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DR ALLAN FRANCES ADMITS: " WE MADE MISTAKES WITH DSM4 WHICH HAVE HAD TERRIBLE CONSEQUENCES FOR CHILDREN.&quo...
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Friday, 4 January 2013
DSM-5 - Will Mental Health’s ‘Bible’ Make Believers of Insurers?
Mental Health’s ‘Bible’ Make Believers of Insurers?
When does a characteristic become
a disorder? The next edition of the Diagnostic and Statistical Manual of Mental
Disorders means even more coverage decisions and even more reliance on the
codes needed by Insurance Companies.
is not the only big change in the works. Proposed changes in DSM-5, which is
undergoing field testing, spell out new rules regarding the diagnosis of binge
eating, the designation of Asperger’s syndrome, a lower bar for diagnosing type
II bipolar disorder, and many more topics covering millions of patients. And
once DSM-5 becomes official, it will help determine who gets insurance coverage
really can’t ignore it once it’s there,” says Christopher Dennis, MD, chief
medical officer in the commercial division of ValueOptions, a national managed
care organization that specializes in behavioral health and wellness. “Once
it’s in the bible, it’s tough to refute the existence of the disorder.”
but not impossible. Some diagnoses now considered somewhat outdated, such as
histrionic personality disorder, are being eliminated.
when the parity bill on mental health benefits was being hotly debated in the
last decade, a range of conservative organizations that included the National
Center for Policy Analysis (NCPA) argued that DSM-IV (the Roman numeral becomes
Arabic in the next edition) — which includes the payment codes required to gain
coverage — presented payers with unacceptable and potentially enormous expenses
for covering controversial treatments for ailments such as jet lag, caffeine
addiction, and voyeurism. “Critics suspect that mental health professionals
secretly believe there is no such being as a truly mentally healthy individual
who could not benefit from therapy,” suggested John Goodman, who launched the NCPA
back in 2002. DSM-IV, he argued, offered a blank check for practitioners to
essentially abuse the generosity of payers.
group hasn’t lost that focus now that DSM-5 is being discussed. Last year the
NCPA highlighted the new designations being added to the manual, concluding
that “technically, with the classification of so many new disorders, we will
all have disorders.” And that would have a particularly explosive effect on
federal and state payers required to foot the bill for broader treatment.
this time around, the NCPA doesn’t have a lot of allies to amplify its
criticism of the revised manual. The U.S. Chamber of Commerce, the National
Business Group on Health, and other organizations haven’t bothered to weigh in
on these new discussions about expanding the manual. And the mental health
plans working in the field don’t expect to see anything like the same
politically charged accusations flying now that parity made mental health a
routinely accepted part of health care.
mental health moved from the shadows of the couch to a more biologically-based
illness,” says Dennis, attitudes and expectations have undergone a sea change.
As for the changes outlined for DSM-5: “Payers are going to look at it and say,
‘Well, it’s not as if these conditions are new.’ Maybe they weren’t classified
as such, but they may have been addressed under other conditions.
set a level playing field,” Dennis adds. Once the new law put it on par with
medical benefits, it defused the issue. And since then, companies and plans
have been a lot more willing to provide mental health benefits to their
disorders and expanding coverage to specific ailments such as binge eating
won’t fundamentally alter a simple economic reality, says Gary Henschen, MD,
the chief medical officer for behavioral health at Magellan Health Services,
another big managed behavioral health care company.
percent of our claims are depression-related,” says Henschen, “and that’s not
going to change.”
the 2008 parity law, Henschen adds, plans are required to provide benefits for
mental health equal to medical and surgical benefits, if they cover mental
health at all. The law, which went into effect at the beginning of 2010,
requires group health plans that cover 50 or more employees and offer both
medical and mental health benefits to provide mental health and substance abuse
benefits that are no different in terms of copayments or other provisions
levied for medical and surgical benefits. And the conditions covered are all
outlined in the DSM, which is controlled by the APA.
