dividuals requiring mental health services may continue to have unmet needs.
In 1997, the “median” number of days allotted for outpatient care through a managed care system was 25, while the most number allotted was 30. The approximately $25,000 on average as the lifetime limit for mental health inpatient and outpatient services, often has not been enough to cover all necessary treatments or long-term care (Buck et al, 1999). Thus indicating the high cost of both short term and longterm mental healthcare coverage.
The cost estimates of the original Domenici-Wellstone proposal ranged from an increase of 2.5% to 11.4%[xxi] Many retorted that these estimates represented costs to the older indemnity plans that did not control costs as well as the more modern managed care plans. Parity advocates believed that with the newer, more cost effective health care management plans, increases in costs would be minimal if at all.[xxii] Furthermore, they stated, that even minimal costs would be offset by gains made from the reduced absenteeism and greater productivity that would result from increased access to mental health services for employees.[xxiii]
The predictions of three major studies and state experiences did not,, support the idea that costs would rise significantly. First, The Congressional Budget Office predicted a cost increase of .4% as a result of the final Domenici-Wellstone proposal and possibly as low as .16% if employers reduced certain other mental health benefits to compensate for the cost of adjusting cost ceilings of their mental health coverage.[xxiv]
Finally, one of the most famous studies around the time parity was being debated, used data from 24 managed behavioral health care plans with 140,000 enrollees and concluded that the federal law’s removal of dollar ceilings would increase costs for a plan with a $25,000 annual limit only by $1 per enrollee per year. This same study also found that for a plan with no deductible and small co-payments, allowing unlimited inpatient days and outpatient visits would only cost enrollees an additional $7 per year.[xxvi] Roland Sturm, the author of the study thought that costs for parity in the form of managed care, “[were] not going to go through the roof.”[xxvii]
The experiences of states that had already experimented with parity also
supplied helpful information.
These reassurances that costs would not go up significantly, may have seemed fairly convincing, but the research done was confounded by the introduction of managed care. As pointed out by a report by the National Advisory Mental Health Council, “Because in all cases to date parity was implemented in conjunction with managed care, it is difficult to assess the effects of parity alone.”[xxxii]
No more mandates!
Another objection to parity was the increasing intrusion of the government on the health insurance industry. R. Lucia Riddle, vice president for government relations of the Principal Financial Group warned that even if the cost of the MHPA is small, it is just one of many present and possibly future mandates. “…We get hit with a number of mandates, and those costs do add up.” She pointed out a study which showed about 30% of every premium dollar in state-regulated plans were due to mandates.[xxxiii] In 1998, it was estimated by one health insurance official that the total number of all state mandates was near 1,300.[xxxiv] Advocates for mental health parity questioned if the increasing number of mandates strengthened their case that regulation is necessary to ensure proper health coverage.[xxxv]
Push towards more managed care.
When parity was first introduced in many states, managed care was not as ubiquitous or as tight as it is now. The introduction of mandates like parity fueled the growing trend toward managed care. At least one study showed that in the states that adopted parity laws, a switch to managed care soon followed in almost every occasion in which parity was adopted.[xxxvi] The Mathematica study (commissioned by SAMHSA) which looked at the experiences of states who adopted various forms of parity before the MHPA, found that not only did the introduction of managed care at the same time as parity prevent an increase in costs, but it also greatly decreased the amount of mental health and substance abuse services used.[xxxvii] It could have been argued that if costs due to parity were kept down through restricting access to mental health services or otherwise discouraging them, then parity may not really be as helpful as lawmakers meant it to be.
Mental Health Parity and the Consumer
Within the last decade a movement toward increasing mental health benefits for health maintenance organizations (HMO’s) /managed care recipients has been a heated debate. Currently, HMO’s will only cover a set number of outpatient care services for mental health related problems. The decision to set mental health care benefit limitations was supported by insurers who believed an individual with a mental illness would require an extensive amount of treatment; resulting in increased costs and spending for long-term care and hospital visits (Surgeon General 1999). Because of the known need for long-term care treatment for inpatient and outpatient mental healthcare, insurers began to limit the number of visits allotted to a patient enrolled in a managed care system for mental health services. Consequently, consumers of mental health services were given another barrier to overcome toward service utilization. Consumers would now have to pay out-of-pocket for any services needed which extended the allotted visits for mental illness. In an attempt to decrease the amount of money spent on high-risk enrollees (severely mentally ill), insurers attempted to shift responsibility of long-term outpatient mental health care from the private sector to the public sector (Goldman et al., 1994).
