Increase in parity supports building out mental health informatics
Regulations in the last 10 years have been making a push toward mental health parity, which aims to prevent individuals receiving mental health and substance misuse services from getting less favorable benefits than their medical/surgical counterparts. However, as regulatory guidelines push the industry to compliance, a gap in technology persists as there are currently little incentives propelling major health IT vendors to build out data fields related to behavioral health services.
CMS in late March released a final rule aimed to help ensure mental health services are covered the same as physical conditions for Medicaid and CHIP enrollees, a rule the agency estimated would benefit 23 million individuals. The rule was designed to be closely aligned to the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), which mandates group health plans and plan issuers who choose to cover mental health issues to apply parity.
Overall, the Substance Abuse and Mental Health Services Administration (SAMHSA) estimated 43.6 million American adults (about 18.1% of the population) have experienced mental health issues.
"Parity is the new normal," Dr. Colleen Barry, professor and associate chair for research and practice in the department of health policy and management at the Johns Hopkins Bloomberg School of Public Health, recently told Healthcare Dive. "We've passed the phase where transitional violations are OK and need to get to a point where the requirements of parity are being strictly enforced."
Playing along with the new normal
However, it took some time and dedication to get to this point. While the Wellstone-Domenici rule was signed by President Obama in October 2008, the final implementation rule for the mental health parity didn’t hit the federal regulatory streets until November 2013. And that was after the interim final rule was published on February 2010 and a separate March 2010 measure amended the ACA to apply the parity law to those who apply for individual health coverage.
There are a lot of moving parts surrounding mental health parity. HHS oversees non-federal governmental plans while the Department of Labor regulates private employment-based plans. Insurance purchased through the individual market or by an insured group health plan is managed by a state's insurance department.
Because Medicare, Medicaid, and CHIP are public health plans, "provisions of the Social Security Act that govern CHIP plans, Medicaid benchmark benefit plans, and managed care plans that contract with State Medicaid programs to provide services require compliance with certain requirements of MHPAEA," CMS states.
In this rule, CMS gave states an 18-month grace period where they must provide documentation of compliance by October 2, 2017. However, the Wellstone-Domenici law took effect in January 2014 and applied to plan years that began on or after July 2014. Some insurers have begun to feel the sting of noncompliance.
For example, New York Attorney General Eric Schneiderman last March announced a settlement with Excellus Health Plan for denying addiction and mental health benefits to 3,300 policyholders in violation of state and federal parity laws. At the time of the announcement, about $9 million was estimated could be returned to patients.
New York is notably aggressive in going after insurers to ensure mental health parity compliance. The AG office has gone against and settled with Cigna, MVP Health Care, EmblemHealth and ValueOptions over parity issues. Efforts have recovered $2.9 million related to penalties and given back about $1.6 million to consumers, News10 ABC reported this May.
Writing in the June issue of Health Affairs, Barry wrote, "It is worth emphasizing that the incentives for health plans to avoid adverse selection do not go away in the presence of federal parity, since there will still be variation across plans with respect to the generosity of the mental health and substance use disorder benefits offered."
That said, Barry told Healthcare Dive health plans do need guidance over regulations to understand the nuts and bolts of parity implementation/compliance. She noted the Wellstone-Domenici law came out around the time of a major healthcare reform (ACA). And it's easy to get lost in weeds of federal legislation/language. One suggestion for health plans can be to designate an internal parity compliance officer to become the point-person in terms of parity compliance.
In the pursuit of access and technology
As of last month, 29 states and the D.C. require parity of telehealth services, MedCity News reported. For mental health services, reimbursements typically has been a challenge, according to Dr. William Bithoney, managing director at BDO Consulting. But, he believes the behavioral health market is undergoing a sea change.
"You see more interest from private equity" as well as the possibilities of behavioral health entity purchases, Bithoney told Healthcare Dive, adding it's "because reimbursement has improved both from federal government and private insurers."
"We call this market ripe for growth and consolidation," he said.
Yet, even for all the advances in reimbursement/parity regulations, there are some gaps in the quality measurement for such services. One potential growth area is the technology systems capturing and sharing patient data related to mental health and substance misuse issues.
Dr. Harold Pincus, director of quality and outcomes research at New York-Presbyterian Hospital, along with colleagues wrote in the June edition of Health Affairs there is "little evidence" that the quality of behavioral healthcare has significantly improved in the last 10 years. They note parity regulations and the increasing recognition that behavioral health impacts care costs have resulted in "new demands and opportunities for expanded and innovative strategies to assess the quality of care for this patient population."
Part of the problem "is that attention to the details of the nature of information that's needed in behavioral health has been more or less left out of the mainstream over the development of the health IT infrastructure," Pincus told Healthcare Dive. He adds this includes both the developments of information systems as well as policy.
For example, he and his colleagues noted in Health Affairs about 5% of metrics in the CMS' Measures Inventory -- which includes more than 130 databases -- target behavioral health.
He adds that important clinical content relevant to behavioral health has largely not been incorporated into EHR systems nor clinical terminologies and ontologies. For example, he cites in Health Affairs only two of 31 behavioral health quality measures receiving National Quality Forum's endorsement involve psychosocial interventions. He told Healthcare Dive while it may be known that 45 minutes of psychotherapy was administered to a patient, standardized measures don't drill into the needed details throughout an incidence of care. Additional information that could be captured electronically include what sort of approach was used and if the administered care used evidence-based tactics.
This is a big deal to be able to get the needed details that paints a fuller picture of a patient. There's a tremendous need for health data integration among providers in this space as individuals with mental health issues often have chronic, comorbid conditions.
"There needs to be an effort to build the field of behavioral health informatics," Pincus told Healthcare Dive.
Laura Young, executive director of the Behavioral Health Information Network of Arizona (BHINAZ), agrees. The ability for EHR systems to actually capture such non-traditional EHR elements for health information exchange is still a challenge, especially to the degree of specification and data texture that would make an exchange meaningful. Young told Healthcare Dive it can be a struggle for behavioral health-specific organizations to capture data specific to behavioral health, such as whether patients were in court-ordered treatment or were found to be in danger of themselves or others.
However, because behavioral health data elements were largely left out of meaningful use requirements, there haven't been many incentives from a vendor standpoint to add many behavioral health-specific data fields.
The Office of the National Coordinator for Health IT has stated, "The rate of health IT adoption among behavioral healthcare providers is minimal." Young concurs that funding is a problem for behavioral health providers to actually purchase robust EHR products. And yet, as reimbursements and industry shifts move toward value-based care, some like Young believe more exposure to integrated health and the need to exchange behavioral health data will help open up funding.
"I think the EHR vendors that get there first are going to be the ones that stand out in this area," Young said. "It's a largely untapped market from a business aspect. Those that take the time to start working on their platform now and have them ready, those are going to be the big winners when those dollars do start to flow down."
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