The political evolution of mental health parity

This article traces the evolution of the mental health parity debate in American politics, with a focus on how interest groups and politicians have attempted to influence perceptions about treatment effectiveness and the cost of benefit expansion. When parity laws are in place, they require health plans operating in the private health insurance market to provide an equivalent level of coverage for mental health and general medical care. Business and insurance industry groups oppose parity due to cost concerns. The mental health community has framed parity as an antidiscrimination measure that would achieve greater insurance equity across disease groups. The role of personal experience with mental illness among lawmakers and others in framing the parity debate is also considered.

What should non-US behavioral health systems learn from the USA?: US behavior health services trends in the 1980s and 1990s

Several countries, such as the USA, inadvertently created a different behavioral health payment system from the rest of medicine through the introduction of diagnostic-related group exemptions for psychiatric care. This led to isolation in the administration and delivery of care for patients with mental health and substance abuse disorders from other medical services with significant, yet unintended, consequences. To insure an efficient and effective health-care system, it is necessary to recognize the problems introduced by segregating behavioral health from the rest of medical care. In this review, the authors assess trends in behavioral health services during the last two decades in the USA, a period in which independently managed behavioral health care has dominated administrative practices. During this time, behavioral health has been an easy target for aggressive cost cutting measures. There have been no clinically significant improvements in the number of adults receiving minimally adequate treatment or in the percentage of the population with behavior health problems receiving psychiatric care with the possible exception of depression. While decreased spending for behavioral health services has been well documented during this period, these savings are offset by costs shifted to greater medical service use with a net increase in the total cost of health care. Targeting behavioral health for reduction in health-care spending through independent management, starting with diagnostic procedure code or diagnostic-related group exemption may not be the wisest approach in addressing the increasing fiscal burden that medical care is placing on the national economy.

Changes In Mental Health Financing Since 1971: Implications For Policymakers And Patients

The aggregate share that total mental health spending claims of national income has been stable over the past thirty-five years. This stability is a consequence of immense change--new organizational technologies, new treatment technologies, and a growing supply of providers. Aggregate spending stability has been accompanied by major shifts in the composition of financing, which have tended to spread the costs of mental illness more broadly but also have led to fragmentation in public responsibility for people with mental illnesses. Recent developments suggest that financing could be further constrained in the future, even as fragmentation continues to increase.

[The long-term care insurance system and geriatric psychiatry]

The long-term care insurance system targets people who require support because of mental or physical disturbances due to aging. This overlaps in many areas with the field of geriatric psychiatry, which is expected to play a significant role in diagnosis and hospitalization in the long-term care insurance system. Representative of the former is the forgetfulness clinic, and representative of the latter is the "senile dementia disorder center". When a person at home or in a nursing facility becomes seriously demented or suffers serious physical illness, he is generally hospitalized. However, there is an ongoing project which allows group homes to care for the seriously demented or physically damaged elderly. Under the long-term care insurance system, there are many problems that should be dealt with by geriatric psychiatry. One essential issue is the lack of basic research on judgment abilities and mental competency, even though users are expected to select services and make their own decisions under this system. Once there is a social support system for the care-requiring elderly, it is necessary to assess the decision-making ability of individual elderly. If this ability is sufficiently maintained it should be respected to the utmost. If it is impaired, we must have a viewpoint on how to provide care through a social system. A consensus has yet to be reached on informed consent for the demented elderly, and this issue should be considered with a focus on geriatric psychiatry.

Changes in the costs of treating mental health disorders: an overview of recent research findings

This article reviews recent evidence on changes over time in the direct medical costs of treating three of the more common mental health disorders in the US: the acute (16-week) phase of major depressive disorder, the ongoing treatment of schizophrenia, and the ongoing treatment of bipolar I disorders. The three studies discussed in this article cover various time intervals over the decade from 1991 through 2000, and encompass both private sector and governmental funding sources. Although there has been a shift over time away from intensive psychosocial/psychotherapy and towards increasingly expensive psychopharmacotherapy for all three disorders, total direct medical costs of treatment for each of these three mental health disorders have been declining over time. However, a substantial portion of treatment is not supported by clinical evidence.