2014, the stakes go up again for health plans. Any plan offered under the
health exchanges being created by the Affordable Care Act will be required to
provide mental health benefits — it won’t be an option. But health reform has
already had a big effect on the business, says Henschen.
parts of the country, we have seen a marked increase in patients who are 19 to
26,” says Henschen. For many of those young people, coverage had ended when
they turned 18. “Under reform they have coverage, so we’re seeing a sudden
increase in those patients.” And more may be coming if the more than 30 million
people expected to be insured in a post-reform world get the coverage intended.
exactly what excites groups like the National Eating Disorders Association,
which has been advocating official recognition of binge eating.
a huge change,” says Lynn Grefe, CEO of the association. “There are more people
with binge eating disorders than any other” eating disorder.
her what makes it huge, and she responds with just a hint that the answer
should be obvious: “It might get covered by insurance,” she responds. “This is
going to be a good day for [patients]. It improves the odds on coverage. Maybe
they will actually get the psychological counseling they need.
disorder has really been left in the dark,” Grefe adds. “People say the country
is just fat; meanwhile at least 15 million people suffer from binge-eating
disorder. People couldn’t get treatment. They’d go on diets, lose weight, and
then regain it. Binge eaters are the same as people struggling with bulimia,
except they don’t get rid of the food.”
eating is rarely a sole affliction, she notes. These people often suffer from
obsessive-compulsive disorder, anxiety, and depression.
Mental and physical
can put binge eaters on as many diets as you want, but most likely without
treatment they will regain the weight,” says Grefe. “It is a mental disorder —
mental and physical, as with all the eating disorders.”
is probably the most controversial diagnosis we have,” says Henschen. “Many
states mandate treatment and yet there’s no scientifically-based treatment
program. We’re put in position of managing autism spectrum disorders and
for payers, the draft edition of DSM-5 calls for Asperger’s syndrome — a much
milder version of the affliction — to be subsumed under the broad heading of
autism spectrum disorders.
now you cannot get insurance to cover care for Asperger’s as a category,” notes
Michael McManmon, EdD, a member of the U.S. Autism & Asperger Association’s
advisory board. “You also cannot get many state agencies to give funding to
kids who have Asperger’s to go to residential programs and get other types of
assistance. Students have to have an autism diagnosis to access funding and
services. If Asperger’s is included under the umbrella of autism spectrum
disorders, it should qualify.”
it’s a sensitive issue in the Asperger’s community, which isn’t pleased about
being assigned to fall under a broad label for autism.
have done my own mini-poll around the country and the people in the Asperger’s
community do not want to lose that identity,” McManmon added. The identity
signifies something totally distinct from what is typically assessed as autism.
The identity has been a source of strength for people who have been diagnosed
and a way of explaining and understanding who they are socially and intellectually.
feel a compromise would be for Asperger’s to be a subcategory under the autism
spectrum. I do not support the use of the word ‘disorder,’ as I feel it is
demeaning and does not really describe the learning differences experienced by
people with autism,” he added.
primary concern is to have a category that will elicit the funding that young
adults with Asperger’s can obtain by being in the DSM. The disease model is not
the best way to describe Asperger’s and we need to be categorized for funding
purposes without being stigmatized any worse than we already are.”
discussion of DSM-5 has also generated controversy within the psychiatric
profession. Allen Frances, MD, chairman of the DSM-IV task force, wrote an
op-ed piece for Psychology Today taking exception to two proposed changes for
bipolar disorder: “Allowing hypomania to be diagnosed just on the basis of
increased energy/activity (no longer requiring the presence of elevated mood or
irritability), and reducing the duration requirement for a hypomanic episode
(now set at four days by DSM-IV).”
the definition of bipolar disorder, he said, would contribute to overdiagnosis:
More patients would receive powerful drugs associated with a host of possible
Nassir Ghaemi, MD, a professor of psychiatry at Tufts Medical Center, though,
countered that the current limitations are considered arbitrary while the new
definition had survived rigorous diagnostic studies.
say the companies that handle mental health benefits for tens of millions of
Americans, payers still have control over who gets covered for what.
doesn’t define the package,” says Dennis. “Health plans and employers define
the package.” Now they have some new definitions to ponder.
Contributing Editor John Carroll at JCarroll@ManagedCareMag.com