CITATION: Oosthuizen, P. et al. 2004. Health care discrimination against the mentally ill - A comparison of private health insurance benefits for major depressive disorder and ischaemic heart disease in South Africa. South African Medical Journal, 94(10):821-823.The original publication is available at http://www.samj.org.za[No abstract available]Publisher’s versio

Oosthuizen, P.

Scholtz, O.

Hugo, C.

Richards, B.

Emsley, R.

Барков, А. В.

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SAMJ FORUM821Discrimination against the mentally ill dates back to antiquity. Inclassical Greece, people with mental illness were not allowed towalk the streets of the city, and their families were fined if theyfailed to control them.1 In the Middle Ages, many of the mentallyill were branded as witches2 or ‘treated’ by means of starving,flogging and chains.1 In the first half of the previous century thementally ill in Europe were persecuted and killed by the Naziregime.3;4 South Africa has been no different from the rest of theworld in terms of discriminating against psychiatric illness, and in1846 the prison colony on Robben Island was converted into ahospital for ‘lepers, lunatics and other chronically ill patients’.5Although the situation seems to have improved over the last fewdecades, stigmatisation of mental illness remains extremelyprevalent, even in so-called developed societies.6;7Advocacy groups have become increasingly important roleplayers in the field of mental health, although with mixed success.Media-supported educational campaigns have done a great deal toraise the level of public awareness, thereby dispelling old mythsand misconceptions on which the discrimination was based. Also,as a result of governmental lobbying, some countries have movedto address the issue of dicriminatory practices against psychiatricpatients. This includes discriminatory health care fundingpractices, where benefits for the treatment of psychiatric disordersare substantially less than those for other illnesses. In the USA,pressure by these groups led to the introduction of the MentalHealth Parity Act of 1996, which went some way towards reducingdiscriminatory funding practices. At the present time, 35 states inthe USA have passed mental health parity laws establishingstandards for reimbursement coverage of mental illness.8South Africa is a country with a past record of discrimination.However, while the apartheid era was universally condemned asone of the worst examples of human rights violations, thetransition to democracy and the accompanying constitutionstipulating equality for all before the law offers a message ofhope. Unfortunately many South Africans can attest to the factthat a liberal constitution does not necessarily imply freedomfrom discrimination. Psychiatrists have long held that there iswidespread discrimination against the mentally ill in SouthAfrica. In the past few years, various support and advocacygroups, as well as the South African Society of Psychiatrists, haveissued a plethora of press releases highlighting discriminatorypractices against the mentally ill. However, there has been littleresearch published on this subject, particularly in the SouthAfrican context.In order to investigate this issue empirically, we evaluated thebenefits available for two common disorders in South Africa, onea so-called ‘psychiatric disorder’ and one a ‘physical disorder’.We chose major depressive disorder (MDD) and ischaemic heartdisease (IHD), as these are both common disorders in SouthAfrica.9-11 Further, a landmark World Health Report12 identifiedboth of these disorders as major contributors to the worldwideburden of disease in terms of death and disability-adjusted lifeyears. In this report, MDD is identified as the fourth mostimportant cause of disability in the world and IHD as the sixthmost important. The purpose of this study was to comparebenefits available for MDD and IHD to persons with privatehealth insurance in South Africa.What was doneThis was a descriptive study of benefits offered by private medicalfunds open to all members of the public in South Africa. Onlyinformation available in the public domain was used and welimited our search to medical funds where information could beobtained from a website. Only options with a monthly premiumabove R450 were included. All information included refers tosingle members only. Medical fund options were excluded fromthe study if they did not have a website that was accessiblewithout a password. Options that offer only a savings plan orhospital plan were also not included. The study