Mental Health Disparity Version 2.0
An
Open Letter About Financial Discrimination Against Mental Health
Services
Ivan
J. Miller, May 6, 2009
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PDF
Mental health advocates have won the battle to achieve parity
for mental health services paid by health insurance. Almost everywhere
laws prohibit the overt financial discrimination against mental
health services. With the old forms of disparity outlawed, insurance
discrimination against mental health services has reemerged as
Mental Health Disparity Version 2.0. The new disparity is more
than the obvious invasions of privacy, special authorizations,
and extensive paperwork required only for mental health patients.
It is also a systematic pattern of low provider reimbursements
that impairs access to quality services by forcing psychiatric
units to close and by driving quality providers out of the field.
As mental health advocates, we need to, and can do, something
to stop Disparity 2.0.
The evidence assembled here validates that there are differences
in the way insurance companies reimburse mental health care and
physical health care, and that the differences cause difficulties
accessing quality mental health services. It is not the ordinary
marketplace nor is it competition among mental health professionals
that has created the funding shortages. The insurance company
system for managing mental health care is not just discriminatory,
but it consumes a large portion of the funds intended for providing
mental health services. Based on this review of the evidence,
an action plan is proposed to end the ongoing discrimination of
Disparity 2.0.
Historically, when patients pursued mental health care, in comparison
to physical health care, insurance imposed significantly higher
copayments, much lower annual and lifetime maximums, and larger
deductibles. This Version 1.0 funding disparity between physical
and mental health was obvious discrimination, and the campaign
to end it was called the mental health parity campaign. After
victories in most states, the last major battle was won on October
3, 2008 with the passage of the Paul Wellstone and Pete Domenici
Mental Health Parity and Addiction Equity Act of 2008.
Now, with Disparity 2.0, there are substantial funding problems
for mental health services. There is clear evidence that the problems
with funding and reimbursement are not the natural result of market
forces, but that they are the result of a pattern of discrimination
against mental health services. As with traditional disparity,
the discrimination is primarily a result of the practices of the
health care insurance industry, not the actions of government
or society in general.
The closure of psychiatric units across the country is the clearest
evidence of the managed mental health care discrimination against
mental health services. There is a well-documented shortage of
psychiatric hospital beds. The Denver Post (K. Aug_, Psyc. Units
Shutting Doors, 1/25/09) reports that the U.S. has an average
of 30 psychiatric beds/100,000 population. In contrast, Canada
has 190 psychiatric hospital beds/100,000 (M. Lang, Calgary Herald,
Mental Health Bed Shortage, 4/21/09). The American College of
Emergency Physicians has extensively documented that the psychiatric
hospital shortage is a serious nationwide problem. When psychiatric
beds are unavailable, ERs are backed due to holding and boarding
psychiatric patients (ACEP Psychiatric and Substance Abuse Survey
2008). This not only is inappropriate treatment for mental health
patients, it also interferes with service to other ER patients.
How is Disparity 2.0 responsible for the dramatic shortage of
psychiatric hospital beds? The answer is found in understanding
reimbursements. The Denver Post (K. Aug_, Psyc. Units Shutting
Doors, 1/25/09) reports that hospital directors say that the psychiatric
units are closing because, even when patients have insurance,
the insurance doesn’t cover 100% of the cost of care on
these units. As with most hospital units, public payer patients
and the uninsured also pay less than the cost of care. The disparity
is that in physical health care, insurance typically pays 131%
of the cost of services (Lewin Group, final report to the Colorado
Blue Ribbon Commission on Health Care Reform, 2007). This pattern
of under-payment by public payers and the uninsured, and over-payment
by insurance is called cost shifting. Cost shifting, or the insurance
over-payment is what keeps our physical health care hospital units
open. The insurance system underpays psychiatric hospital units
contributing to the underfunding, but it accepts the cost-shifting
burden and overpays for medical inpatient costs, which allows
physical health care units to remain open.
The result of the inpatient reimbursement disparity is the closure
of psychiatric hospital units. With the units closed, patients
who do not have an inpatient option may be boarded in emergency
rooms or jails; are discouraged from trying to obtain services;
and are discharged prematurely to allow for the triage workers
to admit other patients to the hospital beds.
Disparity 2.0 has a more insidious, but still deleterious, impact
on outpatient services. From a patient’s point of view,
some features of the special mental health management are obvious.
Patients are screened by a special mental health referral system,
treatment is under constant vigilance of the managed mental health
care entity, there is often difficulty finding an appropriate
therapist within a panel, and frequently, recommended therapists
are not available on the treatment panels.