Design Of Mental Health Benefits: Still Unequal After All These Years

This paper examines recent trends in the design and organization of coverage for mental health care using data from a Henry J. Kaiser Family Foundation and Health Research and Educational Trust (KFF/HRET) national employer survey. Legislation and changes in the delivery of mental health services have altered how mental health insurance is bought and sold. However, our findings reveal that mental health coverage is still typically not offered at a level equivalent to coverage for other medical conditions. We attempt to synthesize these data with prior research as a foundation for informed debates.

The ‘Quiet’ Crisis In Mental Health Services

The failure of insurers and managed care organizations to reimburse providers of mental health services for the costs of care has led to a crisis in access to these services. Using the situation in Massachusetts as a case example, this paper explores the impact of this defunding. Unable to sustain continued losses, hospitals are closing psychiatric units, and outpatient services are contracting or closing altogether. The situation has been compounded by the withdrawal of many practitioners from managed care networks and cuts in public-sector mental health services. Unless purchasers demand effective coverage of mental health treatment, mental health services will likely continue to wither away.

The current and future state of mental health insurance parity legislation

Health insurance plans typically provide less coverage for mental health and chemical dependency treatment than for general medical services. In 1996 the federal government responded to these inequities by passing the Mental Health Parity Act, requiring equal annual lifetime dollar limits for mental health benefits. However, provisions within the law are easily circumvented, rendering it relatively ineffective as implemented. The Senator Paul Wellstone Mental Health Equitable Treatment Act of 2003 measures (S. 486 & H.R. 953) currently in Congress would expand the language and effectiveness of the Mental Health Parity Act. This paper reviews the limitations of both the 1996 federal law and existing state laws, and explains why federal action to expand the Mental Health Parity Act is so critical to people with mental illnesses.

Trends in mental health insurance benefits and out-of-pocket spending

BACKGROUND

Insurance benefits can have a large effect on whether one is able to access health care services. Mental health and substance abuse (MHSA) insurance coverage has typically been less generous than that of general health services.

AIMS OF THE STUDY

This paper examines trends in the generosity of private insurance benefits for mental health (MH) services in the United States from 1987 to 1996. The paper estimates the benefit-induced change in insurance payments for MH services that would have been made by typical health plans between 1987 and 1996 holding constant utilization of individuals at the 1987 level so that the changes in effective benefits could be isolated.

METHODS

Trends in mental health benefits were measured using two nationally representative household surveys of the U.S. civilian non-institutionalized population, the 1987 National Medical Expenditure Survey (NMES) and the 1996 Medical Expenditure Panel Survey (MEPS). Data on utilization and expenditures from the NMES/MEPS were used to simulate what the average person would have paid out-of-pocket under typical insurance plans in 1987 and in 1996.

RESULTS

The study finds that limits on MH coverage, such as limits on reimbursed days of care, became more prevalent from 1987 to 1996, but that consumer cost-sharing rates declined. The simulations indicate that private insurance would have paid for a lower proportion of total spending in 1996 (60.1 percent) as compared to 1987 (65.8 percent).

DISCUSSION

Despite the fact that limits on mental health services became more prevalent over the time-period evaluated, out-of-pocket expenditures did not increase as significantly because there was a corresponding increase in coinsurance covered by health plans.

IMPLICATIONS FOR HEALTH CARE PROVISION AND USE

Trends in plan design negatively affected those with high costs who are likely to surpass their limits and positively affected coverage for those with minimal use due to lower cost-sharing. These trends also indicate that persons in the most need, those with high utilization, particularly of inpatient care, experienced a decline in coverage while those with less intensive needs may have experienced a slight increase.

IMPLICATIONS FOR HEALTH POLICIES

Out-of-pocket spending in both years of the study was substantial suggesting that improved health care coverage, such as that mandated in parity legislation, could improve access to care for persons needing mental health treatment.

