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By Fran Cronin
Medical students are a challenged lot — sleep-deprived, stressed and driven. With the constant cramming of facts into their overloaded heads, and the constant need to steel themselves against the daily rounds of disease and injury, many medical students are left mentally and emotionally drained. Like their patients, they need a doctor. But many don’t reach out for help.
In a research letter just published in the Journal of the American Medical Association, Drs. Rachel Nardin and J. Wesley Boyd — both from the Harvard-affiliated Cambridge Health Alliance (CHA) — help illuminate the vulnerability of U.S. medical students to untreated and debilitating depression and substance abuse. These at-risk students tend not to seek the mental health services they need, the researchers found, due to the overwhelming cost of appropriate mental health services.
Schools and parents may be mandated to provide health insurance, but the study found that many of the plans offered did not provide affordable or adequate coverage for mental health and substance abuse treatment.
Data culled for this first-time survey of health insurance offered to U.S. medical students was collected from June through December 2010. The findings from 115 of the total 129 public and private medical schools in the U.S. revealed wide variability in annual dollar and visit limitations across the non-uniform plans.
[module align="right" width="half" type="pull-quote"]'Mounting debt from long stints at expensive schools weighs very heavily upon the students.'[/module]
For example, mental health dollar limits ran from $1000 – $200,000 for outpatient services; $800 - $200,000 for outpatient substance abuse treatment; and $1000 - $200,000 for inpatient mental health and substance abuse treatment.
Nardin said the survey also revealed that “Private medical schools are more likely than public schools to offer worse-than-average cost-sharing for outpatient substance abuse treatment. The worst region in the country, she said, was the Northeast.
Boyd, a faculty psychiatrist and an outspoken advocate for physician health, served for six years as associate director of the Physician Health Services, Inc., a nonprofit subsidiary of the Massachusetts Medical Society that provides confidential consultation and support to at-risk medical students and doctors across the state.
“Over the past two decades,” he said, “I have seen medical schools try to humanize the student’s experience and observed hospitals ratcheting up easier practices along with their awareness of physician health.” But the reality remains that medicine is very intense and stressful for those who are vulnerable to depression, anxiety, and substance abuse.
Troubled students often resist seeking treatment at the onset of their symptoms, fearing high out-of-pocket costs and an accumulation of more school debt. “But with any psychiatric disorder or substance abuse,” said Boyd, “early intervention definitely correlates to better outcomes.”
“There is a lack of sympathy for this fear of debt,” he said. “Most people just assume doctors will make a lot of money. But mounting debt from long stints at expensive schools weighs very heavily upon the students and most will do anything they can to avoid increasing it.”
According to statistics from the graduating medical school class of 2008, Nardin said, the median debt for public school students was $145,00 and for private school students it was $180,000.
To provide context for the cost of outpatient substance abuse treatment, I spoke with Talbott Recovery Campus, in Atlanta, Georgia, well known by Boyd and others for its Impaired Professionals Program. Debbie Kingston of the intake department told me: “The 90-day residential treatment program costs $39,000 for out-of network plans. If in-network, most insurance plans only cover $2000-$8000 of the total cost.”
Kingston added that detox, even though required, was not included in this tab. Depending on the addiction, detox can take from two to ten days. These costs also do not include the need for on-going monitoring and mental health support once a patient completes their residential stay.
[module align="left" width="half" type="pull-quote"]'The reality is that access to mental health care is very poor in this country, even for people with private insurance.'[/module]
In an article posted recently on Commonhealth, Rachel Zimmerman reported on a study, also authored by Boyd, that points to a more general obstacle to mental health care. The study’s hypothesis, which was borne out, posited that availability of psychiatric services has greatly diminished “due to a combination of paltry reimbursement rates and budget cutbacks." The study’s authors wrote: “Reimbursements for psychiatric services are far lower than for other types of care, so institutions frequently restrict access as stringently as possible.”
Of the 64 medical facilities listed by Blue Cross and Blue Shield in the greater Boston area and contacted for the study, only four could offer an appointment within two weeks. Others refused to offer an appointment due to requirements that all patients be enrolled with a primary care doctor affiliated with that particular psychiatric facility. Study researcher Andy Lindenmeyer, a fourth- year resident in the Harvard Longwood psychiatric program, said, “I think the point here is that having health insurance does not equal access to care.”
Stephanie Woolhandler, a professor of public health at City University of New York and a visiting professor of medicine at CHA, summed up the state of mental health care in a recent email:
“The reality is that access to mental health care is very poor in this country, even for people with private insurance. Because mental illness is stigmatized, the mentally ill are often unable or unwilling to fight their insurance company to get their care reimbursed.
The result is a very uneven distribution of care, with abundant mental health resources available to those who can pay out of pocket, while those that must rely on their insurance find that mental health care is restricted or even unavailable.”
“We need our medical schools to push themselves to provide students with more affordable care,” said Boyd. “What’s best for the health of our students will result in better physicians and the future wellbeing of their patients.”
A note of disclosure: Both Drs. Boyd and Nardin, authors of the survey letter published in JAMA, are active members of the group Physicians for a National Health Program, an organization of physicians who advocate for single-payer national health insurance.
This program aired on September 7, 2011. The audio for this program is not available.
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