Not obvious to patients, there is a pattern of declining reimbursement
rates for mental health providers over the past 20 years. Most
managed mental health care entities have not raised mental health
reimbursements for 20 years, and in many cases, they have lowered
reimbursements. Consequently, mental health professionals have
arguably the worst reimbursements in health care, and many are
leaving the field or working outside of the health care insurance
system.
I recently became acutely aware of how poorly informed the public
is about the reimbursement crisis in mental health. I am actively
involved in health care reform advocacy, policy development, and
writing policy for grassroots health care reform. In discussions
with reform advocates and legislators there are few issues that
everyone is aware of and in agreement. But two issues have almost
universal acceptance,
-
Every group I meet with is clear that mental health must be
included in health care reform and that there must be parity.
This opinion is expressed by everyone, not just representatives
of mental health. Advocates have effectively convinced the public
that mental health services are important and that parity is
important.
-
The second universal concern is that primary care physicians
and nurses are underpaid, and health care reform must address
reimbursements for primary care. Sometimes, other professions
such as physical therapists are included in the underpaid group,
but mental health professionals have never been included. In
spite of the far more severe reimbursement problem, the mental
health professions have allowed our reimbursement problems to
occur in virtual secrecy.
Within
psychology group discussions, there are two myths that keep us
from effectively addressing the reimbursement problem. First,
there is the myth that mental health professionals have not had
an increase in reimbursement for twenty years because of some
natural market force. Second, doctoral level psychologists have
assumed that reimbursements have fallen because they are paid
the same as master’s level practitioners.
Recently, as part of my health care system research, I was placing
my family medical bills, reimbursements, adjustments, and out-of-pocket
expenses on an Excel worksheet as an example of a consumer with
high medical expenses. In the process, I became aware that the
insurance market forces operated differently for physical health
care than for mental health care. I realized that my physical
therapist had a 3.7% increase in reimbursement from Anthem Blue
Cross in the middle of the year. She has a master’s degree
and an office set up that is no more expensive than a psychologist’s
office. She is reimbursed at $72 for a 25-minute session, and
Anthem pays a psychologist $72 for a 50-minute session. She receives
twice the psychologist pay. She is on the medical track where
market forces determine her reimbursement with regular increases.
In mental health there are no annual adjustments, and occasionally
even periodic reductions. Physical health care uses a different
system for determining reimbursement than mental health care.
Other facts indicate that the managed mental health care is a
special market manipulation that artificially lowers reimbursement.
Medicare rates are determined by a formula that considers the
difficulty of a task, the costs, and the education and skills
necessary to perform the service. The reimbursement that results
from this formula is considered to be around 80% the actual cost
of doing business, and providers are expected to obtain higher
reimbursements from commercial insurance so that the cost shifting
can subsidize the below cost reimbursement from Medicare. As described
in the Colorado Lewin analysis, insurance companies paid 131%
of the cost of providing services. This difference occurs because
the pattern in physical health care is that market forces result
in private and commercial insurance paying much more than Medicare.
Even the most publicized area of under-reimbursement in physical
health care, primary care, is not the result of market forces.
Commercial insurance reimburses primary care adequately, and the
problem is that the bureaucratically determined rates from Medicare
under-reimburse so severely that even with cost shifting, primary
care practitioners sometimes cannot stay in business.
In the managed care manipulation of mental health the opposite
is the case. I conducted a survey of the 14 most common insurance
plans in Boulder, Colorado and found that insurance pays around
80% of Medicare rates. As it turns out, Medicare, whose formula
is intended to reimburse at below the cost of providing services,
has one of the highest reimbursement rates. Something different
is going on with mental health services than with physical health
care, and it is not just market forces. Whereas market forces
allow physical health care providers to satisfactorily earn a
living, the special market manipulation reserved for mental health
is forcing many of the most qualified providers to leave the field
higher income.
Part of the answer to understanding Disparity Version 2.0 is in
the structure of providing mental health services through special
managed mental health care entities, often called carve-outs.
