Parity Time

The world of health insurance and managed care is confusing, especially when it comes to mental or behavioral health coverage (interchangeable terms), even for the lawyers who compose our clientele at LCL. In fact, assistance in searching for adequate and covered treatment is one of the key reasons that lawyers come to LCL rather than seek help on their own. Right now, things are changing in mental health insurance coverage (largely for the better), though few consumers are up to date on these changes (which some insurers have not seemed eager to mention, e.g., in their on-line benefits information).

Mental health coverage has long been the “stepchild” of health insurance, partly because it is more difficult to evaluate or define these conditions with precision, or to determine a specific optimal treatment plan. That very vagueness has served as an excuse for inadequate coverage. When I was first licensed as a psychologist in 1981, before managed care, most people in Massachusetts had an old-fashioned Blue Cross Blue Shield policy. By law, those policies covered up to $500 a year in mental health coverage. Believe it or not (partly because, even then, the insurer gave itself a discount), that was enough for at least 10 sessions. Nowadays, coverage is generally defined by number of services (which helps accommodate inflation), and most people have HMOs, which require “pre-authorization” before subscribers can actually utilize these benefits.

In one form or another, insurers have set fairly arbitrary maximums in mental health coverage, even while there were no such maximums for coverage of most physical health conditions. Sick as you might be, even with severe mental illness, once you had used up your maximum for the year (or, occasionally, your lifetime), you were on your own. In 2000, more or less concurrently with a number of other states, Massachusetts passed its first Mental Health Parity law, which removed predetermined maximums from coverage for psychiatric conditions seen as largely biological in nature. These were:
♦ Schizophrenia
♦ Schizoaffective Disorder
♦ Major Depression
♦ Bipolar Disorder
♦ Psychotic Disorders
♦ Delirium and Dementia
♦ Obsessive-Compulsive Disorder
♦ Panic Disorder
♦ “Affective Disorders” (defined slightly differently by different insurers)

In addition, the 2000 law stipulated that, for most other conditions, the maximum number of outpatient visits per year could not be fewer than 24 for adults (thus every Massachusetts-based insurer began covering 24 visits), with no limits for children. Excluded from the law entirely were alcohol and drug dependence, which are often covered up to just 8 sessions per year. (I am not focusing, here, on the maximums for inpatient hospital stays, since those are virtually always kept extremely brief regardless of stated maximums.) It always seemed very curious to me that alcohol and substance dependence were handled this way, since the biological aspects of those behavioral disorders are so central.

What’s new is that, as of this past July 1, Mass. state law has added four more diagnoses (including chemical addictions) to the list of those covered without a hard-and-fast maximum:
♦ Alcohol/Drug Abuse and Dependence
♦ Eating Disorders
♦ Post-Traumatic Stress Disorder
♦ Autism.

This state law does not apply to (a) self-insured plans [where the money that pays the claims comes directly from the employer], (b) MassHealth, or (c) Medicare.

There is also a new federal parity law coming down the pike. It was actually bundled with the measure congress passed late in the Bush term to permit the massive bailout of financial institutions (in this case the “pork” going toward what I regard as a good cause). As of January 2010,

♦ No plan is required to offer mental health coverage, but if it does (which is mandatory in Massachusetts), the coverage for all legitimate mental health diagnoses must be equivalent to coverage for medical/surgical procedures.
♦ It applies even to self-insured plans, but excludes employers with no more than 50 employees.

When the state and federal laws are in conflict, the more consumer-friendly one generally applies.

Two caveats:
(1) Who can say how Health Care Reform (which I support in principle) may ultimately be worded, and whether, as some kind of trade-off, it will override these legislative measures. In any case, I assume it will not take effect before 2011.
(2) Despite the removal of automatic maximums, the insurers will continue to require pre-authorization—that is, HMOs will cover only those services that they have determined are “medically necessary” for an individual. That is a very slippery concept when it comes to mood and behavior problems. In truth, even with reform or with a “public option,” some kind of mechanism is needed to prevent wasteful spending on unnecessary health care. I do wish, however, that someone would come up with a better means of accomplishing that purpose than the cumbersome,(unpaid) time-consuming, and privacy-reducing forms that providers and their patients/clients often face.

In any case, if you are in need of assistance, now is a good time to look for the right therapist. LCL can help with that process if you are a Massachusetts lawyer, law student, or judge, or a family member of people in those categories. Understand that LCL itself does not use your health insurance – our primary service is to evaluate and refer (not to provide ongoing therapy), and is funded through lawyers’ annual licensing fees. We do, and must, take your health insurance into account in the process of our efforts to refer you for further services.

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Update Feb 2010: You may have noticed that we are not hearing anything about the federal parity law from our insurance providers. As a provider, I can tell you that when I look up new patients' eligibility on-line, there are still references to the 24-session/year maximum for diagnoses not on the Massachusetts list of parity diagnoses.

Based on some web searching, it seems that, although in one sense the federal parity law is already in effect, in another sense it is still in a non-final, feedback-gathering phase until July 1 -- so that may be the point at which it will really kick in.

