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The core problem of mental health and insurance is: 1) resource utilization 2) long term cost-effective value A therapist can induce infinite demand on a pati

The core problem of mental health and insurance is: 1) resource utilization 2) long term cost-effective value A therapist can induce infinite demand on a patient, by just doing follow-up sessions ad-infinitum. In argentina for example, people go to the same therapist for decades!! This means that the insurance model doesn't work well, because you can't do actuarial analysis on how much therapy someone might need and how to distribute that in the population. The second part is that as a patient, if the insurance covers your cost, you might as well go to the most expensive therapist you can find, and consume the infinitely. Also, you know more than the insurance company if you plan on using or needing this care, thus you have a very strong adverse-selection situation going on with any plan that is generous on mental health. Economically speaking, mental health should not be part of an insurance scheme. It should be cash pay. To help people that could not afford mental health and they need it, you would do better to provide state-run service, that is low-cost high-effective-value and cover the lower side of the population.

massysett 7y ago
Mental health is no different from any other health on this regard. People can have mental health needs that can be improved or resolved in a finite time frame. They might have a difficult life event for example. People can also have non-mental issues that are chronic and require lifelong attention—diabetes for example.
- conanbatt 7y ago
  It's its own case because of the subjectivity of the diagnosis and the effectiveness and length of treatment. I'm sure that a bunch of other healthcare services have the same issue, like acupuncture or physical therapy. Also, mental health is not particularly expensive to treat itself: why put the insurance company in the middle. Pay the provider directly..
zilian 7y ago
So what if they need it ? I will see a physiologist all my life as I need it, because of a premature autoimmune disease. The described system is broken.
- conanbatt 7y ago
  Insurance on chronic disease is absolutely doable and it has to be done before diagnosis. I wonder if the market offers a low cost health insurance from the moment a person is born dedicated to chronic diseases. I know life-insurance does ,and rather cheaply.
deleted 7y ago
[deleted]
arcticbull 7y ago
> A therapist can induce infinite demand on a patient, by just doing follow-up sessions ad-infinitum. In argentina for example, people go to the same therapist for decades!! You know people who take insulin are on it for the rest of their lives, but that doesn't make it the fault of their doctors. Therapy actually works. "Hundreds of studies have found that psychotherapy is an effective way to help people make positive changes in their lives," Nordal says. "Compared with medication, psychotherapy has fewer side effects and lower instances of relapse when discontinued." [1] > The second part is that as a patient, if the insurance covers your cost, you might as well go to the most expensive therapist you can find, and consume the infinitely. Also, you know more than the insurance company if you plan on using or needing this care, thus you have a very strong adverse-selection situation going on with any plan that is generous on mental health. This is a very strange American perspective on health care. If it was suddenly available to everyone, there's a perception that we'd all be like kids in the candy store getting 1 of everything at the doctors office. That's just not how it works. Nobody in Canada goes to their GP and asks for the immunotherapy and a few casts. People go to doctors because they're sick, and they need treatment and would rather be literally anywhere else. It's not as though we're socializing the electronics section at Best Buy. > Economically speaking, mental health should not be part of an insurance scheme. It should be cash pay. To help people that could not afford mental health and they need it, you would do better to provide state-run service, that is low-cost high-effective-value and cover the lower side of the population. Sold, but it should cover everyone. [1] https://www.apa.org/monitor/2013/02/therapist https://www.apa.org/monitor/2013/02/therapist
- conanbatt 7y ago
  > You know people who take insulin are on it for the rest of their lives, but that doesn't make it the fault of their doctors. The bet on diabetes has to happen before it is diagnosed to make actuarial analysis. If you want to guarantee that all diabetes patients get access to insulin, what you want is charity, not insurance. Insurance is risk pooling. > This is a very strange American perspective on health care. If it was suddenly available to everyone, there's a perception that we'd all be like kids in the candy store getting 1 of everything at the doctors office The science has already shown that is true. Over and underutilization of healthcare are studied effects, ones insurance companies pay very close attention to because if they don't, they will go bust. That is also why countries with free healthcare also have copays. > People go to doctors because they're sick, and they need treatment and would rather be literally anywhere else. I think you are have an outsider's view on how healthcare provision works. No doctor i met would ever agree with this statement.
goobynight 7y ago
State run will be cheap and I'll tell you right now that cheap mental hospitals are not high value. They are prison lite™. It probably makes sense financially though. I don't want to pay any premiums to help out people with asthma, multiple sclerosis, diabetes, birth defects, and so on if we are going to do this though.
- conanbatt 7y ago
