Bailout Provides More Mental Health Coverage

New York Times
Robert Pear
October 06, 2008

More than one-third of all Americans will soon receive better insurance coverage for mental health treatments because of a new law that, for the first time, requires equal coverage of mental and physical illnesses.

The requirement, included in the economic bailout bill that President Bush signed on Friday, is the result of 12 years of passionate advocacy by friends and relatives of people with mental illness and addiction disorders. They described the new law as a milestone in the quest for civil rights, an effort to end insurance discrimination and to reduce the stigma of mental illness.

Most employers and group health plans provide less coverage for mental health care than for the treatment of physical conditions like cancer, heart disease or broken bones. They will need to adjust their benefits to comply with the new law, which requires equivalence, or parity, in the coverage.

For decades, insurers have set higher co-payments and deductibles and stricter limits on treatment for addiction and mental illnesses.

By wiping away such restrictions, doctors said, the new law will make it easier for people to obtain treatment for a wide range of conditions, including depression, autism, schizophrenia, eating disorders and alcohol and drug abuse.

Frank B. McArdle, a health policy expert at Hewitt Associates, a benefits consulting firm, said the law would force sweeping changes in the workplace.

"A large majority of health plans currently have limits on hospital inpatient days and outpatient visits for mental health treatments, but not for other treatments," Mr. McArdle said. "They will have to change their plan design."

Federal officials said the law would improve coverage for 113 million people, including 82 million in employer-sponsored plans that are not subject to state regulation. The effective date, for most health plans, will be Jan. 1, 2010.

The Congressional Budget Office estimates that the new requirement will increase premiums by an average of about two-tenths of 1 percent. Businesses with 50 or fewer employees are exempt.

The goal of mental health parity once seemed politically unrealistic but gained widespread support for several reasons:

• Researchers have found biological causes and effective treatments for numerous mental illnesses.
• A number of companies now specialize in managing mental health benefits, making the costs to insurers and employers more affordable. The law allows these companies to continue managing benefits.
• Employers have found that productivity tends to increase after workers are treated for mental illnesses and drug or alcohol dependence. Such treatments can reduce the number of lost work days.
• The stigma of mental illness may have faded as people see members of the armed forces returning from Iraq and Afghanistan with serious mental problems.
• Parity has proved workable when tried at the state level and in the health insurance program for federal employees, including members of Congress.

Dr. Steven E. Hyman, a former director of the National Institute of Mental Health, said it was impossible to justify insurance discrimination when an overwhelming body of scientific evidence showed that "mental illnesses represent real diseases of the brain."

"Genetic mutations and unlucky combinations of normal genes contribute to the risk of autism and schizophrenia," Dr. Hyman said. "There is also strong evidence that people with schizophrenia have thinning of the gray matter in parts of the brain that permit us to control our thoughts and behavior."

The drive for mental health parity was led by Senator Pete V. Domenici, Republican of New Mexico, who has a daughter with schizophrenia, and Senator Paul Wellstone, the Minnesota Democrat who was killed in a plane crash in 2002. Mr. Wellstone had a brother with severe mental illness.

Prominent members of both parties, including Betty Ford, Rosalynn Carter and Tipper Gore, pleaded with Congress to pass the legislation.

Representatives Patrick J. Kennedy, Democrat of Rhode Island, and Jim Ramstad, Republican of Minnesota, led the fight in the House. Mr. Kennedy has been treated for depression and, by his own account, became "the public face of alcoholism and addiction" after a car crash on Capitol Hill in 2006. Mr. Ramstad traces his zeal to the day in 1981 when he woke up in a jail cell in South Dakota after an alcoholic blackout.

The Senate passed a mental health parity bill in September 2007. The House passed a different version in March of this year.

A breakthrough occurred when sponsors of the House bill agreed to drop a provision that required insurers to cover treatment for any condition listed in the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association.

Employers objected to such a requirement, saying it would have severely limited their discretion over what benefits to provide. Among the conditions in the manual, critics noted, are caffeine intoxication and sleep disorders resulting from jet lag.

Doctors often complain that insurers, especially managed care companies, interfere in their treatment decisions. But doctors and mental health advocates cited the work of such companies in arguing that mental health parity would be affordable, because the benefits could be managed.

