By Robin Jay, BHC Editorial Director

Exciting milestones are being reached at Behavioral Health Central. In November, the 5 millionth site visitor logged on to BHC. Nothing could please us more than knowing stakeholders in the behavioral health field are actively accessing our comprehensive daily news, custom features, tools and resources. And on December 9, we are pleased to offer another valuable multimedia industry resource: an exclusive Parity Compliance Webinar.

At 2 p.m. EST, BHC and Advocates for Human Potential (AHP) Inc., are pleased to present comprehensive insight into what health plans of all stripes can – and should – be doing now to prepare for the implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA) that goes into effect in January. If you think the delay in regulations is an opportunity to do nothing, think again. Managed Behavioral Healthcare Senior Consultant Patrick Gauthier and Employee Benefits Policy Expert Susan Relland will present compelling data and details that demonstrate those who proactively prepare now are the ones who will reap the rewards down the road.

“There’s a real disparity in people’s preparedness,” says Gauthier. “The more intimate health plans are with the federal employee benefit program, the more they’ve already had to comply with the earlier state laws of Party, and the further along they are in the change process. Conversely, more regional and local plans are not as evolved. That’s where the disparity lies.”

Gauthier says preparing for Parity is actually a dynamic opportunity for health plans – and he’ll go into great detail during the Webinar presentation to explain why. One of the many opportunities involves technology. “It’s an opportunity for a health plan, payers, to reconfigure claims processing system, looking at diagnoses service code, provider codes, and it may beg the question in some shops, ‘do we need a decision support system in place?’ Do we need to look at technology that will support the medical management, the utilization management in mental health and substance abuse? If we are going to be receiving claims from providers whom we’ve never received from before, there’s a technology challenge there to make sure the EDI (electronic data interchange) is working.”

The following is an overview of the rich curriculum to be presented at the Parity Compliance Webinar:

• Learn what Parity is – and perhaps more importantly, what it is not.
• Learn what constitutes a qualified health plan that must comply with Parity legislation.
• Learn how to identify and avoid potential pitfalls.
• Understand the many benefits of employing technology for cost savings, efficiency and outcomes management.
• Discover the lessons already learned and cost impact of the Federal Employee Benefit Program under President Clinton in 1996.
• Understand how to overcome the cultural – and behavioral – barriers to getting consumers to embrace access to behavioral health care.
• Learn why care management is key to coordination of care and cost containment.
• Find out how and why payment reform can improve outcomes.
• Understand why marginalizing mental health and substance use care doesn’t pay.
• Discover why integrating behavioral healthcare into physical health care saves money.
• Learn how to interpret and apply vague legislation verbiage, such as ‘predominant coverage for substantially all covered medical and surgical conditions.’

Get a Sneak Peek

Today on BHC, we interview Gauthier for a preview on what’s to come in the Dec. 9 Parity Compliance Webinar. Take a moment to read through the following Q&A for some intriguing insight into what you’ll gain by participating in this important presentation. Then, to register, click here.

Q&A With Patrick Gauthier:

Patrick Gauthier: I want to go back to qualified plans, but because that is something that is often only partially understood to the degree that the parity legislation is addressing managed care where it occurs with respect to Medicaid to the Children’s Health Insurance Program (CHIP), Parity affects those plans. Secondly, in the commercial side, the employer-sponsored benefit plans, you have to delineate between the ERISA plans, those that are self-insured, both employers and self-ensured, their health benefit programs fall under Federal ERISA laws, they have plan administrators that will need to process and manage those plan accordingly. And then you have the traditional health insurance community of plans, an array of HMOs, PPO, Point of Service Plans, and traditional indemnity plans, and those are going to be impacted where employers have 50 employees or more. It’s important to break these out because the rate of implementation, compliance and fluency is probably a little bit different across the board. You have some very large national players that first adapted to the 1996 Parity Law because they’re in the federal employee program. You have in some cases, some states that have very progressive, very mature Parity laws, and large health plans in those states have had to comply over the years, so they tend to be the early adopters and be further along the learning curve.

