Mental health parity becomes reality
The government’s $700 billion “bailout bill” is meant to rescue the economy, but the improbable means by which it became law may actually do more to rescue people needing mental health care.
Procedural rules prevented Congress from passing the Emergency Economic Stabilization Act of 2008 independently. To bypass this obstacle, the act needed a vehicle – legislation that already had considerable support and met the procedural criteria. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 fit the bill and was signed into law as a provision within and vehicle for the bailout, commencing the most significant change in mental health coverage in at least 12 years.
Laura Robers, MD
“The parity act is an extraordinary milestone for people with mental illness, bringing greater attention to the need for greater access and more equitable reimbursement for psychiatric care and for mental health services, more broadly,”
said Laura Roberts, MD, Charles E. Kubly Professor and Chairman of Psychiatry and Behavioral Medicine at The Medical College of Wisconsin.
Senators Domenici and Wellstone had been leading the charge for more than a decade to bring equality to the manner in which mental health services are insured. Although the road has been marked by numerous disappointments, the new law is a positive step toward greater availability of services and improved continuity of care, many Medical College alumni agree.
“The coupling to the bailout bill was brilliant and quite surprising,” Dr. Roberts said. “It’s the best possible example of positive opportunism I have seen. Most of us in the field believe that this would have succeeded in the next year or so, but it is lovely to have it put in place earlier. This legislation is long overdue and will bring great benefit to all of society.”
The act stipulates that businesses with 51 or more employees that offer a health insurance plan with mental health coverage must provide those mental health benefits at the same level as medical and surgical benefits, including deductibles, co-payments, out-of-pocket expenses, inpatient stays and outpatient visits. The requirements are expected to take effect in January 2010.
Thomas Heinrich, MD ’96, (center) meets with medical students and psychiatry residents at Froedtert Hospital.
One in five people experience a significant episode of mental illness in their lifetimes, and everyone is directly or indirectly affected by the burden and mortality of neuropsychiatric disease. Mental health professionals like Thomas Heinrich, MD ’96, Associate Professor and Vice Chairman for Clinical Services in Psychiatry and Behavioral Medicine at the Medical College, often see how patients are negatively affected by uneven mental health benefits. Some scale back their care while others abandon it altogether because of the financial burden.
“A complete lack of insurance or insufficient coverage for psychiatric illness represents a major barrier to providing adequate mental health care to our patients,” he said. “Patients may drift in and out of care as their benefits are exhausted. This often hampers the clinician’s ability to provide a thorough diagnostic assessment, engage in meaningful psychotherapy and closely monitor treatment response.”
As a staff psychiatrist in the crisis service of the Milwaukee County Behavioral Health Division, child psychiatrist Clarence Chou, MD ’77, GME ’83, sometimes sees patients in the walk-in-clinic who, because of coverage deficiencies, stopped their medication and therapy because the cost was prohibitive. Frequently, these patients deteriorate after ceasing therapy and end up losing their jobs or running afoul of the law.
“We don’t deny treatment for someone with cancer for fiscal reasons,” he said. “When you have heart disease, we don’t say, ‘OK, you’ve reached your million dollar limit, we can’t provide treatment to you anymore.’ So that’s what people in mental health are asking for – they’re asking for equal treatment.”
Dr. Chou is the Immediate Past President of the Wisconsin Medical Society, which has been seeking mental health parity for years. He has also been lobbying for the American Medical Association delegation on this subject in addition to the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry.
Part of the argument in favor of parity has been ethical, as Dr. Chou demonstrated and to which Dr. Heinrich attests.
“Psychiatric disorders are commonly under-recognized, and the associated morbidity and mortality under-appreciated,” Dr. Heinrich said. “In addition, the lack of parity between insurance for psychiatric and medical disease has historically added to the already significant stigma associated with mental illness, thereby making a greatly underserved population more vulnerable.”
Cynthiane J. Morgenweck, MD ’77, MA ’99
Cynthiane J. Morgenweck, MD ’77, MA ’99, is a Clinical Ethicist in the Medical College’s Center for the Study of Bioethics. She suspects that most ethicists would advocate for mental health insurance and consequently, for parity. She personally believes that since mental health is but one aspect of overall health, there ought to be parity, and bringing the issue to the fore is beneficial. She, however, questions how effective the new act can be in light of some of its details and exclusions.
The most obvious omissions in this act are employees of very small businesses, employees who currently receive no mental health benefits (this law will not require them) and people who are uninsured. Additionally, the new law has a cost exemption clause that states that if following this act increases the overall cost of an employer’s health plan by 2 percent in the first year, the provisions of the act will not apply the following year.
“Given that mental health care is frequently a lengthy process and medications are expensive, I believe that there is significant potential for this act to be minimally beneficial,” Dr. Morgenweck said. “Many of the mentally ill do not have insurance, and naturally, this act will not help them.”
There may also be some concern, Dr. Chou said, that some companies could respond to the act by claiming that they now cannot afford to provide any kind of health coverage. That remains to be seen, but Kenneth J. Phenow, MD ’92, MPH, has reasons to believe the costs for employers will be somewhat predictable and not contentious. Dr. Phenow is Senior Medical Director for CIGNA HealthCare of Texas & Oklahoma, a large health services organization located in North Texas.
“The biggest concern we and our clients (employers) would have is increased cost in a system where costs are already out of control and are not sustainable in the near future,” he said. “We don’t expect employers will experience a large increase in utilization from the new parity law, and we expect to be able to manage this utilization properly using the tools we already have in place.”
Large health plans have been at the table with Congress working on parity for years, so everyone’s interests have been represented in the discussions. CIGNA, as well as Dr. Phenow personally, support parity for mental health benefits, he said.
In many ways, the act could lead to a reduction in overall costs, he said. Declining productivity or increased absenteeism among people whose anxiety, depression or other mental illness is not properly treated can come at a substantial cost to employers and to the health care system.
“In my own personal opinion as a physician, parity might help improve overall health care costs or at least improve health because a lot of people may not be getting enough mental health benefits currently,” Dr. Phenow said. “There is a lot of evidence that large costs in the employer population are due to depression or substance abuse.”
Dr. Chou said data indicates that in individual states with parity, mental health costs increased about 1 percent, but overall health care costs declined. If people get adequate mental health coverage, costs for everyone will go down, he said.
“People with mental health issues have physical problems as well, and when we don’t take care of their mental health, they don’t always take care of their physical problems,” Dr. Chou said. “Then these people end up receiving care in emergency rooms or the prison system at an enormous cost to our medical system and society.”
This philosophy begs the question, then, of whether a full mandate for mental health coverage in all insurance plans is in our future. Dr. Morgenweck notes that such a move would certainly raise the cost of insurance and likely a new ethical debate. Everyone agrees that the future will become clearer as details from the current act are implemented and assessed. Meanwhile, Dr. Phenow is personally hopeful that mental and physical health care will one day be on a truly level playing field.
“We are learning behavior is an important part of improving health and the productivity of the nation. Mental health is an important component of that,” he said. “I think we’ll be shooting ourselves in the foot if we don’t take this to its logical conclusion, which would be mandatory benefits.”