Parity was Our First Step; Equitable Access to Our Services is Next

Behavioral healthcare is deeply personal. Many people working in the field find the idea that it is an industry somewhat odd. Such private and intimate work hardly seems industrial. The building blocks have long been small and informal businesses. It is the classic cottage industry. Yet we have outgrown our cottages and await placement in the larger healthcare industry.

Is our role or position not under our control? In fact, our future autonomy rests on decisions that are just coming into focus for many of us. We will be settling into a new place within healthcare over the next decade. Insurance parity was real progress, but equitable access to our services has not been achieved. Structural factors beyond insurance coverage prevent people from accessing needed services.

This critical juncture for our field demands we understand the nature of structural impediments to access. The relevant history is the past four decades. Our industry status has evolved in parallel with our insurance status over that time period. We have progressed from having uninsured services to services covered on par with medical services. That is a positive story we might want to replicate.

The 2008 parity law brought an end to inferior insurance benefits and fueled business activity. Our field is being courted by investors and large healthcare entities. Yet the remaining structural reality is that we are a specialty service, still stigmatized and shunned by many people in need. Our services are more effective and more widely needed than we knew forty years ago. Access can and should be improved.

Shaped by insurance over four decades

The 1980s were a bonanza for behavioral healthcare facilities funded by insurance. Addiction treatment in 28-day inpatient programs and long inpatient stays for adolescents brought a surge in for-profit hospitals. These new insurance benefits covered inpatient care and provided little or no coverage for outpatient care. Authorization for care was not a concept at the time. A crisis over cost ensued.

The 1990s brought managed care into existence for our field. Medical care was being transformed with management under the new HMO model, and behavioral care was carved out from medical oversight given its unfamiliarity. Managed behavioral healthcare organizations (MBHOs) accepted this carve-out challenge and introduced pre-authorization and other cost controls for both private and public payers.

MBHOs confronted their separation from medical care as they matured. Chronic medical conditions came into greater focus due to their high costs and the prevalence of behavioral comorbidities. Disease management and wellness programs flourished, and our industry expanded its healthcare role. MBHOs noted these changes by selecting a new designation (behavioral health and wellness) for our industry.

The last decade brought many models for medical-behavioral integration. Yet clinical models quickly gave way to acquisitions. Investors saw that parity created attractive buying options. Healthcare systems have steadily incorporated behavioral services. MBHO carve-outs ended with the acquisitions of Beacon and Magellan. Behavioral carve-ins do not exist. They are just called healthcare companies.

Diverging paths for our industry

If we follow the natural course of being absorbed into the healthcare industry, we will remain one specialty among many. Specialties fight for funding and attention to their priorities. This occurs within health plans and healthcare systems. There is no malice. Doctors respect all areas of healthcare and our field will be valued. We just need to get in line. We will not be in the front of the line.

We should politely reject that offer. Our field should not be a specialty. Behavioral issues are ubiquitous, extending well beyond the DSM. Such widely needed services are primary, not secondary. PCPs constantly need our expertise, as reflected in the mnemonic Behavior in All Diagnoses (BiAD). Also, primary care is at risk today. We can help PCPs design a more comprehensive and effective model.

Primary care should be our next battleground for equity. The MBHO years and parity legislation brought clarity and fairness to insurance. Yet stigma survives, sustained in part by our secondary, specialty status. We can reduce stigma greatly by moving into the primary care setting and making our services a routine part of healthcare. At that point, fair or reasonable access is possible.

Stigma rarely impacts medical care (consider exceptions like AIDS), but it still drives inequitable access for behavioral care. Psychiatric symptoms can seem strange or embarrassing. Personal disclosures feel shameful. People see entrenched behaviors as character flaws. Unfair access has been fueled by years of ignorance, stigma, and specialty isolation. This history can end in the daylight of primary care.

How is equitable access related to our acquisition by big healthcare? We are at a crossroads. We will either be molded as secondary, less autonomous specialists, or we can embrace a new role in primary care where access to our services is routine and positive. Our services should be more easily accessed given the range of needs, but our management by large healthcare systems is likely to do the opposite.

A structural move into primary care is daunting but achievable. PCPs can use our help. Parity taught us persistence. Let us embark on another equity challenge, this time collaborating with PCPs to make frontline care more effective. We have the tools to help people change behavior for greater health and happiness. We can simultaneously extend a lifeline to primary care and deal a fatal blow to stigma.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.