Mental Health 'Parity' for Rural Americans

February 2000

 Public policy supporting mental health care often ignores and even thwarts the development of services in rural regions, according to four speakers who recently addressed the Capitol Area Rural Health Roundtable, a forum sponsored by the George Mason University Center for Health Policy Research & Ethics.

The February 10th program, Public Policy and Mental Health Services in Rural America, which opened with remarks from Senator Paul Wellstone (D-MN), drew a hundred representatives of national associations, state and federal programs, and mental health practitioners.

Designed as a rural follow-up to last December’s report by the Surgeon General on national mental health needs, the Capitol Hill program offered policy discussions and recommendations by Peter Beeson, President of the National Association of Rural Mental Health (NARMH); former Nebraska Commissioner of Mental Health, Dennis Mohatt; rural health services researcher David Hartley of the University of Southern Maine; and telehealth expert Beth Stamm of the Institute of Rural Health Studies at Idaho State University.

Tough Issues

Mental illness and drug addiction in particular are tough issues to address because they are often misperceived as moral failures instead of something that can strike anyone, Senator Wellstone told attendees.

“Politics is personal,” said Wellstone of his drive to pass the Mental Health Parity Act of 1997 in partnership with New Mexico Senator Pete Domenici (R).  He said their bipartisan alliance grows from their own family experiences with mental illness.

Wellstone said the 1997 act attempts to end “discrimination” in health care insurance by requiring policies to cover mental illness in the same manner as other physical illnesses.  He called it a “citizen’s law,” won by a “citizen’s lobby.”

“It was a great victory because usually when the health insurance industry is opposed to something, that’s it,” he said.  The Minnesota senator also said he is optimistic about passage of their next legislative initiative, the Mental Health Equitable Treatment Act, which prohibits group health plans already providing mental health benefits from limiting the number of hospital days and outpatient visits for mental illness.

“It’s not perfect, but it covers a fairly broad range of illnesses, including childhood illnesses, and it applies to rural in all sorts of compelling ways,” he said.  Wellstone also spoke of the rural need for mental health services in view of the “economic convulsions right now in agriculture.”  He listed severe depression, families under “unbelievable stress,” increasing substance abuse, and increases in suicide.

“Rural America today has become part of The Other America,” he said, a reference to Michael Harrington’s 1963 treatis on the plight of the invisible poor.  Also citing a recent report commissioned by the U.S. Conference of Mayors, Wellstone said the most dramatic increase in addictions is now occurring in rural America -- “but there’s not the infrastructure there for treatment.”*  He said a new addiction recovery bill, Fairness in Treatment, “will need the voice of the recovery community” to win passage.

One Size Doesn’t Fit All

While the Minnesota senator outlined the need for better mental health coverage and treatment, the forum’s rural speakers talked of urban-oriented policies that ignore or frustrate development of rural services.

“People in rural America are at no less risk for mental disorder than those in urban settings,” said NARMH president, Peter Beeson, but they “face shortages of mental health professionals…and overwhelming barriers to accessing services.”

“The diversity of rural is enormous,” said Idaho’s Beth Stamm, adding that rural and frontier areas need latitude in addressing the mental health needs of their communities.

Public policy that does not take such diversity into account will fail, said Dennis Mohatt.  Yet “programmatic solutions to mental health problems are more often than not built on urban models,” said Beeson.  He cited public programs designed for urban neighborhoods and foundations whose per capita funding requirements, he said, funnel the majority of resources to high-density metropolitan areas.

Beeson said it is easy for today’s policy makers to lose sight of “rural realities” because they are increasingly urban-based and more than a generation away from a rural family experience.
He said even national professional associations are developing guidelines and ethical standards molded from urban practice, citing a policy against any social contact between patients and mental health providers that would be impractical in a rural community.

In another example, Beeson and Mohatt said the increasing concentration of public dollars over the past fifteen years on people with serious and persistent mental illness, through programs like Community Mental Health Centers, means that rural areas, which lack the urban “wealth of private and charitable organizations,” have few alternative resources for residents in situational crises.

Meanwhile, national accreditation standards for providers increasingly stress specialization and discourage innovative use of local generalist providers and paraprofessionals, said Mohatt, a mental health executive who also consults to Native American and other rural communities.

“The vast majority of doctoral level providers (physicians and psychologists) practice exclusively in urban and suburban settings,” said Mohatt, but policy often “dictates the active involvement of doctoral-level providers in assessment and treatment.”  This delays treatment for rural residents who are primarily dependent on nondoctorally-prepared.

Also commenting on the tendency of state Medicaid and employee benefit programs to contract separately for mental health services, Mohatt, a former Nebraska Medicaid administrator, said rural sites need to combine medical and mental health services. Rural residents need the anonymity that a one-stop health center allows, and it is also expensive to maintain dual service systems in rural areas, he said.

