Psychosis Treatment Complicated by Loss of Insurance

Loss of insurance by people experiencing early psychosis is a frequent occurrence requiring awareness and monitoring by clinicians and staff in community mental health centers.

Of 31 patients enrolled in a community program for early psychosis treatment who had public or private insurance at baseline, just 14 maintained continuous coverage for a full year, according to a report in the August Psychiatric Services.

"Maintaining continuous health insurance coverage may be difficult for people with early psychosis," study author Tyler Dodds, M.D., told Psychiatric News. "Health care reform will hopefully improve the situation, but it is unclear to what extent. Investigators should continue to track insurance trajectory because lack of insurance is an important modifiable barrier to treatment."

At the time of the study, Dodds was a student at Yale University School of Medicine. He is now a psychiatry resident at the Harvard Longwood Psychiatry Residency Training Program.

In the study, Dodds and colleagues assessed insurance status for 82 individuals enrolled in the Specialized Treatment Early in Psychosis (STEP) program at the Connecticut Mental Health Center. Insurance status was collected at baseline, six months, and 12 months using a combination of self-reports, clinical chart reviews, clinician reports, and a database maintained by the Connecticut Department of Social Services.

Thirty-four participants did not know whether they had health insurance or did not appear for follow-up assessments at six and 12 months. Among the remaining 48 participants, at baseline 18 had private insurance and 13 had public insurance (the rest were uninsured).

By the 12-month assessment, 13 of the privately insured patients and five of the publicly insured patients had lost coverage; participants' clinicians attributed this loss of public insurance primarily to aging out of eligibility or failing to renew enrollment.

Dodds and colleagues noted in their report that the actual frequency of uninterrupted coverage may have been even lower than the data suggest. By assessing insurance status at discrete time points, they said, they may have missed gaps in coverage between assessments. In addition, participants were presumed to have maintained insurance coverage unless loss of coverage was clearly documented, even if follow-up data were incomplete.

The researchers also said that incarceration may play a role in loss of insurance coverage. Among the cohort, nine participants were incarcerated during the first year of follow-up. Five had private insurance at baseline, and all of them had lost it by the six- or 12-month follow-up. The only incarcerated participant with public insurance coverage at baseline maintained it through the 12-month follow-up.

"Community mental health centers may be able to help reduce the disruption in treatment by allowing patients with private insurance to receive their treatment in the public sector," Dodds told Psychiatric News. "And clinicians should be aware that even if patients begin treatment with generous prescription drug benefits, that level of coverage may not endure."

In an editorial in the same issue of Psychiatric Services, Marvin Swartz, M.D., cited the troubling data about longitudinal insurance status found by Dodds and colleagues.

"Will expanded federal eligibility for Medicaid in 2014 remedy these worrisome coverage gaps?" Swartz wondered. "Possibly for those within 133 percent of the federal poverty level, but under health care reform newly eligible consumers are guaranteed mental health coverage equivalent to only basic health plans, not the array of optional Medicaid services that have massively raised the bar for recovery-oriented community-based care. Protecting Medicaid and non-Medicaid state mental health funding will require enormous vigilance and advocacy."