Mental Health Parity is Moving Backward

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COMMENTARY

Despite national attention on the need for parity between mental and physical health coverage, we continue to move backward in the fight for equitable access to treatment. A new ruling by President Biden would help ensure equal mental health coverage by requiring insurance providers to evaluate and update health plans.¹

But, in order to achieve true parity, it is important to understand the specific and ongoing roadblocks that inhibit access to care and how they limit clinicians’ ability to provide treatment.

Even amid a national mental health crisis, many patients struggle to access the treatment they need. Of the 21% of adults who had a mental health condition in 2020, fewer than half received mental health care.² The data is even more stark for children and teens: nearly 70% of those under 18 who sought mental health care did not receive it.²

Insurance coverage is an essential part of enabling affordable access to care, yet there continues to be a wide gap between coverage for mental health and physical health. Those with insurance are more than twice as likely to have to go out-of-network and pay higher costs for mental health care compared with physical health care.³

As a practicing psychiatrist for nearly 20 years, I have seen the impact of this coverage gap on both patients and clinicians. Here are some of the persistent challenges to mental health parity and how collaboration between payers and providers can help close the gap.

The Widening Gap Between Mental and Physical Health Coverage

The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 required health plans to cover mental health benefits at the same level as physical health benefits. Yet, a 2022 reportfrom the Health and Human Services, Labor and Treasury Departments found that compliance with this law is not being measured.⁴ In recent years, I have witnessed the gap in coverage grow even wider.

In my own practice, I have seen an increase in preauthorization requirements for mental health care, as well as a concerning trend around payers limiting the number or length of visits. Similarly, some payers still require in-person visits in order to provide coverage, despite evidence that telehealth is both effective and widens access to care.⁵ I have even seen some payers stop covering services they have covered for years.

Another example I see often is decreased coverage of in-patient treatment and intensive outpatient programs (IOP). A decade ago, if a patient was experiencing a manic episode, they might have spent 5 days in a hospital to access the right level of care needed for stabilization. Today, insurance may not authorize an inpatient hospitalization unless the individual is acutely suicidal, homicidal, or unable to provide their own food, clothing, or shelter. This means outpatient clinicians must contend with patients experiencing higher severity of illnesses.

Each of these limitations makes it more difficult for patients to access the care they need and for clinicians to provide the most effective treatment. To truly deliver on Biden’s recent ruling and the intent of MHPAEA, insurance companies must act to address these discrepancies so that patients are not caught in the middle. Closing the insurance gap for mental health care will ensure that the full range of treatment options remains accessible and affordable.

Collaboration Can Prioritize Care While Managing Costs

There is an opportunity for payers and providers to work in tandem to provide comprehensive care while managing costs. Data sharing is a big part of this. Without a holistic picture of a patient’s health care information, including primary care, claims data, treatment history, and even whether they have picked up their prescriptions, it becomes difficult to assess outcomes.

Part of the challenge involves outdated technology and interoperability issues. For example, up to 70% of health care providers still rely on fax machines to share medical information, making data sharing costly and inefficient.⁶ But this type of collaboration must be prioritized by both insurers and clinicians to provide a clearer view of a patient’s needs.

As a clinician, it is crucial for me to know if a patient is filling their prescriptions every month and completing their lab work as appropriate. But this type of holistic information can be difficult to access outside of appointments. I have had experiences where a patient received an important diagnosis or had even been hospitalized—key information that could impact their treatment plan—and I did not find out about it until the patient told me directly.

Sharing claims, clinical, and administrative data can help clinicians guide care toward effective lower-cost options and help payers manage population health. Programs that incentivize this cross-ecosystem collaboration, such as the Inland Empire Health Plan, have been shown to encourage data sharing and drive improved care coordination.⁷

With a more holistic view of patient data, providers and payers can come together to develop evidence-based clinical best practices, build standardized technology to track responses to treatment, and ultimately coordinate care in a way that prioritizes patient health while managing costs.

The Ripple Effect of Mental Health Parity

The entire health care ecosystem has a stake in solving this problem. Mental health parity can not only expand access for patients and enable clinicians to provide comprehensive treatment—it can also reduce health care costs overall.

If left untreated, mental health and substance abuse disorders can worsen physical conditions and lead to costly treatment. In fact, one report estimates that integrated mental and physical health care could reduce overall health care costs by up to $68 billion per year.⁸ Many payers already understand that when you treat mental health, overall medical spending goes down. It is time for this perspective to become the norm.

Payers have an integral role to play in tackling our country’s mental health crisis. By providing coverage for mental health treatment at parity with physical health and sharing data across the health care sector, we have an opportunity to significantly reduce spending while providing broader access to care and getting patients the treatment they truly need.

Dr Patel-Dunn is chief medical officer at Lifestance Health.

References

1. Fact sheet: Biden-Harris Administration takes action to make it easier to access in-network mental health care. The White House. July 25, 2023. Accessed October 10, 2023. https://www.whitehouse.gov/briefing-room/statements-releases/2023/07/25/fact-sheet-biden-harris-administration-takes-action-to-make-it-easier-to-access-in-network-mental-health-care/

2. Presskreischer R, Barry CL, Lawrence AK, et al. Factors affecting state-level enforcement of the Federal Mental Health Parity and Addiction Equity Act: a cross-case analysis of four states. J Health Polit Policy Law. 2023;48(1):1-34.

3. Equitable access to mental health and substance use care: an urgent need. NORC. July 18, 2023. Accessed October 10, 2023. https://www.mhtari.org/Survey_Conducted_by_NORC.pdf

4. Realizing parity, reducing stigma, and raising awareness: increasing access to mental health and substance use disorder coverage. Department of the Treasury. 2022. Accessed October 10, 2023. https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/mental-health-parity/report-to-congress-2022-realizing-parity-reducing-stigma-and-raising-awareness.pdf

5. Abrams Z. How well is telepsychology working? American Psychological Association. July 1, 2020. Accessed October 10, 2023. https://www.apa.org/monitor/2020/07/cover-telepsychology

6. Brown C. Health care clings to faxes as U.S. pushes electronic records. Bloomberg Law. November 4, 2021. Accessed October 10, 2023. https://news.bloomberglaw.com/health-law-and-business/health-care-clings-to-faxes-as-u-s-pushes-electronic-records

7. Juhn E, Galvez E. Incentivizing data sharing among health plans, hospitals, and providers to improve quality. Am J Manag Care. 2022;28(12):e426-e427.

8. Melek SP, Norris DT, Paulus J, et al. Potential economic impact of integrated medical-behavioral healthcare. Milliman. January 2018. Accessed October 10, 2023. https://www.milliman.com/-/media/milliman/importedfiles/uploadedfiles/insight/2018/potential-economic-impact-integrated-healthcare.ashx