Mental Health Parity May Hold Key to Solving Suicide and Opioid Crises

Taking action to improve mental health parity could help stem the rising tide of suicide and opioid overdose deaths in the United States, panelists said at an APA briefing at the U.S. Senate in November.

“There is a major problem with access to affordable, evidence-based mental health and substance use disorder services,” APA President-elect Bruce Schwartz, M.D., told Senate staffers. Parity is a simple concept: insurance coverage for mental health and substance use disorder treatment should be no more restrictive than coverage for any other medical condition, he said. “In practice, however, parity has been thwarted by insurers who may require prior authorization using medical necessity criteria that are not professionally endorsed or validated.”

Patients are four to six times more frequently forced to obtain more costly out-of-network care for outpatient behavioral health services than for other medical care. Also, another common complaint concerns so-called “phantom networks,” whereby insurers include in their network lists the names of health care professionals who are no longer accepting new patients, Schwartz said. Moreover, psychiatrists are paid 20 percent less for the same office visits billed under identical or similar codes than primary care and medical/surgical physicians.

Remediating these insurance coverage problems is a more pressing concern than ever, given the suicide and opioid crises gripping the nation. “Our success confronting the opioid crisis will be dictated in large part by whether or not we are able to address the underlying mental illnesses that afflict many who become addicted to opioids,” Schwartz said.

Suicide: Missed Opportunities for Simple Action

“Poor access to mental health care has allowed our suicide rate to climb,” said Mike Hogan, Ph.D., of the National Action Alliance on Suicide Prevention and the Case Western Reserve University Department of Psychiatry. “We understand a lot of what should be done, but we’re not doing it.” Sparse detection and management of suicide risk in health care settings, particularly in primary care and emergency departments, represent missed opportunities.

“We have very good predictors of who needs help,” Hogan said. One long-term study of 75,000 participants who completed the PHQ-9 found more than 60 percent of participants who subsequently died by suicide indicated elevated frequency on question 9, which asks how often test takers have thought about self-harm or suicide.

Nearly half of individuals who died by suicide met with their primary care providers in the month before they died. “They fell through the cracks. They were not asked about suicide,” he said. “Just asking people is not perfect, but it’s the strongest predictor we have of who is at great risk.”

Only two populations at high risk for suicide—veterans and youth—have semi-strong national prevention programs directed at them, he said. Others at high risk include older white men, who have a four to six times greater risk of suicide than the general U.S. population; individuals with opioid use disorder (five to nine times greater risk); and people with clinical depression or other serious mental illness (10 to 12 times greater risk), Hogan said.

What is the most effective means of reducing suicide and opioid overdose deaths? “Helping people with targeted, evidence-based preventive interventions for people who have a lot of risk,” Hogan said.

One such method, safety planning, involves a one-time, 30-minute behavioral coaching session aimed at giving high-risk individuals the skills needed to keep themselves safe when they have suicidal thoughts. One study of 1,640 patients in a suicide-related health care visit found that there were 45 percent fewer subsequent suicides among participants after the training than similar patients who did not receive it. Other methods shown to be effective include restricting access to lethal means (for example, firearms removal, bridge enclosures), cognitive-behavioral therapy, and “caring contacts”—sending caring letters and making phone calls to suicidal individuals, he said.

Few With Opioid Use Disorder Get MAT

As the number of drug overdoses continues to climb, with more than 72,000 overdose deaths in the United States last year, treatment rates have remained stagnant, said Kevin Roy, chief public policy officer for Shatterproof, a nonprofit organization working to end the devastation that addiction causes families. This is despite evidence that medication-assisted treatment (MAT) can cut mortality rates by half and lower rates of drug dealing and other criminal behavior, he added.

Although 60 percent to 70 percent of Americans with diabetes receive treatment for their chronic disease, just 15 percent of individuals with opioid use disorder (OUD) are receiving MAT. Health system barriers around treatment include stigma; high barriers to becoming a treatment provider and low reimbursement rates; long wait times for patients entering treatment; and insurance hassles, including prior-authorization rules, unaffordable copayments for patients, and lack of reimbursement for care management and coordinated care.

Some policy changes needed to improve parity for OUD treatment include making MAT a mandated benefit, eliminating preauthorization rules for MAT, and expanding its coverage within Medicaid, he said.

Roy pointed to a few states that have successfully eliminated barriers:

• Missouri’s Medication First: In Missouri, the state has piloted a “Medication First” approach to treatment, whereby the focus is on getting individuals with OUD in front of a prescribing physician as quickly as possible to begin pharmacotherapy and get relief from withdrawal symptoms. Patients are offered, but not required, to engage in psychosocial treatments. The idea is to decrease overdose deaths by stabilizing individuals and boosting treatment retention. So far, the Missouri program substantially slowed the state’s rate of increase of opioid or heroin-related deaths, from 35 percent in 2016 to 5 percent in 2017.

• Vermont’s “Hub and Spoke” Model: In Vermont, the state increased by 56 percent physicians who had a waiver to prescribe buprenorphine and boosted by 50 percent the number of patients served by each physician. It coordinates its care through a “hub and spoke” system, whereby patients initiate treatment in a “hub” and then remain in long-term treatment in community-based provider “spokes.” It is reporting an overall health care cost reduction of 7 percent to 10 percent, with positive reviews from patients.

APA: Compliance With Federal Parity Law Poor

“For every other condition, when people are gravely ill and at risk of death, insurance coverage is a given,” said Tim Clement, M.P.H., the Northeast regional director in APA’s Division of Government Relations. The Mental Health Parity and Addiction Equity Act was signed into law in 2008, yet 10 years later compliance with the law is still spotty. In fact, both state and federal regulators consistently find problems with how health insurers design and apply their managed care practices, for example, with rules surrounding prior authorization, step therapy, reimbursement rate setting, and establishing and maintaining provider networks.

APA has recently helped push parity reporting legislation into law in several states, including Colorado, Delaware, Illinois, Tennessee, and, most recently, Minnesota, with new bills pending in the District of Columbia and New Jersey. A parity reporting law was passed in New York but has not yet been signed by Gov. Andrew Cuomo. Such laws have garnered bipartisan support and serve to hold certain health insurers—as well as state regulators—accountable for evaluating, monitoring, and reporting whether the plans’ managed care practices for behavioral health care are the same as those for other medical care.

More federal laws are still needed, Clement said, because a large number of Americans with group health insurance are members of large, self-funded plans, over which only the federal government—not states—has regulatory authority. Furthermore, federal law does not address the need for mental health parity among Medicare enrollees. ■