The Robert MacNeil Report; Mental Health in America

JIM LEHRER: Good evening. I`m Jim Lehrer in Washington, Robin is on vacation. Rosalind Carter has been saying that one of her main jobs if and when she becomes the First Lady of the land is to help Jimmy, as she puts it, implement a new mental health plan for the nation; and the Democratic Party platform on which her husband is running for President promises such a plan. The problem, as seen by Mrs. Carter, psychiatrists, other experts, members of Congress and others, is simply this: one out of every ten Americans suffers from some form of mental illness, and yet less than one- seventh of them receive professional treatment. A federal plan in 1963 to build and maintain community mental health centers throughout the country for low- and middle-income Americans has faltered recently for lack of funds and support. For the rest, insurance coverage for mental health treatment is rare. A Blue Cross-Blue Shield plan for federal employees that does include such coverage is now being renegotiated because of its high cost, for instance.

Tonight we focus on this problem of mental health care for the general population and some of the financial, insurance and accompanying concerns it brings with it. In June, Congressman James Scheuer, Democrat of New York, co-convened a major conference on the subject, "The Crisis in Psychiatric Care and Insurance Coverage." Congressman Scheuer is a member of the House Health and Environment subcommittee and is co-chairman of the Democratic study group task force on health policy.

Congressman, what is the crisis in your terms? How do you define it?

JAMES SCHEUER: I think the crisis was very well developed and articulated at the conference in June that was co-sponsored by a very brilliant doctor and psychiatrist, Dr. Jay Fischman, president of the American Health Services. And out of that conference came a perception that it`s an education problem. Education of the public, education of the medical profession and education, including the care and feeding, of Congressmen. As far as the public perception is concerned there`s still something of a stigma about mental health, even though the practice of mental health has come out of the closet, so to speak -- people aren`t any longer treated exclusively in state institutions for the insane, that`s from the last century. There are mental health units in every major medical school and every major general hospital; community health centers abound in this country. So the actual practice of mental health is in the mainstream of health treatment, but the public doesn`t perceive it that way -yet. And that`s one of the reasons Congress has had so little public pressure to include mental health in a national health program.

LEHRER: No lobby, in other words.

SCHEUER: Ho lobby, and that`s unfortunate. Second, the medical profession itself hasn`t done the job it should be doing in showing Congress that mental health costs can be control led, that we can set goals for individual treatment, that we can establish a beginning, a middle and an end to psychiatric help, that we can provide cost controls and quality controls, and that it`s not just going to escalate off the chart and out the window; that it`s manageable, which I think it is. But they haven`t done their job, certainly not with the Congress. There has been too much fighting in the profession as to who is going to render the services...

LEHRER: What do you mean, fighting?

SCHEUER: Fighting, for example, between the psychiatrists and the psychologists. The psychiatrists tend to look down their nose at psychologists; and both groups look down their nose at paraprofessionals, who are rendering very significant community mental health services out there in the boondocks. So they have to get their deck in order and come to us with a solid phalanx, a proposal for modalities of treatment that include psychiatrists, psychologists, psychiatric nurses, psychiatric social workers and paraprofessionals in general in their proper, relevant and constructive roles. And a third, of course -- the Congressmen themselves have to do some homework and they have to perceive mental health as an absolutely acceptable part of the total health picture. They have to perceive that over a lifetime many of us are going to need help in coping with problems and that there`s nothing wrong or abnormal or unnatural about that.

LEHRER: They don`t see it that way now, do they?

SCHEUER: They don`t really, because Congresses really are quite representative of the American people, and to the extent that the people themselves don`t see mental health as an essential and elemental part of the general flow of health services, Congressmen reflect that lack of understanding. So the profession has to help us both to understand the necessity of providing mental health services in a national health program and also in giving us some confidence that we`re not entering into a mare`s nest of uncontrollable cost, uncontrollable qualities, total lack of standards and a totally directionless and chaotic system. I think it can be managed, but they`ve got to show us how it can be.

