200213
Inclusion of Substance-Related Disorders as Psychiatric Disorders in Any Program Designed to Assure Access and Quality of Care for Persons With Mental Illness
POSITION STATEMENT
Approved by the Board of Trustees, November 2002
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"Policy documents are approved by the APA Assembly and Board of Trustees… These are …position statements that define APA official policy on specific subjects…" -- APA Operations Manual. |
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The American Psychiatric Association strongly and unequivocally affirms its position that all substance-related disorders are diagnosable mental illnesses for which effective treatments are readily available. Furthermore, the American Psychiatric Association strongly opposes the exclusion of substance-related disorders from legislation or programs that pertain to parity of insurance coverage, access to health care services and quality of care. Other chronic illnesses such as heart disease, diabetes, and asthma, among others, are not subject to the same restricted limits on access to and coverage of care as are substance-related disorders. The American Psychiatric Association considers such exclusion of substance-related disorder diagnoses and patients with these disorders as discriminatory and contrary to the scientific findings of the clinical, research, health economics and policy communities. The American Psychiatric Association, therefore, unequivocally states its position that such exclusions and discrimination should henceforth be ended.
Background to the Position Statement
During the 1990’s there was a great deal of state and federal legislative activity to try to achieve parity in insurance coverage for mental health (MH) care at the same level as that of physical health care. However, substance abuse (SA) care has often been excluded from these parity mandates.1 In 1996 the federal Mental Health Parity Act was passed and was implemented in 1998. This legislation focused on only one aspect of inequities in mental health insurance coverage (catastrophic benefits) by prohibiting the use of lifetime and annual limits on coverage that were different for mental and somatic illnesses. However, the legislation did not apply to companies with fewer than 50 employees, to employers whose compliance with the law would increase health insurance expenses by 1% or more, or to other forms of benefit limits including per episode limits, co-payments or deductibles.2-4 This legislation also specified that eligible illnesses were any mental illness requiring mental health services excluding substance abuse or chemical dependency. Although the legislation was restricted in these ways, it nevertheless set the stage for potential redress of inequities in the insurance coverage of mental health and substance abuse care.3 As one author suggested, the legislation embodied the related concepts of “fairness and non-discrimination” in health care insurance coverage.3
Recent state experiences with parity have varied widely. Prior to 1996, only five states had mental health parity mandates,5 but by November, 2000, thirty-two states had passed mental health parity laws.6 These legislative efforts have included parity for severe mental disorders excluding substance abuse (e.g., Maine, 1995; New Hampshire, 1995; Rhode Island, 1995), as well as a few states that have included substance-related disorders in their state parity legislation (e.g., Maryland, 1995; Minnesota, 1995).3 Experiences with parity at the State level have generally derived from such parity laws enacted by State legislatures or from individual payers that have voluntarily designed MH/SA parity benefits for their own health plans. In the State of Ohio, all health plans serving state employees implemented parity of their MH/SA services.7 In the State of Massachusetts, state employees were enrolled in two types of plans that had a MH/SA parity benefit along with a managed care carve-out of that benefit.8,9
More recently, the federal government enacted parity legislation for federal employees. As of 2001, all health plans that participate in the Federal Employees Health Benefits program are required to offer parity for mental health and substance abuse care in patient cost sharing and service limits.4
Although there has been this recent legislative activity regarding parity, substance abuse care is often excluded in laws and programs designed to achieve parity of mental health care with physical health care. Exclusion of substance-related disorders from mental health parity laws is often based primarily on two ideas: (1) there are no effective treatments for substance-related disorders, and (2) including substance-related disorders and substance abuse care as part of mental health care will drive up the costs of health care as well as insurance premiums.1 Current evidence from multiple sources demonstrates that these two proposed rationales are unfounded. With respect to effectiveness of treatments for substance-related disorders, there is a growing body of evidence that confirms both the biological underpinnings of these illnesses as well as the high rates of treatment success.6, 16-22 Indeed, a 1996 report of the National Treatment Improvement Evaluation Study (NTIES) demonstrated that 12 months after treatment completion, there were substantial reductions in the use of substances as well as other gains in employment, declines in criminal activity, and decreases in alcohol and drug related medical visits.20 Other reports have documented the effectiveness of pharmacotherapies for substance-related disorders18 as well as the effectiveness of other treatments.21,22
Since the passage of the 1996 Mental Health Parity Act, there has also been considerable accumulation of evidence that full parity in benefit design is feasible without dramatically raising costs within the context of manage care.11,12 For example, in a number of states where parity was implemented either concurrently with managed care (e.g., Texas) or in the setting of a system already influenced by managed care (e.g., Maryland, Rhode Island), costs either decreased or increased less than 1 percent of the total health budget.6 Another study has estimated that the cost increases associated with full parity for mental health benefits would represent 1.4 percent of total health benefits.6,13 In addition, one analysis of the removal of dollar and other limits for mental health and substance abuse care within 20 managed behavioral health care plans, produced premium increases of only pennies per member per month.6,14 This report also states that the 1.4 percent increase may be an overestimation of the true costs.13 Overall, results of a number of studies indicate that parity level benefits for both mental health and substance abuse care can occur with minimal cost increases.6
