The Parity Act at a Glance
by Dr. Jason ZW Powers, MD, Chief Medical Officer, The Right Step and Spirit Lodge
In 2010 there will be something quite extraordinary affecting our healthcare system. The United States Congress passed HR 1424 -- the Paul Wellstone and Pete Domenici Mental Health and Addiction Equity Act -- otherwise known as The Parity Act. There is a long and storied history behind the development of this model of equity in healthcare. For many years, managed care has restricted coverage for Americans who sought treatment for mental health and addictive disorders. This prejudicial care was based on fears of increased costs and ignorance of the nature of mental illnesses. Quite simply, studies have demonstrated the effects of parity increase costs by approximately 1% only; and the science behind mental illness and addictive disorders as diseases is rock solid. The days of blaming schizophrenia on bad parenting or addictive disorders on poor character are gone. Furthermore, due to inadequate care, those with serious mental illnesses can expect to live 25 years less than the general population. The Parity Act is a testament to good and thorough scientific understanding coupled with effective mental health validated practices. Let us also not forget about the dedicated individuals and organizations. Along the way, there have been many heroes and champions, from Betty Ford to Bill Clinton to Paul Wellstone and Pete Domenici.
Perhaps the origins of the prejudicial exclusion of mental health and addictive disorder treatment can be traced back to the Cartesian Split espoused by Rene Descartes. The mechanistic model of health and disease has afforded Western medicine an incredible bounty of knowledge and advancement in care. Yet the belief that mental disorders were not real diseases has thwarted the same rapid and expansive advancement in the behavioral sciences; and the stigma of having a second-tier illness has also been a scarlet letter for some and discouraged others from seeking the care they need. Where we once believed that mental illness were chronic diseases with no hope for recovery, we now know that recovery is possible when effective treatment is available. And, where we have painfully discovered that punishing mental illness is inappropriate and a colossal waste of precious resources, we now know that effectively treating substance abuse will lead to more health and healing while also saving the States billions of dollars annually that would otherwise be wasted in the criminal justice, welfare, and healthcare systems.
The Parity Act Basics:
- HR 1424 requires that financial or treatment limitations are made equal between medical, surgical, and behavioral and addictive services, if a health plan covers mental health and addictive services.
- HR 1424 does not require that all plans must provide coverage for behavioral and addictive services. Yet, currently over 90% of employer subsidized health care plans do provide coverage for behavioral and addictive services. So for these plans, the requirements for parity apply.
- HR 1424 does not apply to employers with 50 or fewer employees and individually purchased health plans.
- HR 1424 includes provisos for co-pays, deductibles, annual and lifetime benefit limits, and prevents restrictions on the frequency and intensity of treatments.
- HR 1424 mandates that out-of-network coverage for behavioral and addictive services must be consistent with out-of-network coverage for medical and surgical services.
- HR 1424 exempts employers whose total premium costs increase more than 2% in the first year or 1% in any subsequent year. This will be subject to an annual application and review process.
- HR 1424 will affect Medicaid managed care but will not affect Medicare.
- HR 1424 requires health plans to disclose the criteria used to determine medical necessity and the rationale behind denials of any claims for behavioral and addictive services. The decisions about which specific conditions to be covered appears to be within the jurisdiction of the states, employers, and payers.
There will be enormous implications for everyone. It is estimated that over 113 million Americans will be affected by HR 1424. Administrators, providers, payers, employers, and consumers will be affected. As a business owner, employee, manager, and primary care physician who specializes in Addiction Medicine, I bring a bridged perspective to the future. For example, I understand that there will be an enormous opportunity in the new marketplace. For providers who wish to engage in more behavioral healthcare provisions, now is the time. I also appreciate that health plans will require a systematic and comprehensive set of criteria and best practices in order to define eligibility and authorization for care. For example, in medicine we have adapted to cost savings changes incurred by managed care. Long gone are the days of observing those medical patients in expensive hospital beds who can otherwise be managed as outpatients. Operations that used to require in-house rehabilitation for weeks are now performed as day surgeries. Similarly, in behavioral medicine, we will undoubtedly be encountering similar practice changes. Some of us may wish to explore offering several different levels of care to capitalize on the stratification of illness severity that will correspond to a myriad of corresponding treatment intensities. Others may wish to focus on only one specialized area of the new marketplace. In any case, we must be mindful to adopt only best and evidence-based practices if we wish to maximize our gains while securing some autonomy of our destiny. When managed care denies appropriate care, it is far easier to stand behind my recommendations that are validated by outcome studies. (Behavioral medicine has many variables not inherent in pure physical medicine that create difficulties in producing copious amounts of validated outcome studies…but they do exist and more are being investigated as time passes.)
It is in this vein that I have adopted evidence-based curriculums for The Right Step and Spirit Lodge treatment centers. We have also recently achieved JCAHO accreditation, which reflects our dedication to staff training, policy and procedure implementation, expanded communication and collaboration, and higher overall standard of company-wide practices. Plus, our 30-day (The Right Step) and 35-day (Spirit Lodge) programs that come with our 'commitment to sobriety warranty' provide the length of stay and follow up aftercare plan to enhance treatment outcomes. (Our warranty provides for no-cost readmission for our guests who have relapsed within a year of admission after completing those respective programs). Further, we strive to provide the best standard of care in our detoxification and stabilization phases of treatment. Combining state-of-the-art medication management, evidence-based curriculum, and professional staff is how we effectively serve our patient population and the community. Our goal has always been to be leaders in addiction medicine treatment, providing top notch care in a nurturing environment. In effect, we are ready for the new era in healthcare parity and you can feel assured in sending us your patients.