Pamela B. Greenberg, president of the Association for Behavioral Health and Wellness, a trade group, said providers of mental health care typically drafted a treatment plan for each person. In complex cases, she said, a case manager or care coordinator monitors the patient's progress.

A managed care company can refuse to pay for care, on the grounds that it is not medically necessary or "clinically appropriate." But under the new law, insurers must disclose their criteria for determining medical necessity, as well as the reason for denying any particular claim for mental health services.

Andrew Sperling, a lobbyist at the National Alliance on Mental Illness, an advocacy group, said, "Under the new law, we will probably see more aggressive management of mental health benefits because insurers can no longer impose arbitrary limits."

The law will also encourage insurers to integrate coverage for mental health care with medical and surgical benefits. Under the law, insurers cannot have separate cost-sharing requirements or treatment limits that apply only to mental illness and addiction disorders.

The law comes just three months after Congress eliminated discriminatory co-payments in Medicare, the program for people who are 65 and older or disabled.

Medicare beneficiaries pay 20 percent of the government-approved amount for most doctors' services but 50 percent for outpatient mental health services. The co-payment for mental health care will be gradually reduced to 20 percent over six years.

The mental health parity law was forged in a highly unusual consensus-building process. For years, mental health advocates had been lobbying on the issue.

Insurers and employers, which had resisted earlier versions of the legislation, came to the table in 2004 at the request of Mr. Domenici and Senators Edward M. Kennedy, Democrat of Massachusetts, and Michael B. Enzi, Republican of Wyoming.

Each side had, in effect, a veto over the language of any bill. Insurers and employers, seeing broad bipartisan support for the goal in both houses of Congress, decided to work with mental health advocates. Each side gained the other's trust.

"It was an incredible process," said E. Neil Trautwein, a vice president of the National Retail Federation, a trade group. "We built the bill piece by piece from the ground up. It's a good harbinger for future efforts on health care reform."

Building Better Bodies

New York Times
Milt Freudenheim
October 01, 2008

IN this factory town in south-central Michigan, hard hit by the decline of the auto industry and home to a population whose health grimly lags well below national averages, several dozen small-business owners have joined forces in a wellness campaign that rivals those of the country's giant corporations.

With fewer employees to rely on, small businesses are particularly vulnerable when workers take sick days or function poorly on the job.

"If they're not healthy and alert, they can't do things like designing projects," said Mike Shirkey, owner of Orbitform Group, a machine tools company with 55 employees in Jackson.

An engineering graduate of the University of Michigan, Mr. Shirkey compares the wellness program with the "measure and improve" approach that he applies to manufacturing. Two years ago, Mr. Shirkey helped persuade other business owners in Jackson to join a CEO Roundtable, a forum and self-help group for top executives that is trying to address employees' health as a crucial part of corporate strategy, rather than as simply a cost-management problem.

Kirk Mercer, president of R. W. Mercer, a Jackson-based contractor that builds small factories, doctors' offices and other commercial buildings in the Midwest, said he was so taken with this approach that he was urging his small subcontractors, each with a handful of employees, to join the wellness roundtable.

There, businesspeople share ideas and encourage one another, but each business makes its own health-care decisions and pays for whatever coverage it provides; there is no pooling of employees for insurance purposes or to achieve other economies of scale, and no government contribution to the program.

If the strategy works, the result will probably be healthier workers and lower medical costs, and that will be striking, when many small businesses are unable to provide any health coverage at all -- and one in seven Americans is uninsured. At least half of them work for small companies or are self-employed.

Promoting wellness is especially urgent in Jackson, whose residents have more health problems than people living elsewhere, according to a recent survey paid for by the Allegiance Health system, which operates the local hospital; the county health department; and other local agencies.

In Jackson County, 70 percent of adults are overweight or obese, compared with 63 percent nationally, and 14 percent have diabetes, well above the 9 percent national rate. More than 1 in 4 is a smoker, compared with 1 in 10 nationally. Many people in the county do not realize they are taking serious chances with their health, the survey found; they do not have insurance and cannot afford health services.

Jackson's economic health is shaky as well. As the city's population has declined slowly to about 34,000, median household income has fallen to $31,000, a third less than Michigan as a whole, and the countywide (metropolitan area) unemployment rate has climbed to 9.7 percent, compared with 9.1 percent statewide in July.

