A few weeks ago, I read a Wall Street Journal  article, "Law Prompts Some Health Plans To Cut Mental-Health Benefits," which summarized a Kaiser Family Foundation survey (Employer Health Benefits 2010 Annual Survey) on the effects of the behavioral health parity law on employer-sponsored health plans  – this article shouldn't have come as a surprise to those who are familiar with the past data. Of employers with over 50 employees, 69% didn't change their benefits at all. Of the 31% that did change their benefits, 66% changed their behavioral health benefit limits to equal physical health benefits; 16% increased their use of managed care; and 5% eliminated behavioral health benefits overall. That last 5% was, of course, the focus of The Wall Street Journal article.  

The article's authors did cite the Congressional Budget Office estimate that parity would increase premiums for group health insurance by an average of 0.4%, and the work by Steve Melek, a behavioral health  expert for the actuarial firm Milliman Inc., which showed that not providing benefits for mental health and addiction leads to higher overall health care costs. The article also referred to the fact that these plans would have to add back this coverage if the health care reform legislation moves ahead; the law requires that health plans offered through the soon-to-be-launched health insurance exchanges meet certain minimum level of benefits.

But the line that really got a rise out of me was the very last of the article; it referred to how the Screen Actors Guild (SAG) was going to help their members now that they had eliminated all their behavioral health benefits (both services and pharmaceuticals).  The article stated that their plan "will begin working with its members to help refer them to community-treatment options […]." I don't know what mythical free sources of mental health and addiction treatment services and pharmaceuticals the CEO of SAG was referring to, but I certainly haven't come across any. Our team at OPEN MINDS works with a wide range provider organizations who see the 'flood' of Americans who are uninsured and (in this case) underinsured looking for free services. Provider organization budgets for free services are very small—certainly not enough to cover the U.S. population currently uninsured and underinsured for the treatment of mental illnesses and addictions.

In the future, I'm hoping that policymakers will drop their references to this land of "happily ever after," wherein everyone can magically receive free behavioral health services. Policy decisions only work when you make them for the real world. 

Like many Americans, I was first stunned and then unsettled by the shootings that took place last week in Tucson. Since then, we’ve heard lots of debate about Jared Lee Loughner's motivations. Partisan media hyperbole? Targets on an election map?

Most recently, there has been a chorus of pundits singing about the ills of the mental health system. Michael J. Fitzpatrick, Executive Director of the National Alliance on Mental Illness, said, “The plain truth is that America's mental healthcare system is horribly broken and horribly underfunded. And across the nation, budget cuts continue to eviscerate community mental health programs that reach out to vulnerable individuals and put them on a path to recovery.”

But more surprisingly, have been the statements of key Republicans:

• Republican advisor Mike Murphy said on the Bill Mahar Show on January 14, 2011, "I'd like to see a better linkage between the gun control stuff we have now and the crazy-filter. Because if you look at Virginia Tech and you look at this guy, it is too easy for mentally ill people to get guns; because there’s no mental screening anymore."
  
• Virginia Republican Senate candidate Jamie Radtke (and head of the Richmond Tea Party) told ABC’s Top Line that "instead of it being about the political part, it’s really about needing to get our arms around our health care, the mental health policy here."
  
• Representative Mike Rogers (R-MI) said, "What we have to do is intervene earlier in that cycle of violence when they have this kind of disability. . ."
  
• Newly-elected Representative Allen West (R-FL) said, "The shooter was a very disturbed individual and it appears there were so many warning signs that he was going to do something horrible.  We should be focusing on the mental health crisis in our country, not politics."

Well, I have a simple piece of advice: if we want to stop tragedies like this from happening again, we should not repeal health care reform. Two years ago, national legislation passed that (finally) guaranteed that most individuals with insurance will have coverage for assessment and treatment of mental illness. The health care reform legislation builds on that non-discrimination parity legislation and assures that most Americans will have some form of health coverage that includes coverage of mental health conditions.

