The Essential Mental Health Benefit

January 31, 2012

Steve Larsen
Deputy Administrator and Director
Center for Consumer Information and Insurance Oversight
Centers for Medicare and Medicaid Services
Department of Health and Human Services
200 Independence Avenue S.W., Room 445-G
Washington, DC 20201
EssentialHealthBenefits [at] cms [dot] hhs [dot] gov

Dear Mr. Larsen:

     The Clinical Social Work Association represents the interests of over 200,000 licensed clinical social workers in the country who provide the majority of psychotherapy to citizens with mental disorders.

     CSWA appreciates the opportunity to comment on the Essential Health Benefits (EHB) Bulletin (“the Bulletin”) released by the Center for Consumer Information and Insurance Oversight on December 16, 2011. We believe that the Bulletin is a critically important opportunity to address the health needs of the 25 million Americans, especially those untreated mental disorders, and provide necessary services to those seeking care.
    
     The Bulletin’s explicitly recognizes the Patient Protection Affordable Care Act (PPACA) requirement for the mental health essential health benefit to include treatment for mental health (MH) and substance use disorders (SUD) in a manner consistent with the requirements of the Mental Health Parity and Addiction Equity Act (MHPAEA). By requiring coverage of MH/SUD benefits as one of the EHB categories, and extending MHPAEA to those plans, Congress mandated that all public and private plans are subject to mental health parity, both inside and outside insurance exchanges. The Department’s clear recognition of these important ACA requirements is critical.  

Current Conceptualization of Mental Health Benefits

      The Bulletin allows states to create insurance benefits in four different ways based on current insurance plans.  The way that current plans cover psychotherapy services is an arbitrary system which inappropriately restricts the level of treatment needed for many mental
disorders.  Using existing plans as a model for the mental health EHB will perpetuate these unfair restrictions on mental health treatment and constitute a violation of MHPAEA.

    Outpatient psychotherapy benefits have been systematically limited in most insurance plans in two ways.  

•    Mental health treatment is often construed solely as crisis management with a goal of return to baseline functioning after a severe acute episode.  Many mental disorders are chronic in nature and require ongoing psychotherapy and/or psychotropic medication, often for years, occasionally for a lifetime.  To focus only on the short-term outcomes undermines the patient’s ability to improve their functioning avoid acute episodes, and even suicide.  We advocate for flexibility in frequency and length of treatment in order to effectively assist patients in long-term stabilization and recovery.

•    Many insurers deny coverage for such debilitating mental health conditions such as depression and anxiety.  Patients who have these chronic conditions are often seen as untreatable by insurers despite considerable evidence.

       The failure to provide extended psychotherapy treatment when needed leads to results that are much more costly to society and insurers than the provision of appropriate psychotherapy would be. These costs include high levels of absenteeism, lost productivity, school failure, and, at worst, violent episodes in academia, e.g., the Virginia Tech tragedy, and in the workplace. (1)

      According to Stewart, for every dollar spent on outpatient mental health treatment, four dollars are saved on inpatient mental health treatment. (Stewart W.F., et. al., Journal of the American Medical Association, 289(23), 2003).

Evidence Based Treatment
  
     It is common practice among insurers to describe cognitive behavioral therapy as the only form of psychotherapy that is “evidence-based”, as if solid evidence does not exist for other forms of treatment.  The well-respected Mayo Clinic lists the following as effective psychotherapy methods: cognitive behavioral therapy, interpersonal therapy, psychodynamic psychotherapy, dialectical behavior therapy, acceptance and commitment therapy, family therapy, group therapy, marriage counseling, psychoanalysis, art therapy, exposure therapy, play therapy, and psycho-education (retrieved on January 26, 2012 from http://www.mayoclinic.com/health/psychotherapy/MY00186/DSECTION=what-you-can-expect.

