[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
AN EXAMINATION OF FEDERAL MENTAL HEALTH PARITY LAWS AND REGULATIONS
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
SECOND SESSION
__________
SEPTEMBER 9, 2016
__________
Serial No. 114-167
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
______
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COMMITTEE ON ENERGY AND COMMERCE
FRED UPTON, Michigan
Chairman
JOE BARTON, Texas FRANK PALLONE, Jr., New Jersey
Chairman Emeritus Ranking Member
JOHN SHIMKUS, Illinois BOBBY L. RUSH, Illinois
JOSEPH R. PITTS, Pennsylvania ANNA G. ESHOO, California
GREG WALDEN, Oregon ELIOT L. ENGEL, New York
TIM MURPHY, Pennsylvania GENE GREEN, Texas
MICHAEL C. BURGESS, Texas DIANA DeGETTE, Colorado
MARSHA BLACKBURN, Tennessee LOIS CAPPS, California
Vice Chairman MICHAEL F. DOYLE, Pennsylvania
STEVE SCALISE, Louisiana JANICE D. SCHAKOWSKY, Illinois
ROBERT E. LATTA, Ohio G.K. BUTTERFIELD, North Carolina
CATHY McMORRIS RODGERS, Washington DORIS O. MATSUI, California
GREGG HARPER, Mississippi KATHY CASTOR, Florida
LEONARD LANCE, New Jersey JOHN P. SARBANES, Maryland
BRETT GUTHRIE, Kentucky JERRY McNERNEY, California
PETE OLSON, Texas PETER WELCH, Vermont
DAVID B. McKINLEY, West Virginia BEN RAY LUJAN, New Mexico
MIKE POMPEO, Kansas PAUL TONKO, New York
ADAM KINZINGER, Illinois JOHN A. YARMUTH, Kentucky
H. MORGAN GRIFFITH, Virginia YVETTE D. CLARKE, New York
GUS M. BILIRAKIS, Florida DAVID LOEBSACK, Iowa
BILL JOHNSON, Ohio KURT SCHRADER, Oregon
BILLY LONG, Missouri JOSEPH P. KENNEDY, III,
RENEE L. ELLMERS, North Carolina Massachusetts
LARRY BUCSHON, Indiana TONY CARDENAS, California7
BILL FLORES, Texas
SUSAN W. BROOKS, Indiana
MARKWAYNE MULLIN, Oklahoma
RICHARD HUDSON, North Carolina
CHRIS COLLINS, New York
KEVIN CRAMER, North Dakota
Subcommittee on Health
JOSEPH R. PITTS, Pennsylvania
Chairman
BRETT GUTHRIE, Kentucky GENE GREEN, Texas
Vice Chairman Ranking Member
JOHN SHIMKUS, Illinois ELIOT L. ENGEL, New York
TIM MURPHY, Pennsylvania LOIS CAPPS, California
MICHAEL C. BURGESS, Texas JANICE D. SCHAKOWSKY, Illinois
MARSHA BLACKBURN, Tennessee G.K. BUTTERFIELD, North Carolina
CATHY McMORRIS RODGERS, Washington KATHY CASTOR, Florida
LEONARD LANCE, New Jersey JOHN P. SARBANES, Maryland
H. MORGAN GRIFFITH, Virginia DORIS O. MATSUI, California
GUS M. BILIRAKIS, Florida BEN RAY LUJAN, New Mexico
BILLY LONG, Missouri KURT SCHRADER, Oregon
RENEE L. ELLMERS, North Carolina JOSEPH P. KENNEDY, III,
LARRY BUCSHON, Indiana Massachusetts
SUSAN W. BROOKS, Indiana TONY CARDENAS, California
CHRIS COLLINS, New York FRANK PALLONE, Jr., New Jersey (ex
JOE BARTON, Texas officio)
FRED UPTON, Michigan (ex officio)
(ii)
C O N T E N T S
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Page
Hon. Joseph R. Pitts, a Representative in Congress from the
Commonwealth of Pennsylvania, opening statement................ 1
Prepared statement........................................... 2
Hon. Marsha Blackburn, a Representative in Congress from the
State of Tennessee, opening statement.......................... 3
Hon. Gene Green, a Representative in Congress from the State of
Texas, opening statement....................................... 4
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 5
Prepared statement........................................... 6
Hon. Ben Ray Lujan, a Representative in Congress from the State
of New Mexico, prepared statement.............................. 57
Witnesses
Pamela Greenberg, MPP, President and CEO, Association for
Behavioral Health and Wellness................................. 8
Prepared statement........................................... 11
Michael A. Trangle, M.D., Senior Medical Director, Behavioral
Health Division, HealthPartners Medical Group, Regions Hospital 20
Prepared statement........................................... 23
Matt Selig, Executive Director, Health Law Advocates, Inc........ 32
Prepared statement........................................... 35
Submitted Material
Letter of August 31, 2016, from Carmella Bocchino, Executive Vice
President, et al., America's Health Insurance Plans, to Cecilia
Munoz, Chair, White House Mental Health and Substance Use
Disorder Parity Task Force, submitted by Mr. Pitts............. 59
Letter of September 7, 2016, from Katrina Velasquez, Policy
Director, Eating Disorders Coalition, to committee and
subcommittee leadership, submitted by Mr. Pitts................ 73
Letter of September 8, 2016, from the American Association on
Health and Disability, et al., to Members of Congress,
submitted by Mr. Pitts......................................... 77
Statement of Patrick J. Kennedy, II, a Former Representative in
Congress from the State of Rhode Island, submitted by Hon.