Between 25% and 30% of health care funds are spent on administration
and profit. However, in mental health a much higher proportion
is devoted to administration and profit, keeping health care funds
away from patients and providers. Creative accounting methodology
considers all of the funds assigned to a managed behavioral health
care carve to be funds spent on mental health services. Therefore,
in physical health care, after skimming the 25–30% for administration
and profit, the remainder of funds is assigned to providers. Not
so in mental health. After the 25-–30% is skimmed from the
premiums, the mental health portion is assigned to a mental health
carve out, which actually takes another huge portion of the funds
for administration and profit. Determining the amount that behavioral
health care takes for administration and profit is difficult because
operation of these entities is a proprietary secret. The last
insider estimates that I was able to obtain for this administration
and profit expense came in the late 1990s from James Wrich, a
managed behavioral health care company auditor. He reluctantly
reported that, because it sounded so unbelievable, that he had
never audited a managed behavioral health care company that took
less than 50% for administration and profit if it was at risk
for the cost of services. Personally, I have had a couple of executives
in managed behavioral health care organizations admit that it
is well known that managed behavioral health care is significantly
more expensive than managed physical health care.
So part of the answer to what happens to mental health services
and reimbursements is that a significantly larger portion of the
mental health care dollar is diverted to pay for the administration
and profit of managed behavioral health care companies. The purpose
of the managed mental health carve out companies is to limit services
and funds spent on patients. With the overall administration and
profit expenditures of insurance between 25–30%, and a conservative
estimate of the behavioral health care administration and profit
costs being at 3-0–35%, only 52.5% to 45.5% of the health
care funds remain for the delivery of services to patients. Around
half of mental health’s share of insurance money is spent
on administrative and profit, and the extra administration is
intended to reduce the payment of services. Is this necessary
or is it discrimination? Does this sound like a normal market,
with over half of the money going to administration and profit?
Does this seem more like a financial scheme to divert funds intended
for the treatment of mental illness?
The second myth is one that is often discussed by my professional
group, doctoral degree psychologists. Many doctoral level providers
believe that their reimbursements are low due to a mistaken belief
that they are paid the same as master’s level professionals.
Throughout the system, psychologists are consistently paid more
than master’s degree professionals. It is well established
that professionals with markedly different levels of education
and expertise are compensated at a higher level. In my own survey
of 14 insurance companies, there was only one managed care company
that did not pay more to psychologists than master’s level
therapists. The pay to psychologists was poor, but the pay to
master’s level therapists was even worse. The only portion
of mental health that is commensurate with physical health care
is psychiatry. I think this is because there is a psychiatrist
shortage, and as MDs they are considered part of the medical rather
than the mental health profession.
The result of the low reimbursement is demonstrated below in some
statistics from the U.S. Bureau of Labor Statistics, 2006
website.
-
A median annual earnings of mental health and substance abuse
social workers was $35,410. http://www.bls.gov/oco/ocos060.htm
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Marriage and family therapists median was $34,660 http://www.bls.gov/oes/2000/oes211013.htm
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Psychologists median $59,440, and for the category of psychologists
in offices as mental health practitioners, the median is $69,510,
http://www.bls.gov/oco/ocos056.htm
-
Median hourly wage for carpenters is $17.39, and if this is
converted to annual salary it is $36,171 http://www.bls.gov/oco/ocos202.htm
-
Auto mechanics at car dealers, median is $18.85/hr., converted
to an annual salary is $39,208, http://www.bls.gov/oco/ocos181.htm
-
Physical therapists (the majority in this group are employed
by a group or hospital and not in private practice), median,
$66,200, http://www.bls.gov/oco/ocos080.htm
-
Nurses, median $57,280, http://www.bls.gov/oco/ocos083.htm
-
Family Practice physicians with over one year in practice, median
$156, 010, http://www.bls.gov/oco/ocos074.htm
- Psychiatrists
with over one year’s experience, median $180,000, http://www.bls.gov/oco/ocos074.htm
The
reimbursement problem can also be demonstrated by comparing the
annual income of a psychologist and a licensed master’s
level therapist when reimbursed by Medicare, with the annual income
when reimbursed by a typical managed behavioral health care company.
The comparison is based on the reimbursement rates in my Colorado
survey. Assuming that a psychotherapist would have 30 billable
hours a week of patients; work a 48 week year (no pay for sick
days, family emergencies, holidays, overtime, or professional
training); have no loss due to uncollected fees; and have $42,000
of office expenses as I do, in Colorado. It should be noted that
the resulting salaries below do not include employer paid health
insurance benefits.
1.
A psychologist would have an annual income of $89,357 if all of
the patients were Medicare.
2.
A psychologist would have an annual income of $61,680 if all of
the patients were typical in-network insurance patients.
3.
A licensed master’s level therapist would have an annual
income of $61,680 if all of the patients were Medicare.
4.
A master’s level therapist would have an annual income of
$47,280 if all of the patients were typical in-network insurance
patients.