At the other end of the learning curve, probably among the ERISA or self-funded plans, those that are small who didn’t feel the need to be as aggressive might be lagging behind a little bit. There are some regional, local heath plans that have had a not had a need to comply with the federal employee benefit plans or state level laws regarding Parity, so they’re going to be a little later in the learning curve.

There’s a real disparity in people’s preparedness. The more intimate they are with the federal employee benefit program, the more they had to comply with the earlier state laws of Party, the further along they are in the change process.

In conversely, ERISA groups sometimes more regional and local plans are not as evolved. That’s where the disparity lies.

BHC: Patrick what sort of implementation success have we seen overall regarding the 1996 Parity laws? Have they made an impact that’s been measurable in any way?

PG: What’s been measurable is that they didn’t cost anyone anything, other than the immediately up-front costs of making some changes to their plan documents and to their claims systems. The 1996 law was really just a bit of a bump in the road whereby, they had to express their mental health benefits in terms of a unit of care, outpatient and inpatient days, without respect to dollar limits and that’s an easy, simple change that took most people no time at all to change. Because they were able to express things in terms of days, the consumer had no idea what the equivalent was, a lot of plans saved money because they were able to constrain benefits even more – particularly for those that employed a managed behavioral health organization. If you had to manage 25 visits, outpatient, 10 days inpatient, that’s not a difficult benefit to manage, it sort of manages itself. The better experiment, the one that probably analysts and underwriters are looking at is the Federal Employee Benefit Program under President Clinton; they were offered a much more comprehensive Parity benefit, although it didn’t address substance abuse like this new piece of legislation does. It offers a real good view into what is the cost impact. The studies that were done both by the federal government and independent groups and firms, all conclude that the cost impact is negligible, less than 2 percent of the total premium. So there’s no question that if you’re managing the care, and you’re doing a good job as a plan and have good partners in the field, there is not a cost change.

BHC: What about access? Are people taking advantage of having better access to care?

PG: Consumers, when the benefits are expanded or enhanced, there is some degree, some evidence of greater utilization, but we’re not there yet. The idea that people are going to proactively in a prevention kind of way take care of their own mental health needs and take advantage of their benefits, that’s a cultural phenomenon much more so than a behavioral kind of phenomenon. In other words, it has to be acceptable first before the full range of people get up out of their chairs and say, “you know, I’m not feeling well today, I that I’m going to go get screened, assessed and diagnosed and get on a treatment, there’s still too much regarding stigma against that.

BHC: Once Parity gets underway and healthcare reform gets underway, how is it that we’re going to educate consumers about getting over the stigma. Let’s go back to the qualified health plans that really need to take a look now to see what they have to do to be ready for Parity.

PG: They need to get with their broker, consultant or legal counsel if they’re working with a compliance attorney. There are certain provision in this legislation that requires some tough questions be answered sort of right off the top with respect to cost-sharing, limitations, the new Parity legislation mandates that all cost-sharing, deductibles, co-pays and other forms of co-insurance, including lag time limits and annual limits have to be equal to the predominant coverage for substantially all of the covered medical and surgical conditions. I want to underscore that predominant coverage for substantially all is a mouth full is it leaves wide open the door for interpretation – what is predominant coverage and what is predominately all medical and surgical. Taking the time with an expert to go through your plan and try to find a reasonable place to land so that if, for instance, in your primary care coverage you have a $20 co-pay, then you make the decision that well, that’s predominantly and substantially, people are going to access the primary care physician, so we’re going to use that $20 marker for yourself and we’re going to send the $20 co-pay the same for mental health. The other is the conditions and diagnosis that are covered. The Parity legislation leaves it up to the plan or employer to decide which of the DSM diagnosis you’re going to cover, that gets compounded in mental health by ICD-9 and ICD-10 coming, but the real need to drill down on at least the biologically based disorders, like bipolar, major depression, schizophrenia. You need to decide which you’re going to cover and which permeatations of each, because each have different qualifiers. You may end up with 10 covered conditions.

