Kennedy Calling For Equal Coverage Of Mental Health — Yes, Still

Former Congressman Patrick Kennedy testifies at a Massachusetts hearing on mental health parity. (Courtesy of Scott Bryson)

Former Congressman Patrick Kennedy testifies at a Massachusetts hearing on mental health parity. (Courtesy of Scott Bryson)

Mental health “parity” is officially a done deal. Congress passed a law back in 2008 requiring health insurers to treat mental health on a par with physical health, covering care for mental illness and addiction no less than they cover physical care. Many states have also passed their own mental health parity laws.

So why has former Congressman Patrick Kennedy of Rhode Island — lead sponsor of the 2008 bill together with his late father, Sen. Ted Kennedy — spent much of the last couple of years criss-crossing the country to advocate for mental health parity? Why did he feel the need to come to a Massachusetts Division of Insurance hearing this week to push parity yet again?

You could find the answer at the hearing itself.

It came from Benedetto Mitrano, who testified that his drug-addicted son, Michael, had been through several treatment programs, but died in August. “Insurance always refused to pay for one reason or another,” Mitrano said. “He was never ‘sick enough.’ My son is dead. Is he sick enough for them now?”

He was never ‘sick enough.’ My son is dead. Is he sick enough for them now?”

And from Dr. Matthew Mostofi, a Tufts Medical Center emergency physician who compared two patients from his previous night’s shift, one with appendicitis, who was treated quickly, and one who was suicidal, and had to wait many hours for care, held up by insurance requirements:

“Both have emergency medical conditions,” he said. “If you look at these two patients, which is more life-threatening? The fact of the matter is, this depressed suicidal patient has a higher mortality [risk] than the patient with appendicitis, and yet this is the one that we delay and make wait, and I believe illustrates disparity.”

And from Trudy Avery, who fought to get her insurance carrier to pay for her son’s addiction treatment: “What is written on paper and what actually occurs are two different things,” she said.

Therein lies the rub. Though mental health parity is the law of the land, the federal government has not yet issued its final regulations translating the law into practice, so it cannot be actively enforced. In the wake of the Newtown shooting, the Obama administration pledged to issue those final rules, but they are still not out.

Some can wait no longer. Class action lawsuits alleging violations of the parity law have been filed in California and, just this month, in New York. The New York State Psychiatric Association accuses insurer UnitedHealth Group of limiting actively suicidal patients to just one psychotherapy session a week, among other denials, Psychiatry News reports.

Former Congressman Patrick Kennedy (YouTube/NAMI)

Former Congressman Patrick Kennedy (YouTube/NAMI)

Meanwhile, around the country, many states have been moving forward to decide for themselves how to enforce parity — hence the Massachusetts hearing, and Kennedy’s presence. (Listen to an excerpt of Kennedy speaking in the sound file at the bottom of this post.)

Massachusetts is gathering public comment on proposed parity rules through April 5, and Kennedy says that given the state’s leadership in health reform, what it decides will serve as an important bellwether for other states.

“You are where the rubber hits the road,” Kennedy told the commissioners presiding at the hearing.

If Massachusetts is any indication, several points of contention on parity rules arise:

Is there a problem? How can you know?

Talk to psychiatrists who deal daily with insurers, and they’ll likely tell you that parity is a fiction. (“It’s not even good fiction,” notes Dr. Steve Schlozman, a psychiatrist at Massachusetts General Hospital. “Good fiction has an arc and a satisfying resolution. This is more like a lousy 70′s sit com, over-using the same tired themes and hijinks. The problem is, we’re powerless to change the station.”)

But health insurers question whether there’s a problem. Lora Pellegrini, president of the Massachusetts Association of Health Plans, said in a phone interview: “Our plans set a high priority on ensuring access to high quality and appropriate behavioral health care, and I think we demonstrate that through our national quality scores.”

Patient satisfaction ratings are high as well, she said. The association also pointed to state statistics that show that mental health care visits have been rising for the last several years, and that the existing Office of Patient Protection gets few formal complaints about denials of mental health coverage.

Those mental health complaints, however, are the most common sort of complaint the patient-protection office receives, emphasized Matt Selig, executive director of Health Law Advocates, a non-profit law firm that helps low-income consumers denied access to health care.

We don’t want any more than physical health care, but we demand no less.

The proposed Massachusetts rules require health insurers to formally certify that they are complying with parity rules, or explain how they’ve fallen short and what improvements they plan. Pellegrini’s group says that should be enough.

