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Addiction Battle a Fight for Parity - Courier-Post
Sunday, February 14, 2010
Kim Mulford, Courier-Post staff
Addiction battle a fight for parity
By KIM MULFORD
Courier-Post Staff
Kathleen Dobbs had a good job with solid health benefits and, like most insured workers, her plan included coverage for mental illness and substance abuse.
But in 1996, when her 16-year-old son needed long-term rehab for his cocaine addiction, Dobbs' insurance company repeatedly turned down his therapists' recommended treatment plan.
Eventually, the Barrington mom won long-term residential rehab for her son -- the bill paid by New Jersey taxpayers. Dobbs wanted more. With a handful of South Jersey mothers of addicted children, she helped form Parent to Parent, a grass-roots, support group which works to get better treatment for substance-abusers and their families. They joined thousands of other mental health and addiction advocates who lobbied lawmakers for change.
"My son took a state-funded bed away from someone who really needed it, who had no insurance," Dobbs told state legislators. "My insurance company, like so many others, had to pay hnothing."
Fourteen years after Dobbs' insurance company rejected her claim, new federal regulations issued this month are expected to improve access to mental health and addiction care for 118 million insured Americans.
The Mental Health Parity and Addiction Equity Act of 2008 requires group health plans offered by companies with more than 50 employees to treat mental illness and substance abuse addiction benefits the same as physical and surgical benefits. The law took effect Oct. 3.
The law strengthens a 1996 parity act that required annual and lifetime limits for mental illnesses on par with those for surgical and physical benefits. The new law adds substance abuse treatment.
"Civil rights'
Managed care providers can no longer require patients to pay higher deductibles, out-of-network charges or co-pays for visits to a therapist than to their primary care doctor. The new requirements also apply to day and visit limits.
"First and foremost, it's really a piece of civil rights legislation," said Edward Diehl, president of Seabrook House, an addiction treatment center in Upper Deerfield, Cumberland County. "It's a fairness doctrine that sets the stage and clears the landscape for what I would project future contention over just really where the rubber hits the road."
That contention will center on how insurance companies interpret their patients' need for mental health or addiction services, "which will always come down on "spend less' of the premium dollar," said Diehl, past chairman of the National Association of Addiction Treatment Providers.
The law has shortcomings. If you are not insured, the law doesn't help you. Plans offered by small businesses are exempt, and so are plans bought by individuals and public insurance plans like Medicare.
Self-insured state, county and local governments can "opt out," of the law, too. In New Jersey, for example, 800,000 state and school employees will not be covered under the new law.
Others say insurance rates could be driven up, causing higher premiums. Employers are allowed to drop mental health and substance abuse coverage altogether. And insurance companies can opt out for a year if their costs rise too much.
Already, insurance companies are predicting the new rules "could have a significant impact on the cost to employers," said Wardell Sanders, president of the New Jersey Association of Health Plans, a trade group that represents eight health insurers.
As insurance companies and employers watch costs, mental health care and addiction treatment providers and their patients are skeptical the law will be as sweeping as they had hoped.
"I don't believe insurance companies will just roll over now and agree to cover addiction on par with other illnesses," said Dobbs, who counsels parents of addicted children. "I understand that some companies have already tried to put plans in place that get around the law."
The impact
The government expects the regulations will have the greatest impact on people who need the most intensive treatment and financial protection.
Issued by the Departments of Labor, Health and Human Services and the Treasury, the 43-page "interim final rules" are complex and may be changed once insurance companies, providers and mental-health advocates are done sifting through them.
The agencies will collect comments on the rules until May 3, before issuing the final version. The new regulations will apply to plans beginning on or after July 1.
Since mental disorders and addictions often are chronic and lifelong, insurance companies have traditionally set stricter limits on such coverage in order to predict their payouts and keep costs down.
Mental-health advocates who have fought for parity contend such limits discriminate against people with disorders such as depression and addiction. At the very least, they hope parity will reduce the stigma attached to mental illness.
They hope more people will seek -- and even demand -- the treatment they need. But that, too, is causing debate over whether parity will lower health care costs or increase them.
Advocates say appropriate treatment for mental disorders will prevent more expensive health problems down the road. Businesses also will benefit from increased work productivity and efficiency, according to The American Psychiatric Foundation.
The cost
When the legislation was passed in 2008, the Congressional Budget Office reported parity will raise premiums by 0.2 percent to 0.4 percent on average. The Office of Personnel Management estimates an individual would pay an additional 46 cents for the benefit every two weeks, and a family would pay $1.02.
The law allows insurers to apply for a one-year exemption if parity causes costs to rise by more than 2 percent in the first year, or more than 1 percent in any following year.
Walt Cherniak, a spokesman for Aetna, said it's too soon to say how much parity will impact the company's health care costs. However, at least one South Jersey insurance broker said he's seeing a 1.5 to 2.5 percent increase in premiums.