  I would be fine with that setup. Its pretty ridicolous to me to keep all the crazy homeless people crapping on the streets of san francisco: very low standards of care will yield fantastic results for them, and not be extended to users that can pay better care somewhere else. This duality is most common in countries with socialized healthcare: allows for the affluent to spend more, and for everyone to have a base level. (An UBI for healthcare!)
we89ielsdk 7y ago
Psychologist here. The arguments you're making could really be applied to healthcare in general. Others have pointed out the comparisons to insulin, etc. I think you've basically made an argument for single-payer government healthcare. However, it's really not true that the typical mental healthcare user is a chronic user. The modal number of visits per outpatient therapy client/patient is 1. Many people feel better after one visit, or decide they don't need it, or it's not worth it (some of it is probably related to availability too, to be fair--they'd like to come more but can't afford it or can't get into the therapist's schedule). You can extrapolate outward from that. Many people come for a few sessions, and then stop without any explanation because they're feeling better but don't want to have an awkward conversation about stopping. The current zeitgeist with therapy is to taper off or terminate as soon as possible, and reinitiate as needed, at least in the US. My sense is the pendulum has swung too far in the shorter end of the spectrum, and a lot of people would benefit from more sessions, but even when they can afford it, are being cut off as soon as possible by therapists who are afraid of being seen as stringing people along. In some ways this is a good thing, but therapy length should really be dictated by need (short or long).
- conanbatt 7y ago
  > The arguments you're making could really be applied to healthcare in general. For many areas sure. Most importantly to primary care. I believe primary care should not be part of an insurance model. It's been brought to this for some good reasons and some bad reasons. Single-payer cannot fix over-utilization. The iron triangle of healthcare: cost, quality, access. If access is unlimited, cost will go up. (Over-utilization a term commonly understood for the use of resources for very low marginal returns). > The modal number of visits per outpatient therapy client/patient is 1 Even more sensical to make it cash pay! I would agree that cash pay in the current system probably leads to underutilization. Which is why a low(access x quality) x low(price) solution from the state would be great to help the bottom ranks and the rest can pay for it themselves. > The current zeitgeist with therapy is to taper off or terminate as soon as possible, and reinitiate as needed, at least in the US This brings another argument on utilization: if you look at it across cultures, it's going to be radically different. It's not something reasonable to insure against. Long term, freeing therapy from insurance works in the favor of therapists: as a political body I would ask tax exemptions that match what insurance companies get and be on your own. (I would recommend the same strategy to primary care doctors, and they are already doing it with the DPC model).
marvin 7y ago
I have a lot of criticism for the Scandinavian economic model, with 50% of the working population employed in the public sector and a >50% tax burden on average. This will be visible if someone happens to read my HN comments once in a while. But I have to say that this purely market economic view of life-saving healthcare, concluding "there is no economically viable way to ensure that everyone has access to life-saving aid, because participation has to be voluntary and that means insurance will be prohibitably expensive" is deeply cruel. Honest question, is it broadly representative for Americans to take this view without considering the human consequences to someone who is unlucky with genetics, family or circumstances? Or is the question just ignored until a problem hits? It's really very simple to solve this in a humane way. Government pays for all healthcare that's necessary to survive and thrive to a humanely minimum standard of care, either providing the services themselves or employing private-sector partners to do so. This is paid through taxation of everyone, spreading the cost on the entire population. Private insurance or paying for elective procedures is still an option for those who have the means and wish to do so. There will be some upheaval because the insurance sector and treatment centers will be in a dramatically worse negotiation position, but it's worth it for the public good.
- conanbatt 7y ago
  > Honest question, is it broadly representative for Americans I don't think so, but what is unique about americans and the healthcare market is very unique sensitivity to quality and access: the idea that you could to a second rate doctor goes very contrary to american culture, but is common currency in socialized health systems, where you are numb to quality as everything has the same price. The US has a private offering called HMO which basically covers everything, and it's had mixed results: even Michael Moore made a documentary where people said "HMO's are evil". Why? Because the idea that you have to be put on a waiting list or might be denied care you want on utilization is unthinkable for americans. That is one cultural aspect, but there are many more that make America Health system unique. > Government pays for all healthcare that's necessary to survive and thrive to a humanely minimum standard of care... It's a solution. Maybe because of the above, no democrat has put it forward: it would be unpopular to tell people they will get free sub-standard, sub-access care. This solution already exists: the VA is basically that. A very low quality service but highly effective. I don't have much sympathy for H. insurance, but if the state wanted to abolish them, they should buy them, not outlaw them. This is so out of how America operates that I don't think it could go through the senate. Personally, i think insurance is the last thing to look at in the space..

