Will mental health parity accelerate adoption of evidence based medicine?

I was delighted to see the Boston Globe lead off its front page with an article on mental health parity (Firms put limits on mental therapy; New scrutiny may break federal law, opponents allege). It’s a fairly straightforward documentation of the squeeze being put on some providers by behavioral health companies, in particular United Behavioral Health, which is trying to hold down the soaring cost of mental health treatment. Left unsaid is the implications this squeeze may have for evidence based medicine throughout health care.

At issue is the growing practice of requiring therapists to undergo lengthy and repeated phone interviews about their patients’ progress before the insurance company will approve further treatment. According to patients and therapists interviewed by the Globe, the reviews have established tougher criteria for additional visits and have been burdensome and intimidating. That has sometimes led to curtailed treatment and protracted appeals.

Advocates for the mentally ill believe the restrictions may violate the 2008 federal mental health parity law, which requires most employers that offer mental health coverage to provide the same level of services as for other medical care. A company’s plan may not limit the number of therapy visits without placing similar restrictions on other doctors’ visits and may not require employees to shoulder more costs for mental health sessions than for other visits. Regulations issued last month went further, saying employers’ plans may not impose other limitations on mental health treatments that are not required of other medical services.

Legal advocates say that the new rule means insurers are not allowed to grill therapists about their patients’ progress unless the insurers require other medical specialists, such as those who prescribe regular dialysis for patients with kidney failure, to undergo similar scrutiny.

“We are seeing what seem to be excessive preauthorization and other reviews that we don’t typically see for other medical services,’’ said Matt Selig, executive director of Health Law Advocates, a public interest law firm based in Boston.

Mental health advocates clearly hope to see scrutiny of mental health services lowered to the level that other treatments face. The mental health parity law means they are likely to succeed. But there’s another possibility that I think is just as likely if not more likely: raising the level of scrutiny of all services to the same level that mental health services face.

Payers and purchasers are going to be reluctant to lower the barriers to mental health treatment –the cost implications are just too great. Once they understand that they may have to lower those barriers to comply with the law, they may begin to explore why such a small percentage of what they pay for in other fields is evidence based. (If anyone has a statistic on this percentage please let me know.) Rather than loosening requirements and scrutiny in mental health insurers may raise the barriers in areas such as cardiology (do you really need that stent?) and orthopedics (why should we pay for that back surgery?)

In some ways this scenario represents a return to the bad old days of managed care circa 1992. And yet cost pressures are strong enough that employers and health plans may be ready to give it a try, even if doctors and patients aren’t enthused.

May 17, 2010

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