The above graphic is a headline search of mental health parity going back to 2004. I was in the thick of things from 2009-2012 as the transitioning President of a District Branch of the American Psychiatric Association - the Minnesota Psychiatric Society. Not that it gave me the inside track on anything. I think officers in district branches spend most of their time trying to get members motivated to do something. My strategy was basically to approach things in the way I do on this blog. I don't think that is was any more or less successful than the dialogue promoters, but at one point some people became uncomfortable when I suggested that one of the hospitals could have been managed better. It was apparent to me at that time that professional organizations do not tolerate disagreement very well. As far as I can tell, there can be no real changes in organizations without disagreement and disagreement should be expected anytime there are people who want to talk endlessly and people who want action. On the other hand nobody has to take it personally. That may not be possible in Minnesota or in professional organizations. I have previously referred to it here as the "big tent" approach where multiple goals are tolerated even some that conflict with the overall goals and ethics of the organization. An example would be prior authorization of medications. The vast majority of members find it extremely intrusive and a waste of their time, but the members who are executives in managed care organizations do not. Accepting both of those positions is a tacit acceptance of prior authorization while working with the members to change it. How do you think that will work out?
Parity or equal coverage for mental illness and physical illness was a legislative initiative of two U.S. Senators Paul Wellstone and Peter Domenici. Both had personal experience with the problem having family members with severe mental illness. That personal experience remains critical in the political and cultural landscape. There are still plenty of people pushing the "myth of mental illness" fallacies. Some have moved on to just blame psychiatrists. People with experience recognize those arguments for what they really are and can try to proceed with real solutions. I never met Paul Wellstone, but I liked him a lot. He was one of a handful of US Senators who voted against authorizing the invasion of Iraq based on the flawed weapons of mass destruction argument. He was vilified by some for the vote and referred to as an ultra-liberal. That is a glib characterization during an era where there are no liberals. In Minnesota he was widely known as a populist. People perceived him as a common man who cared about the common people. He was tragically killed in a in a plane crash in northern Minnesota in 2002 while campaigning for his fourth term in the Senate. Senator Domenici retired from the Senate in 2009, after the longest tenure at that position by anyone from the state of New Mexico. My guess is that the final form of this bill and the way it is implemented was not the intent of either of these Senators.
I read through several iterations of their bill until it became The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). All of those versions are available on the Congressional web sites, but the factsheet is available from CMS. It should be fairly obvious by any casual read of the factsheet that there are so many exceptions and vagaries associated with this law that it would not take the insurance industry and their government affiliates long to shred it. I pointed this out at the APA 2011 Annual Meeting in Hawaii. There was a meeting about how the MHPAEA was going to revolutionize the care of people with addictions. A prominent psychiatrist and government official was scheduled to be there to explain how this was going to happen. At the time, the impact of the law was not apparent on any of the acute care services where I was working. At the meeting after listening to an overenthusiastic presenter explain how funding all of these programs were going to greatly increase bed capacity and services for all, I asked the simple question: "What would prevent any managed care company from providing a screening test and calling that assessment and treatment?" The answer was "Nothing would prevent that." No elaboration. No discussion of how employers can just opt out of mental health and substance use treatment.
That introduction allows me to flash forward to the current time. I was recently interested in referral for an acute psychiatric hospitalization in the Twin Cities - a metropolitan area of 3.8 million people. According to a 2007 state report there were a total of 563 acute care beds for that area or 14.8 beds per 100,000 population. According to the Organisation for Economic Co-operation and Development (OECD), the US ranks about 30th of 35 ranked industrial countries in terms of psychiatric beds per 100,000 population and the Minnesota metro is significantly below the US average of 25/100,000. Based on those factors it should not be surprising that I was advised that there were no available beds and that the emergency department we could refer to had a 30 hour wait for assessments.
Compare that to Cardiology services in the same area. Any middle-aged person (or younger) with chest pain would be immediately admitted to a coronary care unit or telemetry and have a standard evaluation completed even if they were discharged or undergo emergency catheterization and angioplasty/stenting. I have never heard of a wait for acute Cardiology services. I have never heard of a 30 hour wait in the emergency department for Cardiology services. My point here is that the MHPAEA or parity legislation has done exactly nothing for the availability of acute psychiatric services. These same numbers and waiting times in the ED have been there for the past 15 years. There is no parity as long as there is no equal funding, and mental health services are funded at a fraction of what Cardiology services are. Walk through any modern Cardiology Department or Heart Hospital and ask yourself: "Where are the equivalent psychiatric or mental health services?" There are a few exceptions but generally not many and even then, a new facility is still managed by rationing strategies that result in people being discharged with inadequate plans and before their problems are completely addressed. Inpatient psychiatric services are in effect behind a firewall and accessible only through the bottleneck in the ED.
The grim picture of acute care mental health services is only exceeded by the state of acute care addiction services. As early as 1988, I was being advised by managed care companies that I could not detoxify patients with alcohol dependence on inpatient psychiatric units, even if they had significant psychiatric comorbidity like suicidal ideation and depression. The picture has gotten progressively worse since then. It is common practice these days to send alcohol dependent people home with benzodiazepines and expect them to manage their own detox. The lack of functional detoxification services keeps many people in the cycle of addiction to benzodiazepines, opioids and alcohol.
Confirmation of my skepticism about parity came in the form of the Mental Health Reform Act of 2015. It is also a bipartisan bill introduced by Senators Bill Cassidy (R-Louisiana) and Chris Murphy (D-Connecticut). There are House and Senate versions. Both establish a new assistant secretary position for mental health and substance use disorders under the Department of Health and Human Services (HHS). The fate of the Substance Abuse and Mental Health Services Administration (SAMHSA) hangs in the balance and getting rid of this highly flawed agency should be a priority. SAMHSA has been the lead agency for mental health during this time of no parity and has not said anything about it. The remaining description of the bill has to do with education people about HIPAA (do we really need that?) and insurance company accountability for a lack of parity. The fanfare for this bill including praise from the APA is the exact same way the parity legislation started. It should be evidence to every American by now that Congress is really interested in appearing to do something and appearing to want reform rather than getting the job done.
I don't think that there is anyone in Washington who knows the meaning of the word reform. Until politicians everywhere realize that mental health services and substance use services have been an easy way for health care companies to make money by denying reasonable services nothing will happen. It would help legislators to realize that they also have the highly flawed idea that managed care actually saves money and it is a conflict of interest for them to continue to promote this middle man on that basis. I am not holding my breath, but it should be obvious that when a reform bill happens every 7 years, and there are still 30 hour emergency department waits and no acute care beds for admissions - there is no parity and there has been no reform.
George Dawson, MD, DFAPA