Although
the above compares psychologists with master’s level therapists,
all non-MDs are in the same boat when it comes to discriminatory
reimbursement levels. A rising tide lifts all boats. However,
when the tide or water level goes down, blaming the captains of
other boats does nothing to lift one’s own boat. Mental
health practitioners include doctoral level psychologists as well
as social workers, family therapists, and counselors. They are
all necessary as treatment providers, and they are all the victims
of the managed mental health market manipulation. If the professions
blame each other, we will all sink, and while sinking we will
maintain a level of discord and conflict that is a blemish on
our professions. We need to make an alliance with
all professional groups, and with consumer groups, to fight the
real problem—those managed care entities,
health care economists, and insurance companies which use mental
health funds for their own profit, not for the welfare of mental
health patients.
Adequate mental health services occur when patients can find a
therapist able to deal expertly with their needs, and when conditions
allow the treatment to continue as long as necessary. Therapists
have varying specialties, and for therapy to be optimally successful,
it is important to find a therapist that meets a patient’s
interpersonal and treatment needs. Traditionally, referral networks
help patients locate the right therapist. When reimbursement rates
are low, provider panels are limited. Traditional referral networks
are disrupted by these limited panels. Some patients simply are
unable to find appropriate therapists.
The American Psychological Association Interdivisional (39/42)
Task Force on Managed Care and Health Care Policy (for which I
serve as co-Chair) has obtained several surveys showing that insurance
provider panels often contain names of unavailable providers (phantoms).
These “Phantom Panels” give the illusion of access
to mental health care. These studies show patterns of provider
shortages—usually there are very few, if any, providers
who are available and able to deal with specialized areas of treatment
such as child therapy, treatment of teens, dual diagnosis, etc.
It is not desirable, from a patient’s point of view or society’s
point of view, to have a mental health system in which master’s
level therapists earn little more than skilled laborers like carpenters
and doctoral level psychologists working for the typical managed
care entity earn at the pinnacle of their career only slightly
more than occupations that do not require a bachelor’s degree.
The low reimbursements cause a brain drain, with obvious deleterious
effects on mental health services.
In discussion of Disparity 2.0 with colleagues we have developed
ideas about a strategy for addressing low reimbursements and the
resulting effects on access to quality mental health services.
I believe that if an alliance of mental health care professionals
could win the Mental Health Parity battle, we can also win the
Disparity 2.0 battle. In the Parity battle, we learned that the
public does not support the insurance driven discrimination against
mental health care, and when informed, they will be on our side.
The public wants their health care premiums to be spent providing
health care, not creating large, profitable managed mental health
care carve-outs.
The alliance of mental health advocates who won the Mental Health
Parity battle can implement the following course of action.
1. Advocacy groups should maintain a strong and primary focus
on adequate reimbursement and adequate patient access to traditional
treatment services including inpatient services; individual,
family, and group psychotherapy; and psychological testing.
Professional organizations have too often avoided the reimbursement
crisis by encouraging their members to find other sources of
income.
(a)
Many professional organizations are addressing the reimbursement
crisis by suggesting that their members pursue other services
such as coaching, psychologist prescription privileges, and
new niches. These new services are valuable, but are not a reason
to divert attention from offering traditional mental health
services.
(b) Some professional groups are advocating for including mental
health in all aspects of health care reform. These groups advocate
for integrating delivery of mental health services with primary
care. Increasing availability of mental health services through
primary care is valuable but irrelevant to promoting the most
important issues—adequate reimbursement and adequate level
of services. In the 1990s, health care economists promoted integrated
delivery, group practices, one-stop shopping, and services combined
with primary care providers. Some of these are relevant to future
mental health services. However, these developing services were
not as important as their proponents claimed in the 1990s, and
now, they still do not address the problem with reimbursement
and adequate level of services. As my Texan colleague says,
“How is it better to eat a bowl of tasteless non-nourishing
gruel in a primary physician’s office, either as an employee
or private practitioner, than it is to swallow the same managed
care gruel in your own office? The problem is the stuff we need
to swallow, not the location where we are forced to eat it.”
2.
Mental health advocates need to make a commitment to an overall
strategy and campaign that results in health care reform advocates
across the country insisting that health care reform include four
elements:
(a)
Inclusion of the full range of mental health services.
(b) Traditional mental health parity for deductibles, copayments,
and benefit limits.
(c) Adequate reimbursement for mental health services.
(d) Access to adequate services for mental health patients.
