What’s Healthy?
If you were an insurance company trying to cut your costs, how would you do it? Emphasize prevention over cure? Cover birth control? Allow coverage of cheaper alternatives, like in-home care over nursing homes or examine ways to encourage use of primary care providers over the emergency room?
Or perhaps you’d try to avoid paying for the treatment of teens with eating disorders and then when you get sued, demand that they give you their diaries, e-mails, and private MySpace and Facebook posts to “prove” that the conditions were “emotionally based” not “biologically based.”
In New Jersey, Horizon Blue Cross Blue Shield, may they receive the corporate death penalty, has chosen the latter. Of course they are enabled in this by an asinine New Jersey law that says health insurers are only responsible for covering mental illness when it’s “biologically based.” ...
As much as I like to harp on insurance companies, in this case they are not entirely to blame. The state Legislature wrote the law. Ms. Axel-Lute called the law "asinine." I would not have used that word.
Having said that, I do not know what word I would have used.
"Corrupt" comes to mind, although it does not exactly capture the essence of the situation. What we have is a law that, on the surface, seems so stupid that it is hard to believe that any politician would consider it in good conscience.
Most likely, it was not considered in good conscience. Rather, it was passed as a giveaway to an industry. It was passed without consideration of the well-being of the people who put them in office, who pay their salaries. That is why I thought of the word "corrupt."
This sort of thing is so common, it seems that we ought to have a word for it. It is sort of like Eskimos not having a word for "snow."
I am sitting her trying to imagine a sensible way that insurance company folks, or the courts, or the legislature, could possibly hope to come up with a meaningful way to decide what illnesses are not biologically based.
Really, either it is natural or it is supernatural, and I don't believe in the supernatural.
The mental health field did go through a controversy about this, some decades ago. In fact, one of my favorite authors, Glen Gabbard, wrote a nice article about in in Am J Psychiatry in 2005. The journal allows open access for some of their older stuff, so anyone can read it.
Mind, Brain, and Personality Disorders -- Gabbard 162 (4): 648 -- Am J Psychiatry
With abundant examples, he shows how various conditions clearly have a biological basis, even though they also have traumatic antecedents in some cases. These are things that formerly were considered to be psychological, not biological. But with a little bit of investigation, once the right methodology was developed, it turned out that there simply is no evidence for a mind-brain dichotomy.
People have tried to find it, but it keeps not being there. In fact, much of the earliest work in biological psychiatry was directed specifically at the task of finding a test to distinguish biologically-based conditions from psychologically-based conditions. The dexamethasone suppression test is a good example.
The DST did turn out to be useful in a research setting. It demonstrated that alterations in the HPA axis are important in psychiatric conditions. But it never was possible to use it to distinguish biological from psychological conditions.
A search for "dexamethasone suppression test depression", in PubMed, will retrieve 1260 citations. Clearly a lot of effort went into this.
Of course, failure to find something does not mean that it does not exist. But at some point, after the search has gone on far a long time and has consumed a lot of resources, the only practical conclusion is to say that it is not there. It is ridiculous to write a law that hinges on a distinction that no one has been able to demonstrate.
Medicine & Health
Brain & Behavior
Comments
It just depends on your perspective. You might say that this is just one more example of the ways in which our for-profit health care delivery model fails in its mission -- if one considers that its mission is the provision of health care. If one considers its mission to be maximizing profits for executives and shareholders in these companies, then the health care system works pretty well. Likewise, the article illustrates one more example of the ways in which our government fails in its mission -- if one considers that its mission to be implementing the will of the people, while maximizing the common good. If one considers that the mission of government is to perpetuate a quid-pro-quo between rich special interests and politicians whose primary objective is to stay in office, then government, too, seems to be working well.
Posted by: stumpy | March 20, 2008 1:09 PM
Call me crazy, but I've come to understand that our emotions are a product of biology, making the distinction meaningless.
Under this absurd standard, can insurers refuse to pay for treatment of depression?
Posted by: Davis | March 20, 2008 1:40 PM
Do you have a citation for an actual law that says "not biologically based" or the equivalent? I would expect that they simply provide that insurance companies may limit reimbursement for treatment of the mind. All the insurance policies I've read come right out and say reimbursement for treatment of the mind is limited. They don't tiptoe around the topic with allusions to medieval philosophy; it is a contract written by lawyers, after all.
The limitations are a very good thing! Without them health care would be utterly destroyed. The problem is that most mental health treatment consists of someone with half a clue giving their time and attention to the patient, a service with virtually unlimited demand. Worse, the diagnostic criteria are so fuzzy that it is nearly impossible to prove that a formerly-ill person has gotten enough better to stop treatment, meaning that a crappy or dishonest treater can milk the insurance company for money indefinitely. Even worse, there are unscrupulous treaters who will actually make their patients worse to make them permanent cash cows.
The insurance companies learned this the hard way by having expenditures grow without apparent limit. If things like loneliness could be fixed as swiftly and surely as a broken bone, they would line up to advertise the best coverage.
"Under this absurd standard, can insurers refuse to pay for treatment of depression?"
They can and do. Specialist treatment is either unreimbursed, or only reimbursed up to a yearly limit.
Posted by: Daniel Newby | March 20, 2008 3:48 PM
I'm confused...
It seems to me that this NJ law is trying to separate Axis I and Axis II conditions.
Pay for the former, not the latter....
I'm not sure they got it "right" in your specific example, I'm not sure the principle is so "wrong".
or am I missing something?
Posted by: Ian | March 20, 2008 6:50 PM
The fact is that, with the exception of a leading edge of scientists, our society has not learned or accepted the fact that our minds ARE our brains, that there is not a fundamental distinction between a psychological and a biological condition. Both the coverage plans and the laws that we are stuck with for now are simply a reflection of this state of understanding, and I don't think it's fair to call anyone corrupt because of it. There is a deep seeded ignorance about this issue that extends far beyond the health care and political institutions that create these policies. And for the reasons that Daniel Newby (comment #3) gives, it is simply impractical to force health insurance companies to cover illnesses like depression in the same way they cover broken bones...currently available treatments are far too expensive and not nearly effective enough to justify it...not if we want health insurance to continue to exist to cover things that CAN be reasonably treated.
Posted by: Jacob Basson | March 20, 2008 8:09 PM