But advocates at the hearing, including Kennedy, say the health plans should be required to report publicly on how exactly they cover, say, cancer or diabetes, so that an “apples-to-apples comparison” with mental health coverage can be made.

“We want to be treated the same,” Kennedy said. “We don’t want any more than physical health care, but we demand no less.”

How easy is it for consumers to complain? And what happens once they do?

Kennedy and others argued that people with parity-based complaints need help making them official.

“People need to know the state is on their side,” said Laurie Martinelli of the National Alliance on Mental Illness. “There needs to be a transparent and user-friendly complaint system,” including an easy-to-use complaint form and time frames for how quickly a response must come.

Money must also be invested in publicizing the system, she said, because “people don’t really know these channels exist.”

Kennedy called for a requirement that when insurers deny coverage for mental health or addiction treatment, they must also notify the members who’ve been denied of their right to file a parity complaint with the state.

The Massachusetts Association of Health Plans is asking, rather, for a sort of intermediate step once a member complains, a chance to work out the coverage dispute before the state starts to investigate it.

Is this complex? Or simple?

Speaking for the Massachusetts Association of Health Plans at the hearing, Sarah Gordon Chiaramida pointed out that insurers need more government guidance to address the complexities of the federal parity rules.

In response, Kennedy asked for a final word, emphatically delivered, including:

The law is very specific. It’s…Do you do it for diabetes? Would you cover preventive care? Would you cover intermediate care? Would you cover acute care? Yes, yes, yes? Then do it for addiction and depression and other mental illnesses.

…Do you do it for rehab for stroke? Do you do inpatient, do you do outpatient? You do? Okay, then we’ve got to provide it for addiction and mental health. This is not complicated stuff, folks. And what we need you to do is force the insurers to publish what they do for diabetes, what they do for cancer, what they do for stroke… And if it compares up the same, then you’re in compliance. You don’t have to wonder if you’re in compliance. You’re in compliance. But if it doesn’t marry up, guess what? You’re out of compliance…

All we want is to be treated the same. That’s the message of this legislation.

When Kennedy says “we,” he’s including himself very personally: He has been diagnosed with bipolar disorder, and “I have addiction and alcoholism in my story,” he said in a phone interview.

But “because I was a member of Congress, I got my treatment paid for. The bottom line is that mental health benefits are really for the Fortune 100 and members of Congress, because everyone recognizes the important of mental health to high-functioning people. The Green Berets have the best mental health of any branch of the military. These are really strong people, the Green Berets, what do they need mental health for? They want to be their best. This isn’t about weakness or strength, it’s about, how do we reach our potential?”

Kennedy credited health insurers with significantly improving their mental health coverage over the last few years. “They know the world’s going to change and they’re scrambling,” he said. “We may not think they’re moving fast enough, but there are a lot more people who are getting health care that wouldn’t otherwise be getting it, because the insurance companies know they’re going to be held to this new standard.”

Still, he said, “it’s really shocking, as you could hear from the testimony, the extent of the disparity in treatment.” Part of the problem, he said, is that because of stigma, people with mental illness or addiction have not tended to speak up the way people with, say, breast cancer or AIDS have.

“When was the last time,” he asked, “that you had someone with bipolar disorder or alcoholism get up and say, ‘It’s absolutely wrong, the way you’re treating me, and I’m not going to stand for it’?”

Readers, responses? Click the orange play button on the sound file below to hear an excerpt of Patrick Kennedy’s remarks.

More information on parity in Massachusetts: Health Law Advocates Parity Initiative

To submit a comment to the Division of Insurance, email doidocket.mailbox@state.ma.us and refer to “Docket No. G2013-02″ in the subject line.

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  • Andrew Malekoff

    My name is Andrew Malekoff. I am the execuitve director of a children’s mental health agency – North Shore Child and Family Guidance Center – in New York. Following is a true story to illustrate neglect by government and private insurance companies. About 25-years ago. And, let me preface my story by stating that although we are celebrating our 60th anniversary this year, New York State and Nassau County (where we are located) have not increased our contract for outpatient mental health services in over 25 years.

    I was swimming in the ocean off Long Beach, NY, where I live, and someone pointed to a group of girls that had drifted towards the jetty. The girls must have been pulled out by the undertow and were unnoticed by the lifeguards.

    I swam to them. When I arrived, there were three little girls; one
    looked about nine-years-old. The others, who were crying and holding on to the
    older girl, appeared to be six or seven. The older girl was barely in control
    of her emotions. I wrapped my arms around the three of them and said, “Hang
    on.” Swimming in with them as a group was not an option; neither was leaving
    any of them behind. All I could do was hold on, calm them, steer them away from
    the jetty and wait.

