Special to Medical Journal – Houston BY TED SHAW, President/CEO, Texas Hospital Association
Each year, one in five Texans experience a behavioral health condition like depression or anxiety. But, only 60 percent of those individuals get treatment. Some individuals do not seek care, but others who want treatment are unable to get it. A myriad of factors play into why some Texans might not seek behavioral health treatment, but for some individuals with health insurance that includes coverage for behavioral health treatment—through private insurance and most Medicare and Medicaid managed care plans—accessing allowable behavioral health treatment can be a challenge.
For many insured Texans, getting treatment for physical health conditions can be easier than for behavioral health conditions. Often the cause is managed care plans’ differential treatment of covered benefits for physical health conditions like diabetes than of benefits for behavioral health conditions.
A new state law, passed during the last Texas legislative session, however, should help. House Bill 10 empowers the Texas Department of Insurance, the state agency that regulates insurers and health plans, to better enforce the longstanding federal law requiring health plans to treat benefits the same for behavioral health conditions as for physical health conditions.
Although the federal law, the Mental Health Parity and Addiction Equity Act of 2008, has been in effect for a decade, gaps remained in applicability and enforcement. Until recently, for example, Medicaid managed care organizations, which cover more than 80 percent of Texas Medicaid enrollees, were exempt from parity requirements. In addition, the state’s failure to fully enforce parity requirements left gaps in access to allowable behavioral health services for individuals with private health insurance. The consequences of these gaps are significant and include delays in treatment, worsening of conditions and mental health crisis. Hospital emergency departments then are the only available source of treatment.
An estimated one in eight emergency department visits in the U.S. stems from a mental health or substance use need, even though most general acute care hospitals are not set up to handle psychiatric emergencies. This number has only increased in recent years. The result is medical staff diverted from patients in need of other critical treatment for trauma, heart attacks or broken bones, for example, to care for individuals who would be better served in a specialized behavioral health environment or who should have received preventive or intervention services in community-based care settings.
In addition to allowing the Texas Department of Insurance to better enforce the federal mental health parity law, House Bill 10 requires the Texas Health and Human Services Commission to establish a behavioral health ombudsman to which consumers may report mental health parity violations and a workgroup to study and make recommendations to limit parity violations and increase enforcement. THHSC’s behavioral health ombudsman is available to answer consumers’ and providers’ questions and help with concerns about access to care through public or private health insurance plans. Consumers can report parity violations to the ombudsman by submitting questions or complaints online, by phone, mail or fax. Through participation on the parity workgroup, Texas hospitals are providing examples of parity violations they see to identify solutions to improve access to care. Texas’ behavioral health hospitals often see parity violations in the form of “fail first” requirements, prior authorizations, peer reviews and medical necessity disqualifications. In its testimony to the workgroup, Texas hospitals have offered informal recommendations to improve access to care, including encouraging the state to examine managed care plans’ denial practices.
In addition to normalizing treatment for behavioral health treatment, eliminating differences in how care for physical and behavioral health conditions is reimbursed and administered will improve access to medically necessary treatment, improve behavioral health outcomes and reduce crisis as well as reduce hospitals’ uncompensated care costs – clinical and financial outcomes that are better for all Texans.