Davis: We Must Have Tougher Enforcement of Parity Law

NYAPRS Note: A well stated articulation of why we need states to fully enforce parity laws and to prosecute health plan violators, as has been the case in California and New York, and why mental health treatment requires more than 15 minute sessions and payments.

Mental Health Parity Is A Serious Issue

Kenneth L. Davis  Forbes   October 7, 2016


As a psychiatrist who has spent much of my career researching schizophrenia and other mental disorders, I am acutely aware of a major flaw in our health system: the need for behavioral health care far outweighs its availability, in part because our system does not value or pay for it on par with medical and surgical care. While this failure is understandable–it is difficult to operationalize and quantify measures of behavioral health parity within the existing health care reimbursement system, which is fundamentally based on a cost-of-care framework for physical health conditions–the consequences to individuals and society are devastating.


Because behavioral health services are undervalued, resources too often are insufficient to reach mentally ill people who desperately need therapeutic intervention. This predicament can have a far-reaching impact, because mentally ill people by themselves frequently are unable to seek treatment for physical ailments. A downward spiral can accelerate quickly, as a person in need of help becomes vulnerable to falling through the holes of our social service safety net into a cycle of helplessness.


Consider the example of a mentally ill person suffering from diabetes who does not receive proper care for his mental health problems and therefore is unable to obtain and take the insulin he needs. He ends up at the hospital emergency department, is admitted as an inpatient, and then is released, only to be readmitted within a matter of months.


Such failures are extremely costly to society. A chronically homeless person cycling through hospital emergency departments, inpatient beds, psychiatric institutions, detox programs, halfway houses and, perhaps, jail costs taxpayers about $40,000 per year. Of the more than half a million people who are homeless on a given night, 83,000 are chronically homeless, according to the latest Annual Homeless Assessment Report to Congress.


That subset of the homeless population costs taxpayers $3.3 billion a year. Separately, the cost of healthcare for those suffering from substance abuse is $11 billion, as calculated by the National Institute on Drug Abuse. The terrible human cost adds further urgency to the need to address this problem, particularly since the suicide rate in the United States is at a 30-year high.


A recent survey from the National Association of Mental Illness that analyzed 84 insurance plans in 15 states found that a patient attempting to obtain mental health services was twice as likely to be denied coverage by a private insurer as a patient seeking medical or surgical care.


The Mental Health Parity Act of 2008, however, requires insurers offering behavioral care to cover it as generously as physical care. This means insurers are forbidden from requiring members to obtain extra authorizations for behavioral therapy, while co-pays and deductibles are to be no higher than those for medical benefits.


The Affordable Care Act of 2010 extended the law beyond insurance plans for employers with more than 50 employees to plans in the Health Insurance Marketplace that cover individuals. Enforcement is spread across the Department of Health and Human Services, the Department of Labor, the Department of Treasury and state insurance commissioners, depending upon the type of health insurance plan; it has been spotty at best.


Only a few states, notably New York and California, have prosecuted insurers that have failed to comply with the law. It is time for tougher enforcement by all regulators, for insurers to comply with parity requirements, and for our entire payment system to recognize that health encompasses both mental and physical well-being.


Enforcement of mental health parity means creating measurements of equivalency for mental and physical health services. This is not easy because they are vastly different in nature, but it must be done.


Consider that a doctor visit for a sore throat will take about 20 minutes; the internist can see three patients over the course of an hour, billing each one for services. In contrast, a psychiatrist must discover a behavioral health problem that may not be as apparent as a physical ailment, through a diagnostic interview; he must develop a treatment plan that addresses mental health, physical health and, often, social determinants of health; and engage in treatment with the patient, which can take months until lasting benefits are achieved.


Behavioral health care by its very nature is far more time-consuming than most physical care. However, practitioners are not compensated for their time, but rather for each visit with a patient. The field of psychiatry needs to reframe its work in terms of “procedures” that can then be valued in terms equivalent to the work of other doctors.