Historically, Jackson has several claims to fame. It calls itself the birthplace of the Republican Party, noting that on July 6, 1854, the party formally organized itself and held its first convention here, according to the city's Web site; among those in attendance was Abraham Lincoln.

Jackson was a major rail hub and the onetime headquarters of Buick Motors, and it remains home to a state prison, now more than a century old, that looms over the city like a medieval fortress and was for decades the largest prison in the country.

If Jackson's wellness initiative succeeds, the small city may once again be at the forefront of a national trend.

Several states, including Maryland, New Hampshire and Rhode Island, have recently required insurance companies to offer wellness benefits to employees of small businesses, and a foundation-financed business group in Colorado, with encouragement from Lt. Gov. Barbara O'Brien, is also planning a wellness program for small- and medium-size employers.

As part of the broad national debate about health care, Senator Barack Obama, the Democratic candidate for president, has proposed a tax credit for small businesses to help them pay health insurance premiums for their employees. His Republican rival, Senator John McCain, has called for every family to receive a tax credit of up to $5,000 to help pay for insurance, while making employees' health benefits taxable as income. Mr. McCain has recommended incentives to reduce costs, including disease management and health and wellness programs.

No matter what kinds of changes are made in the health system, many policy experts are counting on wellness and disease-management programs to slow the relentless rise of medical costs.

In Jackson, the two largest employers are Consumers Energy, the local power company; and Allegiance Health, the local hospital, and the latter has been especially involved in the initiative. "We hope we can develop ways for the providers and payers to work together," said Georgia Fojtasek, a nurse with a doctorate in education who is the chief executive of Allegiance Health. Allegiance administers the wellness program and spends $2 million annually to support community health projects.

Among the small-business participants in the wellness program is Bob Lefere, president of the Pioneer Foundry, which is paying for a nicotine patch to help a 30-year-old mold maker quit smoking. He was the last smoker on the foundry's 15-person staff.

The link between smoking and dangerous lung and heart problems is widely recognized, and some large companies require workers who smoke to pay higher premiums unless they at least try to quit. Pioneer Foundry, a union shop for 50 years, already provides for annual physicals and 12 months of infant care under its contract with the Glass, Molders, Pottery, Plastics and Allied Workers International Union. Mr. Lefere said that when contract talks open next year, he might propose adding a health club membership for workers.

Orbitform has already installed a fitness center, with exercise machines and showers that workers can use at lunchtime and before and after work.

At Great Lakes Industry, which makes power-transmission equipment and auto parts, Larry Schultz, the president, marshaled some fellow exercise enthusiasts to clean up a storage area and transform it into a small fitness center. Mr. Schultz also got rid of the candy machines and offers free fruit and vegetable snacks.

Running on one of its treadmills helped Gary Lykins, a shipping and customer service manager at Great Lakes Industry, shed 45 pounds he had gained after he left the factory floor for a more sedentary job. "I run 100 miles a month on that thing," Mr. Lykins said.

Great Lakes Industry and Orbitform also pay for health coaches, provided by Allegiance Health, who meet several times a year with employees and their spouses to guide them toward goals like losing weight, eating healthy food and lowering blood pressure and cholesterol levels.

"There are a lot of things you just don't think about until somebody sits down with you and explains," said Robert Dean, 36, a machinist who works the night shift at Great Lakes Industry.

His wife Sarah, 28, said she had not smoked for almost two years after they met with a coach for the first time. "We both smoked before that, and we tried to quit a lot of times," she said.

Mrs. Dean, who operates a day care center for 11 toddlers, said she put on weight after she and Robert were married. "I didn't have to fit into my dress anymore," she said. "It was kind of a mental thing." Now, with daily exercising and dutifully eating fruits and vegetables, she has slimmed down. "I fit into a size 8," she said. "I haven't fit into an 8 since sixth grade."

Great Lakes Industry, which is self-insured, offers single employees a $681-a-year reduction in their health insurance premiums if they participate in the wellness program. Married employees get the same reduction and an additional $681 discount for their spouses, who are required to join. The deductible is also waived, and co-payments for medical services are halved to 10 percent for participating workers.

