Talk Is Cheap: How Insurance Changed The Face Of Psychiatry

"In 2010, Blue Cross Blue Shield of MA collapsed our reimbursement rate to the lowest, which coincided with the cheapest plan. The company did this despite maintaining tiered premiums for their various offerings," says MacLean-Hoover. So while policyholders continued to pay for these health plans, believing the higher rates provided better coverage, psychotherapists no longer received the higher reimbursement rates.

Indeed, spending on outpatient mental health has been flat or declining at a time that parity laws suggest mental health services should be more accessible and therefore increasing, says a 2009 report titled "Trends in Mental Health Cost Growth" in the journal Health Affairs.

"I refuse to do med visits because they do not treat anyone's psychological problems," says Dr. Carole Lieberman, a California-based psychiatrist and author. "Medications are only band-aids while the patient is supposed to be undergoing weekly psychotherapy to get at the root of their problem. Far too many psychiatrists have simply gone against what they know is best for the patient and acceded to med visits in order to be able to pay their mortgage and other living expenses. This is what's causing the failure of our mental health system and the increase in insufficiently treated patients."

The future of psychiatry

The problem is clearly multi-layered and, with violent incidents becoming a topic of national mental health fodder, the system seems broken.

"In terms of any individual incident I don't know if it could have been prevented, but if you look at the mental health system as a whole, very few people become violent but [substandard mental health care] could factor in some of them," says Reiss.

There's also the problem that mental health services are an easy target for managed-care cost cutting. And there's a long-standing stigma associated with having a mental illness. When managed care mishandles treatment of a physical health problem, patients go to their employers and complain about the insurance company. But when the issue is a mental health problem, most employees keep quiet.

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