A number of other studies have focused on whether implementing parity for substance abuse care as part of parity for mental health care would increase costs. One study used data from 25 carve-out plans that had no deductible and low co-payments for substance abuse and mental health care.14,15 Such unlimited benefits were found to increase insurance payments by $5.11 for substance abuse care per member in the years 1996-1997.1,14,15 For an annual insurance premium of $1500 per member, this would represent approximately 0.3 percent of the employer’s total health care costs.1 Imposing an annual limit of $10,000 represented a savings of only 6 cents per member per year but would have adversely affected 1.3 percent of users of these services. Imposing an annual limit of $5,000 would have lowered insurance payments by 78 cents but would have adversely affected 11.3 percent of users of these services.1 The author concludes that concerns about cost increases have been the main reason for excluding substance abuse care from parity legislation, but data such as these indicate that inclusion of full parity for substance abuse care show that actual cost increases are quite small.1
Another study estimated the increased costs that would be associated by implementing full parity defined as providing insurance benefits for mental health and substance-related disorder diagnoses that would be no less restrictive than benefits for medical and surgical diagnoses in the areas of cost sharing, service limits, and annual or lifetime limits.4 This study used data on the distribution of mental health and substance abuse expenses for enrollees in indemnity and managed care plans as well as for high-cost users. The study found that across four types of plans (i.e. indemnity plan, preferred provider organization, point-of-service plan, and health maintenance organization), implementing full parity resulted in percent increases in total family annual premiums of 5.1% in preferred-provider organization plans, 5.0% in indemnity plans, 3.5% in point-of-service plans, and 0.6% in health maintenance organizations.4 Importantly, the study also examined percent cost increases if mental health care is included but substance abuse is excluded versus the inclusion of both mental health and substance abuse care. The study concluded that the relative premium increase related to parity for all substance-related disorder diagnoses is small, adding only 0.3 percent additional percentage points at the most in one type of plan and less for the others.4
Legislative efforts for full parity may also represent only a first step in establishing equitable insurance coverage for mental and substance-related disorders.6 Even with the promising changes in legislation both federally and in some states, there is evidence to suggest that health insurance did not improve in the United States for those with mental illnesses between 1997 and 1999.10 For example, in that time period although there was little change in the percentage of individuals without health insurance in the general population, insurance status deteriorated for those individuals at risk for mental health problems.10 For these groups of individuals, rates of being uninsured increased, perceived quality of insurance declined, and perceived access to good health care decreased faster than for other groups.10 Another study found that state parity legislation between 1997 and 1999 was not associated with a significant increase in any measure of mental health services utilization.5 One possible reason for the finding of this study was the possible loss of coverage for those people most at risk for mental health disorders.5
It seems that the greatest barrier to enacting full parity legislation for mental health and substance abuse care has been the fear of an unmanageable rise in health care costs. To date, the data do not support this fear. Providers, patients, and policy makers are currently faced with both the current lack of mandated full parity in many states as well as concerns that legislation of full parity in benefits may be insufficient to achieve true equity.11 Rather, full parity may be a sequential step toward achieving insurance coverage that represents fairness and nondiscrimination for patients with mental health and substance-related disorder diagnoses.6 Full parity may in fact lead to a “nominal expansion of benefits”6 but may not represent effective equity for mental health and substance abuse care insofar as management of care can be applied differentially. This may result in continued inequities in health care access and quality of care for those with mental health and substance-related disorders in spite of legislative mandates for parity. Another significant barrier to care is societal stigma and the internalization of that stigma by those who suffer from these disorders.6 Such internalization may deter individuals from seeking care. On the other hand, legislation of full parity for those with both mental health and substance-related disorders can send a strong message to the public that these disorders are real, that effective treatments exist, and that these treatments are offered within a health care system that provides equivalent care for all disorders whether they be medical, surgical, or psychiatric, including all substance-related disorders. Finally, although full parity would potentially positively affect those who are insured, it does little to provide these services to the estimated 40 million uninsured individuals in the United States.6 Expanding coverage to include these individuals would likely address another major factor in the unmet need for mental health and substance abuse care as well.6
References:
1. Sturm R: Substance Abuse Treatment , State Parity Legislation and Managed Care, Connection: A Newsletter Linking the Users and Producers of Drug Abuse Services Research, June, 1999, page 3.
