Jarrod Gutman | Mental health care suffers under HMOs

Over the past three years, the Psychiatry department received nearly $217 million to study disorders from substance abuse to schizophrenia. Ironically, many of the employees doing the legwork have limited access to quality mental-health care themselves.

To better serve the mental health demands of the student population, the University recently increased staffing at its Counseling and Psychological Services office by 25 percent. But the University has taken a curious step to ensure the mental health of its more than 13,000 employees.

Since July 2004, the Point of Service and Preferred Provider Organization employee health plans have contracted their mental health services to Penn Behavioral Health. So if you need a psychiatrist and can afford one of these plans - which range from $765 to $1,548 per year for full-time employees - you have access to the best doctors in the field.

The cheapest plans, Keystone Health Plan East Inc. and Aetna Inc., cost only $417 a year. But the affordability of health maintenance organizations comes with a price. HMOs generally contract their mental-health services to a third-party firm, which offers a limited selection of qualified in-network providers.

Regardless of insurance, the University does offer an Employee Assistance Program for free psychological counseling, but there is a limit of six sessions.

Despite HMO limitations, the majority of employees still choose them - 44 percent Keystone and 13 percent Aetna, according to figures from the University's Human Resources department. A survey of 12 coordinators in my lab revealed that eight chose an HMO, with an even split between the two providers. The main reason was their low cost.

If you're among the minority that chose Aetna, though, you're in good shape. In May, the Psychiatry department negotiated a contract with the company that will allow in-house psychiatrists to treat Aetna subscribers. However, Keystone subscribers still must choose from a pool of less-competent doctors.

Keystone carves out its mental health care to Magellan Health Services Inc., the largest managed behavioral-care company in America. Yet, despite its market share, Magellan is woefully incompetent. In May 2005, the Pennsylvania Psychological Association released a report charging Magellan with fundamental mismanagement leading to the degradation of patient care. Ask any private psychiatrist, and you're likely to get a similar report.

According to one department psychiatrist, the Hospital of the University of Pennsylvania will treat Keystone subscribers for medical conditions. But should you happen to develop a serious psychiatric issue as a result of your treatment, the staff will be forced to transfer you to a less-competent hospital - even if there's an open bed just one floor above you.

HMOs are notorious for short-changing psychiatrists for their services. This has increased the role of primary care physicians and non-psychiatrist therapists in treating mentally ill people. It's also why more than half of psychiatrists in private practice have eschewed managed-care insurance altogether.

Rather than dropping HMOs outright, the University has instead chosen to negotiate contracts with them. This may indeed improve access to quality mental health care, especially for those at the low end of the salary spectrum. But it will also increase the burden on treating psychiatrists and administrative workers, who will have to cut through layers of red tape to get reimbursed.

Consider the case of a patient with schizophrenia who comes for treatment to my lab. Out of the $220, the department bills Aetna for a 45-minute psychotherapy session; Aetna reimburses Penn about $100. With the 35 percent overhead, the department ends up pocketing a mere 38 percent of the amount of the original bill. Remember, we're talking about seriously mentally ill people receiving desperately needed services. Yet, Aetna has already thrown up barriers to consistent care for these individuals, citing leniency in the collection of patient copays as a way to refuse reimbursement altogether.

Just how far will the University take this policy of HMO collusion?

If the University were to have a contract with Magellan, it would ostensibly improve the mental health care needs of nearly half of Penn's employees. But given Magellan's history, and that of HMOs in general, the policy could also be a financial disaster. Typical HMO schemes could end up doing more harm than good to people who really need care.

The University might do better to take HMOs out of the picture, as Brown and Yale universities have done, and instead work at making its PPO and POS plans more affordable.

Jarrod Gutman is a research coordinator in the School of Medicine from Philadelphia, Pa., and a College of General Studies graduate student. His e-mail address is gutman@dailypennsylvanian.com. The Fifth Column appears on Fridays.

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