LEHRER: You`ve laid out the problem, and let`s pursue it a little while now, first of all with Dr. John McGrath, who is a private practicing psychiatrist; he is a member of the Washington Psychiatric Society and chairman of the Washington Psychiatric Political Action Committee. Doctor, you`ve just listened to the Congressman, what`s your reaction from the psychiatrist`s point of view?

Dr. JOHTT McGRATH: Certainly the crisis is quite real...

LEHRER: in other words, people who need treatment for mental illness are not getting it right now, is that correct?

McGRATH: Yes, I would think that certainly is fair to say. That`s only one aspect of the problem; untreated mental illness results in suffering, just like untreated physical illness. That`s one important thing -- I think it is all too easy for many of us to think of mental illness as something that should be corrected volitionally, something that if a person is mentally ill, well, they`ve either done something wrong or they should work their way out of it.

And this is an attitude that results in the failure to set aside adequate funding, adequate professional talent and all the other things, and that results in suffering. Mental illness has a particular characteristic, I think, in terms of suffering, that it is not limited to the individual; it spreads across families -- an ill parent, an ill mother, her effect, if untreated, on children, their effect in the community, this branching out throughout the whole city. So there can be -- I think there is -- a growing awareness that the crisis results in real human suffering, it`s simply not a crisis of facts and figures, it`s not a crisis of legislation, it`s a crisis of people needing care.

LEHRER: I just want to say that the Congressman says that you and your colleagues, and your profession, have done a very poor job of getting that message over, number one, to the public, number two, to the Congress and everybody else concerned.

McGRATH: I don`t think you`ll be surprised to know that I don`t fully agree with that. I think he rightly touches on one aspect of it; there are other aspects, too. We do have to talk to the Congressmen, but they also have to listen; and I know they do but listening to some of these problems takes a special kind of listening. There are ways in which legislation and such things as cost efficiency reviews can be introduced, even with the best intentions - the intentions of controlling the cost, of making sure that claims and treatment are appropriate -- all the laudatory goals supported by all professional psychiatric organizations; but yet the legislative introduction of some of these, or the administrative carrying out of them can actually result in difficulties in patient treatment, they can have the effect of driving people away from treatment, and even more significant1n they can limit somewhat the modalities and the types of treatment available. it is all too easy, I think, to favor certain types of treatment because perhaps they are more easily managed from the standpoint of cost and utilization. That does not make them, however, the best treatment for that patient.

LEHRER: Cost and utilization and insurance and all of that are the crux of a lot of the problems here. Let`s move on for a moment to James Gillman, who is a Vice President of Blue Cross Blue Shield and director of the company`s federal employee health program. Before joining Blue Cross he was Commissioner of Social Services in the Department of Social and Rehabilitative Services in the State of Iowa.

Why do not insurance companies want to cover mental health costs? What are the problems?

JAMES GILLMAN: That`s probably a better question. I can`t speak: for those other folks -- we have a mental health program in Blue Cross-Blue Shield; there`s a mental health program in all most all the Blue Cross and Blue Shield lines of business, too, that are sold to the various companies. I think the problems that they have are those that the Congressman hit upon, the understanding of identification -- being able to identify the treatment -- as opposed to something that maybe is a custodial sort of thing: patients that are admitted to hospitals maybe are being kept there not under treatment but because it`s convenient for someone to be there.

SCHEUER: A warehousing operation.

GILLMAN: Yes.

LEHRER: You folks are really trying to get out of the business of mental health care coverage, are you not?

GILLMAN: No, we`re not. Two years ago, when it was proposed that there was a cutback in that -- at that time, the reason for that was because we were under a lot of pressure regarding the cost of the program. The way to reduce costs in such a program is to reduce benefits; if you reduce benefits then the costs aren`t as great and you don`t have to charge as much for it.

LEHRER: In a practical way, Mr. Gillman, so we`ll all understand, what are the problems of administering mental health insurance coverage for a company like Blue Cross-Blue Shield, that are different than, say, for a broken arm, for a broken leg, for major surgery, etcetera?