This
campaign should result in the level of reimbursements and services
being addressed as often as the inadequate reimbursements for
primary care providers and nurses are mentioned. Judging by the
success of the mental health parity campaign, the pro-mental health
campaign, and the primary care practitioner’s campaign,
it is reasonable to expect that an adequate reimbursement and
adequate level of services campaign can receive widespread public
support and eventual success in health care reform. This strategy
should include
a.
Building alliances among all mental health professionals
and consumer groups, just as the successful parity campaign
was based on these alliances
b. A comprehensive effort by the professional groups to document
the number of professionals who are leaving clinical work due
to the poor reimbursements and the financial difficulty that
mental health professionals encounter in the current health
care reimbursement system
c. Comprehensive study of why and how the health care
system is unfairly targeting mental health services These studies
would include survey research of reimbursement practices and
phantom networks in mental health and a comparison of these
practices to practices in physical health care, and they would
connect the dots between poor reimbursement and limitations
in access to mental health services. This research is necessary
to describe Disparity 2.0. This research should cost no more
than several hundred thousand dollars, not too much to protect
the financial survival of the mental health professions.
d. A comprehensive effort to end the practice of diverting
a larger portion of mental health funds to administration and
profit than is diverted in physical health care.
e. While this article focuses on the role the private insurance
industry plays in Disparity, 2.0, the campaign for True Parity
needs to include the public payers that fund services for
the severely and chronically mentally ill.
e.
While this article focuses on the role the private insurance
industry plays in Disparity, 2.0, the campaign for True Parity
needs to include the public payers that fund services for the
severely and chronically mentally ill.
f. A public education component that includes press
releases, publications, and communication with the media. The
public education would emphasize the relationship between discriminatory
reductions in reimbursement for mental health services and a
discriminatory reduction in access by the public to quality
mental health services.
g. A lobbying component that calls for addressing the
problem of inadequate reimbursement in all health care reform
legislation
3.
Mental health advocates need to make a commitment to use the expert
services of attorneys and health care economists to promote mental
health services, not to confine or hide the problems involved
in delivering mental health services. Too often the mental health
professional organization attorneys have focused narrowly on preventing
the slightest risk of anti-trust violations. They have encouraged
mental health professionals to be silent about reimbursement problems
even as our professions are being suffocated. The tax attorneys
have focused narrowly on preserving nonprofit tax advantages of
mental health professional organizations, and urged mental health
professionals to be silent about their needs for financial survival,
all the while, missing the bigger picture that patients cannot
access health care services without a professional workforce.
These organizations have employed health care economists, well
paid to predict success or disaster and influenced primarily by
the biggest players, insurance companies, to direct mental health
professionals to be compliant with the managed behavior health
care entities. The mental health professional organizations have
not adequately employed expert advice to address the kind of discrimination
that is emerging in Disparity 2.0.
Primary care and nursing professionals have successfully conducted
campaigns that address inadequate reimbursement, and they do not
appear to be violating anti-trust laws nor do they appear to be
doing anything that would violate nonprofit status. Mental health
has successfully campaigned for improved reimbursements in parity
legislation, and this advocacy did not violate anti-trust or nonprofit
laws. Moreover, addressing access to mental health services does
not violate anti-trust or nonprofit laws, and reimbursements are
the core of the access problems in mental health. Advocacy is
possible and necessary.
1.
Mental health professional organizations need to tell the anti-trust
attorneys to find a way within the anti-trust laws to fashion
a successful campaign to address the reimbursement
and adequate services problems that are the core of Disparity
2.0.
2. Mental health professional organizations need to tell the
501(c)(3) attorneys to find a way within the nonprofit laws
to fashion a successful educational campaign to address the
reimbursement and adequate services problems that are the core
of Disparity 2.0.
3. Mental health professional organizations need to employ health
care economists to help analyze Disparity 2.0 and help mental
health professionals design a strategy to address and correct
Disparity 2.0.
The
final question that remains is, “Why has mental health been
singled out for such disproportionate discrimination by insurance
companies?” I do not believe that the insurance companies
or managed mental health care entities hate mental health patients.
I do believe that these entities are inclined to take money where
it is easy to take. I have a managed-care-free practice and make
a living as a psychologist treating patients who will self-pay
or go out-of-network to obtain my services. In other words, I
treat patients who are so dissatisfied with managed mental health
care services that they would rather pay the full cost of treatment
out-of-pocket than see a managed care provider. Over the past
23 years, I have only had two patients who made small protests
to insurance or to their employer about inadequate in-network
mental health services. Because of the stigma and emotional drain
of mental health problems, my patients would rather just pay me
than complain or attract attention to their problems. On the other
hand, when there is a problem with physical health care or access
to a physical health care provider, many of my patients have been
willing to battle with their insurance company. I think that the
stigma and drain of mental illness is the only explanation needed
to explain why mental health is vulnerable, and when a financially
vulnerable population exists, it is the responsibility of the
professionals to do the educating and the advocacy.