Earmarked funding for community mental health services will not solve the problem. We need to end fundamental discrimination against people with mental illnesses, and ensure that they have consistent access to the health care services that they need.

The health care reform bill tug-of-war currently happening between the House and Senate is too much for many of us to keep up with. I took interest with an article in Slate by Christopher Beam that includes a hit-list of those health care reform issues that still need to be ‘hammered out’ in the final bill. His six issues include:

• The exchanges—while the House bill would create a national exchange, the Senate bill would create a series of state-based exchanges. There’s no happy medium. It is either state or national.
• The mandates—what will be the real penalty for not buying health insurance? The House bill would charge a 2.5% tax on all income above the filing threshold ($9,000/individuals or $19,000 for couples), while the Senate bill would impose a flat penalty, which itself fails to acknowledge the wide variance in American income levels and their ability to pay up. The employer mandate is a big one as well; will employers pay an 8% tax on total wages or levy a $750 fine per employee? Who will be eligible for exemptions?
• Medicaid expansion and subsidies—the House bill would make Medicaid available to individuals earning up to 150% of the poverty level, while Senate bill would expand it 133%. The differences are in the subsidies, in that the House bill provides far more support for families at or below 300%, while the Senate bill seems to focus more on middle income families between 300% and 400%.
• CHIP—key questions posed by Beam: “Does Congress really want to end the Children’s Health Insurance Program and push kids into exchanges and Medicaid, as the House bill would do? Or does it want to extend CHIP until 2015, as the Senate bill would do?
• Narrowing the ‘donut hole’—the gap in Medicare coverage known as the ‘donut hole’ is addressed far more in the House bill, which phases it out altogether by 2019 by ‘filling’ it with money from the pharma industry. The Senate bill would only close the gap halfway (and only temporarily).
• Paying for it—the House would levy a 5.4% surtax on individual income above $500,000 while the Senate would tax plans that cost more than $8,500 for individual and $23,000 for a family; Senate would also tax indoor tanning services (yes, seriously).

As our eyes dart back and forth between this legislative ‘volley,’ I will be interested to see how flexible the House and Senate are on certain issues—and which issues they refuse to compromise on.

We're on the eve of the implementation of behavioral health parity legislation. Medicare has released the procedures for implementation of parity for their beneficiaries—see “Medicare Claims Processing Transmittal 1843: Outpatient Mental Health Treatment Limitation.” The regulations for the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act will be released in January of 2009, “Wellstone Act Mental Health Parity Effective Date Delayed Until 2010.”

But the various pieces of parity legislation will only be as meaningful to consumers as their implementation. To that end, there is a great piece in the December 2, 2009 issue of Medical News Today, “Lessons From the Implementation of Mental Health Parity in California.” Coauthors Margo L. Rosenbach, Ph.D., Timothy K. Lake, Ph.D.; Susan R. Williams, M.P.P., also affiliated with the Mathematica Policy Institute, and Jeffrey A. Buck, Ph.D., offer three pieces of advice from their research:

• The need for increased oversight of health plans—monitoring health plan performance related to access and quality, in addition to monitoring coverage and costs;
• The need to look at the breadth of diagnoses covered by health plans; and
• The need to ensure consumer awareness of parity—mounting a campaign to education consumers about their insurance benefits.
  

Three points we should all put on our 2010 new year's resolutions!

After November’s election results, I’m left wondering…was it a referendum on the President? Where were all those young Obama supporters? Is the GOP dead of its own internal bickering? That independents would within one year swing from Obama enthusiasts to backing decent-to-weak Republicans in Virginia and New Jersey is “simply astonishing,” writes The Wall Street Journal opinion editor.

I don't think it's so astonishing. But, it means accepting the fact that technology has made both political parties—as they currently operate—irrelevant. The world of Internet information; web-based political advocacy groups; and flash mobs (e.g. ‘tea party’ folks) has changed the political landscape. Political parties no longer have coherent platforms that mean anything to anyone and they don't have the ‘member control’ that allows them to mobilize voters. In the future, the winning candidate (and the winning party) will be one who can engage the independent voter around specific issues by using technology to build candidate-specific coalitions of specific voter and interest groups.