    Finally, the lifeguards arrived and took over. I swam to shore and went
    back to my beach chair. When I recall this encounter, I realize that the four
    of us were strangers who spent maybe 90 seconds together. I said only two words
    to them: “Hang on.” Ninety seconds, two words and 25-years and I still think
    about them often.

    Now, let’s consider another scenario. Try to imagine me swimming out to
    the three girls. Now, imagine if, instead of telling them to hang on, if I
    treaded water at a safe distance and asked them if they had Medicaid insurance.
    Imagine if they answered, “No mister.” And, if I then said to them, “Sorry,
    girls,” and turned my back on them and swam to shore.

    This is the situation that we now face as New York State has made a
    dramatic departure from its responsibility to make sure that our most
    vulnerable citizens – our children – get community-based mental health care,
    regardless of their family’s economic status. They expect us to throw the
    underinsured middle class and working poor overboard with no life preserver.
    That’s our government.

    And, the health insurance industry is no better. Most private health
    insurers pay substandard rates that community-based agencies can no longer
    afford to accept. To add insult to injury, profit-driven insurance
    authorization denials kill people, as Benedetto Mitrano testified. Here is another
    example – in 2001 Timmy O’Clair, a 12-year-old from upstate New York, committed
    suicide after his parents were unable to obtain mental health treatment for him
    due to health-insurance coverage limits.

    Timmy’s death was the impetus for the passage of Timothy’s Law, which
    extended insurance coverage for mental health treatment in New York. Although
    the Affordable Care Act, set to begin in January 2014, will extend federal
    parity protections, profit-driven insurance companies have a very long way to
    go to meet their mandate for adequate networks of care. And, when they don’t
    meet the mandate we must expose them and fight to have their licenses revoked.

    I invite you to jump into my Atlantic Ocean memory with me, because it
    is a story that is about more than me and three little girls. It is about all of
    us. To do this we need to overcome stigma, fight for funding that allows for
    ready access to quality mental health care and advocate for real parity versus
    the paper tiger that it seems to be.

  • JS

    In the mental health field in Colorado, we see huge disparity between clients with private insurance and those with Medicaid. It is absolutely abhorrent!

  • http://www.facebook.com/futo.buddy Futo Buddy

    why has oboma not made this a priority after newtown? this may have actually made a difference instead of pushing the same old gun control line and it is a matter of enforcing a law thats already passed a perfect place to use executive authority

    • dust truck

      What? Enforcing existing laws instead of enacting new ones? What do you expect our government to do? Function?? ;-)

      • http://www.facebook.com/futo.buddy Futo Buddy

        i guess he would not get to parade around kids and make empassioned pleas if he actually spent his effort enforcing the laws like he is supposed to

        • dust truck

          personally, I blame all levels of government for this. It’s like after the Station Nightclub fire, they tried rewriting the laws, never mind the fact that the Station Nightclub was flagrantly violating existing laws to begin with.

          These problems will continue if the government cannot enforce the laws.

          • http://www.facebook.com/futo.buddy Futo Buddy

            or will not

  • pennyroyal

    work with http://www.nami.org or http://www.nami-mass.org.

    I helped run a local affiliate of the National Alliance for the Mentally Ill in southeastern Mass. We met at the local library. We did excellent programs like a psychiatrist who spoke on preventing suicide and a prescribing psychiatrist who talked about polypharmacia. We also brought in child psychiatrists to talk about autism and another on children with behavioral problems.

    That local group is now defunct. People didn’t show up: not the general public or the mentally ill themselves. All we had was a sprinkling of retired social workers and a couple parents of adult children with mental illness. The latter were struggling to get their family members (often in group homes) adequate care.

    The biggest issue: the stigma. The old notion that mental illness is a moral flaw, which goes back to a pre-scientific age. First we have to educate the public and motivate them to dog their public officials.