protocol wasapproved by the institutional review board of the University ofStellenbosch. One hundred and sixty-four South African medical funds wereidentified using the Internet search engine ‘ananzi’. Each medicalfund was then contacted telephonically to obtain a web address.ISSUES IN MEDICINEHealth care discrimination against the mentally ill — acomparison of private health insurance benefits for majordepressive disorder and ischaemic heart disease in South Africa Piet Oosthuizen, Olge Scholtz, Charmaine Hugo, Belinda Richards, Robin EmsleyProfessor Oosthuizen is Associate Professor of Psychiatry atStellenbosch University. He also has a part-time private practice. DrScholtz is a registrar in Psychiatry in her final year at the samedepartment. Mrs Hugo is Director of the Mental Health InformationCentre of South Africa. Dr Richards is a general practitioner inprivate practice, but is also closely involved with managed health carein South Africa. Professor Robin Emsley is Head of the Department ofPsychiatry at Stellenbosch University.October  2004, Vol. 94, No. 10  SAMJInformation obtained from the website concerning inpatient care,outpatient care, specialist consultations, psychotherapy andchronic medications was entered into a Statistica database. Allinformation was gathered over a 5-month period stretching fromNovember 2002 to March 2003.Statistical analysis Statistical analysis was performed using Statistica 6 software(StatSoft, Inc. 1999 - 2003). The majority of the analyses werediscriptive in nature. Where means were calculated, standarddeviations (in brackets) and ranges are presented. Correlationsbetween numerical variables were calculated using Spearman’srank order correlation coefficients.What was foundOf the 164 funds identified, 57 fulfilled the criteria for inclusion inthis study. Funds excluded and reasons for doing so are listed inTable I. The remaining 57 funds offered 130 different options thatwere included in the analysis. The mean monthly premium for the130 options was R994.80 (SD R370.80) per member per month.Benefits provided for inpatient and outpatient treatment for thetwo disorders are presented in Table II. These amounts onlyinclude options where limits had been placed on benefits.  Whenwe considered options with no limits placed on benefits, we foundthat there were 96 options (73.8% of the total) with no limits placedon inpatient benefits for the treatment of IHD, but only 11 options(8.5% of the total) with no limits placed on inpatient treatment forMDD. We did not find a statistically significant correlationbetween the monthly premium paid by members and inpatientbenefits for either IHD (r = 0.15, t = 0.79, p = 0.43) or MDD (r =0.07, t = 0.80, p = 0.43).In terms of outpatient benefits, 10 options (7.7% of the total)offered unlimited benefits for the treatment of IHD whereas 3options (2.3% of the total) offered unlimited benefits for MDD.When correlations were sought between monthly premiums andoutpatient benefits, we found that although there was a trendtowards such an association for IHD, this did not reach statisticalsignificance (r = 0.17, t = 1.90, p = 0.06). In the case of outpatienttreatment for MDD, a significant correlation was found betweenthe monthly premium and benefits for psychiatry (r = 0.20, t = 2.19,p = 0.03) and psychology (r = 0.26, t = 2.93, p = 0.004).Although our information on chronic benefits was somewhatlimited, we found that in the majority of options (115/130,representing 88.5% of the total) chronic medication benefits for thetwo disorders were the same. The benefits for IHD wereconsidered to be better than for MDD in 12 of the options. In 4 ofthese, limits were placed on the amounts available for psychiatricdisorders that were not placed on the treatment of IHD; in 4 otheroptions there were co-payments for prescriptions for psychiatricmedications that did not apply to IHD; and in a further 4 optionschronic medications for the treatment of psychiatric disordersrequired prior motivation by a specialist whereas chronic benefitsfor the treatment of IHD received automatic authorisation. Twooptions (1.5% of the total) offered no chronic benefits for eitherdisorder. There were no instances where chronic benefits offeredfor MDD were considered more favourable than those for IHD. Wedid not find any significant differences in the premiums betweenoptions with greater benefits for IHD and those with equal benefits(t = 0.12, df = 119, p = 0.91).Discussion Notwithstanding the fact that the global disease burden of MDD isgreater than that of IHD, there is, at our most conservativeestimate, a 20-fold greater benefit availability for the inpatienttreatment of IHD than for the treatment of MDD in private healthcare settings in South Africa. In fact, the vast majority of theoptions that we considered placed no limitations on the inpatienttreatment of IHD whereas in most cases there were severeTable I.  