At issue | March 10 Merlene Davis column "A feel-bad survey when we need it least; only West Virginians' well-being ranks lower"
Columnist Merlene Davis reported the results of a recent Gallup-Healthways poll ranking Kentucky 49th in the country with regard to overall well-being. According to Gallup, communities with a higher Well-being Index benefit from lower overall health care costs and greater economic growth. Access to medical care and overall emotional health are two important measures incorporated into the index.
Unfortunately, the 285,000 current and retired state government and school employees, along with their dependents, covered by the Kentucky Employee Health Plan often face overwhelming obstacles accessing mental health care.
These unrecognized barriers not only hurt individuals in need of mental health treatment, but also burden our community efforts to recover from the recent economic downturn.
As a psychiatrist, I frequently receive calls from people asking for help finding someone who will accept insurance through Humana, the health insurance company currently managing KEHP. Many of my own patients with KEHP fight Humana for deserved out-of-network reimbursement. And I became alarmed when Humana, citing a technicality, refused to a personal friend and KEHP beneficiary a covered out-of-network mental health service.
Before addressing my friend's problem, I want to share concerns about Humana's management of KEHP's mental health benefits. If you wish to see an in-network psychiatrist, you have few options, especially if you need a child psychiatrist.
In Fayette County, Humana's Web site claims to have 53 in-network child and adult psychiatrists, but 39 of these are errors or redundant listings. Of the 83 active psychiatrists with a primary office in Fayette County (excluding psychiatric residents in training), only 12 work in clinics accepting Humana plans.
To make the situation worse, several of these psychiatrists are not accepting new Humana patients. Many psychiatrists decide not to accept Humana for two primary reasons: It offers poor reimbursement and it creates excessive paperwork.
In-network psychiatrists cannot set their own fees. Humana dictates the fee, which is often significantly lower than the regional market rate. Humana also requires in-network psychiatrists to submit medical records and documentation so they can determine if an appointment is medically necessary, a process called pre-authorization.
Many psychiatrists are uncomfortable with this practice because it jeopardizes confidentiality and leaves major treatment decisions in the hands of an anonymous Humana employee. Furthermore, pre-authorization does not guarantee insurance payment.
If you decide to see an out-of-network psychiatrist, be prepared to fight for your limited benefits. Suppose you see an out-of-network psychiatrist for a 45-minute psychotherapy appointment. The psychiatrist charges $160, the regional average rate according to the Healthcare Bluebook.
Under your KEHP plan, Humana agrees to pay 70 percent after you meet an $800 deductible. Based on this information, you naturally assume that you will meet your deductible after your first five appointments. Afterwards, you assume Humana will pay $112 per appointment, leaving you responsible for the $48 remainder.
Unfortunately, Humana uses its own rate, the "usual and customary rate" of $69. By comparison, the Medicare rate is $102 and the Kentucky Medicaid rate is $77. You will therefore reach your deductible after 12 appointments and a cost of $1,920.
Afterwards, Humana will pay $48 per appointment (70 percent of the $69 customary rate), leaving you responsible for $112 per appointment.
If you decide to see an out-of-network psychiatrist, Humana will still require you to pre-authorize your appointments. For initial appointments, you may pre-authorize yourself by calling Humana and asking permission to schedule an appointment.
Afterward, however, Humana will require the psychiatrist to submit the pre-authorization paperwork. Since the psychiatrist is out-of-network, in part to avoid this, he or she may refuse to cooperate with Humana, expressing concerns about Humana's involvement in treatment planning.
This is the problem my friend faces. After five months of psychotherapy, Humana required the psychiatrist to submit a treatment plan in order to continue receiving out-of-network reimbursement.
Because the psychiatrist has the right to refuse, my friend now faces the possibility of not being able to use the benefits for a legitimate service. Humana understands that patients are reluctant to change psychotherapists in the middle of treatment, and it exploits this to minimize benefit payments.
Regrettably, health insurance does not guarantee access to treatment.
While the problems KEHP beneficiaries face accessing mental health care are not the only factors contributing Kentucky's poor ranking in the Gallup-Healthway's Well-Being Index, corrective action would send the message that Kentucky values the emotional health of our state employees and the economic success of our entire community.