MANAGED CARE August 2011. ©MediMedia USA
When does a characteristic become a disorder? The next edition of the Diagnostic and Statistical Manual of Mental Disorders means even more coverage decisions.
Last May, members of the American Psychological Association turned up at a gathering in Hawaii to review some of the fine points related to diagnosing hypersexual disorder, a condition that some people in the field have associated with Tiger Woods’s high-profile extramarital escapades. The APA has proposed that sexual obsession be added to the next edition of the Diagnostic and Statistical Manual of Mental Disorders — initiates know it as DSM-5 — which is due in 2013.
Under the current draft, the culmination of more than 10 years of discussion, a practitioner would be able to diagnose a case of hypersexual disorder in the event that someone spent an “excessive” amount of time consumed with sexual fantasies or planning for sex, especially if it seemed associated with anxiety, depression, boredom, and irritability. Efforts to stop the behavior are frustrated and the subject engaged in sexual escapades while disregarding the risks associated with that behavior.
These activities could involve cybersex, strip clubs, or pornography.
That 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 for treatment.
“You 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.”
Tough, but not impossible. Some diagnoses now considered somewhat outdated, such as histrionic personality disorder, are being eliminated.
Back 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.
Goodman’s 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.
But 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.
“As 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.
“Parity 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 members.
Adding 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.
“Eighty percent of our claims are depression-related,” says Henschen, “and that’s not going to change.”
Under 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.
In 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.
“In 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.
That’s exactly what excites groups like the National Eating Disorders Association, which has been advocating official recognition of binge eating.
“That’s a huge change,” says Lynn Grefe, CEO of the association. “There are more people with binge eating disorders than any other” eating disorder.
Ask 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.
“Binge-eating 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.”
Binge eating is rarely a sole affliction, she notes. These people often suffer from obsessive-compulsive disorder, anxiety, and depression.
Mental and physical
“You 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.”
“Autism 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 measuring progress.”
Significantly 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.
“Right 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.”
But 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.
“I 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.
“I 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.
“The 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.”
The 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).”
Changing the definition of bipolar disorder, he said, would contribute to overdiagnosis: More patients would receive powerful drugs associated with a host of possible side effects.
S. 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.
Ultimately, say the companies that handle mental health benefits for tens of millions of Americans, payers still have control over who gets covered for what.
“ValueOptions doesn’t define the package,” says Dennis. “Health plans and employers define the package.” Now they have some new definitions to ponder.