewed by the Globe, the reviews have established tougher criteria for additional visits and have been burdensome and intimidating. That has sometimes led to curtailed treatment and protracted appeals.

Among those feeling the squeeze are state and municipal employees who get their insurance through the Group Insurance Commission, a quasi-state agency that provides mental health coverage for more than 100,000 workers and their families.

The commission, facing double-digit increases in its mental health insurance costs, changed its rules last year and now requires therapists who are not in the commission’s roster of approved specialists to justify, usually through lengthy telephone reviews, a patient’s need for continued treatment after every 10 sessions. Previously, the commission simply required the therapists to regularly fax the insurer a progress report.

For Lorna Simon, a 54-year-old mental health researcher from Shrewsbury who works for the state, the commission’s tighter rules mean that her weekly therapy sessions will soon be cut back to once every two weeks. Simon said that four years ago she struggled with depression that left her unable to work full time. But the weekly sessions, she said, have helped her get back on track. Now she is worried that, as her sessions are reduced, her depression may once again engulf her. “Some weeks I am OK,’’ Simon said, “but other weeks I really need more support.’’

Dolores Mitchell, executive director of the Group Insurance Commission, said her agency tightened its rules because mental health insurance rates in some of its employees’ plans jumped 22 percent in the past year. “I don’t think we’ll have savings with these changes, but I think we will put the brakes on increases,’’ Mitchell said.

The commission is studying whether its rules comply with federal regulations, she said.

Advocates for the mentally ill believe the restrictions may violate the 2008 federal mental health parity law, which requires most employers that offer mental health coverage to provide the same level of services as for other medical care. A company’s plan may not limit the number of therapy visits without placing similar restrictions on other doctors’ visits and may not require employees to shoulder more costs for mental health sessions than for other visits. Regulations issued last month went further, saying employers’ plans may not impose other limitations on mental health treatments that are not required of other medical services.

Legal advocates say that the new rule means insurers are not allowed to grill therapists about their patients’ progress unless the insurers require other medical specialists, such as those who prescribe regular dialysis for patients with kidney failure, to undergo similar scrutiny.

“We are seeing what seem to be excessive preauthorization and other reviews that we don’t typically see for other medical services,’’ said Matt Selig, executive director of Health Law Advocates, a public interest law firm based in Boston.

Selig said his organization is compiling examples to determine whether to file a legal challenge on behalf of some patients and therapists.

Massachusetts residents seek mental health treatment at levels higher than just about anywhere else in the country, according to data from United Behavioral Health, a California-based insurer that is the nation’s largest providing mental health services.

It is the insurer used by the Group Insurance Commission and many Massachusetts companies, and its records show that nearly 12 percent of the nearly 1.2 million state residents covered by United’s insurance receive mental health treatment, second in the nation to Rhode Islanders, at 12.9 percent.

Dr. Rhonda Robinson Beale, United’s chief medical officer, said the recession has forced many of the companies for which it provides coverage to make tough choices. “Our customers are facing downsizing or laying off people,’’ Beale said, “and they’re also trying to maintain benefits for people and trying not to increase their out-of-pocket costs.’’

She said the tighter rules adopted by the Group Insurance Commission are similar to those being put in place by many other Massachusetts companies for their workers’ mental health coverage. The aim, she said, is to ensure that employers and the insurer are paying for only the treatment that is medically necessary, while maintaining good-quality care. But therapists say the crackdown has forced them to spend many more hours fighting with United’s reviewers for care their patients need.

Lexington psychologist Stephen Schlein said that in the last several months United Behavioral Health reviewers decided to terminate coverage of mental health sessions for three of his patients, including a 21-year-old suicidal college student and a man in his 60s who has terminal cancer and depression.

“In all my years, I have not seen anything like this,’’ said Schlein, a 40-year veteran. He said that he spent hours on the phone fighting to save his patients’ coverage and that ultimately his appeals were successful. But he said he felt so bullied that he will no longer accept new patients with United Behaviorial Health coverage.

Schlein’s dismay has been echoed by others, prompting the National Association of Social Workers, Massachusetts chapter, to request a meeting with executives from United Behavioral Health. “We want to make sure the reviewers that are calling are well trained and thoughtful about the suggestions they are making,’’ said Carol Trust, the association’s executive director.

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