The Mental Health Parity Act of 1996 and The Health Insurance Portability and Accountability Act mandate that dollars for mental healthcare be equivalent to that of general healthcare coverage. However, restrictions on number of visits are still a growing concern. If there is no lifetime or annual limitation on dollars spent on coverage but there is a limitation on the amount of services allowed for access than there is by default a cap on spending. A 2001 study conducted by Haas et.al, examined three groups; usual care, health education, and enriched mental health benefit. The usual care group was allotted 20 visits for outpatient psychotherapy per one year scheduled 4-6 weeks apart with a group therapy option as well. The health education group was given educational classes focusing on “stress management” techniques that met once a week for 6 weeks. This group was not provided contact with a psychiatrist or psychologist during the study. Finally, the enhanced mental health benefit group was provided an extensive amount of mental health services. A psychologist was retained for consultations and supervision of medications and other mental health treatments. The study concluded that those individuals in the enhanced mental health group were more likely to utilize services. Furthermore indicating how the removal of visit limitations would increase patient utilization.
Even with insurance it is not unlikely for an individual to be unable to
pay for mental health care treatment. It
is also not unlikely for many severely mentally ill patients to drop well below
the poverty line and become eligible for publicly supported healthcare (Ohio
H.B. 33). Within the state of
Not only do visit restrictions decrease patient utilization of services, visit limitations increase the potential for harm to the patient. Despite a diagnosis of mental illness an individual is still only allotted a specific number of outpatient or inpatient visitation days. The patient and his provider can petition to his HMO to request an extension of visits but is most often denied. A considerable ethical dilemma is encountered. The provider must stop treatment for the patient because he cannot continue to pay out-of-pocket for care, yet the decision to stop treatment was determined by a managed care system, not a physician. An article written by Perina (2002), most accurately portrays what is occurring in the managed care system. “…After 30 days as an inpatient at Porter Adventist Hospital in Denver, Hochalter's behavioral managed-care provider, PacifiCare, ruled hospitalization no longer medically necessary, forcing her into a partial-treatment program. One week after her inpatient discharge, Hochalter entered a gun shop, asked for a pistol, loaded the weapon and killed herself on the spot.” In an attempt to lower costs by denying extended care, the managed care system, in this case PacifiCare may have been responsible for Hochalter’s death.
The Aftermath of Federal Parity
The management of care
As was seen in other states, and as predicted by some involved in the federal debate, managed care found ways to circumvent increased costs due to parity. For example, major report by Mercer/Foster Higgins found Since the introduction of the MHPA, one third of firms with more than 500 employees introduced changes in day or visit limits.[xxxviii] In addition, according to the U.S. General Accounting Office report issued in May of 2000, 14% of employers had yet to comply with the MHPA, and of those who did comply, 87% continued to limit their mental health benefits in some other way.[xxxix]
Do these changes made by managed care negatively affect access to mental health care? Yes. According to Sturm, et al., who conducted a national household survey found that although those in managed care are less likely to receive no mental health care at all, they experience more delays in treatment or less treatment than desired, than those in unmanaged care settings.[xl] A NIMH (National Institute of Mental Health) study supports this; they found that while the number of people seeking outpatient care increased, the number of visits per person did not increase, and the use of inpatient mental health services declined.[xli]
Because the managed care system is now being forced to make changes for the treatment of acute mental health problems, there is a growing concern that the majority of severally mentally ill consumers will utilize healthcare in the public sector (Goldman et. al., 1999). This presents another problem. As severally mentally ill consumers enter into the public healthcare sector taxpayers become responsible for their care. This shifts the burden of cost to yet another source. Public sector insurance (in this case Medicaid) is supported through taxpayers and federal entitlements (although a switch is being made to block grants). The money allotted to public healthcare (Medicaid) requires a specific set of services be covered through reimbursement. States are encouraged to match or exceed the funds provided with federal dollars but are not required to do so. Thus, some states may have extensive coverage for the severely mentally ill while others may have less than adequate mental health coverage. Clearly, there is no guarantee that shifting the higher risk enrollee to public sector insurance will ensure the individual receives the necessary and sufficient healthcare.
