Mental Health and Substance Abuse
Under Parity and Health Reform:
Marriage Made in Heaven?
Kavita Patel, MD, MSHS
Ken Wells MD,
MD MPH
Moderators
A d
AcademyHealth
H l h 2010
Background to Panel

Coverage for MHSA care has expanded and contracted over the last 40
years



For past 10-15 years, MHSA care has been more intensively managed than
medical care in private sector.
Arguments for and against parity and level of coverage overall and for
vulnerable MHSA groups are based on principles/biases, market
experience, and some data;



But over the last 15-20 years, has typically been less generous than for medical
care.
Opinions are often strong and findings are somewhat mixed and lag behind the
evolving market and new policies.
Complex
p policy
p y changes
g and their rationale are often not transparent
p
in
the community.
Can we understand together what may happen and what we need to
know to make health reform & parity work for MHSA?
Panel Members







Kavita Patel – Policy staff perspective
Haiden Huskamp (Harvard) – MHSA parity and reform/federal
employees
Dominic Hodgkin (Brandeis) – MHSA reform and parity;
substance abuse
F li Jones
Felica
J
(Healthy
(H l h African
Af i
American
A
i
FFamilies)
ili ) – community
i
perspective
Benjamin Miller (University
(Uni ersit off C
Colorado)
l rad ) – medical homes
h mes and
mental health
Francisca Azocar (Optum Health Behavioral Solutions) –
behavioral health management perspective
Ken Wells (UCLA/RAND) – old guy (historical) perspective
10 Key Questions
1.
What are opportunities for parity & reform to improve public MHSA? Who will
gain and how?
2.
What will happen to access, costs, and quality of behavioral health care?
3.
How will the market for behavioral health services change?
4.
What will happen to the public sector and persons left out of coverage
(such as undocumented immigrants)?
5.
What are the challenges -- what might go wrong?
6.
How can community members become informed of choices and options for
behavioral health care? Can there be community accountability?
7.
What about
Wh
b
prevention?
i ? Can
C it
i bbe d
defined,
fi d implemented,
i l
d and
d covered
d for
f
behavioral health under reform?
8.
Medical homes: what do we know and for whom, in terms of behavioral
health care and outcomes?
9.
What can be achieved in health information technology for MHSA?
10.
What are key research questions? How can they be addressed to inform policy in
real time?
Applicability
Financial
Coverage
Mental Health Parity
and Addiction Equity
Act (2008)
Patient Protection and
Affordable Care Act
(2010)
Comments
Group plans subject to:
• Employee Retirement
I
Income
SSecurity
i A
Act
• Public Health Services
Act
• Internal Revenue Code
Added to previous Group
plans:
+ “Q
“Qualified
lifi d Health
H l h Plans”
Pl ”
+ Medicaid
The major
expansion
comes from
the intro. of
the rules to
the exchanges
=Annual/Lifetime limits
=Deductibles, Co-pays
and out-of-pocket
expenses
across Mental, Surgical,
and Medical coverage.
No Change
(non-managed care benchmark
and benchmark-equivalent)
benchmark eq i alent)
+ Individual plans.
The financial
parity
i
established by
the MHPAEA
continue
under the
PPACA
MHPAEA
PPACA
Comments
Treatment
Coverage
Equivalent limits on the
freq. of:
• treatments
• # of visits
• # days of coverage
• other limits on scope or
duration of treatment.
treatment
Creates the
Essential Health
Benefits Package
• Must be offered byy all
plans in the exchanges.
EHBs will
include both
mental health
treatments as
well as addiction
and substance
abuse
assistance.
Small
S
ll
Business
Exemption
Companies averaging
C
1 to 100 employees/year.
???
PPACA doesn’t
d
’
clarify if the
exchange’s rules
will apply to the
previously
exempted small
businesses.
Parity Law: Access and Cost


MHPAEA improves benefits for some who already had MH/SA
coverage
 Based on previous parity experience: Expect reduced out-of-pocket
burden, but little effect on utilization or total spending (on average)
 But new restrictions on managed care tools could mean different
impacts this time (the final regulations are crucial)
MHPAEA could lead some employers to drop MH/SA coverage
 Little sign of this so far
Federal Health Reform: Access and Cost


Under
U
d PPACA,
PPACA many uninsured
i
d people
l will
ill get coverage –
improving access:
 Low-income uninsured can jjoin Medicaid
 Others will get private insurance (some through exchanges)
But, issues:
 Will state MH/SA budgets be shifted to Medicaid?


