Obama Administration Issues New Parity Rules

It was great to learn that within the past month, the Obama Administration issued new rules that promise to improve insurance coverage of mental healthcare for more than 140 million people insured through their jobs. It is also is likely that these regulations would be incorporated into any federal healthcare insurance program. Under the rules that go into effect July 1, "employers and group health plans cannot provide less coverage for mental healthcare than for the treatment of physical conditions such as cancer and heart disease."

These rules will apply to group plans of 50 or more people. They prohibit health plans from setting limits on the number of visits or hospital days for mental health problems that are different from any such limitations on treatment for medical problems. They also will not allow separate annual deductibles for mental health treatment or higher copayments for visiting a psychiatrist or a social worker.

APA says that is good—but we have to check further as to meaning

The American Psychiatric Association (APA) praised these interim rules for implementing parity but pointed out that some important issues still need to be clarified and resolved. They are:

1. Will group health plans that include mental health and substance use disorders along with standard medical and surgical coverage treat them equally in terms of practices such as prior authorization and utilization review?
2. What kind of restrictions will be put on health care insurance to prevent them from limiting private networks?
3. Will healthcare insurance programs limit the medications available on formularies?

It is unclear whether the new healthcare regulations—which are meant to apply for private health insurance in the workplace—will require psychiatrists who treat patients to accept the fee in full with no opportunity for balance billing. At present, some insurance arrangements do and some do not. Physicians always have to make a decision when there are fixed fees, if they wish to participate. A large number of all physicians—including psychiatrists—often accept such an arrangement with a certain number of insurance plans. This provides the largest coverage of health care and often allows physicians to fill their practices. Perhaps this would mean that more patients are seen in a finite number of hours leading to shorter visits and less personal care. Hopefully, quality and safety of care do not get seriously impaired.

Is psychotherapy the 800-lb gorilla in the room?

When discussing this issue in regard to psychiatry, however, there is an 800-lb gorilla in the room that is being ignored and that is “Psychotherapy.” To understand this question, you have to look at the federal Medicare program.

Current Medicare regulations in most states will pay less than half of the usual and customary psychiatric fee of psychotherapy visits. This means that every day psychiatrists are having “Happy 65th birthday – Your fee now is reduced to more than half” conversations with patients in ongoing psychotherapy who graduate to Medicare.

If a Medicare patient wants to pay a doctor’s full fee or at least make up the difference, the doctor cannot accept such an offer. By law, the doctor can’t charge the patient a fee above the Medicare fee—even if the patient is in agreement.

The only thing that the doctor can do to treat patients over 65 and charge the patient above the Medicare established fee is to “ Opt Out “ of Medicare. Once this is done, the doctor can treat patients 65 and over but will not be able to submit the bills to Medicare for any reimbursement. Any patient over the age of 65 treated by this doctor must sign a document stating that they understand neither they and/or their heirs will ever be able to submit bills from this doctor to Medicare for reimbursement.

So now the question is how will the new regulations impact the ability of psychiatrists to deliver psychotherapy in the United States? Will increased numbers of people who would benefit from psychotherapy now have access to it? Or will these new changes force those psychiatrists who are skilled in psychotherapy and who want to practice it to opt out of insurance programs because the fee for this time-intensive therapy is not acceptable? Will psychiatrists gradually stop offering most psychotherapy techniques to patients and stick to consultation, psychopharmacology, and time-limited psychotherapy techniques? What are the potential implications to the quality of mental health care in this country?
 
Let us clarify and advocate in the next 2 months

There are approximately 2 months remaining for the comment period to the federal government for these new mental health parity regulations. I hope the APA in its response will closely examine the implications for psychiatrists doing psychotherapy.

I also hope that other organizations, which have psychiatrists as members who value psychotherapy, will weigh in on this issue. Not only do psychiatrists have a great deal at stake here but also so do future generations of patients who could benefit from the continued skills of psychiatrists performing psychotherapy.