The health coaches help establish goals for the workers, who are expected to "make an honest effort" to reach them, Mr. Schultz said. The coaches give special attention to people with chronic conditions like diabetes, asthma and heart disease.

Last year, Great Lakes Industry added fully paid health "prevention benefits," including immunization shots and physical exams. Participants must select a primary-care doctor and follow her recommendations.

With 95 percent of its 65 or so employees participating in the program, health costs for Great Lakes Industry employees average $7,363 each last year, including $200 for the coach. That was down from $9,158 in 2006.

But "return on investment is difficult to measure," Mr. Schultz said, because a small company's health costs were likely to be erratic from year to year, with variables like births, accidents and illnesses. He is estimating an average cost of $8,095 for 2008.

"I believe we have at least flattened or dampened the trend line," he said, referring to annual cost increases. His employees have been paying 14 to 20 percent of total costs, and he does not want to shift more of the costs to them.

"These are factory folks," Mr. Schultz said. "Health care is an important benefit. I don't believe the solution to the cost problem is to shift more to families. If they are actively participating in improving their health, we as an employer can afford to provide them with a rich benefit plan."

His daughter, Dr. Amy M. Schultz, began learning about health insurance when she helped out at Great Lakes Industry as a teenager; now she is director of prevention and community health at the local hospital, and she works with Prof. Dee Edington, director of the University of Michigan Health Management Research Center, which advises the Jackson programs.

Participants fill out questionnaires about their medical history and health-related behavior, and the health risk appraisals and analyses for the employers are conducted through the U.M. Health Management Research Center, Dr. Schultz said.

Phil Sponsler, the president of Orbitform, said he was "a big proponent" of the program. He is 6-foot-3 and weighed 248 pounds when he learned that his blood pressure was high, he said. Now he gets up early and works out with a friend (who happens to be his cardiologist). When he gets to work at 6:30 a.m., he eats his own concoction of cereal, nuts, olive oil, flax seed and cinnamon for breakfast. He said he now weighs 231 and his blood pressure is managed.

Ms. Fojtasek of Allegiance Health said businesspeople on the hospital's board, like Mr. Shirkey and Mr. Schultz, had encouraged the hospital to push for health improvements in Jackson.

Healthy employees are good for business in more ways than one, Mr. Schultz said, adding, "We treat our customers and each other better when we are feeling good."

You're Sick. Now What? Knowledge Is Power.

New York Times
Tara Parker-Pope
September 30, 2008

Are Patients Swimming in a Sea of Health Information? Or Are They Drowning in it?

The rise of the Internet, along with thousands of health-oriented Web sites, medical blogs and even doctor-based television and radio programs, means that today's patients have more opportunities than ever to take charge of their medical care. Technological advances have vastly increased doctors' diagnostic tools and treatments, and have exponentially expanded the amount of information on just about every known disease.

The daily bombardment of news reports and drug advertising offers little guidance on how to make sense of self-proclaimed medical breakthroughs and claims of worrisome risks. And doctors, the people best equipped to guide us through these murky waters, are finding themselves with less time to spend with their patients.

But patients have more than ever to gain by decoding the latest health news and researching their own medical care.

"I don't think people have a choice -- it's mandatory," said Dr. Marisa Weiss, a breast oncologist in Pennsylvania who founded the Web site breastcancer.org. "The time you have with your doctor is getting progressively shorter, yet there's so much more to talk about. You have to prepare for this important meeting."

Whether you are trying to make sense of the latest health news or you have a diagnosis of a serious illness, the basic rules of health research are the same. From interviews with doctors and patients, here are the most important steps to take in a search for medical answers.

Determine Your Information Personality.

Information gives some people a sense of control. For others, it's overwhelming. An acquaintance of this reporter, a New York father coping with his infant son's heart problem, knew he would be paralyzed with indecision if his research led to too many choices. So he focused on finding the area's best pediatric cardiologist and left the decisions to the experts.

Others, like Amy Haberland, 50, a breast cancer patient in Arlington, Mass., pore through medical journals, looking not just for answers but also for better questions to ask their doctors.

"Knowledge is power," Ms. Haberland said. "I think knowing the reality of the risks of my cancer makes me more comfortable undergoing my treatment."

Dr. Michael Fisch, interim chairman of general oncology for the University of Texas M. D. Anderson Cancer Center, says that before patients embark on a quest for information, they need to think about their goals and how they might react to information overload.