massysett 7y ago

Mental health is no different from any other health on this regard. People can have mental health needs that can be improved or resolved in a finite time frame. They might have a difficult life event for example. People can also have non-mental issues that are chronic and require lifelong attention—diabetes for example.

conanbatt 7y ago
It's its own case because of the subjectivity of the diagnosis and the effectiveness and length of treatment. I'm sure that a bunch of other healthcare services have the same issue, like acupuncture or physical therapy. Also, mental health is not particularly expensive to treat itself: why put the insurance company in the middle. Pay the provider directly..

zilian 7y ago

So what if they need it ? I will see a physiologist all my life as I need it, because of a premature autoimmune disease. The described system is broken.

conanbatt 7y ago
Insurance on chronic disease is absolutely doable and it has to be done before diagnosis. I wonder if the market offers a low cost health insurance from the moment a person is born dedicated to chronic diseases. I know life-insurance does ,and rather cheaply.

deleted 7y ago

[deleted]

arcticbull 7y ago

> A therapist can induce infinite demand on a patient, by just doing follow-up sessions ad-infinitum. In argentina for example, people go to the same therapist for decades!! You know people who take insulin are on it for the rest of their lives, but that doesn't make it the fault of their doctors. Therapy actually works. "Hundreds of studies have found that psychotherapy is an effective way to help people make positive changes in their lives," Nordal says. "Compared with medication, psychotherapy has fewer side effects and lower instances of relapse when discontinued." [1] > The second part is that as a patient, if the insurance covers your cost, you might as well go to the most expensive therapist you can find, and consume the infinitely. Also, you know more than the insurance company if you plan on using or needing this care, thus you have a very strong adverse-selection situation going on with any plan that is generous on mental health. This is a very strange American perspective on health care. If it was suddenly available to everyone, there's a perception that we'd all be like kids in the candy store getting 1 of everything at the doctors office. That's just not how it works. Nobody in Canada goes to their GP and asks for the immunotherapy and a few casts. People go to doctors because they're sick, and they need treatment and would rather be literally anywhere else. It's not as though we're socializing the electronics section at Best Buy. > Economically speaking, mental health should not be part of an insurance scheme. It should be cash pay. To help people that could not afford mental health and they need it, you would do better to provide state-run service, that is low-cost high-effective-value and cover the lower side of the population. Sold, but it should cover everyone. [1] https://www.apa.org/monitor/2013/02/therapist https://www.apa.org/monitor/2013/02/therapist

conanbatt 7y ago
> You know people who take insulin are on it for the rest of their lives, but that doesn't make it the fault of their doctors. The bet on diabetes has to happen before it is diagnosed to make actuarial analysis. If you want to guarantee that all diabetes patients get access to insulin, what you want is charity, not insurance. Insurance is risk pooling. > This is a very strange American perspective on health care. If it was suddenly available to everyone, there's a perception that we'd all be like kids in the candy store getting 1 of everything at the doctors office The science has already shown that is true. Over and underutilization of healthcare are studied effects, ones insurance companies pay very close attention to because if they don't, they will go bust. That is also why countries with free healthcare also have copays. > People go to doctors because they're sick, and they need treatment and would rather be literally anywhere else. I think you are have an outsider's view on how healthcare provision works. No doctor i met would ever agree with this statement.

goobynight 7y ago

State run will be cheap and I'll tell you right now that cheap mental hospitals are not high value. They are prison lite™. It probably makes sense financially though. I don't want to pay any premiums to help out people with asthma, multiple sclerosis, diabetes, birth defects, and so on if we are going to do this though.

conanbatt 7y ago
I would be fine with that setup. Its pretty ridicolous to me to keep all the crazy homeless people crapping on the streets of san francisco: very low standards of care will yield fantastic results for them, and not be extended to users that can pay better care somewhere else. This duality is most common in countries with socialized healthcare: allows for the affluent to spend more, and for everyone to have a base level. (An UBI for healthcare!)