That then takes us to the coverages for specific services and providers. If we’re covering substance abuse disorders, then you need to understand before I communicate this to my members, what kind of providers are able to treat them that the plan recognizes, and what levels of service can they provide. Substance abuse is a good example because there are a number of different levels of care. People tend to be familiar with the 28 days inpatient care, when in fact, it’s more complex in that there’s medical detoxification, there’s inpatient residential, there are partial levels of care, there’s intensive outpatient programs, and then outpatient group and individual therapy in recovery. So that’s important to be able to decide which provider types, which levels of care, which service codes. The other is out-of-network benefits. With the new mental health and addiction equity act that allows for out-of-network coverage, it’s on par or equal to that the medical and surgical plan allows, so that has to be specified. I think most importantly is getting to the level of care guidelines, or a tools that a plan might use to determine medical necessity. In some cases, those might be antiquated and in some cases they might not exist and plans are going to need to be prepared to share the tools that they’re ‘using with their plan members if there’s any kind of grievance or appeal or if something is going to be denied, the law stipulates that whatever tool was used to make the decision are openly shared with the plan member.

So those are examples that need to be decided at a policy level before people take next steps.

BHC: Patrick, if I’m understanding correctly, a plan can pre-determine which condition they’ll cover – such as bipolar and major depression, but we won’t cover eating disorders, and that would be perfectly line?

PG: Yes, it would . The caveat is that I don’t think anyone can say for sure today what “perfectly aligned” means with regulations. Because when the regulations come out, and when is anyone’s guess, they’re clearly late, they were due in October. Now Secretary [Katherine] Sebelius has told us sometime in January, plans will already have taken affect come January, and there are some people who are suggesting they really have until June. They may take til June, it’s anybody’s guess because they understand that the federal government agencies that these plans have an opportunity – be it a year – to make adjustments and modifications, then if that’s the case, they may as well take their time and issue them sometime in March or April, which is the belief, suspicion or fear.

BHC: Has there been any word about what is causing the delay. Is it that they want to get it right, or that once they hand it down, they’ll be easy to understand and comply with. Or is it that it’s so complicated that it’s taking time to get through.

PG: You know, there’s pretty broad consensus around how to do this properly and fairly without going overboard. For instance, it’s a lot less complicated by a factor of 1000 than healthcare and insurance reform. You get enough people in the room, they had a comment period, they got wonderful feedback and a lot of it winds up pretty well, and no one is trying to rob anyone when they say cover these major biologically based disorders, give people access to a full continuum of care, and so forth, and all of that is in line with the cost projections. I think the delay is more a function of reform. That reform has got everybody tied up in knots right now. The most likely scenario is that Congress and the President have told these agencies, whether concerning Parity, to wait because reform takes precedence. Those issues need to be decided. They are of national consequence, enormous consequence to the economy. They’ve got the entire political system in gridlock right now. I think it’s probably more related to reform moving to the head of the totem pole and it has to be resolved first. Then these agencies can worry about issuing other kinds of regulations and rules. If you released Parity regulations today, it would exacerbate the reform process that we’ve got.

BHC: Patrick, let’s talk about what health plans can do now and what are some of the pitfalls if they don’t properly understand what it is they need to do.

PG: The major pitfall is a belief that you can marginalize mental health and addiction. By way of marginalize, I mean try to constrain and limit people’s access. Two things happen. One, you blatantly disregard the economic associated with these disorders for the employer, workplace, or community. Untreated mental health, there are mountains of research to demonstrate that untreated mental health is an economic burden. To say we’re going to constrain it and narrow it to a very narrow interpretation of the law, we’re going to make it difficult for people to take advantage of their benefits, produces a medical cost offset, first of all, and people then say, ‘okay, if I can go through the mental health door or the substance abuse door, then I’ll go to the emergency room at the cost of 10 times what I could have done in an outpatient counselor’s office. It fails o acknowledge the role of mental health in other medical conditions, So if health plans don’t have a solid medical director who understands clinically and medically the role that depression plays in the treatment of diabetes, for example, where they co-occur 50 percent of the time, then they’re short changing the treatment of diabetes and will create costs. They need to be held accountable, frankly, I believe, for the costs they’re creating by constraining benefits that should be open to people, creating an open atmosphere for the highly coordinated collaborative treatment of chronic disease. Where these things are so often co-morbid, plans that understand that and have designed their approach, their network, their medical management around that occurrence will reap the rewards. Those that try to put up artificial barriers and silos between mental health and medical are going to reap the risks and the consequences and most of those are medical cost offsets. Sadly for the consumer, the consequences are mortality related.

