As we learned with racial segregation, separate is not equal. Insurance plans should cover all diseases equally.  In America, perhaps due to stigma or prejudice, insurance plans have historically paid more generous benefits to what they called “physical health” as opposed to “mental health” and substance use disorder (addiction) treatment. In medicine, it is often said that behavioral health care is paid the lowest fees, and within behavioral health, the very lowest fees are paid to treat substance use disorder.

In 2008, Former US Representative Patrick Kennedy was a chief sponsor of the Mental Health Parity and Addiction Equity Act (MHPAEA). This bill was signed into law under President George W. Bush, as part of the Troubled Asset Relief Program also know as TARP. Let’s hear what he has to say about parity today:

” When you think you’ve done it, check again. Historical biases and prejudices have a sneaky way of infiltrating our practices.”

Steve Defossez: What can hospitals and health systems do to make sure we finally see full implementation of the 2008 Mental Health Parity Act (the federal parity law)?

Patrick Kennedy: Well, we have to change our cultural predisposition towards these issues. Historically, we segregate mental health issues to the margins of healthcare. Why? because they were not seen as real healthcare issues. Unfortunately that’s the backdrop from which we come. So if I were to emphasize anything, it’s that when you think you’ve done it, check again. Historical biases and prejudices have a sneaky way of infiltrating our practices.

Patrick Kennedy: We don’t know what the future looks like in healthcare delivery because it hasn’t happened yet. We know academically that mental health is essential health and the brain mediates the health of the whole body. We know that you can’t properly treat any illness without treating the mental illness as well, which may underlie it. Mental illnesses often underlie physical diseases. Depression and anxiety are often co-occurring with all other major illnesses and physical disabilities. I would say that we need to start with the parity law because it’s very tangible and easy to wrap our arms around. Ask yourself, are we treating mental health and addiction the same way we treat physical and surgical diseases? Do patients with mental health issues have the same access to inpatient and outpatient care? Is this true for in-network providers and out-of-network providers? Do patients with mental illness have the same pharmacy benefits (coverage and deductibles) and the same ER benefits as patients with “physical disease?”

Patrick Kennedy: The parity law (which requires health insurance plans to pay for mental illness treatments just as it pays for physical illness treatment) is not just for payers. Hospitals are increasingly becoming part of these Accountable Care Organizations (ACOs) which are taking on insurance risk. This concept of bifurcating (separating) the payer from the provider; that obviously is quickly becoming a thing of the past.

“Lack of access to mental health care and addiction treatment… is driven by money and the lack of resources.”

Steve Defossez: How does the current system fail to treat behavioral health issues the same as so called, “physical health?”

Patrick Kennedy: One needs to really understand the practices of insurance plans to see the discrimination occurring today. Technical insurance procedures, including:

• medical necessity determination, (where an insurer can determine that a procedure is not “medically necessary” and therefore not pay for it.)
• retrospective review (where an insurer can fail to pay for a service which has already taken place)
• prior authorization (a time consuming hoop physicians need to jump through, in order to get the insurer to approve a service. If the service is performed, even if medically necessary, the insurer will not pay for it unless prior authorization is obtained first.)

These insurance procedures, and others often result in inadequate payment of those who provide mental health services.

This, of course, has led to the historic lack of access to mental health and addiction treatment. By the way, every hospital system and every state is still suffering from lack of access in terms of the inability to really address this public health opioid epidemic. And there is lack of access just to address the day-to-day needs of every patient. All of that is driven by money and the lack of resources that have gone into paying for reimbursement for professionals in mental health. The lack of payment for providers and other ancillary services can actually increase cost and lead to worse outcomes.

Patrick Kennedy: For example, we know stable housing produces as big an impact on stable mental health as anything else you can do on the medical side. We need to do more to provide access to stable housing, and this will be cost effective, as it reduces healthcare costs. We know the science of mental health. It’s not always just biological in terms of its intervention. Social services can be as important as medications. So we need to treat the delivery of mental health services as scientific. If you do that, we can start to move away from this cultural bias among medical staffs and hospitals that this somehow is not what they do. In fact, in order to achieve better outcomes using fewer resources, ACOs need to be thinking about how they address the mental health component of all diseases, whether it’s oncology, cardiovascular disease, diabetes or what have you.

The time for healthcare parity is long overdo. Unless we make it known that our behavioral health benefits are not equal to our physical health benefits, nothing will change, If you experience second class treatment for a behavioral health issue, please contact your state’s insurance commissioner, US representative, US senator or me at Steve@DefoSays.com.

Please be on the lookout for the next and final installment (Part Two) of our two part interview with Former US Representative Patrick Kennedy, where we will address the US opioid crisis.