Aetna refused to pay for a visit of a child with a probable goiter and strong family history who needed diagnostic lab tests—they do not accept rule-outs.  Last week Oxford levied a $50 deductible and $25 co-pay for the most efficacious eardrop we have in our armamentarium; Reason? This drop, containing an antibiotic and a steroid was not available generically; they were forcing me to use a plain ear drop – not what the doctor ordered!

Mental Health Parity; Let the HMO's Be Damned!

To improve the insurance coverage of mental health care, employers and group health plans are ruled against discrimination, * i.e., providing less coverage for mental health conditions than physical ones. 

Note: this rule was originally approved in 2008 and it will finally become law in July 2010.  "The administration said the new requirements could increase premiums by four-tenths of 1 percent, or $25.6 billion over 10 years. Businesses with 50 or fewer employees are exempt."

• However, under it, insurers can still second guess practitioners and challenge payment for lack of “medical necessity.”  This is shameful on its face as any practitioner can attest—the patient is often in crisis, demanding treatment that is uncomfortable for the average doctor because of poly-pharmacy, black-box warnings on meds, and the unpredictable nature of mental illness itself.
• Then there's the insidious fear of litigation.
• How about Insurers' Hustle, Hurdles and Hubris?  How arrogant of insurers when it comes to behavioral medicine--patients do not always know when they're not going to be able to cope and, by definition, they're unaware when on the 'slippery slope' of a breakdown. Compounding this is the stigma of mental illness that itself contributes to delays in diagnosis and treatment. Enter managed care with its promises of coverage, only to be followed by hurdles [see: "Battling for Health Coverage as Cancer Spreads"], denials and delays.  Think you can legislate fair treatment?  Think again--adding insult to injury, insurers "can still require prior approval of some services and can still charge consumers more for using doctors and hospitals that are not on a list of preferred providers."
• It is disgraceful that this coverage is job-related and it is outrageous that the immoral disparity was ever allowed.  (But, it has not been that long since those with mental illness were incarcerated as the mainstay of treatment.  [Ref. Dorothea Dix's reform efforts in 1844])
• The standards, guidelines and methods used to manage mental health benefits must be comparable to those for other medical care and cannot be applied more rigorously.  Discrimination is manifest by disparities such as: setting separate or higher co-payments or deductibles or applying stricter limits on the treatment of mental conditions, addiction disorders or physical illnesses.

Disparities are, unfortunately all too common in the insurance industry. "By sweeping away such restrictions, doctors said, the rules 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."

Pear R. "New Rules Promise Better Mental Health Coverage."

OTOH: here's a more progressive approach that improves compliance while reducing financial barriers to affordable health care, courtesy of  Daiichi Sankyo, Inc.:

With the Savings That Last card and the progressive discount, patients save on their prescriptions for all 4 products in the Daiichi Sankyo Hypertension Care olmesartan medoxomil family: Benicar, Benicar HCT, AZOR, and TRIBENZOR.

After one year, patient co-pays may be reduced to $15 for a 30- or 90-day prescription through 2016*

• Both 30- and 90-day prescriptions are covered
• Easy activation takes only a few minutes

For questions or to determine patient enrollment eligibility, call 1-855-809-5826 or visit www.SavingsThatLast.com.

*Savings are subject to a maximum benefit of $70 per 30-day prescription and $125 per 90-day prescription. For patients with commercial insurance, savings per prescription will apply after the following out-of-pocket expenses are met: $25 per prescription from months 1 to 6; $20 per prescription from months 7 to 12; and $15 per prescription after month 12. Patients without insurance receive $25 off retail price per prescription. Savings begin after card activation and first fill. One month is defined as a 30-tablet supply being filled; 3 months is defined as one 90-tablet supply being filled through retail or mail order. Savings benefit does not cover a patient’s insurance deductible obligation. Offer expires 2016. If a mail-order pharmacy does not accept the Savings That Last card, patients may obtain a Direct Member Reimbursement form by calling the number on the back of the card or visiting www.patientrebateonline.com to receive instructions on how to obtain the savings benefit. Patients not eligible if enrolled in any state or federal healthcare program including, but not limited to, Medicare, Medicaid, VA, DOD, or TRICARE/CHAMPUS; where taxed, restricted or prohibited by law; or if the patient does not otherwise comply with the terms herein. Card void in Massachusetts, except for patients without insurance. Offer valid in U.S. and Puerto Rico only. Daiichi Sankyo, Inc., reserves the right to rescind, revoke, or amend this program, at any time, without notice.