The Mental Health Parity and Addiction Equity Act (MHPAEA) has been law since 2008. MHPAEA provided that health plans could not limit mental health or substance use disorder benefits in a way that was more restrictive than how most medical/surgical benefits were limited. This sounds simple enough, but in this year alone there has been a White House task force, voluminous Department of Labor guidance, a SAMHSA best practices manual, and an Energy & Commerce Committee hearing to find out why most people still can’t access care.
We still don’t have all the answers. The issues these efforts have uncovered are numerous: coverage criteria for medical/surgical benefits are often considered proprietary so comparison is impossible; benefit denials often do not offer enough information to allow consumers to appeal; independent reviewers sometimes have perverse incentives when looking at appeals; and the list goes on. All of these issues are exacerbated by growing pains as regulators, health plans, providers, and patients work out their rights and responsibilities under the law. In fact, a bill just passed by Congress will clarify what is even required for health plans to be compliant with parity rules.
Unless there is further guidance on this point, one thing will still confuse us — people still won’t be access a number of cost-effective and evidence-based behavioral health services, and the role of MHPAEA in addressing this issue is unclear.
A Case Study: The Collaborative Care Model
The Collaborative Care Model (CoCM) is a way for primary care providers to offer mental health treatment in the primary care setting by using a case manager and consulting with a mental health specialty care provider. More than 80 randomized control trials have demonstrated its effectiveness in treating mental health conditions. It has been the subject of a favorable Cochrane review, and has been recommended by the Community Preventive Services Task Force. Studies have found that CoCM reduces overall health care costs compared with usual primary care and The Washington State Institute for Public Policy estimates an almost 9:1 return on investment for society as a whole. The Centers for Medicare and Medicaid Services (CMS) recently demonstrated its support for this service by introducing billable codes for CoCM in the most recent Medicare Physician Fee Schedule.
Despite all of that, very little is known about access to CoCM outside of clinical trials. In fact, despite our work on the issue, none of us have heard of even a single instance of anyone receiving formal, regular CoCM services. We wonder if anyone else has either?
You can understand our confusion. If CoCM works so well and has such a good return on investment, it should be commonplace in a post-parity world. Why isn’t it? And if it is available, how come people don’t know about it, and why can’t anyone access it?
We understand that mental health parity does not mean you get every mental health benefit you want all of the time. CoCM should easily fit within any health plan’s fairly written medical necessity criteria. In 1985, it was estimated that only 15 percent of medicine had solid clinical trials behind it, and evidence-based medicine was only popularized as a concept in 1991. Given this backdrop, CoCM has more evidence for its effectiveness and cost-effectiveness than many medical/surgical benefits that health plans cover
For example, the Mayo Clinic found that numerous medical treatments commonly covered by insurance, such as routine hormone therapy for post-menopausal women or the routine use of the pulmonary artery catheters, were not supported or were directly contradicted by research. Meanwhile, it is still not clear if CoCM is covered. It would be difficult to construct neutral parity guidelines, fairly applied, that would exclude CoCM without simultaneously disregarding the pillars of quality care and cost effectiveness that should define our health care system.
Most of the litigation around parity compliance centers around benefit denials. Because no one is being offered collaborative care, no one is being denied it. This means that it is challenging to raise any sort of parity claim. If there have been no coverage determinations, it is not even clear whether a service is covered or not. Without certainty that CoCM is covered, providers will not go through the necessary training practice transformation to go out on a limb and begin providing it.
The mystery deepens when we consider that health insurers should want to work with providers who offer CoCM.
With parity, health plans now have to provide coverage for a range of behavioral health services. Compared to many of the current offerings, CoCM not only improves depression outcomes, but has been demonstrated to reduce overall health care costs, both through clinical trials and economic modeling. Putting aside the mandate, health insurance plans have a built-in incentive to push for the growth of CoCM in primary care settings as a way to reduce overall costs and pursue value-based insurance design post-parity. Workforce and training issues definitely impeded uptake, but some of the lag is likely related to the time it takes to adapt to the shifting incentive structures as MHPAEA is implemented.
What should this mean for CoCM and other services that are certainly medically necessary? From any perspective, CoCM is a good idea, so we should see its proliferation across the country, but for other cost-effective and evidence-based behavioral health services, regulators will need to give stakeholders a clearer way to engage with parity aside from appealing denials. Perhaps there could be a process for providers to seek greater clarity on coverage under parity as research shapes medical necessity in behavioral health and providers try to stay cutting-edge. Perhaps also consumers could submit claims in a process for “constructive denials” when services cannot be denied because they are not available. Whatever steps are taken to overcome this issue, regulators should view the success of parity implementation in part by the proportion of individuals that practically have access to CoCM and other medically necessary services, rather than relying on denial rates and analyses of the plan design.
When people have access to the behavioral health care that we would reasonably expect, then parity is beginning to work the way that it was intended to.