NIMH assessed the findings of many large studies, including that of a large state that introduced parity. They determined that parity contributes little if at all to total healthcare costs. NIMH is thus far unable to determine, however, to what degree costs were shifted between different healthcare sectors due to parity.[xlii] The Surgeon General also found no reason to fear parity, characterizing it as, “an affordable and effective objective.”[xliii]
Getting the ball rolling
The enactment of Federal Parity may have been the impetus for more states to enact their own parity laws, some of which are even more powerful than the MHPA. The NIMH (2000) report states:
“Following the 1996 MHPA, 14 States also enacted
statutes to match the federal parity statute including: in 1997, Alaska,
Arizona, Delaware, Indiana, Kansas, Louisiana, Montana, Nevada, North Carolina,
South Carolina, Tennessee, and West Virginia; and in 1998, Florida and New
Mexico. Of the 14, seven States matched the federal statute in 1997 or 1998,
and then opted to have a "stronger" State parity statute:
Different states enacting different parity laws give rise to the opportunity for researchers to look at the effects of a variety of legislation on health care. This could provide the federal government with valuable ideas for parity policy supported by scientific data.
The MHPA also may have influenced increased parity for about 9 million employees covered by the Federal Employees Health Benefits Program. In 1999, President Clinton had the Office of Personnel Management benefit federal employees with not only full mental health parity, but also full parity for substance abuse services.[xlv]
The Mental Health Equitable Treatment Act
Recognizing the setting of the sun on the MHPA, in March of 2001, Senators Domenici and Wellstone once again introduced an amendment enforcing parity for mental health. The Mental Health Equitable Treatment Act of 2001 (S. 543), is much closer to full parity than is the MHPA. This piece of legislation mandates that health plans that provide mental health coverage cannot provide different regulations between mental health coverage and medical or surgical coverage for the following: frequency of treatment, number of visits or days in the hospital, general duration of treatment, deductibles, coinsurance, co-payments, or other costs to the consumer.
S. 543 passed the Senate committee of Health, Education, Labor, and Pensions, and was attached by the Senate to a fiscal year 2002 Labor-HHS appropriations bill in October of 2001. However, S. 543 did not replace the existing mental health parity act as hoped and was removed from the appropriations bill, however, President George W. Bush signed a one-year extension to the MHPA, ensuring one more year of mandated mental health coverage. The MHPA is now scheduled to expire December 31, 2002.
The potential for expanded federal parity is far from over. As of this writing, S. 543 is still alive in the Senate, awaiting passage. Furthermore, on March 13, 2002, the U.S. House of Representatives Committee on Education and the Workforce Subcommittee on Employer-Employee Relations held a hearing entitled, "Assessing Mental Health Parity: Implications for Patients and Employers", the first House hearing ever on parity. Shortly after this hearing, on March 20, 2002, Reps. Marge Roukema (RNJ) and Patrick Kennedy (D-RI) introduced a version of S. 543 to the House: The Mental Health Equitable Treatment Act of 2002.[xlvi] This bill is very similar to its version in the Senate, but it goes even further in that it includes a provision for studying the cost of including substance abuse in federal parity regulations.
Despite the current push for stronger federal parity, the question still remains how effective it really is. Even when the original MHPA was first introduced, many believed that parity would not actually benefit consumers because in order to comply with the new requirements, managed health care plans would just cut back in other areas.[xlvii] The Mercer/Foster Higgins and the General Accounting Office reports mentioned above both bear this out. Furthermore, substance abuse is still not included as a mental illness under the MHPA. The House version of the Mental Health Equitable Treatment Act of 2002 may move in this direction, but only by very little.
Lastly, there are still more than forty million Americans have no health insurance at all.[xlviii] Some feel that we ought to be focusing first on finding a way to grant access to basic health care for the many before we start spending money as a nation to give better health care to the few.[xlix]
In contrast to these arguments, modern advances in the understanding and treatment of mental illness beg the question, why should mental illness be treated differently? The 1999 Surgeon General Report on Mental Illness clearly showed with a preponderance of evidence that mental illness is real illness that can treated. Millions of people who are currently suffering could be leading much more satisfying and productive lives, to the benefit of us all.[l] If parity laws do not actually help the mentally ill in the short run with improved access to services, perhaps they will help in the long run as a symbolic gesture that mental illness is just that, an illness, and it can be treated.
