The Biden administration this fall issued new rules aimed at achieving parity between mental and physical health. Among other provisions, the rules prohibit health plans from using more restrictive prior authorizations for mental health than physical health — and require plans to analyze their provider networks to make sure patients can access mental health care.
Congress has passed measures aimed at mental health parity in the past, and while there has been progress in this area, there is also more to do.
Marisa Domino is a health economist in ASU’s College of Health Solutions and executive director of the Center for Health Information and Research. She spoke to The Show about this.
Full conversation
MARISA DOMINO: They're gonna move in the right direction. I think they're not gonna solve the problem in terms of eliminating disparities between mental health and medical surgical benefits. But I think that this is a really complicated area.
And I, I think, you know, we've seen progression over the last 20 to 30 years and this is still a move in the right direction.
MARK BRODIE: Why is it so complicated? Like why is it so hard for health insurance to cover mental and behavioral health the same way it covers physical health?
DOMINO: In part because coverage is a really complicated thing. So when we think of insurance coverage, we might think of what our co-payments are. How much do we have to spend every time we go to the doctor, you know, and those are set by the insurance company.
But there's also other things called non-quantitative treatment limits. So behind the scenes, the insurers can have other tools that they can use to control the kinds of services and the quantity of services we use.
So one example is something called prior authorization for certain kinds of benefits, services used. You actually, you know, just can't go to the pharmacy and fill a prescription. There might be a process where your provider has to get permission specifically for certain kinds of treatments from the health insurer before you know, you can actually obtain the, the treatment or service.
And those are more commonly used in behavioral health care than they are on the medical surgical side. So even though we might say, you know, the copayments are the same, what the patient has to pay out of pocket are the same. There might be efforts behind the scenes that control or restrict the supply of those services that are available to patients.
BRODIE: Is there something that the government could be doing to try to increase parity, like is this even something the government can facilitate?
DOMINO: I think there are greater efforts that can be made. So, you know, one of my mentors Richard Frank, who works at the Brookings Institute recently published a letter to the Center for Medicare and Medicaid Services director indicating that, you know, there, there may be other ways like examining outcomes, examining the percent of patients that use behavioral health services and comparing that to the percent to use primary care, we wouldn't expect those to be equal, but there may be sort of a predictable fraction of people who need behavioral health services and keeping an eye on that.
Comparing that across health insurance plans across populations may be a way to at least better get at who's got access to services versus who's being restricted by either quantitative or non-quantitative treatment limits.
BRODIE: Is any of this related to the fact that in many ways behavioral or mental health, when people are having, having issues with them, like it's not as obvious as like a broken arm or, you know, you're having a heart attack or something like that. Is, is there still that element at play here?
DOMINO: Unfortunately yes, I think that's very much the case. I think we don't have a litmus test for a mental illness. We rely on people to tell us about, the, the symptoms that they're experiencing and the burden of illness that they're feeling from this constellation of symptoms.
And unlike, you know, diabetes where we have a very specific test that indicates whether some he has diabetes or doesn't, or as you indicate an X-ray for a broken bone or not, we really just don't have that level of diagnostics in mental health. And I think there's still, you know, a fair amount of stigma against mental illnesses and substance use disorders.
BRODIE: What are the conversations like in your world right now about what the new administration might do in this area come January?
DOMINO: Yeah, that's a great question. I think that, you know, there's concerns about restrictions in benefits.
I think that there's been a lot of progress made with the idea that a lot of health can be improved, not just through health services, but through improvements in what are often called health related social factors or social determinants of health, things like food insecurity, housing instability, those are areas that we've seen a lot of progress with health plans, especially Medicaid programs being able to fund really innovative programs in that area that have spillover effects on health.
And I think that there's a concern that some of those initiatives, you know, might be pulled in the current administration. So I think that's one area of concern and just generosity of benefits.
I think, you know, there's a strong emphasis on private sector care, you know, possibly to the detriment of public approaches to providing health care, which I think are just so instrumental, especially in behavioral health.
Since there's there are these complex mechanisms where, you know, the price structure may not work as well as it does for, you know, the consumption of apples or something like that, that's fairly straightforward through the private sector.
BRODIE: Do you think this is the kind of thing that individual states could take up? Like if the federal government isn't doing enough in the minds of some folks, is this something that like Arizona officials could try to put into place here or is there just not enough scale for that?
DOMINO: No, absolutely. I think that states do a lot in this space individually. So one of the really great things about the Medicaid program is there a state federal partnership.
And so the federal government creates a set of ground rules that all states must follow, but states have a lot of opportunity for innovation. And so I think states could absolutely require new outcomes being monitored when care is being contracted out to private health plans or even public health plans so that, you know, they can ensure that there's access.
I think, you know, we often talk about the provider network, the providers who accept the particular kind of insurance and there's already a lot being done in that space that's required by states.
Some states to, you know, require health plans to make sure that they have enough providers available to serve the expected needs of the populations that they're insuring.
BRODIE: Is there movement in this area in Arizona?
DOMINO: Oh, absolutely. I think Arizona's Medicaid program, AHCCCS, has just been a real innovator in the behavioral health space. They've come up with new criteria, new ways to integrate mental health and primary care together so that people are receiving seamless care, whether they have medical surgical needs or behavioral health needs, they've set new standards, you know, to watch, to make sure that access really is happening on a meaningful basis.
So I think Arizona has been a real example in this space.
BRODIE: All right, that is Marisa Domino, a health economist and executive director of the Center for Health Information and Research at ASU’s College of Health Solutions. Marisa thanks so much for the conversation, I appreciate it.
DOMINO: I enjoyed talking with you, Mark. Thank you.