we89ielsdk 7y ago

Psychologist here. The arguments you're making could really be applied to healthcare in general. Others have pointed out the comparisons to insulin, etc. I think you've basically made an argument for single-payer government healthcare. However, it's really not true that the typical mental healthcare user is a chronic user. The modal number of visits per outpatient therapy client/patient is 1. Many people feel better after one visit, or decide they don't need it, or it's not worth it (some of it is probably related to availability too, to be fair--they'd like to come more but can't afford it or can't get into the therapist's schedule). You can extrapolate outward from that. Many people come for a few sessions, and then stop without any explanation because they're feeling better but don't want to have an awkward conversation about stopping. The current zeitgeist with therapy is to taper off or terminate as soon as possible, and reinitiate as needed, at least in the US. My sense is the pendulum has swung too far in the shorter end of the spectrum, and a lot of people would benefit from more sessions, but even when they can afford it, are being cut off as soon as possible by therapists who are afraid of being seen as stringing people along. In some ways this is a good thing, but therapy length should really be dictated by need (short or long).

conanbatt 7y ago
> The arguments you're making could really be applied to healthcare in general. For many areas sure. Most importantly to primary care. I believe primary care should not be part of an insurance model. It's been brought to this for some good reasons and some bad reasons. Single-payer cannot fix over-utilization. The iron triangle of healthcare: cost, quality, access. If access is unlimited, cost will go up. (Over-utilization a term commonly understood for the use of resources for very low marginal returns). > The modal number of visits per outpatient therapy client/patient is 1 Even more sensical to make it cash pay! I would agree that cash pay in the current system probably leads to underutilization. Which is why a low(access x quality) x low(price) solution from the state would be great to help the bottom ranks and the rest can pay for it themselves. > The current zeitgeist with therapy is to taper off or terminate as soon as possible, and reinitiate as needed, at least in the US This brings another argument on utilization: if you look at it across cultures, it's going to be radically different. It's not something reasonable to insure against. Long term, freeing therapy from insurance works in the favor of therapists: as a political body I would ask tax exemptions that match what insurance companies get and be on your own. (I would recommend the same strategy to primary care doctors, and they are already doing it with the DPC model).

marvin 7y ago

I have a lot of criticism for the Scandinavian economic model, with 50% of the working population employed in the public sector and a >50% tax burden on average. This will be visible if someone happens to read my HN comments once in a while. But I have to say that this purely market economic view of life-saving healthcare, concluding "there is no economically viable way to ensure that everyone has access to life-saving aid, because participation has to be voluntary and that means insurance will be prohibitably expensive" is deeply cruel. Honest question, is it broadly representative for Americans to take this view without considering the human consequences to someone who is unlucky with genetics, family or circumstances? Or is the question just ignored until a problem hits? It's really very simple to solve this in a humane way. Government pays for all healthcare that's necessary to survive and thrive to a humanely minimum standard of care, either providing the services themselves or employing private-sector partners to do so. This is paid through taxation of everyone, spreading the cost on the entire population. Private insurance or paying for elective procedures is still an option for those who have the means and wish to do so. There will be some upheaval because the insurance sector and treatment centers will be in a dramatically worse negotiation position, but it's worth it for the public good.

conanbatt 7y ago
> Honest question, is it broadly representative for Americans I don't think so, but what is unique about americans and the healthcare market is very unique sensitivity to quality and access: the idea that you could to a second rate doctor goes very contrary to american culture, but is common currency in socialized health systems, where you are numb to quality as everything has the same price. The US has a private offering called HMO which basically covers everything, and it's had mixed results: even Michael Moore made a documentary where people said "HMO's are evil". Why? Because the idea that you have to be put on a waiting list or might be denied care you want on utilization is unthinkable for americans. That is one cultural aspect, but there are many more that make America Health system unique. > Government pays for all healthcare that's necessary to survive and thrive to a humanely minimum standard of care... It's a solution. Maybe because of the above, no democrat has put it forward: it would be unpopular to tell people they will get free sub-standard, sub-access care. This solution already exists: the VA is basically that. A very low quality service but highly effective. I don't have much sympathy for H. insurance, but if the state wanted to abolish them, they should buy them, not outlaw them. This is so out of how America operates that I don't think it could go through the senate. Personally, i think insurance is the last thing to look at in the space..