Medical funds excluded from the analysisReason for exclusion Number of fundsClosed schemes — not open to the public 59No telephone number available 26No website 7Insufficient information on website 11Only offering hospital plan 1Only offering savings plan 1No longer in existence 1Fund liquidated 1Total 107Table II. Inpatient and outpatient benefits for IHD and MDDMean (Rands) Minimum (Rands) Maximum (Rands) Standard deviation (Rands)Inpatient IHD* 411 509.09 10 000.00 2 000 000.00 440 091.29Inpatient MDD* 20 283.19 0.00 300 000.00 35 196.32Outpatient IHD 1 755.71 0.00 9 600.00 2 024.08Outpatient MDD 850.17 0.00 7 500.00 1 365.60Psychology 736.85 0.00 3 000.00 803.64* These figures include only capped options (IHD = 33 and MDD = 118) and exclude options with no limits.IHD = ischaemic heart disease; MDD = major depressive disorder.October  2004, Vol. 94, No. 10  SAMJSAMJ FORUM822SAMJ FORUM823October  2004, Vol. 94, No. 10  SAMJrestrictions placed on the treatment of MDD. Although this wasthe most prominent discrepancy, outpatient benefits and evenchronic medication benefits showed discriminatory fundingpolicies, albeit not to the same degree.Another sobering finding was that the outpatient benefits forpsychiatry or psychology do not cover more than three sessionsper year with either of these professions — a visit frequency thatis hopelessly inadequate to provide a reasonable standard ofcare. In fact, the data on outpatient benefits suggest that, inSouth Africa, most medical fund options offer little beyond ahospital plan. Although most people with mental illness canattest to discrimination on a variety of levels,13 it is so muchmore disconcerting when this occurs within the health careindustry.There will no doubt be defenders of the current approach ofdifferentiating psychiatric disorders from other medical illnessin terms of service provision, possibly arguing that psychiatricpatients are less ill, or less likely to benefit from treatmentinterventions. This is simply not true, however, as the disabilitycaused by MDD in terms of impaired physical and rolefunctioning, more days in bed due to illness, more work dayslost, increased impairment at work, and high use of healthservices is greater than for most other diseases.14,15 Furthermore,modern psychiatry is able to provide extensive evidence foreffective intervention in MDD and other psychiatric disorders.16Ironically, depression is a co-morbid disorder in up to 25% ofpatients with IHD and has also been identified as an importantindependent risk factor for cardiac events after coronary arterybypass surgery.17,18 Clearly, restricting funding for the treatmentof MDD is not only discriminatory, but also shortsighted aseffective intervention is likely to be cost saving when takinginto account the total direct and indirect costs of treatingMDD.19Psychiatrists frequently encounter obstacles to the admissionof their patients to private hospitals.  While stigmatisation andnegative stereotypes probably contribute to this, there may beanother reason for this problem — the fee structure forinpatient treatment of psychiatric patients is different from thatof patients with other disorders, with the daily tariff for apsychiatric bed often only about 50% of that of a generalmedical bed. Hospital financial managers, eager to balancebudgets and maximise profits, may therefore be less eager tohave psychiatric patients in their hospitals. Another risk ofdiscriminating against psychiatric patients and reimbursementof psychiatrists and other health care workers is that workingconditions become increasingly difficult, and rewards fewer.This is likely to be a substantial contributory factor to thecurrent mass exodus of psychiatrists and other mental healthcare workers from South Africa.  According to the SouthAfrican Society of Psychiatrists, almost 40% of all practisingpsychiatrists  in the country have left over the past 2 years!The Bill of Rights of the Republic of South Africa20 specifiespeople with disability as one of the groups that may not bediscriminated against. It goes on to state that ‘Nationallegislation must be enacted to prevent or prohibit unfairdiscrimination.’  