The other issue with respect to artificially constraining diagnoses or service levels is that you drive people artificially into that diagnostic group or into that service level. So people will go, frankly, where they can, and providers will do what they can to get their patients care. A real life example might be if the only form of depression covered is major depression, and I’m a psychologist and someone comes in and they’re suffering from a situational adjustment disorder, I’m probably going to diagnose them up, which we know has happened in the past. All providers want to do is treat their patients and if they have to tweak the diagnosis, then they will. So why put everyone through that to create this sort of artificial inflation in the number of people with one diagnosis when you could have left the door open and then managed the care with case management, with utilization management, and understand that psychotherapy and behavioral healthcare of all kinds are not fun. People are not in a hurry to go out and get a bunch of behavioral healthcare, and the vast majority fall into this great big zone in the middle, where the costs are very low, very cost effective treatment, but there are some outliers. Health plans have all kinds of data to rely on to know how to identify outliers and how to medically manage outliers. And that’s really where people aught to be focusing their energy – on the 10 percent of utilization that produces the most costs.

BHC: With integrated care, and then changing the payment structure for providers so that they’re motivated based on outcomes, which will require more coordination of care. You had mentioned how healthcare should not be siloed any more. Back before chronic was a main focused. Medicare is still acute care focused. Chronic care and co-morbidity management is becoming more mainstream, and so all of these changes are going to happen.

PG: The primary focus is cost control and cost containment, a function of underwriting and system management and providers don’t have a big chair at the table. Whether it’s a medical director, medical director, nursing director, my advice to them is that this is not just a function of complying with the law, or a function of underwriting and assessing the risk, it’s an opportunity to reform from the inside. To say, okay, let’s get everyone at the table with in our plan, whether we’re a small HMO or we’re a mid-size ERISA group, and let’s get some experts around the table and say, ‘what’s best for us without breaking the bank.’ But it’s broadening the conversation that I think is at risk – that’s the risk. If it’s too narrow a definition, then people will miss an opportunity to treat the whole person and take advantage of these early interventions and less expensive, less intensive interventions that can produce a real positive economic outcome down the road.

Substance abuse will be a real wise example for people. People will see that substance abusers are twice the economic burden as non-substance abusers. So if I give my employees or my plan members access to a screening and early intervention and referral and treatment through a healthy continuum of care, that all the data tells us it doesn’t really cost very, what might I save myself on the other side on the medical and surgical and prescription drug expense.

BHC: It’s so true that you mention substance abuse costing so much more in healthcare overall. I saw an interesting study recently that the impact of the cost on the healthcare side impact also on the family and caregivers. They often times don’t have time to take care of themselves and then they fall into the need for more acute and chronic care – definitely has a domino.

PG: I’d like to return to the theme of the potential pitfalls. One of them is trying to manage mental health and substance abuse benefits without having good mental health and substance abuse training. So if I’m a health plan and have RNs on my staff and my medical management department, I’m going to want to make sure that they feel comfortable, well versed and adequately trained in the complexities of mental health and substance abuse. You can’t just hand them a manual and say, ‘okay, you guys do this now.’ It’s unfair to them and unfair to the provider and the patient or plan member because there are oftentimes when people who are calling in very dire straights suicide and decisions made in medical management need to take into consideration – homicidality, suicidality, child abuse, and other domestic issues that might be present. So that’s one possible risk.