2. Hennessy and Stephens, Mental health parity: Clarifying our objectives. Psychiatric Services 1997; 48:161-167.
3. Goldman HH, Parity redux. Harvard Review of Psychiatry 1997; 5:91-93.
4. Sing M, Hill SC. The costs of parity mandates for mental health and substance abuse insurance benefits. Psychiatric Services. 2001; 52:437-440.
5. Pacula RL, Sturm R. Mental health parity legislation: much ado about nothing? Health Services Research 2000; 35:1, Part II: 263-275.
6. Hennessy KD, Goldman HH. Full Parity: Steps Toward Treatment Equity for Mental and Addictive Disorders. Health Affairs. 2001;20:58-67.
7. Sturm R, McCulloch J. Mental health and substance abuse benefits in carve-out plans and the Mental Health Parity Act of 1996. Journal of Health Care Finance 1998; 24:82-92.
8. Ma C, McGuire T. Costs and incentives in a mental health carve-out. Health Affairs 1998; 17:53-69.
9. Huskamp HA. Episodes of mental health and substance abuse treatment under a managed behavioral health care carve-out. Inquiry 1999; 36:147-161.
10. Sturm R, Wells K. Health insurance may be improving - but not for individuals with mental illness. Health Services Research 2000; 35:1,Part II: 253-262.
11. Gitterman DP, Sturm R, Scheffler. Toward Full Mental Health Parity and Beyond. Health Affairs.2001;20:68-76.
12. National Institute of Mental Health. Insurance Parity for Mental Health: Cost, Access, and Quality: Final Report to Congress by the National Advisory Mental Health Council, Rockville, MD: U.S. Department of Health and Human Services, June, 2000.
13. Kirschstein RI, Insurance Parity for Mental Health: Cost, Access, and Quality. Final Report to Congress by the National Advisory Mental Health Council, NIH Pub no. 00-4787, Bethesda, MD: National Institutes of Health, June, 2000.
14. Sturm R, Zhang W, Schoenbaum: How expensive are unlimited substance abuse benefits under managed care? Journal of Behavioral Health Services and Research 1999; 26:203-210.
15. Sturm R, Pacula RL. State Mental Health Parity Laws: Cause or Consequence of Differences in Use? Health Affairs 1999; 18:182-192.
16. Leshner AI. Addiction is a Brain Disease and it Matters. Science 1997;278:45-47.
17. Leshner AI: Science-based views of drug addiction and its treatment. Journal of the American Medical Association. Science 1999;282:1314-1316.
18. O’Brien C.P. A Range of Research-Based Pharmacotherapies for Addiction. Science 1997;273:66-70.
19. O’Brien C.P. Myths about the Treatment of Addiction. Lancet 1996;347:237-340.
20. U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. The National Treatment Improvement Evaluation Study: Preliminary Report: The Persistent Effects of Treatment – One Year Later, September, 1996.
21. McLellan AT, et al: Evaluating the Effectiveness of Addiction Treatments: Reasonable Expectations: Appropriate Comparisons. Milbank Quarterly 1996;74:51-85.
22. National Institute on Drug Abuse. Principles of Drug Addiction Treatment: A Research-Based Guide, NIH Publication Number 99-4180, October, 1999.