  • Virginia

    To Steve Daviss, MD: Do you really believe that provider relations in these limited insurer panels care to have the innacuracies in their data base corrected? If you are a psychiatrist or PCP, your response perspective makes sense, and your recommendations solid: IF the company wants their data base to be sturdily maintained. I am making an assumption here, since MD’s in the aforementioned specialties are in such high demand. If my assumption is accurate, please mount a petition to your professional organizations to demand of the insurers that their data base be corrected following the recommendations that you suggest. Psychologists do have a different situation. Most PPO or HMO panels are very restrictive in the acceptance of new psychologists, no matter the skill set or specialty. The panels limit the number of psychologists in a given network; and the insurers say this directly to new applicants. Except for child psychologists, which has a clinical demand harder to meet for restricted panels. Recent blog responses on HealthCare Savvy, past articles on CommonHealth, and articles in The Boston Globe have addressed the child psychiatry and psychologist shortages in MA. And the MassHealth provider shortage is much, much worse. I do not readily have exact citations of when published; but to me, shameful data for a progressive state.

  • M. Leroy

    Beyond parity lie other important hurdles to effective treatment:
    (1) Claiming reimbursement from insurers is so complex that many psychotherapists don’t accept insurance at all. Those that do are able to choose which carriers they work with. In many cases, that does not include Medicaid (and in Massachusetts, Commonwealth Care) because the paperwork is so burdensome and the reimbursement so relatively small — well below the rate these practitioners can command from self-pay patients. The situation is compounded by the fact that in contrast with physicians, who typically share practice costs, therapists are more likely to be solo practitioners. Some therapists are responding to the cost burdens by trimming the treatment hour to 45 minutes instead of the traditional 50.
    (2) Insurers are allowed to limit the length of treatment per day (one session only) and the number of sessions per week. Again, this limit is not imposed on self-pay patients (except at the discretion of the therapist). The result is a two-tier (or even three-tier) treatment system, which in many instances operates like the worst HMO experience.
    Solutions to these problems are simple:
    (a) A single-payer health-care system, or, failing that, a single insurer standard and reporting system, would reduce billing costs and incentivize therapists’ willingness to accept patients’ insurance.
    (b) Reimbursement for therapists that more closely resembles the market rate (which could be tiered by level of qualification).
    (c) Perhaps, mandatory participation in all insurance plans should be considered — this should be the case for physicians, too.
    (d) Loosening restrictions on length and frequency of psychotherapy sessions.
    Granted, these issues echo similar flaws in health-care system as a whole. The best solution for producing better-quality treatment, in both realms, lies in streamlining the systems, while working to minimize perverse incentives.

  • http://www.facebook.com/aimee.yermish Aimee Yermish

    Note also that the insurers restrict the options for patients to use their benefits at all when they wish to contract with a provider who has specialty expertise in their area of need who is not in the network. If the client were working with someone in network, the insurer would cover some amount of the bill and typically would also require a copayment. When using someone out of network, the insurer will offer the out-of-network provider the same low reimbursement they would get if they were in network, but then denies the provider the right to collect the remainder of their fee from the client. So the client is on the hook for the whole thing, which, if they cannot afford it, means they get no care. It is the same amount of money out of the insurer’s pocket either way, but this way, they get to pay nothing because the client must pay the whole thing on their own. Doesn’t help the client, just gives the insurer yet one more way to not pay.

    And don’t even get me started on the onerous paperwork requirements and the unconscionable delays in payment for the providers. Or the massive intrusions into patient privacy for mental health records. They tell the providers, “you want reimbursement? Then tell us everything that is happening in session.” Providers are in an impossible position — if we stand up for patient privacy, we risk having to stop therapy completely.

  • http://www.facebook.com/richard.robb1 Richard Robb

    It still breaks down to a fight between us, and the new Royalty. Congressmen. They get, we don’t. Is there anymore of a stronger argument to bring our lawmakers is line with the populace? Tea party anyone?

  • http://twitter.com/HITshrink Steven Daviss MD

    Virginia mentioned the limited provider networks. This is one of the last ways — aside from fees paid that are not on par with primary care rates for the exact same codes — that the payers are able to limit access to outpatient care. By combining all provider types together, it looks like a robust network. But start calling around and what you find is the following:
    - many of the phone numbers are incorrect: disconnected, moved, retired, deceased.
    - they mix in providers who are not accepting outpatients (such as inpatient-only providers) with those that are, making their available network look larger than what it is.
    - many of the ones that are accurate are either full or not taking new outpatients for that insurance.
    - the ones who are taking new patients often have a next available appointment weeks or months from now. They are either that overwhelmed with patients, or they don’t want to take that low-paying/high-hassle insurance but do not want to come out and say so.

