A Psychiatrist's Parody of Mental Health Parity

One significant development in the psychiatry world for 2014 is the full implementation of mental health parity rules, which set new psychiatric and substance abuse treatment coverage requirements for most private insurance plans, as well as the Medicare system.

There has been much speculation about whether the implementation of these complex rules will actually yield equal coverage of care. Instead of focusing on putting mental healthcare on par with the rest of medicine, I will concentrate on lowering the rest of medicine to the level of mental health. This is happening in 2 ways: one is not funny at all, though the other is rather amusing.

Let’s get the humorless part out of the way. Over the past few decades, patients using private insurance plans for mental healthcare have faced separate deductibles, lower rates of out-of-network reimbursement, and onerous prior authorization requirements. In the Medicare system, mental health has been covered at only 50%, as opposed to 80% for the rest of medicine. These disparities have put the costs of mental healthcare out of reach for many patients.

With the implementation of the Affordable Care Act, many patients will now have access to relatively inexpensive insurance premiums that cover most areas of health. However, the deductibles will be so high that those who qualify for subsidized premiums will not be able to use their coverage. At least non-mental and mental healthcare will be equally unaffordable?

For patients who will be able to afford care, here’s the aspect of “downward parity” that tickles me. The rest of medicine has been appearing as nebulous and incompletely understood as psychiatry over the past year. The well-suited psychiatrist is typically someone who is comfortable with “living in the gray.” Our diagnostic system is made up of syndromes and disorders, rather than the more etiologically-specific disease, so it is subjected to rewriting approximately once a decade.

For better or for worse, psychiatrists’ interest in nosology and their openness to the partially-understood complexities of the brain contributed to the storm of controversy surrounding the recent publication of the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). We also have psychiatric treatments that are more specific for regulatory purposes than evidence-based application.

Patients will typically tolerate — and often appreciate — a psychiatrist who is willing to hedge his or her opinions with unknowing statements. However, a higher degree of confidence and specificity is expected and, justified or not, met by other medical practitioners. But the past year alone has shown us how unjustified the expectation of having “the answer” may be.

A few of my favorites include:

• A new ligament in the knee was discovered.
• The guidelines for the treatment of elevated cholesterol have been significantly revised to address cardiovascular disease (CVD) risk factors, rather than specific numeric targets.
• The target numbers for treating hypertension were changed and the new guidelines acknowledge that lowering blood pressure with medication — as opposed to having lower blood pressure naturally — does not lower CVD risk for many patients.
• The most commonly performed knee surgery is unnecessary for most people.
• Corticosteroid injection — one of the most common procedures for treating back pain — is no more effective than placebo.
• The exciting new weight loss medicine can help an obese patient lose approximately 3% of body weight over the course of 1 year.

We all still have a lot of work to do.