The law gives employers an out, too. Robert Petcove, president and CEO of Advanced Benefit Advisors in Cherry Hill, said the rules don't mandate mental health and substance abuse coverage. Companies could decide to drop such coverage if it became too expensive, but Petcove doesn't expect that will happen.
"I've never had a client who didn't offer mental health benefits," said Petcove, who works with employers of 100 to 15,000 workers. "I wouldn't recommend that, either."
Indeed, a survey conducted last March by the Partnership for Workplace Mental Health, a program of the American Psychiatric Foundation, found most surveyed employers expect health care costs will increase less than 2 percent because of parity. Only about 7 percent said they are considering dropping mental health or substance abuse coverage altogether.
Analysis
About 35 million people suffer from a moderate to severe mental illness each year, according to the American Psychiatric Foundation. About 20 million people need substance abuse treatment, according to the National Council on Alcoholism and Drug Dependence.
Russ Micoli, corporate director of behavioral health services for Kennedy Health System in Cherry Hill, oversees the hospital's 12-bed detox unit. It serves patients with a range of addictions, from alcohol to prescription pills. Patients are medically monitored for two to three days as they go through withdrawal.
Micoli said most of his detox patients are unemployed and uninsured. Medicaid doesn't cover detox services and state funding for uninsured patients is limited. By the last few months of the year, the detox unit is often only half full with patients who haven't yet exhausted their insurance benefits, and patients who have been able to scrape together the money to pay out of pocket.
The federal parity law will help a portion of the population, Micoli said. But it's not a panacea.
"Obviously, it will result in more treatment out there," said Micoli. "We may see some increase in our ability to serve people, but I'm not sure there's going to be a significant change."
A daily fight
At Seabrook House, admissions employees spend 75 percent of their time determining what a patient's insurance covers and then trying to get that patient past the managed-care "gatekeepers," Diehl said.
"It's a game to thwart and obstruct the consumer and their families from being able to get care with the least anxiety possible," said Diehl. "We spend an inordinate amount of time fighting virtually for every day (of care). I have two full-time registered nurses who only do that. All they do on behalf of the patient is to fight for each day."
Virtually no one gets the care outlined in their benefits handbook, Diehl said.
"Is it getting any better under parity?" Diehl said. "Initially, no; not much."
The managed care system irks mental health care providers across the board.
Alicia Ayvas, a therapist who runs the help line for the New Jersey Eating Disorders Association, said treatment for bulimia and anorexia nervosa is costly, even with insurance coverage. Anorexia has the highest mortality rate of any mental illness, up to 20 percent, according to the Eating Disorders Coalition.
Even so, Ayvas said, clinicians spend a lot of time on the phone trying to get authorization for their patients' treatment, and not always successfully.
"It's a plus to say the least to have parity behind you," Ayvas said. "It still needs more work, but it's in the right direction."
When she was a college student covered under her parents' insurance, Ayvas required six months of residential treatment for severe anorexia.
"My parents fought for a few years to get that stuff covered," Ayvas recalled. "They said I didn't need it, but I was very sick. I'm 5-foot-5 and I was 79 pounds, with feeding tubes and everything, and the insurance company said I didn't need that. It puts things into an interesting perspective."
Managing costs
Gail Schoenbach, a recovered bulimic and founder of the Gail R. Schoenbach Foundation For Recovery and Elimination of Eating Disorders, thinks insurance companies will continue to find ways to manage their costs.
The new law allows this. For example, the new regulations don't spell out which mental health illnesses must be covered. The New Jersey chapter of the National Association of Social Workers complains the federal law leaves that decision to the states or the insurers. The law also doesn't specify what treatments are "medically necessary."
"Now what insurance companies are more often saying is there are different parameters for patients being sick. They're not sick enough," said Schoenbach, who lives in Warren County. "It's been very difficult for treatment centers to get approval for what's needed."
Insurance companies are allowed to review services to determine if they are medically necessary, said Sanders, the insurance trade group representative. In New Jersey, residents can appeal those decisions to an independent review organization hired by the state.
"In a significant majority of cases, independent reviewers support the insurer's finding on medical necessity and disagree with the provider's," Sanders said.
Utilization management is a critical tool for both commercial and government health care programs, and is used to monitor quality, contain costs, and promote the efficient delivery of care, Sanders said. Between 80 and 90 percent of the insurance premium goes to pay for health care costs, he said.
"Without any management of costs, claim costs would be higher and thus premiums for consumers would be higher," Sanders said.
Getting approval for treatment is a struggle, said Micoli, who runs the Cherry Hill detox center.
"It's frustrating that every time you spin the wheel," Micoli said, "you're still only able to help a certain portion of the world."
Parity is a very important step, said Dobbs, and people should know that patient protections exist. Still, she said, her job is not done.
"I will be doing this until I am unable to speak," said Dobbs, whose son is now 30 and continuing in his recovery. "No parent should have to walk this road alone."
Reach Kim Mulford at (856) 486-2448 or kmulford@courierpostonline.com
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