Managed behavioral health care companies have only one customer,
the insurance company. How they operate their businesses is a
proprietary secret. They are a special entity within the insurance
industry, and exist for the purpose of limiting the funds spent
on mental health care. As the overt forms of disparity have been
outlawed by parity legislation, it is not surprising that these
poorly regulated entities are continuing the tradition of discrimination.
So what is different about how health care insurance handles mental
health services compared to physical health services? The goal
of insurance companies is not to foster societal goals such as
insuring everyone. The goal of insurance companies is to sell
insurance policies that produce a profit, even if one out of seven
people in the U.S. are uninsured. Likewise, insurance is not concerned
with maintaining the workforce required for access to quality
inpatient and outpatient mental health services. In physical health
care, apparently, the insurance industry believes that in order
to sell profitable insurance policies, it must adequately reimburse
physical health care. Therefore, it cares about accessibility
to quality physical health care services. On the other hand, although
the law requires that most health insurance include mental health
services, apparently, insurance does not see a need to adequately
reimburse these services. The reasons may be that mental health
is a minor part of health care, the beneficiaries of these services
are unlikely to complain, and there is a history of years of insurance-driven
financial discrimination. The bottom line is that the health
care insurance system does not care about access to quality mental
health services, and the reality is that it prefers to reduce
funding in spite of harming access to quality health care services.
Cutting funding for mental health services probably increases
health care insurance profitability, and therefore, the insurance
industry has developed financing systems that end up contributing
to the historical discrimination against mental health services.
Conclusion
This open letter calls for a new, organized direction and effort
by all mental health advocates to address the problems in Disparity
2.0. Achieving the social goals of access to quality mental health
care will not come spontaneously from insurance companies, but
will only come from public and governmental pressure. If we keep
our alliance, and keep our focus, we can create adequate reimbursements
for inpatient treatment until we have restored an adequate number
of psychiatric beds. We can reverse a 20 year pattern of reducing
provider reimbursements. We can reestablish mental health professions
as middle-income professions. And we can assure patients of an
adequate selection of providers who can treat their individual
and special needs. Victory in the battle over Disparity 2.0, the
same as the victory in the Mental Health Parity battle, will avoid
the tendency to dwell on our conflicts, and require that we maintain
our alliance in order to lift all boats.
Addendum regarding health care reform
The colleagues who have helped with this paper and I have developed
a hybrid health care financing proposal, Balanced Choice, that
combines the benefits of a public system with market forces, and
bypasses the need for insurance companies. It would eliminate
the insurance-driven discrimination against mental health services
and prevent the administrative waste and abuses of insurance-driven
healthcare. This hybrid has the administrative efficiency of a
single payer system without the rigid reimbursement rules that
other single payer systems employ. As a hybrid, it has the ability
to attract advocates of both market driven systems and single
payer systems. Information about Balanced Choice is available
at www.BalancedChoiceHealthCare.org.
Acknowledgements:
Many of the ideas in information in this article have come from
colleagues and Members of the Boulder Psychotherapists’
Guild, Inc. In particular, I want to acknowledge contributions
from the members of the American Psychological Association, Interdivisional
(39/42) Task Force on Managed Care and Health Care Policy—Elaine
Levine, Russ Holstein, Stanley Graham, Stan Moldawsky, Joe Bak,
Sharon Brennan, Bill McGillivray, Mary Kilburn, Frank Goldberg,
and Ed Lundeen. A special thanks to my Task Force co-Chair, Gordon
Herz, who contributed greatly to developing these ideas. In addition
to contributing ideas, Bill Semple and Lyn Gullette have assisted
with the writing and editing.
© 2009 Ivan J. Miller—As owner of the copyright, I
authorize the document to be reproduced and/or published, either
in print form or electronically, as long as it is reproduced in
its entirety and the authorship is acknowledged.
This article is available at http://www.ivanjmiller.com/disparity_article.html
Ivan J. Miller, Ph.D., IvanJMiller@gmail.com
350 Broadway, Suite 210, Boulder, CO 80305
Phone 303-499-3888, Cell 303-870-1529
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