IMPLICATION FOR FURTHER RESEARCH

Additional research is needed to understand how trends in out-of-pocket spending and insurance benefits have influenced access to care.

Nowhere else to turn. As the ax falls on mental health funding, hospital EDs fill the gap--reluctantly

As the ax falls on mental health funding, state mental hospitals are closing and investor-owned psychiatric organizations are filing for bankruptcy or shifting their focus to more lucrative general acute care services. That leaves patients--many of them uninsured--with nowhere to seek help except hospital emergency departments.

Behavioral health benefits for public employees: effect of mental health parity legislation

With the passage of the Mental Health Parity Act of 1996 (MHPA), Congress took an important first step toward equalizing treatment under medical plans between physical and mental illnesses by requiring parity in annual and lifetime dollar limits between physical and mental illness. But the Act was limited in scope: it did not mandate mental health benefits nor prohibit other common types of differentials between physical and mental illnesses, such as higher cost-sharing or lower limits on outpatient visits or inpatient treatments. Before Congress' action in 1996, a few of the states had adopted some type of parity requirement. Since 1996, state parity activity has accelerated.Recently, the Center for Health Services Research and Policy through a grant from the Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services, examined contracts providing for mental health benefits for state employees in eight states to assess whether legislative attempts to require parity between physical and mental illnesses resulted in noticeable differences in behavioral health benefits for state employees. We concluded that, except in states that have mandated full parity for some or all types of mental illnesses, behavioral health benefits for state employees have not changed significantly as a result of the state parity laws, since they still remain subject to traditional restrictions, such as higher cost-sharing and greater limitations on outpatient visits and inpatient treatment days, than those imposed on physical illnesses. Thus the considerable state activity surrounding mental health parity may have little effect on state employees' access to mental health services, since although state laws required parity in dollar limitations, they generally permitted the continuation of other plan design features that are more restrictive for mental health coverage. However, many of the contracts we examined were multi-year contract and may not have fully reflected recent state activity. Moreover, if Congress renews the Mental Health Parity Act when it expires in September, 2001, and expands the scope of the Act to cover some of these other plan design features, states with more limited parity laws are likely to follow. In that case, perhaps state employees with mental illnesses may see significant change in the future.

Recent trends in the financing of substance abuse treatment: implications for the future

OBJECTIVE

This article focuses on the implications of a recent study of substance abuse (SA) and mental health treatment expenditures for substance abuse treatment policy. Public and private expenditures for SA treatment are estimated and compared with those for mental health and all health care in the period between 1987 and 1997.

METHODS/DATA SOURCES

Estimates of SA treatment expenditures were segregated from the Health Care Financing Administration's National Health Accounts across the ten-year period. Information about use, charges, and payments by provider type, payer, and diagnosis was obtained from numerous nationally representative data sets and large claims databases. Those data were used to estimate SA treatment expenditures in the general service sector. For the specialty sector two specialty facility surveys were used to estimate SA treatment expenditures. Information from the two sectors was combined and reconciled to the National Health Accounts. PRINCIPAL FINDINGS. A dramatic shift in SA expenditures away from private financing and toward public payers, as well as a shift away from hospital treatment settings, occurred between 1987 and 1997.

CONCLUSIONS

Evidence from this article and other research suggests that growth in SA expenditures has been contained relative to growth in all health spending. How savings from SA treatment are being invested and whether expenditure levels are appropriate to supply treatment of acceptable quality needs further study.

Psychiatric hospital care and changes in insurance coverage strategies: a national study

The 1975, 1980, and 1986 sample surveys from the National Institute of Mental Health were used to predict the type of inpatient psychiatric facility where people were admitted. Predictors used were demographics (age, gender, race, marital status, and education), psychiatric diagnosis, and insurance status (primary payment source). A discriminant analysis revealed that insurance status was the most important discriminator in predicting hospital type. State hospitals were more likely to care for patients with little or no resources, whereas private hospitals cared for patients with some form of insurance. The authors discuss the implications of insurance status and access to psychiatric treatment.

