The Paradox of Parity



With implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA) and the Affordable Care Act (ACA) underway, the nation is “now in one of the most dynamic periods of mental health care change since the advent of the community mental health movement of the 1960’s” says Tom Insel, M.D., director of the National Institute of Mental Health (NIMH). MHPAEA, signed into law in 2008, calls for treatment of mental illness and substance abuse equal to that of other medical disorders. The ACA, passed in 2010, includes mental health as part of the essential health benefits and has new rules for the implementation of MHPAEA. However, Insel cautions the mental health community from celebrating and suggests that it be ready for some unintended consequences of combining the two laws. For instance, there still remain questions as to how effective psychosocial treatments like cognitive behavioral therapy (CBT) will be covered and if they will be reimbursed at the same rate as pharmacological treatments. If psychosocial interventions are reimbursed at the same rate, there are questions as to how to define dosage/duration, adherence to evidence-based practices, and quality of treatment. Psychosocial treatments that do not have a large evidence base are also of concern. Can there really be parity of treatment where there’s no parity of evidence and rigor? Moreover, there is no “regulatory pathway for (psychosocial) procedures and therapies” that can answer these questions.

The reality is that without a regulatory framework, “some treatments might not be covered even to the extent that they were covered in the past” under the new parity laws. NIMH and other stakeholders have asked the Institute of Medicine (IOM) to create a framework that will establish psychotherapeutic standards for payers and providers. The expert panel, convened by IOM to review the issues and make recommendations, has met and heard that other providers like surgeons have developed “guidelines for rigor and quality and ensured parity” for interventions with an evidence base smaller than that of CBT. Under parity, psychosocial treatments will require quality and fidelity measures, dose and duration measures, outcomes measures, and electronic records to ensure that care meets standards and is reimbursed.

Less than half of psychiatrists accept Medicaid, and slightly more than half accept private, non-capitated insurance. Significantly higher proportions of other medical specialty physicians accept Medicaid and private insurance. Insel comments “it would be a sad irony if in the era of parity only those who could afford to pay out of pocket could get access to effective psychosocial treatments.” While the IOM effort will provide useful guidelines, the mental health community may have to find a way “to demonstrate that they provide the most evidence-based treatments with measures of both rigor and fidelity.” Standardized reporting systems will be needed, as well as a detailed definition for each evidence-based intervention. In the last 5 years, the Department of Veterans Affairs Health Care System has proven this is possible. Recent evidence about the VA indicates “that when psychosocial treatments are delivered with high quality and fidelity, outcomes improve.” “That,” says Insel “is the parity all of us should be fighting for.”

Read Dr. Insel’s related blogpsot: