Patients Could See Major Advance in Access to Treatment

Patients Could See Major Advance in Access to Treatment

Fifteen years ago, behavioral health advocates hailed the signing of a federal insurance parity law as a landmark moment for patient access to treatment. Today, few would contend that the bipartisan Mental Health Parity and Addiction Equity Act has fulfilled that promise.

The shortcomings of the federal law that mandates equitable coverage for mental health and substance use disorders result from several factors, from uneven enforcement to shortages of behavioral health providers in many communities. But this summer’s national headlines suggest that breakthroughs for patients may be on the horizon, with significant developments both administratively and in the courts.

Because treatment advocates have been frustrated over policy-makers’ lack of consensus to enact stronger protections for the insured, they have looked to the federal Wit v. United Behavioral Health class-action lawsuit for a judicial remedy. The Wit case and a companion lawsuit, covering both residential and outpatient care, allege that  the insurer violated federal law by developing coverage guidelines that were not in keeping with generally accepted standards of care. Plaintiffs allege that United Behavioral Health (UBH) then denied benefits to plan members based on use of these flawed guidelines.

A U.S. District Court judge in 2019 ruled in favor of the plaintiffs and ordered the reprocessing of 50,000 denied claims. Earlier this year, an appellate court panel reversed the ruling and suggested that the insurer had the authority to establish its own guidelines without regard to whether they conformed to accepted standards. But in August, plan members’ fortunes again changed, when the same panel vacated the previous ruling and revived the claim that UBH had violated its fiduciary duty to insured individuals.

Mental health and substance use treatment advocates have expressed great hope for this case. Absent any congressional action to strengthen consumer protections, they see it creating a needed pathway to help the insured. But now there’s evidence that stronger enforcement of parity from Washington could also be on its way.

President Biden in July announced a new proposed federal rule that would place clearer obligations on insurers in guaranteeing equitable access to mental health and substance use treatment. The rule, now in a public comment period, would require insurers to take measures such as expanding their behavioral health provider networks when analyses show that the insurers are falling short in meeting the requirements of parity.

The proposed rule also would spell out in greater detail the types of limits on access that aren’t allowed under parity, such as restrictive prior authorization requirements. The head of the Biden administration’s domestic policy counsel said in a Politico article this month, “We hope insurers will change their behavior going forward without the sticks, but we will continue to fully enforce the parity law.”

The eventual outcomes of the Wit case and the proposed federal rule remain unclear. The lawsuit still could face years of appeals, and insurers are asking the administration to reconsider provisions of the rule that they believe could further burden the service system. But these developments still could be beneficial at the level of local systems of care, calling attention to weak points in access to treatment at a time of soaring need.

Already several states have enacted laws of their own that govern the health plans that are subject to state regulation, requiring that coverage decisions are based on industry-accepted clinical standards. A larger number of states have passed funding initiatives designed to combat staffing shortages, through strategies such as payment rate increases and student loan reimbursement.

Operating at the provider level, we at Sigmund Software see ourselves assisting the effort to expand access to care. The extensive data collection and reporting capability of our software solution can improve provider efficiency, which in turn will enhance the provider-patient relationship. The AURA solution’s ability to maximize care coordination also improves integration of care among multiple providers, and that can help patients and families navigate a complex system of care that often hinders access.

It is exciting to see meaningful developments at the administrative and judicial level that could unleash parity’s full potential to improve lives.