I was invited to testify at a congressional forum last week by Congressman Chris Van Hollen about challenges in the implementation and enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA). Also present were Congressmen Jim Moran and Paul Tonko, and former Congressmen Patrick Kennedy and Jim Ramstad. These dedicated representatives stayed past 9 p.m., reflecting their dedication and resolve to ensure that the Parity Act be fully implemented.
As most readers of Clinical Psychiatry News are aware, people with mental health and addiction problems have long been stigmatized and marginalized in the health care system, and this one action – passing the 2008 Parity Act – will prove to be a historic correction of this great wrong. Indeed, the first attempt to correct the discriminatory practices of the health insurance industry was passed in 1996, but the industry figured out how to get around the intent of that first Parity Act. The ongoing efforts to close these loopholes are currently stuck, with the lack of final regulations that would dictate to payers how MHPAEA will be implemented and enforced, despite the law being passed 4 years ago.
Even URAC, the standards-based accreditation organization that accredits health insurance plans, has beat the federal government by recently updating its standards to require health plans to clearly and effectively demonstrate compliance with the Parity Act. To my knowledge, this is the first organization to specifically build Parity Act compliance into its standards for accreditation.
There has been an interim final rule passed, but such temporary regulations lack the finality that makes health plans address the more challenging aspects of compliance, particularly the nonquantitative treatment limits, or NQTLs. One of the more pervasive, yet hidden, NQTLs is the inadequacy of behavioral health provider networks compared to that of primary care networks.
I believe that network adequacy is probably THE biggest barrier to accessing care for our patients. When I ask patients about any problems finding a primary care physician, they rarely have problems. But finding an in-network psychiatrist has become an overwhelming problem. The insurance plans do not maintain a large enough network of physicians who specialize in psychiatry, creating a bottleneck that makes it hard for patients to initiate treatment.
While there has been some reductions in the need to obtain prior authorizations for outpatient treatment, the loophole here is that if there are not enough psychiatrists in the network who can actually see the patients needing care, many patients go without. This effectively limits the number of claims a payer must pay out. This is a nonquantitative treatment limit that is more restrictive on the mental health and addictions side than on the physical health side.
You’d think that one could determine the adequacy of the network by the number of providers in it, but this number is not an accurate reflection of the true size of the network. Look more closely and you discover a number of tricks that inflate the apparent size of the network. Whether these “tricks” are intentional or not, they amount to – in my opinion – fraud. If you pay for a plan that has 40 doctors listed in its online provider directory, you expect that you can see most of these 40 doctors. If the truth was that there are only four who could actually see you, then this is false advertising. It is a form of treatment limitation that seems to be applied particularly to behavioral health much more than to primary care.