Implications for safety-net providers?
Insurance models mayy not cover wraparound
p
services currentlyy
provided through state systems
Key Issues for Research





Impact of parity for non-quantitative treatment limits,
diagnoses covered,
covered out of network benefit
Impact on public system – will vary based on state/local
response
Can provider capacity handle increased demand?
Differingg impacts
p
for subgroups
g p depending
p
g on prior
p
situation
(e.g. newly insured vs. other)
Complications for research include:



Multi-layered implementation of parity and health reform laws
Difficulty identifying comparison groups for many segments of
population
Lack of information on MH/SA management practices
Felica Jones: HAAF

Parity and health reform are first of all about improving
social justice in healthcare


Can underserved communities and those with behavioral
h l h conditions
health
di i
understand
d
d and
d benefit?
b fi ?
Community engagement skills are needed to realize the
goals
l off parity/reform
i / f
for
f MHSA:
MHSA


Advocacy: Bring people to the table, support their voice, and
exercise their options for themselves
themselves, their family
family, and their
community under parity/reform
Knowledge Exchange: 2
2-way
way sharing of information across
people affected, to build capacity for all, to use and respond to
opportunities & challenges of reform
How We Build Capacity






Build relationships and trust, & invite people to the table
Knowledge exchange activities: conferences,
Knowledge-exchange
conferences webinars
webinars, websites
websites,
discussion groups, newsletters, radio
 Develop a common, simple language
S
Support
working
ki groups off many stakeholder
k h ld levels,
l l to workk
together as equals on key parity/reform issues
Develop action plans & programs to support understanding and
implementation
Disseminate information & products to community
Witness 4 Wellness & Community Partners in Care
 37% of underserved community agency clients are depressed
 Many agencies are stressed and short-staffed
 Limited
Li it d kknowledge
l d off evidence-based
id
b d services
i
delivery
d li
models
d l
 High cultural competency and knowledge of local populations
 Little understanding of parity/reform and what it means for them
CPIC (Community Partners in Care)
Fragmentation
Physical Health
y
Mental Health
Care Delivery Systems
Payment Systems
Training and Education Systems
P bli P
Public Perception
i
Primary Care
Mental Health Never Sits Alone
Psychosocial
Determinants
of Health
Medical
Presentations
Which Need
Behavioral
Treatment
Mental Health
Presentations
Comorbid
Medical and
Psychological
Presentations
Severe Mental
Health/
Substance
Abuse
Presentations
Annual Cost – those
without MH condition
Annual Cost – those
with MH condition
Heart Condition
$4,697
$6,919
High Blood Pressure
$3,481
$5,492
Asthma
,
$2,908
$4,028
,
Diabetes
$4,172
$5,559
Number of Physical Symptoms and Likelihood of Mental Diagnosis
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
0-1
01
2-3
23
4-5
45
6-8
68
>8
Original source data is the U.S. Dept of HHS the 2002 and 2003 MEPS. AHRQ as Spitzer, R. L., J. B. W. Williams, et al. (1994). "Utility of a New Procedure for Diagnosing Mental cited in Petterson et al. “Why there must be room for mental health in the Disorders in Primary Care: The PRIME‐MD 1000 Study." JAMA 272(22): 1749‐1756.
medical home (Graham Center One‐Pager)
Opportunities within the Patient‐Centered Medical Home?
Joint Principles of PCMH
Personal Physician
Physician Directed Practice
y
Whole Person Orientation
Care is Coordinated Care
is Coordinated
and/or Integrated
Quality and Safety
Enhanced Access to Care
Enhanced Access to Care
Payment to Support PCMH
Federal Mental Health Parity:
A Managed Behavioral Health Perspective
 Brief overview of the Federal Mental Health Parity (FMHP)
regulations
 What are the tools and processes that MBHO’s are following
to become parity compliant
 What are the challenges faced by health plans, MBHO’s
employers, patients and providers
 What are some unforeseen consequences
 What are opportunities for improving access and quality of
care
Confidential property of OptumHealth. Do not distribute or reproduce without express permission from OptumHealth.
General Rule and Categories
Group health plans offering both medical/surgical benefits and mental health or
substance use disorder benefits must ensure that the financial requirements
q
and
treatment limitations are no more restrictive than those predominately applied to
substantially all medical/surgical benefits under the plan
No coverage mandate – plans (or state law for insured plans) drive what is covered, but if
you cover it, you must do so in parity
1. Financial Requirements:
 Copayments
 Coinsurance
C i
 Deductibles
 Out-of-pocket maximums
 Annual dollar limits on benefits*
 Lifetime dollar limits on benefits*