In addition, while most interpreters of the law see it as applying to all mental health diagnoses (thus not just the ones that Massachusetts has deemed parity-worthy), some commentaries note that this only applies to coverage of conditions included in the plan. Although I have seen no evidence of this as yet, it seems possible that an insurance company could decide, for example, that they do not cover substance absue at all, or that they do not cover adjustment disorders at all. My impression is that they could get away with that gambit, because the law only states that whatever is covered must be covered equivalently to medical/surgical conditions, and that providing no coverage whatsoever, for a given condition, gets around that requirement. We'll see. In either case, we should be beyond the 24-session limit that is probably still being shown in your insurance provider's information packet. Caveat: I am a psychologist and not a lawyer or policy expert. My only expertise is that I've been dealing with health insurance claims, authorizations, and limitations (though a series of changes) since 1981 as a working clinician, and that I've taken the time to look up this information extensively on line.

ON LAWYER SUICIDES

The recurrent issue of lawyer suicide has come to the fore recently with reports that lawyers at three prominent firms have taken their lives since December. In subsequent months, there has been a flurry of correspondence as to what kinds of programs can be offered to target the problem. The prevalence of unhappy lawyers, and the very high incidence of depression in the profession are, of course, not new findings. Despite repeated calls for humanizing and balancing the lives of attorneys, there seems to have been no way to stem the tide of ever-increasing stress, the emphasis on billables and bottom lines for those who work in large firms and the difficulties making ends meet for many sole practitioners and small firms. I see so many lawyers who wish they could find another way to make a living but feel trapped; it is always a refreshing counterpoint to visit with some of my college buddies who went into the law and are enjoying themselves.

Feeling trapped, of course, can readily lead to both depressed mood and suicidal thinking (an exit), especially for people who are predisposed, either biologically or psychologically, to depression. The risk is heightened in the presence of a disinhibiting substance (most commonly alcohol) and/or access to a gun (particularly lethal in response to an impulse).

The programs being contemplated may be very helpful in addressing the needs of the grieving survivors – those of us who have lost a colleague, friend, family member, or client to suicide. The normal sense of grief is, in these cases, often compounded by such feelings as guilt (“What could I have done?”), anger (“How dare he choose to take himself away from his friends, family, etc?”), and even fear of contagion (“He seemed no different from me… Will this happen to me, too?”). In addition, when a loss seems to come from out of the blue, it is difficult not to become more vigilant, seeing the world as a place where dire events can strike us without warning. Fortunately, for most of us these emotions fade over time as we gain perspective and talk it over with others, but if not, it’s a good idea to talk it over with a therapist.

Brief prevention programs, on the other hand, seem not to be very effective in reducing rates of suicide – no more than those one-shot high school drug education assemblies made a long-term difference in who would eventually use or develop an addiction. What is likely to make more of a difference are long-term, ongoing factors. To what extent does an individual feel connected to, cared about, and accepted by a community – of friends, coworkers, fellow congregants, etc.? To what extent do lawyers allow themselves to become overwhelmed with burdens (cases, finances, home life, etc.) and tell no one, because of a perceived need to always appear in control? And although in many cases we see no advance warning of a suicide, do we make ourselves available to listen when something seems amiss with a colleague, or do we feel that acknowledging human frailty on the job would be a faux pas?

These kinds of factors probably make a great difference in the path toward (or away from) the sense of entrapment or despair. Listening is a powerful antidote to the sense of aloneness and isolation, but it’s hard to come by nowadays. Primary care physicians, back in the days when they were known as “general practitioners,” had time to listen. Managed care, combined with the cost of maintaining their desired lifestyle, has made it almost impossible for physicians to take time with patients, as you may have noticed last time you went to the doctor.

Fortunately, the vast majority of lawyers, even the many who may have fleeting thoughts of suicide, never reach the point of readiness to take their lives. But at the lawyer assistance program, we often wish that people had come to see us sooner – before the onset of severe symptoms or the license suspension or the daunting pile of unopened mail or the drunk-driving arrest. People tend to put off reaching out for help, a feature especially prominent in lawyers (and also doctors) – those who feel they should be the “knowers” and not the “needers.” [Lawyer assistance programs, however, are not emergency services; if the danger of harmful action is imminent, the appropriate resource is an emergency room, or if slightly less imminent, a suicide hotline – shown for each state at suicide hotlines.com.]

I feel particularly heartened when a lawyer comes to LCL accompanied by one or two friends/colleagues who have prevailed upon him or her to see me for assessment. There is no need for the concerned party to diagnose the problem – just to recognize that something is wrong and to not turn away. Sometimes, of course, the colleagues are partners in a firm seeking to avoid losing a valuable lawyer – and that’s certainly a good idea. But at other times the only motivation is friendship and human concern, motivation of a higher order. Although some individuals, whose covert agenda is to avoid change, find ways to give lip service and evade my further attention and recommendations, some actually grab the lifeline and embark on a path toward health.

Hello and Welcome.

We, the staff of Lawyers Concerned for Lawyers of Massachusetts, look forward to finding ways to increase our usefulness to the legal community through the medium of blogging.

At this location, you will begin to see a series of observational and informational postings about the human side of lawyering from the perspective of non-lawyers who have interviewed hundreds of lawyers over the years, usually for the purpose of assessing problems that are impeding their functioning (professionally or personally or both). We are excited about adding this means of communication to our existing toolbox, which includes, for example, the many articles and resources posted on our web site, our many types of presentations, our newsletter, and our Q&A column featured in Mass. Bar Association Lawyers Journal.