‘People Are Being Tossed to the Winds’

One argument for a strong mental health care system is that mental problems have a way of becoming problems for everyone. Mental suffering creates a kind of static that cuts people off from themselves and those around them. Thus, it can undermine a family, disrupt a classroom, demoralize a workplace, put a homeless man in the park where your dad plays with his grandkids. Mental illness is the urban bag lady who ends up being shot by the policeman whose city ends up being sued by her children. It’s the day trader who breaks down and goes gunning for his family and colleagues.

In other words, a mental illness tends to be everyone’s illness. And its managed-care issues tend to land at the doorstep of everyone.

This is one reason why everyone should care about the latest chapter in the struggle--and it is a struggle--to salvage a modicum of effective mental health care here. On the heels of recent good news--the new “parity” law that finally makes private insurers cover serious mental illness at the same levels as serious physical illness--comes worrisome news from the public sector: Bureaucracy and economics are threatening treatment for one of Southern California’s neediest populations, those who are insured by Medi-Cal.

The situation is most acute in Los Angeles County, where the number of private psychiatrists and psychologists who will take Medi-Cal patients has plummeted by almost 70%. Two years ago the county had about 6,400 such providers to buttress an overwhelmed network of nonprofit and county clinics. There are now fewer than 2,000, only a small fraction of whom do the individual therapy that can help, say, a schizophrenic stay out of the hospital, or a welfare mom become a reliable worker. The rest either only do evaluations--of foster kids, for instance--or only do in-patient work, says Robert Rome, who chairs the California Psychological Assn.’s committee on this sad state of affairs. Rome says it is now all but impossible to find a fee-for-service psychiatrist in L.A. County who’ll accept new direct referrals on Medi-Cal.

The Orange County situation is anecdotally not much better, though the firm handling county payouts says the overall number of private Medi-Cal therapists (360) is unchanged. Those who have dropped Medi-Cal echo the L.A. story--blizzards of paperwork and untenable reimbursement rates.

“The rates are so low, and we’re in such a managed-care squeeze as it is, that I just can’t afford it. I’d go under and then I couldn’t help anyone,” says Michael Angioli, a Mission Viejo psychologist. “There’s a tremendous need for the care. But with all the insurance companies low-balling, and the hours of documentation, if I take those patients, I can’t break even. I can’t make the numbers work.”

“Those patients” tend to have more than their share of problems. Medi-Cal recipients tend to be disabled or poor. The people jamming the waiting lists for state-insured care here are among the hardest to treat and the most heart-wrenching if left untreated: raped and abandoned welfare children, homeless people who hear voices, veterans of psychiatric wards.

Medi-Cal reimbursement for psychological treatment has long been disgraceful--for years, the going rate has been $29 for an $80 to $150 hour of therapy. The number of sessions is tightly restricted. Most therapists can’t cover billing and overhead for less than $60 to $80 an hour. Thus to take Medi-Cal is almost to work for free.

But, because the work is important and rewarding, some veteran therapists and idealistic rookies have stayed with it (along with, it must be noted, some sharks who have nickel-and-dimed the system and sometimes even done harm). Last year, when the state completed a handoff of Medi-Cal administration to the counties, advocates hoped local control would raise rates through efficiency, and thus encourage more experienced providers. This happened in some places, but locally, what increases there were were offset by fresh red tape and treatment obstacles.

Thus, much lobbying by the L.A. County Psychological Assn. prompted an L.A. increase--of a measly $10 per session. Meanwhile, the paperwork has swelled to a tsunami of self-assessments and chart review lists and county butt-covering proofs of insurance and treatment plans. Carla Jacobs of the National Alliance for the Mentally Ill calls it “rationing through inconvenience.” County officials say the new system is a work in progress and that they’re just trying to root out fraud.

Meanwhile, the sick get sicker as the system plagues doctors. “It’s a crime,” says Brea psychologist Rosalyn Ladauti. “People are being tossed to the winds.” If only the winds didn’t carry them back to our doorsteps, whispering, “Whatsoever ye do to the least of my brothers. . . .” Pay now or pay later, everyone.

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Shawn Hubler’s column runs Mondays and Thursdays. Her e-mail address is [email protected].