"Just like with medicine, you have to ask yourself what dose you can take," he said. "For some people, more information makes them wackier, while others get more relaxed and feel more empowered."

The Goal is to Find an M.D., Not Become One.

Often patients begin a medical search hoping to discover a breakthrough medical study or a cure buried on the Internet. But even the best medical searches don't always give you the answers. Instead, they lead you to doctors who can provide you with even more information.

"It's probably the most important thing in your cancer care that you believe someone has your best interests at heart," said Dr. Anna Pavlick, director of the melanoma program at the New York University Cancer Institute. "In an area where there are no right answers, you're going to get a different opinion with every doctor you see. You've got to find a doctor you feel most comfortable with, the one you most trust."

Keep Statistics in Perspective.

Patients researching their health often come across frightening statistics. Statistics can give you a sense of overall risk, but they shouldn't be the deciding factor in your care.

Jolanta Stettler, 39, of Denver, was told she had less than six months to live after getting a diagnosis of ocular melanoma, a rare cancer of the eye that had spread to her liver.

"I was told there is absolutely nothing they could help me with, no treatment," said Ms. Stettler, a mother of three. "I was left on my own."

Ms. Stettler and her husband, a truck driver, began searching the Internet. She found Dr. Charles Nutting, an interventional radiologist at Swedish Medical Center in Englewood, Colo., who was just beginning to study a treatment that involves injecting tiny beads that emit small amounts of radiation. That appeared to help for about 18 months.

When her disease progressed again, Ms. Stettler searched for clinical trials of treatments for advanced ocular melanoma, and found a National Institutes of Health study of "isolated hepatic perfusion," which delivers concentrated chemotherapy to patients with liver metastases. After the first treatment, Ms. Stettler's tumors had shrunk by half.

"I don't like statistics," she said. "If this study stops working for me, I'll go find another study. Each type of treatment I have is stretching out my life. It gives me more time, and it gives more time to the people who are working really hard to come up with a treatment for this cancer."

Don't Limit Yourself to the Web.

There's more to decoding your health than the Web. Along with your doctor, your family, other patients and support groups can be resources. So can the library. When she found out she had Type 2 diabetes in 2006, Barbara Johnson, 53, of Chanhassen, Minn., spent time on the Internet, but also took nutrition classes and read books to study up on the disease.

"I was blindsided -- I didn't know anybody who had it," said Ms. Johnson, who told her story on the American Heart Association's Web site, IKnowDiabetes.org. "But this is a disease you have to manage yourself."

Tell Your Doctor About Your Research.

Often patients begin a health search because their own doctors don't seem to have the right answers. All her life, Lynne Kaiser, 44, of Plano, Tex., suffered from leg pain and poor sleep; her gynecologist told her she had "extreme PMS." But by searching the medical literature for "adult growing pains," she learned about restless legs syndrome and a doctor who had studied it.

"I had gone to the doctors too many times and gotten no help and no results," said Ms. Kaiser, who is now a volunteer patient advocate for the Web site WhatIsRLS.org. The new doctor she found "really pushed me to educate myself further and pushed me to look for support."

Although some doctors may discourage patients from doing their own research, many say they want to be included in the process.

Dr. Fisch of M. D. Anderson recalls a patient with advanced pancreatic cancer who decided against conventional chemotherapy, opting for clinical trials and alternative treatments. But instead of sending her away, Dr. Fisch said he kept her in the "loop of care." He even had his colleagues use a mass spectroscopy machine to evaluate a blue scorpion venom treatment the patient had stumbled on. It turned out to be just blue water.

"We monitored no therapy like we would anything else, by watching her and staying open to her choices," Dr. Fisch said. "She lived about a year from the time of diagnosis, and she had a high quality of life."

Dr. Shalom Kalnicki, chairman of Radiation Oncology at the Montefiore-Einstein Cancer Center, says he tries to guide his patients, explaining the importance of peer-reviewed information to help them filter out less reliable advice. He also encourages them to call or e-mail him with questions as they "study their own case."

"We need to help them sort through it, not discourage the use of information," he said. "We have to acknowledge that patients do this research. It's important that instead of fighting against it, that we join them and become their coaches in the process."