Progress on parity for persons with SMI

Parity again is at the forefront of our consciousness. Now, it produces feelings of apprehension rather than feelings of a job well done. After eight years, we still are left wondering what has changed. Clearly, many of the hoped for advances in behavioral health insurance benefits and their management have yet to arrive on the scene.

Symptoms of this apprehension abound. President Obama has just created a Parity Task Force, which is due to report to him in October. (See my testimony to the Task Force and my related blog). Research shows that people seeking health insurance do not understand parity. And former representative Patrick Kennedy and the Coalition for Whole Health are on an important crusade asking the Department of Health and Human Services (HHS) to enforce the federal parity laws.

Parity refers to the equivalence of quantitative limits (QTLs) between medical insurance benefits and mental health and substance use insurance benefits. It also encompasses the equivalence of non-quantitative limits (NQTLs) for insurance benefit management between medical care and mental health and substance use care.

These concepts derive from the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and their extension in the Affordable Care Act of 2010 (ACA). Final regulations for private insurance were issued by HHS in 2013. Regulations governing parity applications to Medicaid managed care programs were issued in draft form during 2015 and finalized in 2016.

Slow progress

Recently, John Bartlett and I have examined the impact of parity on the care of persons with serious mental illness (SMI)¹. We were invited to do this analysis because so little has been written on the topic. We examined the impact of changes over the period 2008-2016. However, we acknowledge that many of the advances made in the care of adults with SMI have been slow and incremental over the past 50 years.

Parity mandates do apply to insurance benefits and to benefit management for Medicaid alternative benefit plans developed as part of the state Medicaid expansions under the ACA. These now are being implemented in 31 states and D.C. Parity requirements also apply to all private health insurance provided through the state health insurance marketplaces, and to all new insurance issued through individual and small group plans. Hence, with the exception of the 20 states that have not undertaken the state Medicaid Expansion, we conclude that most adults with SMI potentially have access to health insurance covered by parity mandates. We estimate that about 820,000 adults with SMI actually have enrolled in one of these new plans. This is a very important step forward, yet full implementation is as yet incomplete.

One of the issues with parity is that it is a relative concept rather than an absolute one.

This means that many of the insurance benefits needed by adults with SMI, such as rehabilitation, job and housing supports, etc. are not likely to be available because such benefits are almost never available to medical care populations. This assertion is borne out by the very limited behavioral health insurance benefits included in the current state-defined Essential Health Benefits that drive parity in each of the 50 states and D.C. The proposed new Essential Health Benefits for 2017 suffer from these same deficiencies.

Similarly, management of insurance benefits depends upon the definition of medical necessity. This definition currently varies greatly from plan to plan not only in fact, but also in interpretation. As a relevant example for adults with SMI, management of a person’s medical benefits by one company and management of their behavioral health benefits by another company can be based on very different definitions of medical necessity. Usually, in such situations, behavioral health benefits are managed more stringently than medical care benefits.

It also is important to acknowledge that parity only addresses a small segment of the entire insurance-access-care-outcome calculus. The complete framework includes issue recognition, insurance coverage, access to care, delivery of quality care, and the achievement of improved outcomes. Today, parity only addresses insurance coverage and a component of care access.

Parity in context

A related point also is salient. In our minds, current initial efforts to implement parity are akin to the first stage of the Civil Rights Movement in the U.S. Clearly, later stages may apply parity requirements to delivery of quality care and to the achievement of improved outcomes. Similarly, one also could envision all of this being done via integrated care arrangements, including integrated insurance benefits and integrated benefit management using common medical necessity criteria, as the ACA continues to move us in that direction..

We conclude that parity has great potential for behavioral healthcare and for adults with SMI, yet most of this potential currently is as yet unrealized.

We have many miles to go before we can sleep.