*Exceptions to Interim Final Rule per 1996 MHP Act requirements.
Confidential property of OptumHealth. Do not distribute or reproduce without express permission from OptumHealth.
General Rule and Categories
2. Quantitative Limits (illustrative list, not exhaustive):
Examples:
 Day limits
 Visit limits
 Limits on number of episodes of treatment
3. Non-Quantitative Limits (illustrative list, not exhaustive):
M
Medical
di l managementt standards
t d d lilimiting
iti or excluding
l di b
benefits
fit b
based
d on medical
di l
necessity or medical appropriateness, or based on whether the treatment is
experimental or investigative
 Formulary design for prescription drugs
 Standards for provider admission to participate in a network, including reimbursement
rates
 Plan methods for determining usual, customary and reasonable charges
 Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy
is not effective (also known as fail-first or step therapy protocols) – Example: EAP
gatekeeper
t k
models
d l
 Exclusions based on failure to complete a course of treatment
Confidential property of OptumHealth. Do not distribute or reproduce without express permission from OptumHealth.
Benefit Category Classification
The Interim Final Rule organizes
benefits by
y Classification
You must align the Type, Level and
Coverage
g Unit for each classification
Classification
Type
 The Rule establishes six benefit classifications:
 Refers to a requirement or limitation of the same
nature
t
(e.g.,
(
copayments,
t coinsurance
i
and
d
deductibles are different types of financial
requirements)
1 Inpatient, In-Network
2 Inpatient, Out-of-Network
 Compare
p
type
yp to type
yp
3 Outpatient, In-Network
Level
4 Outpatient, Out-of-Network
 Refers to varied magnitudes of a single type that
may exist (e.g., copayments of $10, $20 or $30
based on service, each of those is a Level of the
copayment Type)
5 Pharmacy
6 Emergency
 Apply the predominant level
Coverage Unit
Parity is to be assessed classification by
classification
 Refers to groupings of individuals used to
determine benefits, premiums or contributions
(e.g., individual, individual + spouse, family, etc.)
 Assess parity for coverage unit
Confidential property of OptumHealth. Do not distribute or reproduce without express permission from OptumHealth.
Quantitative Treatment Limitations
Quantitative treatment limitations
(e.g., day and visit limits):
Apply the same test as financial requirements
C
Cumulative
l ti quantitative
tit ti ttreatment
t
t li
limitations
it ti
may not be separate!
IInpatient,
i
in-network
i
k limit
li i off 60 d
days ffor medical
di l and
d 60 d
days
for MH/SUD does not comply, must have a single combined day limit
Confidential property of OptumHealth. Do not distribute or reproduce without express permission from OptumHealth.
Non-Quantitative Treatment Limitations
General parity rule is applied differently to non-quantitative treatment limits
than for financial requirements
q
and q
quantitative treatment limits
 No “substantially all” or “predominant” test applies to non-quantitative
treatment limits
 The rule for non-quantitative treatment limits is stated as:
The processes, strategies, evidentiary standards or other factors used in
applying non-quantitative treatment limits must be “comparable”, and
applied no more stringently”
stringently for mental health and substance use
“applied
disorder benefits, to the processes, strategies, etc. applied to
medical/surgical benefits in the same Classification
 Processes for applying medical management standards specifically include:
pre-authorization, concurrent review, retrospective review,
case management and
d utilization
ili i review
i
Confidential property of OptumHealth. Do not distribute or reproduce without express permission from OptumHealth.
Next Steps: Compliance Assessment Tool
 Developed an assessment guide to assist our clients in
applying
pp y g the formula and tests articulated by
y the Interim
Final Rule
Sections include:
q
 Financial Requirements
 Quantitative Treatment Limitations
 Non-Quantitative Treatment
Limitations
Confidential property of OptumHealth. Do not distribute or reproduce without express permission from OptumHealth.
Next Steps: Benefit Data Assessment Profile
 This toolcollects the required medical and behavioral plan data needed to assess
both p
parity
y compliance
p
((in conjunction
j
with the Compliance
p
Assessment Tool)) and
the cost impact of parity changes necessary for compliance with the Interim Final
Rule
This tool works to align key medical and
behavioral plan data for the purposes of:
 Identifying non-compliant elements of the
existing plan designs
 Providing information regarding potential
plan changes so that a cost estimate can
be established for new designs
Confidential property of OptumHealth. Do not distribute or reproduce without express permission from OptumHealth.
Touch of History:
H lth IInsurance E
Health
Experiment
i
t (HIE)



