Emerging Opportunities in Mental Health and Substance Use Benefits

By Cristie Travis

In what many would call the year of the tipping point for employer focus on mental health and substance use disorder (MH/SUD), it’s difficult to identify just a few emerging opportunities in MH/SUD benefits since there are so many. But that said, here are a few for your consideration.

Achieving Parity

The Mental Health Parity and Addiction Equality Act of 2008 required behavioral benefits be comparable to and not applied more stringently than “medical-surgical” benefits. Although summary plan documents, policies and procedures have been rewritten to comply, we have not achieved parity.

The National Alliance for Healthcare Purchaser Coalitions’ (NA) Achieving Value in Mental Health Support: A Deep Dive Powered by eValue8 (August 2018), which evaluated the performance of six national and two regional health plans,found:

• The percent of out-of-network utilization was higher for MH/SUD than medical-surgical across all settings of care. Out-of-network care costs more than in-network care and is a significant barrier to getting care.

• The access standards for urgent office visits were longer for MH/SUD (48 hours) compared to medical-surgical (24 hours) and aren’t even being monitored for compliance;

• Plans are not taking systematic approaches that include equalizing reimbursement rates; rapid credentialing; and removing “hassle” factors such as pre-authorization to increase in-network participation.

The NA outlines several steps for employers to hold their TPAs accountable for achieving real parity:

• Require the same urgent office visit access standards for MH/SUD as for medical-surgical.

• Report regularly on key metrics to evaluate parity, such as out-of-network use, reimbursement rates, denial rates, and network directory accuracy. Use the form at http://bit.ly/2B8aG8V .

• Require an action plan to reduce parity inequities and measure progress regularly. Be sure it includes the systemic issues listed above.

• Consider indemnification from your vendors for assuming risks related to certain aspects of parity compliance. Review the model “hold harmless” language at http://bit.ly/2MH8bQ7 . The model language is for informational purposes only and is not intended and should not be construed as providing legal advice.

• Require your plan to have an independent, external audit by an auditor that fully understands the parity requirements.

Only by knowing how your plan is actually operating will you be in a position to understand if your plan is achieving parity and where your TPA needs to make improvements.

Linking Physical and Mental Health: To Address the Whole Person

Almost 1/3 of those with medical conditions also have a MH/SUD. For health care providers to treat these as separate issues when they are so intertwined does not serve the patient’s needs. Today there are two promising approaches to treating the whole person.

Collaborative Care: The majority of MH/SUD care is actually delivered in primary care offices including screening for MH/SUD; prescribing of psychotropic drugs, and treatment of mild-moderate MH/SUD. The Collaborative Care Model was designed to link the primary care physician with a behavioral health specialist who has the training and expertise to support the primary care physician in their treatment of MH/SUD.

The NA reports that only one of the responding plans was actively promoting the billing codes to support this collaborative care and only two plans actually had claims flowing through the codes.

Employers should require their TPA to turn on these codes and ask how many claims and dollars are flowing through them. The TPA should have a plan for educating, training, and giving technical assistance to bill for these codes.

Embedding behavioralists into primary care: A study released in the Journal of Primary Care and Community Health in 2015 (Vol. 6(2) 100-104) notes that few primary care patients actually follow through with a MH/SUD referral that is made to a different clinic. Embedding behavioralists into primary care practices can help more patients get the care they need.

In this model, the behavioralist is an integral part of the practice’s care team and serves as a consultant to the primary care physician and other team members; often provides same day/same appointment brief interventions as needed; and sees patients on an on-going basis.

This same study found that more than half of the patients who saw the embedded behavioralist had never seen a mental health professional before. And, slightly over half of the patients needing continuing care attended subsequent visits.

Here are three more opportunities for you to dig deeper into:

Worksite clinics: The Gallagher/National Alliance of Worksite Health Center (NAWHC) survey (http://bit.ly/2Bck4bx ) shows that 31% of employers have integrated behavioral health into their clinics and this service is the second fastest growing with 15% planning to do so! According to Larry Boress, Executive Director of NAWHC (nawhc.org), “Employers with worksite clinics today are increasingly adding both onsite and tele-behavioral health to their menu of low or no cost services to enable employees to obtain mental health, EAP and substance abuse services in an accessible and confidential setting.”

Mindfulness: “Technology has increased the speed of everything we do in the workplace.  Therefore, our accelerated culture basically operates on an instant gratification mindset.  A practice of mindfulness equips us with the skills to deal with our mental clutter and regulate our emotions during this midst of this chaos.” says Greg Graber, mindfulness teacher/consultant and author (www.greggraber.com) Organizations can also benefit from being mindful. Check out how leaders can create a culture of mindfulness in the workplace at http://bit.ly/2MfnFf5 .

Burnout: Did you know burnout has a “diagnosis code” in the latest version of the World Health Organization’s International Classification of Diseases (ICD-11)? Although not yet considered a disease, the code is now specified as a syndrome resulting from workplace stress. Read this article from Forbes http://bit.ly/32fNEJb to learn more and start thinking about the implications for your workplace culture, policies, and procedures.

All year Memphis Business Group on Health has focused on MH/SUD. It is clear to us that employers need to erase those artificial lines that have separated MH/SUD benefits from medical benefits. Our employees are “whole people” and our benefit programs should reflect the interconnectedness of mind, body, and spirit.