Med Students Also Plagued by High Insurance Costs for Mental Health

Health insurance coverage for mental health treatment for medical students after the worst of the COVID-19 pandemic had a median out-of-network annual deductible at least twice the median in-network deductible, though most schools offered free therapy sessions, a quality improvement study showed.

Among the health insurance plans for the 138 U.S. medical schools included in this study, the median out-of-network annual deductible was $700 compared with $300 for in-network providers, reported J. Wesley Boyd, MD, PhD, of Baylor College of Medicine in Houston, and colleagues.

Meanwhile, the median out-of-pocket maximum was $10,000 out-of-network versus $5,500 in-network, they noted in JAMA Internal Medicine.

However, free therapy sessions were offered by 124 of the medical schools, and over half of school plans (58.7%) offered co-payment without co-insurance for outpatient mental health treatment.

"The pandemic has hit medical students hard, just like the rest of the world, and medical students were already suffering pre-pandemic," Boyd told MedPage Today. "So it seems imperative that medical schools offer their students the best possible insurance coverage for mental health conditions and for substance use disorders."

A number of studies have shown that U.S. medical students have high rates of depression, suicidal ideation, and substance use. During the early months of the COVID-19 pandemic, 70% of medical students rated their mental health as worse than baseline in one study.

Boyd told MedPage Today that he was pleasantly surprised to find most medical schools offered free therapy sessions, but that student concerns over the privacy of their care and potential professional repercussions still prevent many from using these services.

He recalled one instance he'd heard about in which information a student spoke about in a counseling session in confidence was shared with a university official. "There have been breaches for sure, and whether or not that's likely to occur, or unlikely to occur, or never going to occur, it is certainly something that students think about," Boyd said.

With this perception, students may be more likely to seek counseling outside of school, where in-network costs become a concern, he noted.

Additionally, the student co-authors said that if they were to seek care, they would prefer it to be closer to home and family, on weekends or on a break from school. "Anyone I reach out to there is going to be out of network, so it's a disincentive there, someone's taking time off due to mental health issues," Boyd said. "That's where the in-network versus out-of-network issue could actually have real implications for where you go for care and how you access it."

The "old guard" of medicine, he added, may still convey to medical students that when it comes to mental health, "either there are no problems, or if you think you have a problem, you're emoting too much. It's your fault. You can't suck it up well enough."

Briana Christophers, an MD-PhD student at Weill Cornell Medical College in New York City, who was not involved in this study but led the study on medical student mental health during the COVID-19 pandemic, told MedPage Today in an email that, apart from the stigma, "the timing of medical school courses and clinical rotations may limit whether students are able to participate in these mental health activities even if they are offered."

Financial situations vary among medical students, she said, with most coming from high-income families, but some taking out loans to cover costs of living, who "may also not be able to afford certain offerings through their health insurance even if the school requires them to have insurance."

The cost of prescription drugs for managing mental health must also be factored in, Christophers added.

For this study, Boyd and colleagues obtained data on medical school-offered health insurance plans via school website or phone calls from the 157 U.S. medical schools. They excluded 16 schools that either did not offer their own insurance plan, did not provide access to insurance information, or did not have a matriculated class.

For each plan, the researchers recorded the annual deductible, out-of-pocket maximum, and co-payment and/or co-insurance amounts for mental health outpatient and inpatient services for both in-network and out-of-network. They also looked at costs by region of the U.S.

For in-network outpatient services, 81 schools required co-payment without co-insurance. For out-of-network outpatient services, 106 schools required co-insurance without co-payment. For in-network and out-of-network inpatient services, 102 and 120 schools, respectively, required co-insurance without co-payment. Median co-insurance doubled from in-network to out-of-network for most schools. Schools in the western U.S. had the lowest in-network annual deductible and out-of-pocket maximum, and southern schools had the most expensive median out-of-pocket maximum, whether in network or out of network.

Limitations acknowledged by the study authors included a lack of data on how many students opted out of medical school insurance plans, and how many students are covered by their parents' or other plans. It was also unclear how medical student insurance coverage for mental health compared to that of the general population, other students, or employees.

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