While there is no guarantee that if Mental Health Parity was accepted by all states and visit restrictions were eliminated, insurers in the managed care system would not attempt to find loopholes to decrease costs. It is evident that HMO’s will make it as difficult as possible for mental health consumers to obtain the necessary treatment and services to maintain a productive lifestyle. With the rising of healthcare costs, even fewer individuals will be able to pay out-of-pocket costs for much needed extended mental health treatments. Thus, it is imperative something is done to ensure equal coverage in both lifetime dollar limitations and visit limitations for those with mental illness and those with general healthcare coverage needs.
B, Martin, K, et al. Americans’ views of mental health and illness at century’s
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[ii] National Advisory Mental Health Council. 1997. Parity in
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[iv] Mental Health: a report of the Surgeon General.
[v] Otten, A. Mental health parity: what can it accomplish in a market dominated by managed care?. Milbank Memorial Fund 1998. http://www.milbank.org/mrparity.html (February 2, 2002).
[vi] Fein R. Economics of
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[vii] Hennessy, K. & Goldman, H. Full parity: steps toward equity for mental and addictive disorders. Health Affairs 2001; 20:58-67.
[viii] Otten, A. Mental health parity: what can it accomplish in a market dominated by managed care?. Milbank Memorial Fund 1998. http://www.milbank.org/mrparity.html (February 2, 2002).
[xi] Levinson, CM. and Druss, BG. The evolution of mental health parity in American politics. Administration and Policy in Mental Health 2000; 28:139-146.
[xii] Senate vote confirms public’s demand for parity in mental health benefits. (1996, April 24). [Newswire}. PR Newswire. As cited in Levinson & Druss. (2000).
[xiii] Levinson, CM. and Druss, BG. The evolution of mental health parity in American politics. Administration and Policy in Mental Health 2000; 28:139-146.
[xiv] Otten, A. Mental health parity: what can it accomplish in a market dominated by managed care?. Milbank Memorial Fund 1998. http://www.milbank.org/mrparity.html (February 2, 2002).
[xv] Mercer/Foster Higgins.
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[xvi] Otten, A. Mental health parity: what can it accomplish in a market dominated by managed care?. Milbank Memorial Fund 1998. http://www.milbank.org/mrparity.html (February 2, 2002).
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[xix] Sturm, R. 1997. How Expensive Is Unlimited Mental Health Care Coverage under Managed Care? Journal of the American Medical Association 278:1533-7.
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[xxi] Watson Wyatt Data
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[xxii] Otten, A. Mental health parity: what can it accomplish in a market dominated by managed care?. Milbank Memorial Fund 1998. http://www.milbank.org/mrparity.html (February 2, 2002).
[xxiv] Congressional Budget
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[xxv] Sing, M, Hill, S, Smolkin,S, and Heiser, N.
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[xxvi] Sturm, R. 1997. How Expensive Is Unlimited Mental Health Care Coverage under Managed Care? Journal of the American Medical Association 278:1533-7. As cited in Otten (1998).
[xxvii] Otten, A. Mental health parity: what can it accomplish in a market dominated by managed care?. Milbank Memorial Fund 1998. http://www.milbank.org/mrparity.html (February 2, 2002).
[xxxii] National Advisory Mental Health Council. 1997. Parity in
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[xxxiii] Otten, A. Mental health parity: what can it accomplish in a market dominated by managed care?. Milbank Memorial Fund 1998. http://www.milbank.org/mrparity.html (February 2, 2002).
[xxxvii] Sing, M, Hill, S, Smolkin,S,
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[xxxix] General Accounting
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[xli] National Institute of
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[xliii] Mental Health: a report
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[xlv] FEEB Carrier Letter no. 1999-027,7 June 1999. As cited in Hennesy & Goldman (2001).
[xlvi] American Psychiatric Association. News Release. 2002. (Release No. 02-07). March 20, 2002.
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