With newly proposed mental health parity requirements, Medicaid is joining the decades-long payment reform effort that has sought to boost access to mental health services.
As cost-consciousness spreads throughout the healthcare industry, awareness is rising about the steep price of unmet mental health needs.
Statistics compiled at the Arlington, VA-based National Association on Mental Illness illustrate the crushing cost impact on healthcare providers and payers.
- For youths and adults under the age of 45, mood disorders such as depression are the third most common cause of hospitalization.
- Serious mental illness has been linked to many chronic diseases, with the life-expectancy of the seriously mentally ill 25 years lower than other Americans
- About half of all chronic mental health conditions start by age 14, but years pass before care is provided at higher costs than early interventions.
For the healthcare industry, part of the solution to this daunting economic problem is mental health parity, a visionary goal for healthcare coverage that policy makers in Washington began pursuing in earnest nearly two decades ago.
How Payers Are Curbing Behavioral-Health Cost Drivers
The tentative first step toward parity in group insurance coverage began during the Clinton administration, with passage of the Mental Health Parity Act of 1996. The law's requirements included equating the coverage caps for physical health conditions and mental health conditions, but huge parity gaps remained, such as exempting substance abuse services from provisions of the law.
A leap forward came in 2008, when President George W. Bush signed the Mental Health Parity and Addiction Equity Act. The law embraced and extended the provisions of the 1996 legislation, including coverage parity requirements for substance abuse services.
In 2010, the Patient Protection and Affordable Care Act introduced mental health parity requirements to the individual insurance market.
The latest advancement for mental health parity came this month, with federal officials proposing mental health parity requirements for Medicaid and the Children's Health Insurance Program (CHIP). "The goal is to align as much as possible with the approach taken in the final [federal mental health parity] regulation to create consistency between the commercial and Medicaid markets, according to a Centers for Medicare & Medicaid Services fact sheet released with the proposed rules.
The proposed rules include two crucial provisions:
- Plans must provide beneficiaries and providers with the criteria for medical-necessity determinations for mental health and substance abuse disorder benefits.
- Plan enrollees would gain the right to know the reasons behind denials of claims for mental health or substance abuse services.
This week, Vikki Wachino, director of the Center for Medicaid and CHIP Services, told me the proposed rules reflect a continued commitment at the federal level to push for mental health parity reforms.
"Improving quality and access to care impacts the health of our nation. Whether private insurance, Medicaid, or CHIP, all Americans deserve access to quality mental health services and substance use disorder services… The proposed rule is a way to advance equity in the delivery of mental health and substance use disorder services. The proposal will support federal and state efforts to promote access to mental health and substance use services as part of broader delivery system reform through the Affordable Care Act."
Kimberly DiBella-Farber, COO of the Child Guidance Center of Southern Connecticut Inc., says the proposed mental health parity rules for Medicaid and CHIP are another step in the right direction, particularly for states with tight-fisted Medicaid benefits that limit access to services. However, the mental health parity journey is far from over, she says.
'Still a Lot of Work to Do'
Many steps must be taken before it is as easy to seek treatment for a broken bone as a broken spirit, DiBella-Farber told me. Payment reform has strengthened the legal and regulatory framework for requiring coverage of mental health services, but there are gaping holes in the continuum of care that providers can offer people with mental health conditions, she says. "There's still a lot of work to do."
Integrating Mental Health and Primary Care
For starters, there are not enough mental health providers to meet the demand for mental health services, particularly for the Medicaid-eligible population, DiBella-Farber says. "New graduates are not looking to become Medicaid providers. In some areas of Connecticut and New York, you can put up a shingle and work in the insurance realm. For clinics, it's hard to compete for staff when private practice salaries range from $150 per hour to $200 per hour."
Mental health providers also face an intractable infrastructure investment shortage, she says. "We have clinics, we have emergency rooms, and we have hospitals. We don't have any in-between levels of care. Not only do we need staff, we need programs."
Across the country, transitional housing facilities for people with mental health conditions are either woefully inadequate or nonexistent, DiBella-Farber says. "There are a lot of people who can't live on their own or hold down a job for 12 months a year because of their condition. It makes a huge difference to their health when they know they're not going to be kicked out onto the streets because they experience a difficult episode."
She says there are several other vitally important programs missing or underfunded in the mental health continuum of care, including intensive outpatient programs, home therapy visits, and case management for "concrete needs" such as groceries and employment services.
The mass shooting at Sandy Hook Elementary School in Newtown, CT, has prompted discussions about beefing up mental health programs in The Constitution State, but progress has been painfully slow, DiBella-Farber says.
"We're two-and-a-half years later, and really nothing has changed. Now we're looking at a state budget deficit. … It's definitely worth the investment, but it's a hard sell when there's no guarantee where the money is going to come from."
High Stakes and Untapped Opportunities
Katherine Hempstead, health insurance program director at the Princeton, NJ-based Robert Wood Johnson Foundation, says demand for mental health services is clearly outstripping supply. "There needs to be better ways to provide access to behavioral health providers at a lower cost. I believe there are untapped opportunities involving scope of practice and use of technology that can contribute to better access and care management," she told me this week.
Hempstead says the proposed mental health parity rules for Medicaid and CHIP appear well-intended, adding the stakes are high for people suffering from mental illness.
"The actual enforcement of parity provisions is challenging, and has been so in the private insurance arena as well. The requirement for more transparency about medical necessity rules is a helpful step. … A lot of mental health conditions are treatable rather than curable, but the treatment can make an enormous difference in terms of quality of life and productivity, in the Medicaid population as well as the privately insured population."
The deadline for public comment on the proposed mental health parity rules for Medicaid and CHIP is June 9.
Christopher Cheney is the CMO editor at HealthLeaders.