The work of achieving parity for the treatment of mental illness and substance use is not over.
Education of patients and clinicians, oversight and enforcement of the new parity law, and, especially, guidance and clarity from the federal government about the application of the parity law to Medicaid and the State Children’s Health Insurance Program (SCHIP) make up the new agenda now that the federal government has—nearly five years after passage of the Mental Health Parity and Addiction Equity Act (MHPAEA)—issued a final rule providing guidance for enforcement of the law.
That was the consensus at a unique “stakeholders” meeting convened by APA in Washington, D.C., in the wake of the government’s release of the final rule last November. The meeting brought together more than 35 groups representing psychiatry and other medical fields, as well as social work, psychology, and patient-advocacy groups
“So many people have worked so many years to get us this far, but we are starting all over again,” said former member of Congress Patrick Kennedy at the meeting. “The new mission is oversight and implementation and enforcement of MHPAEA. The last thing we need to do is let up on the momentum now because we have lulled ourselves into a false sense of security that somehow we have done it. Until this is written into the hearts and minds of practitioners across the whole spectrum of mental health and substance use [care], and until it is written into the hearts and minds of the American people that this is something they should expect when they seek care, then we still have work to do. . . . We are here to discuss the mechanics of a law and its regulations, but I hope you are all aware that this is a civil-rights issue.”
In addition to APA, the groups at the December 6 meeting included the AMA, Academy of Psychosomatic Medicine, American Academy of Child and Adolescent Psychiatry, American Academy of Psychiatry and the Law, American Society of Addiction Medicine, Group for the Advancement of Psychiatry, American Congress of Obstetricians and Gynecologists, National Council for Behavioral Health, American Psychiatric Nurses Association, American Academy of Pediatrics, and American College of Physicians.
There was widespread agreement that the final rule to implement the parity law was an enormous step forward, clarifying a number of issues, especially the status of intermediate levels of care. (For a complete report on the final rule, see Psychiatric News, December 6, 2013).
Mark Covall, president and chief executive officer of the National Association of Psychiatric Health Systems, told Psychiatric News that the stakeholders meeting convened by APA was an important way to build momentum around ensuring proper enforcement of the parity law.
“I think it’s always very important to build broad-based coalitions, and I think the stakeholders meeting did a great job of doing that, bringing together not just people from mental health and addiction services but also general medical and hospital colleagues,” he said. “We definitely felt that the final rule was a very important step toward clarifying some of the gray areas in the interim rule.”
Covall especially emphasized the importance of the final rule’s clarification that parity applies to intermediate levels of care. The rule clarified the scope-of-service issue by stating that the six classifications of benefit schemes (inpatient in and out of network, outpatient in and out of network, emergency care, and prescription drugs) were never intended to exclude intermediate levels of care (intensive outpatient, partial hospitalization, residential care).
“We see that as one of the big wins in the final rule,” he said. “Intermediate levels of psychiatric care need to be covered as they are on the medical side.”
But as Kennedy and others at the meeting noted, there is more work to be done. The stakeholders meeting focused on three core issues related to implementation of the MHAPEA: education, compliance/disclosure/enforcement, and issues related to Medicaid and the SCHIP program.
Former Congressman Patrick Kennedy addresses a meeting convened by APA last month to engage other medical and advocacy organizations in plans to ensure that the Mental Health Parity and Addiction Equity Act is implemented fairly and enforced. “We are here to discuss the mechanics of a law and its regulations,” Kennedy told the group, “but I hope you are all aware that this is a civil-rights issue.” At right are APA President Jeffrey Lieberman, M.D., and APA President-elect Paul Summergrad, M.D.
APA CEO and Medical Director Saul Levin, M.D., M.P.A., said a key action item around which there was unanimous consensus at the meeting was the need for guidance and clarity from the federal government on how—or if—the parity law applies to Medicaid and SCHIP.
Levin said there was also a consensus that there is a need for education of patients and providers of all disciplines about the parity law generally—that it exists and how it affects them—as well as assistance and training around technical aspects of the law such as how to appeal denied claims. “Who do providers and patients report to if they believe there has been a violation of the law?” he wondered. “There needs to be a nationally recognized source that everyone in the field would know they could call to get assistance of that kind.”
Irvin “Sam” Muszynski, J.D., director of APA’s Office of Healthcare Systems and Financing, told Psychiatric News that APA was developing educational material for key state audiences including insurance commissioners and attorneys general.
Discussion at the stakeholders meeting was also devoted to the possible creation of a quasi-volunteer workforce of “parity navigators” who could go around the country to assist health systems and physician practices with technical aspects of the law.
Finally, Levin said enforcement of parity—which the law delegates to states—including monitoring and tracking of violations is a large and complex task that will require advocacy at the state level. Moreover, he said stakeholders agreed that there is a need for published vignettes of actions taken against a health plan for violations—with a description of those violations—that could be used to guide payers and state regulators in enforcing the law.
“We know of cases where the government has acted against a health plan and ruled in [the patient’s] favor, but all we know is the outcome—we don’t know the reasoning behind the action.”
In concluding remarks at the meeting, Levin emphasized the need for unity across all disciplines in helping to ensure enforcement of the parity law; he also emphasized that substance abuse and addictions are to be included in parity coverage. And the South African-born Levin also used the occasion—the day after the death of Nelson Mandela—to commemorate the antiapartheid leader and said Mandela served as a model for how to stand up against discrimination.
And APA President Jeffrey Lieberman, M.D., stressed that the present time marks a pivotal moment in history for the equitable treatment of patients with mental illness and substance abuse.
“We are at the best time ever in terms of being able to provide care . . . and at this point, we are really uniquely advantaged in terms of possibilities. . . . We have a tremendous research capacity we have never had before, and it is progressing at an accelerated rate. We have tremendous prospects. . . . It’s up to all of us to make the most of [this moment].” ■