The other is that for employers who have an EAP, employee assistance program, the knee-jerk reaction might be that they don’t need that anymore because they’re expanding mental healthcare benefits. I think that’s a mistake. An EAP is an employee and employer service, it’s not a medical type benefit and people use their EAP for a wide variety of reasons, most of which are work related. If it’s kind of a family issue that’s having an impact on the workplace, then they can use the EAP. If it’s a workplace issue, like conflict with a supervisor, they can use the EAP to deal with that. They provide a lot of human resource support, critical incident debriefing following a tragic accident, training on how to deal with substance abuse. Those kinds of things are so critical in the workplace – it’s a mistake to say they no longer need an EAP anymore. It will have negative consequences in the short and long-term.

BHC: Any other potential pitfalls you want to discuss?

PG: Network composition. If health plans and employers sit back and say what is it that this law is trying to accomplish, and particularly open and expand the conditions to include serious mental illness, serious emotional disturbance in children, and substance use disorders, how then does our provider network align with those objectives or those intentions? Yes, the law is very clear with children who have serious emotional disturbance. So my provider network had better have adequate professional representation to deal with that – therapists who specializes in child therapy, psychologists who are child psychologist. Just because someone is a PhD psychologist doesn’t necessarily mean they are trained to work with children who have serious emotional disturbances (SEDs). Child psychologists who are few and far between, who are critical in the treatment of kids, so sometimes on paper it reads well to say they’ve looked through our network and put the screws to our network, sometimes that backfires if you’re not making some care accessible, you’re driving people into more expensive levels of care. So open the panel a little bit to be deliberate and proactive to make sure the whole continuum is there for everybody. If I were a health plan or employer who has carved that out to an MBHO, then it behooves me to sit down with them and tell them to show you how the network will meet these new needs, because otherwise, if I have a blanket philosophy that says I’ve given it over to the MBHO and I don’t scrutinize what they’re doing, then I’m missing an opportunity.

BHC: When you listen to the debate over healthcare reform, one of the things you’ll often hear about is once we give access to the majority of folks who don’t currently have healthcare coverage, are we going to have enough primary care providers for them to be in the system. The American College of Physicians has met with President Obama about this, but they’ve they’d that when this next medical school class graduates, we’ll have only about 20 percent PCPs when we really need about 50 percent. So my question to you is, if we expand access for behavioral healthcare coverage and we’re able to work on the issue of stigma that prevents one to seek care, are we going to have enough specialists for the serious situations?

PG: I think the short answer is no, we’re not going to have enough. But it’s a layered answer. There are going to be years before we really feel that we’re strongly sensing a shortage because I don’t think utilization will spike anytime soon and it will probably take three to five years before we see the cultural shift that’s necessary for utilization to go up dramatically. The other thing that sort of makes it a layered answer is that it depends on location, frankly. What I mean is that in rural and frontier parts of the country, you’re absolutely right, any measurable expansion of the number of p9eople who want to use behavioral health benefits is going to aggravate a situation that already exists. In rural and frontier parts of the country, there is a very tangible shortage of mental health providers and primary care providers; they tend to sort of happen in the same places. In more urban areas, its sort of depends. There are some urban centers that have too many mental health providers and so some of them are struggling to make ends meet and to keep their doors open, and in some other urban areas you have a shortage. The differentiator is often socioeconomic. Is it a more affluent community in New York City versus a less affluent community, such as Detroit, that is struggling socio-economically. The mental health professionals aren’t going to stick around. In tough times, they’re going to shut their doors and leave. We’re seeing that among addiction treatment providers, because their out of pocket consumers are losing their jobs and losing their 401Ks and investments during the past two years of recession. Their beds are not as full as they should be and there are a lot of addiction treatment providers who are shutting their doors and going out of business. What that means is that when things turn around and there’s an opportunity to make the system flush again with coverage, and the economy turn around, then we’re probably going to have some access capacity in some area. Which raised the questions from a system of care standpoint, if you take a state or region of the country and say we have too many over her and not enough over there, what can we do to coax the excess capacity enough to move it to where we have a shortage?

BHC: A family medicine professor a the University of Colorado was saying this fall that they foresaw the gaps in the need for primary care in rural areas, so in recruitment efforts, they expanded the number of slots for students interested in primary care and servicing rural markets. Also, with healthcare finally starting to embrace technology, then access will become less of a problem – such as with online group therapy in behavioral healthcare. And, as we shift from an acute care focus, such as with Medicare, to a chronic care management and prevention focus, then the burden on primary care and subspecialty care may level out.