Focus on Providers

“Senator Wellstone has made a convincing case for parity with respect to the financing of mental health, but parity of coverage doesn’t guarantee parity of access,” said David Hartley, Director of the Rural Health Division of the Muskie School for Public Service at the University of Southern Maine.  His center’s own four-year study of Maine state employees showed that even when all employees received a hike in benefits through a new behavioral health care contract, rural employees had a significantly lower increase in utilization than urban employees that was traceable to a lack of providers.

A major factor feeding provider shortages, said Mohatt is the “poor payer mix” typical of rural insurance markets.  Dominated by small employers and individual purchasers, they serve up a poorer benefit package – without mental health services.  Federal government policy contributes to this poor mix, said Mohatt by making Medicaid mental health benefits optional for states and by low Medicare reimbursements.

“This is something Congress could do something about,” he said.  He recommended a basic mental health and substance abuse benefit under Medicaid and improvement in Medicare reimbursement levels for outpatient mental health services, which require more than 15-20 minute patient encounters.

Charting mental health provider shortages also has a low priority in public policy, said Hartley, because most programs to bolster health care in underserved areas are focused on primary care.  Only one, the National Health Service Corps, addresses mental health workforce shortages.  The Corps has begun to increase its mental health field placements in recent years, said Hartley.  But the program’s requirements for licensure, said Mohatt, make it difficult to recruit mental health providers to rural areas before they have settled into an urban career site.

Hartley said managed behavioral health organizations could also help pinpoint rural mental health provider shortages, but his research indicates they have few incentives to do so.  Neither the National Committee on Quality Assurance nor many state Medicaid contracts have very specific requirements to guarantee access to providers, he said.

The Maine researcher said the federal government’s current overhaul of its shortage designation process should include mental health and involve state offices of mental health, not just primary care associations.  He also supported a proposal for a joint task force of federal agencies to study data collection.  Hartley called on professional organizations to follow the AMA’s example of tracking all providers -- not just their members -- and making the database available to analysts, policymakers and planners.

Still, lamented Mohatt, “we’re not training rural mental health providers.”  He said internship and residency program requirements prevent the development of rural placements that could provide rural expertise.  He blamed the problem on a lack of federal support for rural training and on what he called the competitive “guild” mentality of the disciplines that limits  practice scope for non-doctoral professionals.

Digital Divide

The Internet and telecommunications hold enormous potential for delivering primary care, mental health and specialty services in rural communities, said Beth Stamm of Idaho State University’s Institute of Rural Health Studies.  Unfortunately, “those who need telehealth most have the least opportunity to access it,” she said, because they live “in the digital frontier.”

Describing frontier realities, Stamm said there are 208 towns in Idaho, two with populations over 50,000 and the rest with fewer than 10,000.  There is no major east-west highway in the state, so it takes longer to drive 257 miles from eastern Idaho’s school of health professions to the state capital in Boise than it takes to fly from Portland Oregon to Washington D.C.  It also costs more if she tries to fly:  “I can fly from Portland to Washington for about $398 dollars, but it costs me $450 to fly across our state.”

Stamm said that while more than half of U.S. counties (which are also rural) are without mental health specialists, “eighty-six percent of the Internet resources that could connect local providers and their patients with psychiatrists and psychologists are held in the financial and scientific districts of our top 20 cities.”

“I can tell you years of stories of jumping on bush planes with boxes of old urban cast-off equipment trying to figure out how to patch together a system that would give us anything at all,” she said.

Stamm, who specializes in low infrastructure applications and who founded an Alaska telemedicine project, advised her audience to examine any new policy that “widens the digital divide.”  She said the Balanced Budget Act of 1997 was supposed to improve Medicare reimbursement for telemedicine, “but something happened between these halls of Congress and the halls in my clinic.”

Telecommunications can also overcome burnout among rural practitioners, she said, by overcoming the stress of their isolation.  She also recommended legislation to support interdisciplinary training.  Stamm, who serves on the American Psychological Association’s Committee on Rural Health, said the association is developing an interdisciplinary handbook on behavioral healthcare for rural and frontier areas that will be available next year.

Avoiding Catch-22s

NARHM’s Beeson advised rural advocates to avoid getting trapped by  “Catch-22” circular reasoning from policymakers who say they can’t justify directing resources to places that need them because of low density.

“If we’d followed that reasoning in the past, rural areas would be without electricity, postal service, and education,” he said.  Beeson referred to “the law of large numbers” as “covert discrimination.”  The change in the proportion of urban to rural Americans in the last century has led to political disenfranchisement, he said.  He urged his audience to “remember the political realities you encounter are not laws of the universe.”

Additional proposals offered by the Roundtable panelists included recommendations to:

• credential rural provider organizations through quality assurance systems rather than by requiring specific provider credentials,
• support rural insurance purchasing cooperatives,
• amend the “IMD” (Institute of Mental Disorders) restriction on Medicare reimbursement to state and private psychiatric hospitals that deters short-term psychiatric care in rural facilities.

*No Place to Hide:  Substance Abuse in Midsize Cities and Rural America, Jan. 2000, the National Center on Addiction and Substance Abuse (CASA) at Columbia University.
 

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