GILLMAN: I think it`s a matter of; visibility, it`s a matter of identification again; you can identify a broken arm. If you go into the hospital and have an appendectomy or have a gall bladder removed, you know that something has been done for you, you know that a piece of tissue has been sent to the pathologist; he looks at it and makes a decision as to whether it`s diseased or not, he can do that in terms of looking through the microscope and making a determination. That`s a very visible kind of thing that can be done, it`s easily accomplished simply because it is visible, and something you can see. It isn`t something that you have to think about and come up with a concept. With regard to mental health it becomes a different kind of thing. A person who is mentally ill often doesn`t know he is mentally ill himself. He doesn`t, even when he does recognize the need for treatment, quite often recognize that he`s receiving treatment when he`s receiving it, because maybe it doesn`t look to him say though something is being done. He`s not receiving medicine, he isn`t being cut upon, he`s being talked to in some cases; in some cases he might be receiving drugs, but a lot of times he just really doesn`t understand that he`s even receiving treatment. The same tying is true when you`re talking about the claims processor, who looks at it. Now, if you assume that every patient who is admitted to a psychiatric facility is mentally ill and assume that the treatment he`s receiving is, in fact, treatment, then there is no problem because all you have to do is go ahead and pay them. The question comes when you have someone who is in a facility, and the information can lead you to believe that, as the Congressman says, it`s a warehousing kind of thing for that individual. That`s not true of hospitals in general; most patients who go into them, and most physicians who put patients in hospitals put them in for treatment. But sometimes it`s a convenience, for the patient or for the physician or for the hospital -- for whoever. It`s convenient for someone.

SCHEUER: It`s frequently convenient for the sons and daughters, who don`t want them at home.

LEHRER: And Blue Cross-Blue Shield, or whatever insurance company, ends up paying for that convenience.

GILLMAN: We would hope not; that`s what we`re trying to avoid. And that`s where the difficulty comes, when you try to decide which way it`s going to be, and that`s some of the problems that we face when we`re dealing with a claim from a psychiatrist or from a psychiatric facility.

LEHRER: Let`s move on a moment, and then I want to open all this up. I want to move on now to Dr. Steven Sharfstein, who is the Director or Program Evaluation in the office of Program Development and Analysis in the National Institute of Mental Health. Next week he will assume the role of acting director of mental health programs, overseeing the country`s community mental health centers. He is the author of a survey about insurance coverage of mental health care. You`ve done the only study, I believe, that is recognized on this total issue. What is the problem as far as insurance coverage as it comes to mental health, as you found out in your study?

Dr. STEVEN SHARFSTEIN: I think despite recent progress the mentally ill remain the most discriminated against and stigmatized sick in America today. As far as health costs are concerned, 25 percent of health costs are taken care of by private health insurance; little over ten percent for mental health costs. This means that if You or a member of your family gets sick with a sinus infection, diabetes, or cancer, and you go to a doctor, chances are your private health insurance will cover it. Chances are if you develop a depression or a schizophrenic illness and you go to a doctor, your insurance will not cover it. Who pays? Still today in America, I`m sorry to say that two-thirds of the bill for mental health care is paid for by the public to the state and county mental hospitals. We have in our country a two-class system of care; there`s a substantial inequity when we cover physical illness at least twice as great as mental illness. The exception to this is the federal employees program. This program insures, by and large, mental illness on an equal basis with physical illness, and as such I think it`s a model program for future national health insurance coverage for the mentally ill.

LEHRER: When that program was initiated, as I understand it, it was set up with that idea in mind, that this would be used as a model for future mental health insurance programs. But now apparently that is having its problems because of cost. What did your study find in terms of cost, because that is really the nut of this, is it not?

SHARFSTEIN: We looked at the cost of care in the federal employees program, Blue Cross, and we discovered that despite some predictions that these costs would be unpredictable and unstable, that the costs have stabilized at about seven percent of the health dollar since 1971.

LEHRER: What does that mean?

SHARFSTEIN: What this means is that when the costs were initially tabulated in 1967 -- that was when the mental health benefit was introduced in Blue Cross -- it was around four per cent and then went up to about seven percent in 1971; since 1971 the costs of care have stabilized at seven percent of the health dollar, within the Blue Cross program. This means that instead of it going up and going out of sight, as has been the fear, it has plateaued. The utilization has also plateaued at a little over one percent of the population of federal employees utilizing the benefit.