Psychiatric disorders are included amongthese disabilities. Section 10(1) of the recently approved MentalHealth Care Act of South Africa21 states: ‘A mental health careuser may not be unfairly discriminated against on the groundsof his or her mental health status.’ Despite these legalsafeguards, discriminatory practices continue unabated. A limiting factor in interpreting the results of this study maybe the fact that we did not present standardised cost models forthe two disorders. Future studies should preferably incorporatesome sense of the cost of ‘standard practice’ and ‘best practice’to further ensure fairness in the comparison. However, themagnitude of the difference in benefits as well as the fact thatthere are time limits placed on psychiatric treatment only,should convince even the most jaded sceptic. Discrimination bythe health industry against the mentally ill is a fact. Healthprofessionals, in conjunction with consumer advocacy groups,should address this issue without delay.1. Henderson D, Gillespie RD, Batchelor IRC. Historical review of the care and treatment ofmental illness. In: Henderson D, Gillespie RD, Batchelor IRC, eds. A Textbook of Psychiatry forStudents and Practitioners. London: Oxford University Press, 1956: 1-16.2. Kaplan BJ. Possessed by the Devil? Complex interactions between Catholics and Calvinistsfrom diverse social strata in influencing and understanding the phenomenon of demonicpossession in early 17th century — A very public dispute in Utrecht. Renaissance Quarterly1996; 49: 738-759.3. Birley JLT. Political abuse of psychiatry. Acta Psychiatr Scand 2000; 101:13-15.4. Masson M, Azorin JM. The excessive mortality of subjects with mental disorders in history.The example of the Saint-Jean-de-Dieu Hospital in Lyon during the Second World War.Evolution Psychiatrique 2002; 67: 465-479.5. Makepeace R. The history of psychiatry in South Africa. Canadian Psychiatric AssociationJournal 1969; 14: 221-222.6. Corrigan PW. The impact of stigma on severe mental illness. Cognitive and Behavioral Practice1998; 5: 201-222.7. Corrigan P, Thompson V, Lambert D, Sangster Y, Noel JG, Campbell J. Perceptions ofdiscrimination among persons with serious mental illness. Psychiatr Serv 2003; 54: 1105-1110.8. Frank R, Goldman H, McGuire T. Will parity in coverage result in better mental health care? NEngl J Med 2001;  345: 1701-1704.9. Bhagwanjee A, Parekh A, Paruk Z, Petersen I, Subedar H. Prevalence of minor psychiatricdisorders in an adult African rural community in South Africa. Psychol Med 1998; 28: 1137-1147.10. Bradshaw D, Schneider M, Dorrington R, Bourne DE, Laubscher R. South African cause-of-deathprofile in transition — 1996 and future trends. S Afr Med J 2002; 92: 618-623.11. Rumble S, Swartz L, Parry C, Zwarenstein M. Prevalence of psychiatric morbidity in the adultpopulation of a rural South Africa village. Psychol Med 1996; 26: 997-1007.12. World Health Organization. World Health Report 2001. Geneva: WHO, 2001. 13. Dickerson FB, Sommerville J, Origoni AE, Ringel NB, Parente F. Experiences of stigma amongoutpatients with schizophrenia. Schizophr Bull 2002; 28(1):143-155.14. Lecrubier Y. Depressive illness and disability. Eur Neuropsychopharmacol 2000; 10: S439-S443.15. Lecrubier Y. The burden of depression and anxiety in general medicine. J Clin Psychiatry 2001; 62:4-11.16. Kasper S, Lepine JP, Mendlewicz J, Montgomery S, Rush J jun. Efficacy, safety and indications fortricyclic and newer antidepressants. Depression 1995; 2: 127-137.17. Connerney I, Shapiro PA, McLaughlin JS, Bagiella E, Sloan RP. Relation between depression aftercoronary artery bypass surgery and 12-month outcome: a prospective study. Lancet 2001; 358: 1766-1771.18. Sheps DS, Sheffield D. Depression, anxiety, and the cardiovascular system: The cardiologist'sperspective. J Clin Psychiatry 2001; 62: 12-18.19. Stoudemire A, Frank R, Hedemark N, Kamlet M, Blazer D. The economic burden of depression.Gen Hosp Psychiatry 1986; 8: 387-394.20. Department of Constitutional Affairs. Constitution of the Republic of South Africa. Act No. 108 of1996. Government Gazette 17678, 18 December 1996. 21. Department of Health. Mental Health Care Act. Act 17 of 2002. Government Gazette 24024, 6November 2002. 

Health care discrimination against the mentally ill - A comparison of private health insurance benefits for major depressive disorder and ischaemic heart disease in South Africa

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Health care discrimination against the mentally ill - A comparison of private health insurance benefits for major depressive disorder and ischaemic heart disease in South Africa

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