U.S. Enforcing Insurance Law to Help Fight Opioid Abuse

www.nytimes.com/2016/11/08/us/mental-health-parity.html

We have abt TWO MILLION serious opiate substance abusers and 116 million chronic pain pts and look at where the administration is using its FORCE to get certain pts appropriate therapy ?

WASHINGTON — In one of President Obama’s last major health care initiatives, the administration is stepping up enforcement of laws that require equal insurance coverage for mental and physical illnesses, a move officials say will help combat an opioid overdose epidemic.

A White House task force on Oct. 27 said insurers needed to understand that coverage for the treatment of drug addiction must be comparable to that for other conditions like depression, schizophrenia, cancer and heart disease. As an example, the administration said, insurers may not require prior approval for drugs to treat opioid addiction, like buprenorphine, if they do not impose similar restrictions on drugs with similar safety risks that are prescribed for physical illnesses.

Federal laws and rules requiring mental health parity have been adopted with bipartisan support over the last 20 years, but the task force found that compliance was lagging.

“While the right laws are on the books, they are too often ignored or not enforced,” Hillary Clinton, the Democratic nominee for president, said in August, promising stronger enforcement of parity laws as part of an ambitious mental health agenda.

The White House task force called for more frequent audits of health plans and warned insurers against imposing stricter requirements on mental health services than on other types of medical care.

More than 40 million people — about one in five American adults — experience some kind of mental illness each year, the administration said, and more than 20 million have a “substance use disorder” involving drugs or alcohol.

Mr. Obama created the task force in March. Along with its final report last month, the administration issued a guide for consumers explaining that they have a legal right to see the criteria used by insurers to determine if a specific mental health treatment is medically necessary.

In the last five years, the Labor Department conducted 1,515 investigations of possible parity violations and issued 171 citations for noncompliance by employer-sponsored health plans.

Those 171 citations are more significant than the number might appear, said Phyllis C. Borzi, an assistant secretary of labor. When the government finds violations, she said, it requires insurers to correct all their health plans, so that a single citation may produce “global changes” affecting tens of thousands of group health plans with millions of participants.

Kate Berry, a senior vice president for America’s Health Insurance Plans, a trade group for insurers, praised the report, saying it included “a lot of good recommendations to help consumers understand what parity means.” Insurers are “working very hard to comply and have made significant progress,” she said.

The Obama administration said that insurers clearly violated the law if they charged higher co-payments for mental health care than for other care, or if they imposed stricter limits on the number of visits to mental health professionals.

Certain other practices do not automatically violate the law, but they do raise a red flag and must be justified by insurers, the administration said.

If, for example, a health plan requires prior approval, or preauthorization, for all mental health care services or all addiction treatments, the government may investigate. Likewise, federal officials said they could investigate if an insurer required a psychiatrist to file a treatment plan or a progress report on a patient every 30 days, or paid only for mental health treatments that produced a “measurable and substantial improvement” within 90 days.

Insurers would have to show that they imposed similar requirements for medical and surgical benefits.

Under a 1996 law, health plans were forbidden to set annual or lifetime dollar limits on mental health care that were lower than the limits for other services. But insurers got around the law by replacing dollar limits on mental health care with numerical limits on doctor visits or days in the hospital. In 2008, Congress banned such differential standards in large employer-sponsored health plans and provided protection for addiction treatments as well. Two years later, in the Affordable Care Act, Congress extended similar protections to people enrolled in individual health insurance policies.

Since then, federal agencies have issued rules and guidelines to ensure that prior authorization requirements, medical necessity criteria and other cost-control techniques do not become barriers to mental health care and addiction treatment.

Patients’ advocates welcomed the new initiative, but said it did not go far enough.

“Enforcement still relies too heavily on complaints,” said Carol A. McDaid, the coordinator of a coalition of mental health advocates. “The government still puts the onus on consumers to understand a complex law and file complaints.”

Ellen M. Weber, an expert on health law at the University of Maryland school of law, said, “It would be much better to require insurers to show compliance up front, as a condition of obtaining approval to offer plans on the market.”

“Regrettably,” Professor Weber said, “some insurers continue to discriminate against their members, who pay high premiums for substance use and mental health coverage.”

The task force found “significant shortages” of psychiatrists, clinical social workers and providers of addiction treatment. And state officials have found that some insurers do not have enough providers in their networks.

Ms. Berry, of the insurance industry group, said insurers were not to blame for such shortages of mental health providers.

“You can’t have them in your network if they don’t exist,” or if they are unwilling to join an insurer’s network, she said.

Filed under: General Problems