Meeting managed care: An identity and value crisis for therapists

The micromanagement of the psychotherapy enterprise by private insurance interests has placed clinicians in new and unfamiliar roles in relation to their patients and to the professional marketplace. The value systems compatible with most managed care organizations are divergent from those held by an earlier generation of mental health professionals.

The effect of managed care on the treatment outcome of substance use disorders

This study examined the effect of managed care and other reimbursement mechanisms on the outcome of substance abuse treatment at a single treatment facility. A retrospective review of 1594 patient records yielded treatment utilization, diagnostic, and demographic data. Recidivism rates for intensive managed care, traditional managed care, private pay, and state-funded groups of patients were compared. Results showed that, contrary to expectations, recidivism rates were not different for managed vs nonmanaged care patients. In addition, recidivist patients had significantly more ICD-9 diagnoses than nonrecidivist patients. A discussion of future research suggests that other outcome measures need to be examined in addition to recidivism rate, such as psychosocial functioning following treatment and indicator(s) of severity of illness, to better determine the effect of managed care and other reimbursement mechanisms on treatment outcome.

Brief therapy for managed mental health companies: becoming a learning organization

Nearly all of the services offered through managed behavioral health care companies are brief or time effective in nature. It is often the view of these companies that many of their providers have insufficient backgrounds in doing such treatment and have been trained in longer, less efficient modes of service delivery. Although this is often the case, what is frequently not recognized is that most managed behavioral health care companies themselves lack knowledge and clarity about such therapies. We address the critical need for behavioral health care companies to become learning organizations focused on research and development and internal as well as external training in time-efficient therapies. Such activities will allow for creativity and enhancement of the substance abuse and mental health care areas.

Trends in the inpatient care of persons with schizophrenia

This report analyzes nationally representative data to examine inpatient services provided to persons with schizophrenia. The data are for patients admitted to general hospitals, private psychiatric hospitals, and State and county mental hospitals between 1970 and 1986 (weighted n = 860,637). The proportion of admissions diagnosed as having schizophrenia decreased from 21 percent in 1970 to 16 percent in 1986; this proportion decreased in public general hospitals and increased in private general hospitals. The rate of admissions for schizophrenia decreased in public general hospitals and State and county mental hospitals and increased in private general hospitals. The overall admissions rate decreased for whites with schizophrenia and increased for African-Americans, owing entirely to increased admissions of African-American males. Private general hospitals and State and county mental hospitals relied less over time on private insurance; the use of Medicare increased in both public and private general hospitals; and Medicaid use increased in private general hospitals. Further research on services for this population is necessary as a baseline for health care reform.

The role of capitation in quality behavioral healthcare systems of the future

Capitation is more than just a challenge for the behavioral healthcare industry. It also presents an opportunity to develop comprehensive systems of care--driven by the appropriate use of technology and of quality methods--that will meet the needs of designated populations.

Planning for the future of behavioral health services

Psychiatric and chemical dependency services are increasingly being delivered through managed care with greater emphasis on ambulatory and outpatient treatments. Inpatient facilities can preserve their involvement in behavioral health services by actively developing a managed care product line. This article describes the nature of change in behavioral services, what competitive behavioral health providers will look like in the future, and the actions hospital administrators should be taking now.

Marketing guidelines for providers of mental health and chemical dependency services--responding to changes in the packaging and purchase of behavioral health benefits

In summary, the mental health and chemical dependency market has changed to the point that providers and programs of any type can no longer survey financially without well-developed marketing strategies--including a conscious decision about target markets and niches within those markets. Behavioral health providers and programs need to thoroughly evaluate their internal resources, along with possible market niches, in order to develop these strategies.

Behavioral health managers take hold

With mental health and substance-abuse treatment costs averaging about 10% of a company's annual health bill, companies are looking for new ways to cap expenses. Some firms have decided to give specialists the job of managing the behavioral health portion of their medical benefits programs, according to a new survey of 350 companies by the Wyatt Co.

