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Mind Games

The squeeze in managed mental-health care is choking patients and providers alike.

Lauren Murray's easy smile and trim figure give no hint of the years of life-threatening turmoil she's endured. The 41-year-old Denver woman has built a successful career in marketing, and her colleagues rarely suspect that anything might be seriously wrong with her. But Murray has struggled with severe mental illness since she was an adolescent.

Three years ago, she became deeply depressed and started planning to commit suicide. So despondent she could hardly get out of bed, Murray felt as though she could not tolerate another day.

"I couldn't figure out how to stop this madness," she says. "I couldn't think of any alternative but to stop living."

 
Hadley Hooper
 
Psychologist Ivan Miller says that mental-health patients are targets for HMO cuts.
Phil Anson
Psychologist Ivan Miller says that mental-health patients are targets for HMO cuts.

Alarmed friends helped to arrange for her admission to a private Boulder mental hospital, where she was diagnosed as bipolar. People with that condition experience dramatic mood swings between soul-crushing depression and manic exultation, and scientists now see it as a biologically based illness triggered by chemical imbalances in the brain.

As Murray struggled to pull herself together, she suddenly was faced with a new problem: Her Prudential insurance policy said it would cover several weeks in a mental hospital, but her insurer refused to authorize her stay. Under managed care, a clerk who had never talked to Murray was denying her claim, ruling that her stay in the hospital wasn't "medically necessary."

"After five days in the hospital, someone came in and said, 'You've been denied. You have to pay cash or find somewhere else to go,'" Murray recalls.

Not knowing what else to do, she put the charges on her credit card. She spent a month in the hospital and was discharged with a bill for $17,000.

"I thought I would get reimbursed," she says.

Ironically, during her stay in the mental hospital, Murray had a firsthand view of the difference in the way mental and physical health claims are treated. She developed a heart murmur and was sent to a regular hospital for treatment. "It was all pre-approved by the managed-care company," she says. "There wasn't a question asked."

Trying to get reimbursed for her stay in the mental ward was another story. "They'd say, 'The claim hasn't been processed,'" she remembers. "The supervisor would never call me back."

Instead, the insurer denied her request for payment, and she began an endless round of appeals. Finally she hired an attorney, and, more than a year after Murray had left the hospital, the insurer agreed to settle the claim for $3,600, leaving her to come up with more than $13,000.

Murray has been able to make good money working in sales and marketing, an ability she attributes to the manic side of her personality. After leaving the hospital, she took a job with a large corporation and found that her insurance was covered under Colorado's "parity" law, which mandates that treatment for biologically based mental illness be covered to the same extent as physical illnesses. She had regular appointments with a psychiatrist that were paid for and found that a combination of medication and talk therapy stabilized her condition and allowed her to function fairly well.

Then she took a new job with an insurance plan that was self-insured and exempt from the state parity law. She soon found out why that mattered.

"Last December, out of nowhere, I was slammed with another depression," she says. "I was so sick. I saw the psychiatrist once a week and the therapist once a week. When I go in to see the psychiatrist, they'll pay 50 percent of ten visits a year. I used that up by the end of February."

No longer able to work, Murray now faces out-of-pocket medical expenses of $1,200 a month.

"It's Jurassic Age treatment to keep people from getting treated for mental illness when it's physiologically based," says Murray. "I've used up all my benefits for the year, and I have no coverage. That's managed care."

Murray's frustration with her mental-health coverage is commonplace.

Local psychologists and psychiatrists have to do constant battle with insurers to get approval for their patients' treatment. Professional Web sites and magazines are filled with angry diatribes against an insurance system many believe has singled out mental health as an easy target for cost-cutting. Several national studies have found that spending on mental-health care by insurance carriers has declined to a far greater degree than spending for general health care over the past decade.

"I think the mental-health profession is an easy target to be exploited because our patient population has special vulnerabilities," says Dr. Doris Gundersen, president of the Colorado Psychiatric Society.

Because there is still a stigma attached to mental illness, Gundersen says patients feel embarrassed by their condition and hesitate to raise a fuss when an insurer denies their claim. "Someone who's trying to get treatment for depression isn't going to go to the press," she says. "These patients can't advocate for themselves the way someone might who has diabetes."

Dr. Harry Corsover, an Evergreen psychologist, agrees. "If [insurance companies] had designed this system to make depressed and anxious people go away, they couldn't have done a better job."

As a result, many mental-health professionals these days engage in a sad new avocation -- exchanging managed-care horror stories. The most tragic cases involve suicidally depressed clients who are denied admission to psychiatric hospitals and then take their own lives.

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