Don’t Go Overboard in Medicare Crackdown

Federal officials overseeing Medicare health benefits for the elderly and disabled have long known that Southern Californians submit higher mental health claims per capita than Americans elsewhere. Two years ago, Medicare investigators turned up some claims that were too outlandish to be explained by even our area’s penchant for psychotherapy. In one, for example, a psychologist billed for more than 24 hours of therapy in a single day; another claimed to have had numerous “sessions” with brain-dead patients.

With evidence like this, Medicare officials began a crackdown on fraudulent claims earlier this year. So far it has saved the beleaguered system about $1 million a month compared to what it doled out last year. In so doing, however, the government has sparked an outcry from mental health workers who say that in cracking down on fraudulent claims, Medicare has denied some legitimate ones.

At the root of the problem lies a disagreement over what is “medically necessary.” Medicare officials claim that much of what mental health caregivers cite as “medical care” is in fact closer to social work. Their claims are not without merit.

For instance, Mary L. Adams, the director of a San Diego mental health care agency, recently told a Times reporter that the Medicare cuts have deprived her elderly clients of important support systems, such as counselors who work with patients without families. “They are very isolated. And now they feel abandoned too,” she explained.

Social isolation, however, is not the same as mental illness. And given that the need to control Medicare spending has become the subject of raging debate in Washington less than a week after President Clinton’s reelection, it seems neither tenable nor wise for Medicare to continue underwriting expensive mental health treatments for patients such as those of Adams when their problems might be better resolved by less pricey social work programs.

On the other hand, mental health workers have a legitimate gripe with the crackdown on Medicare’s payments to psychologists and similar therapists. The pattern of denials this year has been inconsistent and poorly justified, say mental health officials such as Russ Newman, executive director for professional practice at the American Psychological Assn. And this is a prototype of the payment system that Medicare intends to deploy nationwide.

Research has shown that some kinds of serious mental conditions can be successfully treated by the type of conventional “talk” therapy that Medicare is cutting back on. It’s time for Medicare to sharpen and divulge its criteria for acceptance and denial of mental health care, rather than simply, as one psychologist puts it, “throw the baby out with the bathwater.”