Is too much money spent on treating the mentally ill?
by Gerald D. Klee, M.D., Editor
[Spring 1999; Vol.26 No. 1]
Is it a public service to publish misinformation? It is claimed that in 1997 more money was paid to practitioners for the treatment of mental disorders than for treating any other category of illness. According to the State agency HCACC, these payments accounted for 11.3% of the total paid to practitioners by all payers for the treatment of all diseases. And that's without even including alcohol and drug problems in the category of mental diseases and disorders. Where on earth did HCACC get this information, and should anyone believe it? A less implausible figure in the same report is that psychiatrists account for only 1.6% of the volume of payments to physicians from all third party payers? *
This is from the latest Practitioner Expenditures and Utilization: Experience from 1997 report published by HCACC. In case you forgot, HCACC is the Maryland Health Care Access and Cost Commission, a State health care regulatory agency. HCACC's functions include supplying health care data and advice to State legislators and planners to assist them in regulating and planning health care services in Maryland. In past years I have criticized these reports as seriously inaccurate and misleading.(1,2) HCACC has also been under fire from the MPS and others because of our concerns about confidentiality of patient information in their data banks. HCACC does not collect data directly, but assembles and interprets health care data from a wide variety of sources, both public and private. The latest HCACC report covers 1997, and like previous ones, contains a lot of incorrect information. Unlike earlier reports, however, its tone is less belligerent. We are also happy to say that it contains a couple of statements with which psychiatrists will agree. Unfortunately, much of the report's data are faulty and misleading, and often slanted against psychiatry. It was obviously put together hastily and carelessly.
I have objected to earlier reports which claimed that psychotherapy was over utilized, and which suggested that it should be replaced with drugs as a cheaper alternative.(1, 2) This year's report avoids such remarks and is actually positive in one place. We were pleased to find a statement that depression is greatly under diagnosed and under treated in Maryland. The figures used to illustrate this are consistent with the psychiatric literature. The report also states that better identification of patients with depression and adequate treatment for them would relieve needless suffering, while saving large amounts of money on other medical costs and lost work days. ** None of this is new to psychiatrists. It is something new from HCACC. It is disappointing that the rest of the report does not show similar insight. If the statements about depression were used as a guide, it would suggest that Maryland needs much more in the way of psychiatric services. Unfortunately, the bulk of the report implies that mental health services consume an excessive share of health care expenditures. I believe that the data are often inaccurate and are presented in ways that reveal a bias against mental health services. I will explain why.
As in earlier years, HCACC ranks CPT Code 90844, "Individual psychotherapy with a physician" at the top of the list for utilization and expenditures for most categories of payers. As before (2), I strongly doubt the accuracy of these figures. Dubious data about psychotherapy is not the only problem with the report, however. Most interesting is Table 15*** of the Utilization section, which shows that across all payers, Mental Diseases and Disorders (even without the inclusion of alcohol and drug disorders) consume 11.3% of all payments to practitioners, a larger proportion than for treatment of any other category, such as circulatory diseases, cancer etc. There is no footnote to the table indicating that much of the underlying data are nonexistent. The above figure is based on lumping together payments from all payers. Mental Diseases are ranked at the top only because of Medicaid, in which it is reported that 33.5% of payments were for treatment of mental disorders. Half of the data to support this are missing, due to the entry of Maryland Health Partners (MHP) a behavioral managed care firm which assumed control of these payments in July of 1997. [This change led to a crisis in funding of community mental health centers.(3)] MHP has reported no data for 1997, the year covered in the HCACC report. (page 12) This means that half the data for Medicaid mental health services and payments during that year are unreported. One must carefully read the entire text of the report to learn this. Presumably, whoever made up the table took a guess at what the missing data might have been. This does not inspire trust. It is difficult to compare these figures with those from HCACC reports of previous years because of extreme inconsistencies from year to year in how data are classified and reported.
It might be a good investment if the treatment of mental disorders were as well financed as HCACC says, but there are obvious reasons to doubt the accuracy of their figures. High costs for mental health services under Medicaid would be expected due to the closing of most State hospital beds, but the true costs are unknown. Most of the Medicaid payments for mental health services are for the care of the chronic mentally ill who have been returned to the community. HCACC acknowledges that only a small fraction of these payments went to psychiatrists, but you have to dig through the text to learn this. There is considerable risk that HMOs and government agencies will use these erroneously high figures to justify further cuts in mental health funding. This is one of many ways that false data are used to reduce psychiatric services.
Here are some additional reasons why HCACC's data are questionable. Although it is buried in the text, far from the tables containing the flawed data, the HCACC report is candid enough to indicate that a wide variety of problems were encountered in collecting the information in the report and there are substantial limitations in the data. Here are some additional examples: It was not always possible to assess the quality of underlying data sources. HMOs frequently did not clearly differentiate between specialists. A number of HMO's did not report data at all. Only limited data were reported on capitated services. Reliable information on HMO expenditures through Medicare and Medicaid is extremely limited.(pages 2-4)
It is commendable that the report's authors acknowledge limitations. Unfortunately they seem to have forgotten the limitations when making up many of the tables and drawing conclusions. The result is often seriously misleading information. It's obvious they made liberal use of the fudge factor.
Like the previous reports, this HCACC report is seriously flawed. It illustrates what can go wrong when a government bureaucracy tackles matters for which it is unsuited. A large proportion of the health care expenditures and utilization data being collected and reported are false and misleading. It's a safe bet that this statement applies to data from all payers, public and private. If you don't think it matters, think again. Remember that such data are used to justify massive curtailments and redistribution of health care dollars. False data provide fuel for the machine that is destroying health care, including psychiatry.
I looked for information on how HCACC is dealing with the problem of privacy. This subject is not discussed in the report, but judging from the way HCACC handles data, it is clear that they can't be trusted with patient confidentiality either. Legislative leaders are understandably concerned with the cost of health care, much of which is financed with tax dollars. HCACC is not the answer. There must be a better way to protect the public. After all, taxpayers and patients are the same people. Publishing false and biased information is not a service to the public.
*See Table 10, page36 and page 51 in the "Chart Book" accompanying the report, which states that psychiatry accounts for only 1.6% of the volume of total Payments to practitioners. This is the same figure reported in last year's HCACC report and was associated with about 1.8% of payments according to HCACC.
(Editors note: "volume" refers to the number of payments made, not to the dollar amount.)
*Page 65, Utilization report
** Table 15, Utilization report, DISTRIBUTION OF PAYMENTS BY PAYER AND BY DIAGNOSTIC CATEGORY