Mental health parity insurer accountability is long overdue


What are the news: The AMA urges Congress to hold insurance companies accountable for their repeated failure to comply with the Mental Health Parity and Substance Abuse Equity Act of 2008.

The law requires that coverage for treatment of substance use disorders (SUDs) and mental illnesses by group health insurance and self-funded plans be at parity with the medical and surgical benefits offered by the payer. But a recent report to Congress shows that companies continue to violate this requirement.

The Senate Committee on Health, Education, Labor and Pensions and the House Ways and Means Committee held hearings to review the report (PDF), which was generated by the Departments of Labor, Treasury and Health and Social Services.

“This report underscores two simple facts: insurers will not change their behaviors without increased enforcement and accountability, and patients will continue to suffer until that happens,” wrote the executive vice president and CEO of the company. ‘AMA, James L. Madara, MD, in a letter to leaders. commissions (PDF).

“The report found that insurers’ failures were prevalent across all plans in many ways, including using greater restrictions on treatment, benefits and standards of evidence for mental health care and mental health-related disorders. substance use versus medical/surgical benefits,” Dr. Madara wrote.

Related coverage

Use these new guides to help integrate behavioral health care

He cited several “gross violations” of the parity law, including those that harmed people:

  • Autism—Hundreds of self-funded plans have explicitly excluded evidence-based treatment for people with autism spectrum disorders.
  • Substance use disorder—The plans excluded evidence-based drug coverage for opioid use disorder and required prior authorization for all outpatient mental health and SUD services.
  • An eating disorder—More than 1.2 million enrollees have been denied benefits for nutritional counseling for mental health conditions such as anorexia nervosa, bulimia nervosa and binge eating disorder.

Insurer failures also included the use of greater restrictions on treatment, benefits, and standards of evidence for mental health care and TUS compared to medical or surgical benefits.

The report highlights how “non-quantitative treatment limits” (NQTLs) are used by insurers to limit, delay or deny care for mental health and SUD. Examples of NQTLs include prior authorization, prescription drug formulary design, network tier design, network participation standards for physicians including reimbursement rates, fail-first policies or step therapy protocols, and restrictions based on location, facility type, specialty, and other criteria that limit the scope or duration of benefits.

Find out what every U.S. employer can do to help end the overdose epidemic.

Why it matters: Restricting treatment results in harm to the patient.

The report notes that early intervention and access to treatment for autism spectrum disorders “can improve a child’s developmental trajectory”, while delays or limitations are particularly harmful.

In the 12 months ending in April 2021, more than 100,000 Americans died from drug overdoses, which is more than 30% higher than the previous one-year period, according to the report. Death rates are particularly high among black people and in Native American and Alaska Native communities.

“As these statistics demonstrate, it is critical that the health coverage Americans have access to includes coverage for the treatment” of mental health and substance abuse disorders, the report says.

Insurer policies and practices contribute greatly to stigma and discrimination against people with mental illness or SUD, Dr. Madara wrote, adding that “systematic and widespread violations of Parity insurers have also contributed to increased inequities “in mental health and substance use disorder care” for Black, Hispanic, Native American, Alaska Native, and Asian-American communities.

Related coverage

How language makes a difference in the treatment of substance use disorders

Patients pay the price for payers’ failure to comply with the law.

“Each failure resulted in benefit limitations, delays, and denials of care,” Dr. Madara wrote. “Simply put, each parity failure resulted in increased patient suffering and almost certainly deaths that could have been prevented if care had been provided.”

Congress should pass HR 3753/S. 1962, the Parity Implementation Assistance Act, which provides grants to help states implement federal mental health parity requirements.

WADA agrees with the report’s recommendations to:

  • Grant the Ministry of Labor the power to impose monetary civil penalties for violations of parity.
  • Enable plan participants and beneficiaries to recoup financial losses associated with improper claims denials resulting from violations of law.

Learn more: The AMA believes that science, evidence and compassion must continue to guide patient care and policy change as the nation’s opioid epidemic evolves into a more dangerous and complicated illicit drug overdose epidemic. Learn more on the AMA’s End the Epidemic website.

Previous Universal coverage in California is a better bet than single-payer
Next Lithium Miners: An Excellent Long-Term Buy Opportunity