LEHRER: In other words, only one percent of the people who are covered by the federal employees Blue Cross-Blue Shield plan -- which is really the only major plan that has coverage for mental health treatment -- only one percent of those people have actually used it, is that correct?

SHARFSTEIN: That`s correct. And they accumulate seven percent of the costs.

LEHRER: Seven percent of the total cost of the entire Blue Cross-Blue Shield program for that particular set of employees?

SHARFSTEIN: That`s right.

SCHEUER: I`d like to add one point; it was mentioned that mental illness causes human suffering. It also causes human waste, which is a very expensive luxury for our society. And for that waste all of us pay because if, as Dr. Sharfstein said, a man who is a head of a family has severe depression and he can`t cope with it himself and he doesn`t get help, he becomes functionally disabled. He is unable to work. And when he stops working for perhaps six months or a year or two years, he is no longer a productive member of society, the family is on welfare and all kinds of economic fallout impinges on society and we all pay the tariff.

So sometimes there can be an enormous cost-benefit factor, an enormous saving to society and give you just a modest amount of canceling.

LEHRER: Back to specifics here. Mr. Gillman, what has been the cost situation from your standpoint, from Blue Cross-Blue Shield, do you agree with the doctor`s analysis?

GILLMAN : Yes, I do. I think probably that if it wasn`t for the stigma attached to it that there would be more; I think that it tends to be encouraged by people who look upon people who are mentally ill as having some sort of really bad thing. I think people are surprised when they visit psychiatric facilities, mental health clinics, because they really don`t understand -- they really look at people and expect to see them with their hair all awry...

LEHRER: Sure, screaming maniacs.

GILLMAN: Yes, that sort of thing, and that really is not the case. I believe that -- of course he`s right on the percentages; I think there are three things that cause the percentages to rise, and one of them was the utilization. More people did start using the mental health benefits. The second one was that there were some unit cost changes between 1967 and now, just the CPI went up ... the consumer price index went up, and as that went up the unit cost went up.

LEHRER: So that`s just basic inflation.

GILLMAN: Yes, but deduct for all health costs. The third thing was that there were added benefits. When it was started in 1967 I believe that 30 days was all that was allowed in the hospital; now it`s 365.

LEHRER: Mr. Gillman, I`ve got to confess, I`m confused. What is the position, then, of Blue Cross-Blue Shield as it comes to insuring people for mental health coverage? Are you all trying to get out of that business because of the cost?

GILLMAN: No.

LEHRER: I was under the impression from what I had read today that you all were trying, because the costs were rising, to get out of that. I`m wrong, I guess.

GILLMAN: I think so. I don`t think we would want out of that, I don`t think we ever wanted to get out of it. It was presented when Blue Cross made a presentation to the Civil Service Commission two years ago; the presentation was on the basis that the Civil Service Commission felt that the costs were getting too high, and how can you reduce those costs? Well, if you cut back on psychiatric benefits the cost will go down. The reason for choosing psychiatric benefits? Because they`re hard to administer, administration costs are higher in that.

LEHRER: Sure, it would be a quickie way to cut.

GILLMAN: The point is, though, that we`re not interested in cutting back. in the thing at all; we just have to make sure that we have a product that people are interested in purchasing.

McGRATH: I think that perhaps some of the confusion might be that the whole discussion is perhaps taking a direction that it oaten takes, and one figure that Dr. Sharfstein quoted I think could be put in more human terms. For the Blue Cross and Blue shield federal employees` health program to offer non-discriminatory care, as they have, it costs seven cents out of every dollar they pay out; that is not a tremendous amount of money, that is a stable amount of money over rive years, and that is a predictable amount of money. So any argument, any discussion about mental health benefits that focuses simply on economics -- and particularly that says such things as "We don`t have a handle on it," "It`s going to go through the roof," is dealing with myths that have been substantially disproven statistically.

LEHRER: And the insurance industry would agree with that?

GILLMAN: Well, I don`t know about the industry, but Blue Cross-Blue Shield would.

LEHRER: But you`re the largest single insurance company of this type in the world.

