Mental Health Parity: Of Organs and Access to Care

Every psychiatrist-in-training stumbles, eventually, on a gaping construction zone at the administrative center of our profession: the issue of mental health parity. Parity is the requirement that third party payers, such as insurance companies, cover mental health care with limits no more restrictive than those for medical or surgical care.

Complications emerge from the question of how, concretely, to equate psychiatric care with internal medicine or surgery. Insurers pose obstacles to patients, such as determing that treatment is not medically necessary, and to psychiatrists, with utilization reviews, prior authorizations, and carveouts. These hurdles take time from psychiatrists at all stages of training, impeding our ability to care for patients. Variable parity enforcement, in which some disorders, such as mood disorders, are more reliably covered than others, such as substance abuse disorders, only adds to the confusion.Only through just coverage will our patients receive the care they need; only through reliable reimbursement will our profession remain financially viable. Without strict enforcement, as too much experience has shown, third parties deny care or erect barriers that prevent patients from getting the care to which they are entitled. Without coverage of mental health care, only patients with deep pockets are able to see psychiatrists.

A recent study, published in the April issue of Health Economics, offers a poignant, if unusual, angle on the value of parity. Economists Jose Fernandez and Matthew Lang hypothesized that parity laws would lower suicide rates enough to impact organ donor supply chains, which rely partly on suicides. To test this hypothesis, the authors compared state-level differences in numbers of suicides, post-suicide organ donors, and post-suicide organ donor-to-suicide ratios before and after implementation of parity mandates. After adjusting for numerous covariates, their analysis found that parity mandates decreased suicides, by about 2.5 percent, and by decreasing suicides, parity mandates decreased the organ supply, by about 0.52 percent.

Dr. Lang kindly responded to an inquiry about the study and its context. Asked why he and Dr. Fernandez had chosen to connect parity and suicide, he observed that while he believes that access to care improves many mental health outcomes, “the problem with trying to connect parity laws to nonsuicidal outcomes has to do with measurement.” Suicides and organ donations are relatively easy to track, so these phenomena offer comparatively firm indices of health outcomes.

From a psychiatric standpoint, this study feels conceptually inverted, since it examines suicide in post-clinical terms. The study reveals, in fact, how the patients opposite us might become statistics in the organ supply chain were it not for the vital services that we, as psychiatrists, provide. To be clear, no one is arguing that lack of parity enforcement is a conspiracy to boost the organ supply. Rather, studies like this one provide an opportunity to view a mundane but important issue from a new angle. While this study addresses parity from an economic perspective, the hypothesis tested by Drs. Fernandez and Lang also offers a reminder that mental health care saves lives. Our work as psychiatrists has a measurable impact at the population level. Still, even with laws in place, actual implementation of parity remains under constant construction—in courtrooms, boardrooms, and emergency rooms.

Psychiatrists at any stage of training can help establish parity; APA’s parity site and the Parity Implementation Coalition’s website at are great places to start. In addition to educational resources, these sites provide the APA parity poster (in English and Spanish) for patient education, information about regional hearings and petitions, and platforms for us to organize—for our patients and our profession. ■