     The Substance Abuse and Mental Health Service Administration (SAMHSA) guidelines, i.e., “[mental health treatment]… must link quality improvement with reimbursement and both encourage and reward the use of evidence-based practice without restricting coverage for those consumers who may not achieve desired outcomes with the least-costly alternative. Comparative effectiveness should be a driver in making treatment decisions, but not be the be-all and end-all.” (SAMHSA (2009) Ensuring U.S. Health Reform Includes Prevention and Treatment of Mental and Substance Abuse Disorders – A Framework for Discussion, retrieved on August 20, 2010 at http://www.samhsa.gov/healthreform/docs/HealthReformCoreConsensusPrinciples.pdf

      Limiting treatment options to cognitive behavioral treatment is not in accord with these guidelines.  It is worth noting that 85 percent of outpatient psychotherapy patients are seen for 15 visits or less and show significant improvement (Zientz, White House presentation, 1993).  The widely-held belief among insurers that outpatient mental health treatment will be endless and therefore highly costly is simply not borne out by the literature.

Milliman Guidelines for Mental Health Treatment

      A recent concern has been the rising popularity among insurers of the Milliman Behavioral Care Guidelines.  These guidelines soundly reject extended treatment for chronic disorders. Using selected parts of the voluminous evidence-based literature Milliman Consultants, an actuarial research firm, limits diagnoses and treatment methods to acute crises, ignoring chronic mental health disorders that require ongoing psychotherapy.  

     It is most distressing that the guidelines codify the standards of practice for mental health treatment, bypassing the judgment of mental health professionals. The 15 ‘silos’ that Milliman uses to define all mental health problems deny the complexity and idiosyncrasy of mental health disorders, especially what treating these disorders at parity with medical/surgical benefits entails.  Many patients have multiple mental disorders which require multiple diagnoses and treatment strategies, unacknowledged by Milliman.      

Mental Health Parity
     
    CSWA strongly supports mental health parity and the availability of psychotherapy for mental health crises as well as ongoing chronic mental health conditions.  Mental health parity cannot be achieved by covering only mental health crises. Many mental health conditions
require ongoing psychotherapy treatment or, at the very least, treatment beyond a few sessions after hospitalization.  Similarly, a medical crisis is not comparable to ongoing medical care.  Both mental health and medical areas of health care have disorders and conditions that may be a crisis or an ongoing treatment need.  In both cases, failure to provide needed care can be fatal.  
     
     In both mental health and medical care there are conditions that could be crisis or chronic.  Unfortunately in the name of curbing health care costs, patients with mental health disorders have been denied psychotherapy, their therapists have been denied the right to make clinical decisions, and insurers have taken the liberty of deciding what constitutes adequate psychotherapy.  

Recommendation for Outpatient Mental Health Benefit

     For treatment of mental disorders through psychotherapy, CSWA recommends:

• A mandated outpatient treatment component of 40 psychotherapy sessions a year as a floor, recognizing that successful outcomes of some disorders may require more treatment;
• Use of all accepted mental health treatment methods;
• More access to ongoing psychotherapy for chronic mental health conditions; and
• True parity for mental health treatment with medical/surgical benefits.  

CSWA strongly encourages CMS to let mental health clinicians, not actuarial firms or insurers, make decisions about mental health treatment.

     Thank you for the opportunity to submit these comments.  We welcome further discussion.

Sincerely,

Robin McKenna, LISW, President
Clinical Social Work Association
robinmckenna [at] charter [dot] net

(1)Untreated depression or anxiety in workers results in $226 billion in “lost productive time” a year. (Pauly, M., Health Economics 2002; 11(3): 221-231).
Clinical depression costs American businesses nearly $29 billion a year in lost productivity and absenteeism (Sederer & Clemens, Psychiatric Services, 53(2), 2002).
Untreated mental disorders in children have a direct correlation to absenteeism from school from first through twelfth grade. (Wood, J., et. al., Child Development, 83(1), pp. 351–366, January/February, 2012).
The Veterans Administration last year said that veterans account for roughly 20 percent of the estimated 30,000 suicides annually in the United States….13 died while waiting to receive treatment. (Hokainen, R., Tacoma News Tribune, May 26, 2011).