For health care reform, both parties are at risk. For the Democratic Party, they're going to need to realize that Americans are skeptical about the operation of the current 'public options' (Medicare, Medicaid, IHS, TRICARE, VA) and don't want to abandon their perceived personal ability to pick a health plan or a professional. Republicans are going to have to go beyond the 'party of no' and "Kill the Bill" rhetoric. Americans know they’re in danger of losing health insurance when they lose their jobs; that many health insurance company policies are nightmares; and that most of us are one serious disease away from bankruptcy. The party that ignores the 'middle view' on health care reform will pay the political consequences for whatever happens with health care.

I'm opposed to a new public option health plan & want more competition.

Many of my colleagues are surprised when they hear that I am—like many Republicans and "Blue Dog" Democrats—opposed to the current proposals for a new public option health plan. But, after a brief explanation, both the dismay of the public option folks and the applause from public option opponents ends.

I'm not opposed to government-offered health plans—or to competition. In fact, I strongly encourage both. On the competition side, we have a perfectly fine model for offering Americans a choice among public and private health plans, the Federal Employee Health Benefit Plan (FEHBP) model, which currently offers over 300 health insurance choices to Federal employees. My proposal? Give every American a voucher and let them pick between a wide variety of public and private plans (assuming the plans offered meet minimum requirements for coverage, etc.)

That said, I am opposed to the creation of a new public option health plan for two reasons. We already have 60 public health plans that could be 'options' without creating another new government infrastructure. Don't know what I'm talking about? Serving 30% of Americans already are these 60 plans:

• TRICARE
• Veterans Health Administration
• Medicare
• Healthcare Group of Arizona
• Indian Health Services
• 55 Medicaid plans—each with a variety of public and private options within those
  

My point is that there is no reason to duplicate the administrative expense of these 60 plans and create another public option health plan. Let's just open up the 60 existing public option plans—and the 300+ plans available under the FEHBP—to the American public.

For a great description of existing U.S. public health benefit plans, check out the reviews at propublica.com, Grading the Public Options That Already Exist.

August 28, 2009

There is a thought-provoking article that came out in the August 19 edition of the Schizophrenia Bulletin, “Implementing Evidence-Based Practices for People With Schizophrenia,” by Robert E. Drake; Gary R. Bond; and Susan M. Essock. The article is a great summary of the current sad state of the treatment of serious mental illness at the consumer level. Despite significant research on what works, essentially people with serious mental illness are not getting the treatments they need. While the article is a great state-of-the-nation piece, based on our team's work in the public mental health system I think the recommendations need to be expanded.

Over the last decade, a number of systematic efforts to identify evidence-based interventions for individuals with serious mental illnesses have been made. However, although the interventions have been identified, numerous surveys have shown that consumers are not receiving these interventions. The report states:

Epidemiologic data from the National Comorbidity Study in the early 1990s showed that 60% of persons with serious mental illnesses received no treatment in the past year, 25% received clearly inadequate treatment, and only 15% received minimally adequate (far short of evidence-based) treatment.

The 2005 National Survey on Drug Use and Health found that only 8.5% of adults who reported both serious psychological distress and a substance use disorder received any treatment for both problems in the past year.

In their article, the authors recommend solutions that fall in the domains of information technology, state policy interventions, and federal policy interventions. But, I think these recommended solutions will have a limited effect if there are no changes to fundamentals in system design and financing, needed to assure that consumers with mental illnesses can get the services they need. I know the naysayers will contend that there is not enough money in the system to pay for these changes. I would counter that these are not behavioral health system issues. Rather they are health care issues—and these changes would be budget-neutral if we factor in the costs of emergency room visits and hospital readmissions alone.

To view my proposed solutions, check out: http://www.openminds.com/circlehome/circle/content_schizoebpstudy.htm