    We need a proactive approach to help insurance regulators put an end to these shenanigans. FOUR changes to make the network directories more accurate and hold the plans accountable:
    1. Require that the directories permit providers to log in and update their contact info AND their status regarding whether they are accepting new outpatients. This way, when they are swamped they can simply flip the switch so that their names will not show up when patients are looking for a new provider.
    2. Require a number next to each provider’s listing to indicate roughly how many new outpatient visit codes they have submitted for in the most recently available 6 month period (this can be automatically merged from the payers’ claims data). Those listings with zero new patients are clearly not accepting new patients.
    3. Require that the phone number or a link to the state’s insurance regulator be included on each directory page listing so that patients know how to complain if they are getting the run-around or are unable to obtain an appointment in a timely manner.
    4. Finally, require that each online provider directory listing have two buttons to click — INACCURATE and NOT ACCEPTING NEW PATIENTS so that patients may indicate that they were unable to obtain an appointment with that provider because of wrong info or not taking new patients. The cumulative data would have to be displayed on the listing so that prospective patients are not wasting their time trying to call these providers.

    Making such changes would improve the transparency of the information so that patients, employers shopping for health plans, and regulators, all can make decisions using honest data, not phantom network data. And, this would incentivize the plans to make improvements in their often inadequate networks.
    = Steve Daviss MD
    = fusehealth.org

  • not.patrick.kennedy

    Patrick Kennedy advocates threatening medical marijuana-using cancer patients with jail time if they don’t use the expensive marijuana-based pharmaceutical drugs that his project SAM advocates.

    This is evidence that Pat is the one with Mental Health issues.

    • pennyroyal

      someone let an April Fool in!

  • Virginia

    As a psychologist, I quit APA membership in 2004. I had spent years writing letters and in fruitless discussions with APA legal staff about why the organization was NOT supporting psychologists, fighting “managed-care” insurance for-profit entities because of unnegotiated fee reductions and restriction of trade (limited provider networks), and restrictions of services to patients. I was told by both APA and MPA that they could not lobby for psychologists because it would be an anti-trust issue for them. Is the existence of a national for-profit insurance company not an ant-trust problem? Why pay membership fees when an organization does nothing to protect it’s members? Not me. And I will talk about it with anyone. I have joined the only current organization that is solidly and consistently working for patients and better healthcare in the country: Physicians for National Healthcare Reform http://www.pnhp.org/

  • Andy H.

    Insurers are able to skirt the full force of parity by requiring that
    only “biologically-based” conditions are covered. However, I can’t find
    a clear definition (not examples) of what biologically-based means. Help?

    I’m lucky that I have excellent therapists at Fenway Health – and Fenway Health itself – to help me get treatment for complex trauma (22 years of abuse and neglect at the hands of my father and mother), but even then they’ve had to diagnose me with
    PTSD, which is not the same thing as cPTSD for insurance purposes.

    I’m a well-educated (working on my PhD at Brandeis) and high-functioning individual who knows these things are very real and can be very crippling without excellent help. The health care system must embrace that the mental and the physical are intimately linked.

  • Andy H.

    Insurers are able to skirt the full force of parity by requiring that only “biologically-based” conditions are covered. However, I can’t find a clear definition (not examples) of what biologically-based means. Help?

    I’m lucky that I have excellent therapists at Fenway Health – and Fenway Health itself – to help me get treatment for complex trauma (22 years of abuse and neglect at the hands of my father and mother), but even then they’ve had to diagnose me with PTSD, which is not the same thing as cPTSD (see here: http://outofthefog.net/CommonNonBehaviors/CPTSD.html) for insurance purposes.

    I’m a well-educated (working on my PhD at Brandeis) and high-functioning individual who knows these things are very real and can be very crippling without excellent help. The health care system must embrace that the mental and the physical are intimately linked.

  • PsyD

    Thanks for a great article on an important topic. People should contact their representatives and push for parity. In addition, register to be on the list serve of APA and apa to have your voice heard on these issues.

  • Virginia

    Finally, an article that sketches out the current struggle that patients in this country must contend with to get adequate mental health care. The tip of an iceburg; and mental health services in progressive Massachusetts are better than in most states. But obviously, not nearly good enough. Why does it need the advocacy of Patrick Kennedy to get attention? Patients and mental health providers have been in this struggle since the mid 80′s. There has been a parity law in Massachusetts since 2000. But the law was difficult to enforce because the state offered no guidance or sources of advocacy. Mental health providers make less per hour than a plumber. What does this say about good mental health care? Let’s have a discussion.

  • Lisa

    Parity must include raising reimbursement rates for mental health clinicians. Salaries in Massachusetts are currently 70% of what physical health counterparts make largely due to lower reimbursement.