Randomized trial of variations in familyy health insurance plans
p
on
use/costs/outcomes (1976-1981) -- individual deductible, free care, or
coinsurance (25,50,95) plans up to cap on out-of-pocket expenses.
Annual MH outpatient costs/enrollee modest in free care; costs less in less
generous plans; MH costs more price responsive than medical but less than
expected.
No significant average difference by plan in mental health outcome (MHI)
but significant interaction:
 Low income & good MH less distress in cost-sharing than free care
plans
 Low income & poor MH tend to have greater well-being in free care
than
h cost sharing
h
plans
l
 Keeler, Manning, Wells (1988); Manning et al., (1986); Wells
et al (1987;89;90)
(
; ; )
What are roles of MH professionals in
realizing parity goals? (KW)









Adopt
p a public
p
health perspective
p p
Implement a range of EBPs, more rigorously
Monitor outcomes, improve
p
data systems
y
Expand prevention/early intervention programs and outcomes
Develop practice quality and efficiency standards
Work with diverse stakeholders toward implementation
Develop new models of services delivery in partnership to achieve
reach/quality
Evaluate cost-effectiveness/comparative effectiveness
Ad
Advocate
for
f iinclusion
l i off consumers and
d community
i members
b
with
ih
MHSA conditions as co-leaders
10 Key Questions
1.
What are opportunities for parity & reform to improve public MHSA? Who will
gain and how?
2.
What will happen to access, costs, and quality of behavioral health care?
3.
How will the market for behavioral health services change?
4.
What will happen to the public sector and persons left out of coverage
(such as undocumented immigrants)?
5.
What are the challenges -- what might go wrong?
6.
How can community members become informed of choices and options for
behavioral health care? Can there be community accountability?
7.
What about
Wh
b
prevention?
i ? Can
C it
i bbe d
defined,
fi d implemented,
i l
d and
d covered
d for
f
behavioral health under reform?
8.
Medical homes: what do we know and for whom, in terms of behavioral
health care and outcomes?
9.
What can be achieved in health information technology for MHSA?
10.
What are key research questions? How can they be addressed to inform policy in
real time?