PG: Right, you’re putting your fingers on. I couldn’t agree more. Telemedicine, telepsychiatry resources are fantastic for behavioral healthcare. In California, I know there are more than 900 telemedicine sites that are interconnected and its growing rapidly. The barrier there is how do you get the right kind of bandwidth out to these rural areas? Some states have addressed that more vigorously than others. Some governors have ensured that broadband satellite data is available in rural areas.

I want to go back to this notion of the shortage and how do you create access. I participated very closely in the Access to Recovery, which was a federal grant for the treatment of substance abuse. It focused on a number of areas that were important and effective, and one of them was engaging culture and language-specific communities. For instance, take the Hispanic and Latino communities. How can we engage students and young people and professionals in that community and take the next couple of years, provide them with some technical assistance, or some college education and let’s create an indigenous professional capacity in the community. Doing that with the various tribal nations around the country to do that has been very effective.

Thirdly, with respect to access to recovery and creating that access, is engaging the faith-based community. Where and when those faith-based communities are willing to live up to standards for professionals, you have a really nice mix. You then have an opportunity to really expand the offerings and make up for the perceived shortages. We’re starting to see that federally qualified health centers and community health centers that are adding the behavioral health component. The addition of less expensive professionals, like nurse practitioners and psych-certified RNs, to the mix is also very effective. There are a number of things we can do if we are willing to be innovative and make sure access doesn’t become a problem.

BHC: Patrick, on Tuesday, December 9 at 2 p.m. EST, we’re going to be hosting a webinar on Parity Compliance. Let’s talk about who should attend and what valuable information they stand to gain by attending.

PG: First of all, who should attend the webinar are executive and operations level management staff from health plans of all stripes – indemnity plans, ERISA plans, managed care plans, MBHOs, CHIP plan administrators, Medicaid managed care plans, all of those people should be attending if they can. The regulatory and policy folks from state departments of insurance and state departments of managed care may want to tune in. ERISA groups, employers, someone form personnel and HR, and their counterparts at TPAs, as well as any of the people they might carve work out to – specialty utilization management, disease management, medical management, disease management. PPO networks, specialty provider networks would find it helpful, as well. This is really designed for the payers or health plan side of the equation. That’s not to say that providers want to overlook it. If they understand what payers are doing to be shouldering and doing to operationalize to become compliant, it’s to their advantage to know.

BHC: Let’s recap what they can learn from the webinar. Yes, regulations have not been handed down yet for Parity implementation, but its important to understand why it’s important to attend.

PG: For some people, it will be a primer. Understanding the most likely scenarios will be with regulations. What are some of the pitfalls to be aware of. And what are the next steps toward implementation. First, the implementation of policy and business rules. You’ve got people who job it is to interpret. This is not ivory tower stuff. Marketing and customer service really need to understand how this stuff works. As you bring that in-house, your understanding has to manifest new business rules. Business rules govern how people do their jobs every day. From a policy and process standpoint, how do those new business rules and policies become new business processes and new workflows and new business forms and new fields in the information system. From a staffing standpoint, if I’m a health plan administrator, do I need to staff up in my utilization management department or case management? Do I need to make a change in vendors if I have a managed behavioral health organization that I’m not satisfied with or that the provider network is not adequate? How do I communicate the plan changes to the members and providers so I don’t disrupt the care that’s in process. This is sort of the people side.

Lastly, we also need to look at implementation from the standpoint of technology. It’s an opportunity for a health plan or payer to reconfigure claims processing system, looking at diagnoses service code, provider codes, and it may beg the question in some shops, ‘do we need a decision support system in place?’ Do we need to look at technology that will support the medical management, the utilization management in mental health and substance abuse. If we are going to be receiving claims from providers whom we’ve never received from before, there’s a technology challenge there to make sure the EDI (electronic data interchange) is working. So, that’s the way we’re going to slice and dice it on the first and second steps that need to be taken among those four dimensions.

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