In search of outcomes

Psychiatric hospitals, stung by reports of alleged abuses, are furiously trying to work their way out of an industry slump by embracing outcomes research. For them, such research may be a way to justify the value and effectiveness of their services with increasingly demanding payer groups. Although outcomes research is fairly common in medical/surgical hospitals, its existence is new to mental health.

Improving psychotherapy services: applications of research, audit and evaluation

Psychotherapy services face increasing demand but are vulnerable to critical scrutiny by service purchasers seeking evidence of cost-effectiveness. Psychotherapy research, although it can benefit practitioners, cannot adequately address these concerns because of poor external validity and it is argued that complementary strategies are needed. A number of service-based evaluative methods are reviewed and the distinctions clarified between service evaluation, operational research, professional audit, service audit, quality assurance and total quality management. Maxwell's (1984) six category framework is used to examine a number of issues in psychotherapy services including the assessment process, treatment-of-choice decisions, predicting negative effects of treatment, dose-response in psychotherapy, brief interventions, therapist competence, clinical significance, cost effectiveness and measures of psychotherapy service inputs, process and outcomes. This review advocates reflective practice within a self-evaluating psychotherapy service and a systemic approach which can take account of the perspectives of patients, purchasers, service managers, referrers and practitioners.

Directions in contracting for psychiatric services managed care firms

An "irresistible force" has surely emerged in American healthcare; its name is Managed Care. It's a force embarked on an economic holy war, fired by the passions and anxieties of a competitive market economy that now seems uncommitted to spending more on health services. Its army is made up of an ununited confederation of utilization review organizations, health maintenance organizations (HMOs), preferred provider organizations (PPOs), exclusive provider organizations (EPOs), and a number of other entities that have been enlisted to restrain++ the medical-industrial complex. In their march across America, they have frequently assailed the shibboleths and established structures of treatment systems, especially psychiatry and often fought with one another. While some are mercenary forces, others appear as peoples' armies, committed to preserving and strengthening the healthcare system they are transforming. As it encounters the inhabitants of this domain, Managed Care becomes both their master and their slave. As with any occupying force, it must win their hearts and minds over to the new way of doing things. The winning-over process is not going well now. Many patients and providers are angry at the inefficiencies, unproven effectiveness, administrative burdens, affronts to traditions, and threats to quality sometimes posed by Managed Care. This collective unrest has resulted in both a mounting resistance to the problems emanating from managed care changes in the healthcare system and a call to check its unrestrained incursions into professional practice through regulation. The growing tension between what seems an irresistible force and an immovable object can be viewed as part of the natural evolution of all change, particularly in a free market or in a society with requisite checks and balances.(ABSTRACT TRUNCATED AT 250 WORDS)

[High frequency long-term analysis and psychoanalytic practice. Utopia and reality]

On the basis of the prognostic study of psychotherapeutic treatment in the Federal Republic and of the evaluation of more than 1000 applications for insurance benefits submitted in the years from 1973 to 1983, it is suggested that high-frequency long-term analysis is the exception rather than the rule and that it is carried on almost exclusively by a small group of "privileged" therapists. The author asks what this implies for the definition of psychoanalysis and for daily treatment practice. Are therapists being trained for a kind of treatment that they will rarely or never practice? The author urges resumption of the discussion of theory and technique of psychoanalysis in which these questions will be considered.

The mental health care revolution: Will psychology survive?

Managed mental health care, which encompasses a wide variety of approaches, is a response to precipitous increases in health care expenditures, particularly as they relate to mental health care. The shift from what seemed certain to become a national health insurance program only 15 years ago to the profit-driven corporate health care industry of today is truly revolutionary. These profound changes are beginning to have a major impact on the independent practices of psychologists. In this article, psychologist practitioners are exhorted to recognize this new development in the marketplace. Data are cited that show the rapid shift from free choice care to various forms of managed care, and practitioners are urged to participate in shaping the changes that are now in process in order to develop a humane and effective system of mental health care.