World Mental Health Day falls on 10 October every year. In 2021, we urge that private health insurance in Malaysia be expanded to cover and reimburse for mental healthcare services. This will increase access to affordable mental healthcare services and make Malaysia on par with many developed countries. Then it will be a meaningful celebration of World Mental Health Day 2021 for Malaysia.

The figures for mental health are staggering. According to the Malaysian Institute of Public Health, the number of Malaysians with anxiety, depression or other mental health conditions tripled between 1996-2016, now affecting 29% of all Malaysians (or approximately 10 million people). This tripling is significant as mental healthcare services are estimated to cost the Malaysian economy more than RM 14 billion a year, according to a study published in The Lancet in 2018. The COVID-19 pandemic is certain to have worsened the mental health situation, although no official information has been released.

These ten million Malaysians with mental health conditions receive treatment from both the public and private healthcare systems. While public hospitals and clinics are affordable, there are simply not enough mental healthcare professionals to deliver care. As of July 2021, there are only 268 psychiatrists in the Ministry of Health (MOH) serving the population. According to data provided by the Malaysian Society of Clinical Psychology (MSCP), there are only 43 clinical psychologists in the MOH, and this figure shows a critical shortage of clinical psychologists. This causes long waiting times and inadequate care, forcing some people to seek mental healthcare or support in the private sector.

Unfortunately, access to private care is costly and beyond reach of many. Compounding the problem is that most medical insurance in Malaysia excludes mental health disorders, and the ones that offer coverage have limited reimbursement for mental healthcare services. For example, one plan offers claims of only up to RM1,500 per year for psychiatric consultations, and only for six conditions (Major Depressive Disorders, Postpartum Depression, Schizophrenia, Bipolar Disorder, Obsessive-Compulsive Disorder, and Tourette Syndrome). Another plan (specifically for women only) offers a one-off reimbursement up to RM5,000 that includes psychotherapy treatment for depression and anxiety disorders. This is grossly inadequate, as mental healthcare services extend beyond consultations to include assessment, psychotherapy, counselling and medicine.

People with pre-existing mental health conditions also find it difficult to get private health insurance in Malaysia. Based on our conversations with several insurance agents, we found that people with a history of mental health conditions generally pay higher premiums to get insured and often with specific claims excluded from their policies. Prospective policyholders with pre-existing mental health conditions also face multiple obstacles to get their insurance plan approved by insurers.

We share some lessons from around the world. In the United Kingdom and United States of America, private medical insurers offer coverage for both inpatient and or outpatient mental health coverage, mainly by increasing premiums. Australians with private health insurance can claim payments for counseling sessions and psychiatric services depending on the type of policy and level of coverage. In 2018, Hong Kong launched its first private medical insurance covering 10 mental illnesses, with a range of 10-15% reimbursement. Thailand makes private mental health insurance available for various levels of support depending on the subscribed policy. The wide variety of countries with different health systems, income levels and reliance on insurance show that it is possible for insurance companies to provide risk-based medical insurance premiums to make mental healthcare accessible and affordable. Expanding to mental healthcare services is crucial because mental health problems increases risks of medical problems, like heart disease. There is no health without mental health.

We propose expanding mental health coverage for private insurance in Malaysia in five specific ways. Firstly, we must increase the number of conditions covered, ideally to cover as many conditions as possible. Secondly, we must increase the coverage sum and reduce the deductibles and co-pays, with different premiums and different packages to offer choice to consumers. Thirdly, we must increase the variety of reimbursable and covered services, ideally to cover services including specialist consultations, psychotherapy and counselling sessions, as well as medication costs. Fourthly, we must reduce the barriers to entry for those with pre-existing mental health conditions by introducing a non-decline concept. And finally, private insurers should gradually reimburse mental health services provided by primary care providers (like our neighbourhood GP), as the GPs gradually receive training, credentialling and support to deliver mental healthcare services quickly, safely and effectively.

All this can be done gradually, but with as much urgency as possible. The business model for private insurers in Malaysia will not necessarily be affected if the actuarial calculations are conducted correctly. Indeed, insurance company revenues might even increase because of greater interest by the general public, especially because Malaysians are generally under-insured.

This gradual expansion can take place in several ways. One, continuous engagement by insurers is crucial. They must collaborate with the MOH, as well as a group of experts such as the Malaysian Mental Health Association and Malaysian Society of Clinical Psychologists. Consultations with the Ministry of Finance and Bank Negara Malaysia are needed to set price capitation guidelines and calculate risk-based premiums. Separately, the MOH must build their internal capabilities of health insurance to ensure effective and sustainable implementation.

Secondly, insurance companies must be incentivized to provide transparent actuarial calculations to determine the premiums necessary for mental healthcare services. Any additional premium must be risk-based and tailored to the individual. We suggest that insurance companies start off with health insurance products that cover mental healthcare services for the corporate sector, in line with their duties as a responsible employer and to increase employee well-being and productivity. This can then be expanded for individual policy-holders, who can choose the premiums and benefits that they want.

Thirdly, Malaysia needs the equivalent of a Mental Health Parity and Addiction Equity Act (MHPAEA), an act passed in the United States in 2008. It requires that health insurance plans include mental health benefits with the same annual and lifetime limits as routine medical care. A study by Lang in 2013 has shown that including mental health benefits in insurance coverage increases access to care, reduces suicide rates, and improves outcomes in the long run. One possible reason is that when patients with mental health conditions receive the same benefits as patients with physical health conditions, this parity dispels the notion of discrimination and encourages help-seeking behaviour. Thus, expanding insurance coverage to mental health conditions is necessary to improve access to mental health services.

Expanding insurance coverage to include mental healthcare services will be a meaningful celebration of World Mental Health Day this year. This is one of many necessary policies to improve mental healthcare coverage in Malaysia. Others include regulating private hospital prices through greater transparency, introducing a sustainable National Health Insurance program, reimbursing costs by using the Diagnosis-related Group (DRG) methodology in mental healthcare services, and expanding SOCSO coverage of mental healthcare services. Eventually, Malaysia must move towards community rating, which requires insurers to offer insurance products in a given territory at the same price to all persons, regardless of their age, health conditions or claims history.

The World Health Organisation theme for World Mental Health Day 2021 is “Mental Healthcare for All: Let’s make it a reality”. It is no longer acceptable to deny people with mental health conditions the coverage and reimbursement that they deserve and need. We must bravely take the first step to make this an even playing field.

Authors:

Dr. Sean Thum (Malaysian Health Coalition)

Ms. Yee Hui Fang (Malaysian Health Coalition)

Dato’ Dr Andrew Mohanraj Chandrasekaran (President, Malaysian Mental Health Association)

Dr. Khor Swee Kheng (Malaysian Health Coalition)

Dr. Lynne Yong Ee Lin (President, Malaysian Society of Clinical Psychology)

Prof Dr Sharifa Ezat Wan Puteh (Professor of Health Economics and Public Health, National University of Malaysia)

Prof Dato’ Dr Syed Mohamed Aljunid (President of Malaysian Health Economics Association)