‘Time Has Run Out’: Senate Committee Sends Strong Message About Mental Health Parity Enforcement

This article was originally published by Behavioral Health Business on March 30, 2022.

Members of the U.S. Senate Finance Committee put insurers on notice as they explored ways to better enforce the 13-year-old parity enforcement law meant to be a boon to the behavioral health industry.

During a hearing on Wednesday, Committee Chairman Sen. Ron Wyden (D-Ore.) expressed his frustration over the apparent noncompliance of the health insurance industry to the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).

“We’ve been fed a lot of baloney about this,” Wyden said, recalling a conversation with an unnamed insurance executive who said insurers needed more time to understand MHPAEA. “Well, my message to them is time has run out. We’ve heard from senators on both sides of the aisle — there’s a commitment to getting this fixed.”

He also invoked, as he has several times in public settings, the memory of his late brother, Jeffrey, who died in 2002 at age 51, and lived with schizophrenia for decades.

He also recalled his reaction when MHPAEA became law.

“I said this is for Jeff. This is one that’s gonna really liberate a lot of people. And here we are 13 years later fighting the same problems,” Wyden said.

Wednesday’s committee meeting adds additional evidence that the legislative package around addressing mental health issues in the U.S. — which is expected to be revealed in the early summer — will likely include a heavy focus on ensuring parity enforcement.

Pres. Joe Biden’s State of the Union address laid out a vision for addressing the ailing American mental health care system that was well-received by leaders and advocates in the behavioral health space. And that address included a call for full parity between physical and mental health as part of his so-called “Unity Agenda.”

Biden’s proposed budget for the federal fiscal year 2023, which starts Oct. 1, also includes funds to boost the U.S. Labor Department’s efforts to investigate parity violations on the part of insurance companies. It also includes a provision to apply parity enforcement provisions to Medicare and to “modernize Medicare mental health benefits.”

“We’ve established that Medicare coverage issues persist among seniors just as they do among families,” Sen. Catherine Cortez Masto (D-Nev.) said during the hearing. “And if you believe the old adage that as goes Medicare so goes the market then the mental health coverage gaps in Medicare have consequences for private coverage too.”

The conversation around parity issues was accelerated by a report produced by the U.S. Labor Department, Health and Human Services Department and Department of the Treasury that panned the health insurance industry for not following the law. None of the specific health plans referred to in the report, which weren’t named, provide sufficient information to assess how they approach parity.

Sen. Elizabeth Warren (D-Mass.) questioned witnesses who presented to the committee about the use of non-quantitative treatment limitations (NQTLs) by health plans to limit access to care. Warren said these NQTLs flouted parity enforcement provisions because they appear to target behavioral health care more than other health benefits.

NQTLs were criticized by witnesses and other senators as adding undue burdens on patients and providers who try to use health care benefits to reimburse for mental health services. Andy Keller, president and CEO of the Dallas-based nonprofit Meadows Mental Health Policy Institute, said that NQTLs are one driving reason why many mental health providers only take cash payments from patients.

Warren also condemned what many on the committee and the witnesses called ghost networks. These are lists of providers that are ostensibly in-network with the health plan but are unavailable to a plan members because the listed providers aren’t really in network, the provider is no longer taking new patients, the provider’s office has a long wait time, or doesn’t provide the needed service.

John Dicken, director of health care for the U.S. Government Accountability Office (GAO), told Congress that a recent GAO report found that even people who have health insurance coverage struggle to get connected to a behavioral health provider because of unhelpful insurance health plan networks.

“Challenges like these could cause consumers to face higher health care costs, delays in receiving care or difficulties in finding a provider close to home,” Dicken said. “Many of the stakeholder organizations interviewed and research reviewed and noted that the process for getting approval for mental health services can be more restrictive than it is for other medical services.”

Integrated care held up as a companion reform to parity enforcement

Poor parity enforcement is often blamed for the access crisis to mental health by members of the industry, as it was by several participants in the hearing. However, another focus of the meeting was bolstering the integration of behavioral health in primary care settings. Often, this is referred to as integrated care.

Keller said the most important thing that Congress could do to bring better access to behavioral health is to launch an emergency initiative to drive more integrated care.

Dr. Anna Ratzliff, co-director of the Advancing Integrated Mental Health Solutions Center (AIM Center) and a professor at the University of Washington, called on the committee to consider additional funding to start and implement a collaborative care model, eliminate Medicare cost-sharing requirements for integrated care and increase the current reimbursement for integrated care to “appropriately reflect the value and benefits of services and care provided.”

The AIM Center developed its own integrated care model that it refers to as the collaborative care model, Ratzliff said.

“Expanding the use of the collaborative care model can also help reduce health care costs,” Ratzliff said. “Studies have demonstrated for every dollar spent on the collaborative care model about $6.50 in total health care costs are saved in the subsequent years.”

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