McGRATH: And that`s in keeping, also, with other countries that do have national health insurance. We have checks on that figure.

SCHEUER: The situation is really not quite that simple. At this conference that I co-sponsored with Dr. Fischman, Dr. Roy Meninger, who bears a noble and distinguished name in the field of American psychiatry, made a very clear statement that psychiatric treatment was not susceptible to these kinds of systematic parameters, that treatment had to be uniquely designed for individuals and it couldn`t be systematized or rationalized along these lines of peer review for quality control and cost control, and that you couldn`t force the human element into any kind of a mold or a form or a systematization. He made a very impassioned plea for forgetting about all of these cost controls and quality controls.

McGRATH: Well, not to argue with Dr. Meninger, who isn`t here, obviously, but one thing: an impassioned plea has its place when you`re talking about patients, you`re talking about illness. Patients aren`t vague people; patients are members of our family, our spouses, our children. So the impassioned plea certainly has its place in this discussion -- as much a place as economics. But I will also add, the American Psychiatric Association, the local branches are actively involved in peer review, in utilization review, we have a definite commitment to it, we have ongoing programs, and I think the evidence is mounting up that feelings that these things are not reviewable is going to be myth number two that`s on the verge of being shattered, just like it`s too costly; the other idea that you don`t know where your money`s being spent I think reflects one, there wasn`t enough information but now it`s mounting rapidly, and also it reflects a difficulty with appreciating the subtlety with which you have to treat individuals when you are talking about their problems, their deeply disturbing problems.

LEHRER: Doctor, you wanted to say something.

SHARFSTEIN: I think that there several other myths that have been exploded by the federal employees` program experience and other experience. One of them is that all mental care is longterm -- that`s not true. Most patients are in hospital under two weeks right now for treatment for mental illness. For outpatient care, most patients are handled in 20 visits or less per year. It isn`t unending care, it`s care that is often short-term, and in :germs of quality care review, I think this is untested. But even without quality of care review, the cost issue...

LEHRER: The quality of care review -- what do you mean there, you mean setting up some kind of board of psychiatrists or somebody that helps, say, Blue Cross-Blue Shield determine that they`re not getting ripped off?

McGRATH: There`s a commitment and an ongoing process of working with them.

GILLMAN: Even more importantly, that the patient is being properly taken care of, which is really what you want in the first place. Nobody wants to pay, privately or through government pro grams or through hospitalization programs or to Blue Cross and Blue Shield, they don`t want to pay for what they don`t have covered, they don`t want to pay for things that are not being done for them. The whole point of the thing is to provide care for the patient; that`s what it was originally set up for, and that`s the whole point.

LEHRER: And psychiatrists have been reluctant to do that, up till now, but what you are saying, Dr. McGrath, is that there`s some give on that now.

McGRATH: More than give, I think it`s an active process.

SCHEUER: But there is a communications problem, Dr. McGrath, and there are 535 men on Capitol Hill, 100 on the Senate side and 435 on the House side, who in the next couple of years are going to be reaching incrementally to a national health program, and I desperately hope that mental health will be included as an equal partner with physical health. And unless you communicate some of this now as to those 535 men, you`re going to have a very rocky. time; and I`m going to have a very rocky time selling it, which I want to do.

SHARFSTEIN: It would be tragic if the Congress continued this two-class system of care for the mentally ill and gave second-class status to coverage for mental illness.

McGRATH: The Congressman said he`d have to hear from a psychiatrist, and indeed he does; but I think more is going to be heard from the consumers. This is of course the age of consumer advocacy, and we`ve seen over these past few weeks there have been letters in the Washington Post ...consumers have come to realize that when the insurance companies or federal regulatory bodies, in secret negotiations, play fast and loose with their benefits the consumers suffer. in 1974 we saw an example of that with another major insurance carrier who cut off in midstream people who had paid their premiums.

LEHRER: I`m sorry, but I`ve got to cut you off in midstream. That is a fascinating subject and I wish we had time to pursue that because I had not read that letter. But gentlemen, I thank all of you for being with us, and I`ll see you again tomorrow night. I`m Jim Lehrer. Thank you, and good night.