Carole Owens: Riggs' freedoms of mental health care
STOCKBRIDGE — On Sept. 21 and 22, the Austen Riggs Center presented a conference on "The Mental Health Crisis in America." What exactly is the crisis? The answer is access to care. Too many are not finding their way to adequate treatment or any treatment at all. As one participant put it, they are "stopped at the front door."
[The Austen Riggs Center is celebrating its 100th anniversary: "Carole Owens: Riggs at the century mark," Eagle, Sept. 6.)]
Access to care — whether for a physical or psychological malady — is an issue in America. Contributing factors are a shortage of doctors and nurses, the cost of service, and the behavior of co-payers such as insurance companies and the federal government. The debates are fiery, and the solutions are few. The politics and politicians generate more heat than light.
Austen Riggs Medical Director and CEO Eric Plakun explained there are additional factors when seeking mental health care. Patients may be resistant to receiving care or may have co-occurring problems. Although multiple problems exist, the service providers may treat only one or may concentrate on crisis stabilization rather than full recovery. In either case, relapse is almost certain.
Since 1919 when Austen Fox Riggs opened his center, it has served those in need against whatever obstacles, and so the second day of the conference focused on solutions.
For all the complexities of providing psychological services, there is a single overarching one to be addressed. Access to medically necessary treatment is often a function of the services and the length of service for which insurance companies will pay. Two solutions are being attempted: one is legislative and the other judicial.
On Oct. 3, 2008, Congress enacted the Paul Wellstone and Pete Domenici Mental Health Parity and Addictions Equity Act. Prior to that even the insured had policies that denied coverage for mental health and addition problems." The Affordable Care Act (ACA) included and expanded upon coverage for mental or behavioral health problems. In 2014 the law was further strengthened.
It looked good on paper, but the issue was compliance. While the laws were on the books, there were no consequences for ignoring them. This year, Sens. Bill Cassidy (R-LA.) and Chris Murphy (D.CT) introduced the Mental Health Parity Compliance Act of 2019. If enacted, compliance will be mandatory.
The judicial approach is to sue insurance companies when they refuse to pay for medically necessary mental health services. Parity is one ground on which to sue, however, a current case, just won, sued on different grounds. The new and innovative grounds were: breach of fiduciary responsibility, conflict of interest, and wrongful denial of claims.
In Wit vs United Behavioral Health, it was demonstrated that the insurance company was a trustee and as such had a fiduciary responsibility. The coverage was denied because the company sought to enhance their corporate profits. That is the definition of conflict of interest — to act for the benefit of oneself or one's company to the detriment of the patient. The insurance company set guidelines in conflict with professional standards of care and wrongfully denied claims by using those improper guidelines.
Assuming both the legislative and judicial solutions are put in place and effective, and assuming law and precedent combine to change the mental health service landscape, there are still obstacles. Does the patient want to accept service; does the professional provide adequate service?
In response, Austen Riggs suggests the "Four Freedoms of Mental Health Care". They are:
1 .The freedom from stigma
2. The freedom from dehumanization
3. The freedom to pursue recovery
4. The freedom of access to medically necessary treatment
In our culture, to provide the first is difficult. If you break your leg, your neighbors come by and bring a fruit basket. If you have a psychotic break, they stay away. It may be a form of victim blaming or fear of mental problems. Whatever the underlying cause, it is pervasive in our culture. It is hard to imagine that Austin Riggs can do more than avoid stigma and dehumanization in the treatment environment.
The freedom to pursue recovery relates to providing full treatment for all presenting problems. It is a sharp turn away from the practice of responding to the crisis, stabilizing and releasing. More than stabilize the patient, the provider would discover and treat the underlying problems.
At Austen Riggs, for 100 years, the goal is "lives reclaimed."
A Berkshire writer and historian, Carole Owens is a regular Eagle contributor.
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