Joseph P. Kennedy.............................................. 79
Letter of December 16, 2015, from Renee Binder, President,
American Psychiatric Association, to Mr. Kennedy, submitted by
Mr. Kennedy.................................................... 81
Letter of January 28, 2016, from R. Jeffrey Goldsmith, President,
American Society of Addiction Medicine, to Mr. Kennedy,
submitted by Mr. Kennedy....................................... 83
Letter of January 2016, from Kitty Westin, Member of the Board,
et al., The Emily Program Foundation, to Mr. Kennedy, submitted
by Mr. Kennedy................................................. 85
Letter of August 31, 2016, from William C. Daroff, Senior Vice
President for Public Policy and Director of the Washington
Office, The Jewish Federation of North America, to the White
House Mental Health and Substance Use Disorder Task Force,
submitted by Mr. Kennedy....................................... 86
Letter of September 8, 2016, from Mary T. Giliberti, Chief
Executive Officer, National Alliance on Mental Illness, to Mr.
Pitts and Mr. Green, with NAMI report ``A Long Road Ahead:
Achieving True Parity in Mental Health and Substance Use
Care,'' submitted by Ms. Matsui................................ 88
AN EXAMINATION OF FEDERAL MENTAL HEALTH PARITY LAWS AND REGULATIONS
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FRIDAY, SEPTEMBER 9, 2016
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 9:00 a.m., in
Room 2322, Rayburn House Office Building, Hon. Joseph R. Pitts
(chairman of the subcommittee) presiding.
Members present: Representatives Pitts, Guthrie, Shimkus,
Murphy, Burgess, Blackburn, Lance, Bucshon, Brooks, Collins,
Green, Capps, Castor, Matsui, Lujan, Schrader, Kennedy,
Cardenas, and Pallone (ex officio).
Staff present: Adam Buckalew, Professional Staff, Health;
Rebecca Card, Assistant Press Secretary; Blair Ellis, Press
Secretary; Jay Gulshen, Staff Assistant; Heidi Stirrup, Health
Policy Coordinator; Jeff Carroll, Democratic Staff Director;
Tiffany Guarascio, Democratic Deputy Staff Director and Chief
Health Advisor; Samantha Satchell, Democratic Policy Analyst;
Andrew Souvall, Democratic Director of Communications, Outreach
and Member Services; Arielle Woronoff, Democratic Health
Counsel; and C.J. Young, Democratic Press Secretary.
Mr. Pitts. The subcommittee will come to order.
Before we begin, I want to make a note that Members may be
filtering in and out throughout the hearing. Unfortunately,
with the condensed September session, there are a number of
scheduling conflicts this morning. But we wanted to be sure to
have this important hearing before Congress recessed at the end
of the month.
With that being said, the Chair recognizes himself for an
opening statement.
OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA
Today's Health Subcommittee hearing will examine the
Federal mental health parity laws and regulations. In 2008,
Congress passed a bill requiring most group health plans to
provide more generous coverage for treatment of mental
illnesses, comparable to what is provided for physical
illnesses. This Mental Health Parity and Addiction Equity Act,
MHPAEA, which followed the Mental Health Parity Act of 1996,
the MHPA, requires equivalence or a parity in coverage of
mental and physical ailments. Parity means that insurers need
to treat copayments, treatment limits, prior authorization for
mental health, substance use disorder the same way they treat
for physical health care.
The MHPAEA originally applied to group health plans and
group health insurance coverage and then was amended by the
Affordable Care Act to also apply to individual health
insurance coverage as well as Medicaid benchmark and benchmark-
equivalent plans.
With more than 11 million Americans who suffer with severe
mental illness, such as schizophrenia, bipolar disorder, major
depression, this issue is vitally important for individual
patients as well as families seeking appropriate care for their
loved ones.
Since there seems to be ongoing discussions or protections
as envisioned in the mental health parity laws previously
enacted, it is timely for this committee to consider ways to
streamline the mental health parity system.
Title VIII of the Helping Families in Mental Health Crisis
Act, authored by committee member Tim Murphy of my home State,
Pennsylvania, and Eddie Bernice Johnson of Texas, offers eight
provisions concerning mental health parity, such as improved
compliance guidance and disclosure support.
Of particular interest to our Democratic committee members
is a proposal by Representative Joe Kennedy of Massachusetts,
H.R. 4276, the Behavioral Health Coverage Transparency Act of
2015, and this bill offers one of the many approaches to
modifying parity requirements.
Today, we have three expert panelists who will provide
testimony and answer questions on the strengths and challenges
of mental health parity standards. And I look forward to the
testimony today.
[The prepared statement of Mr. Pitts follows:]
Prepared statement of Hon. Joseph R. Pitts
The subcommittee will come to order.
The chairman will recognize himself for an opening
statement.
Today's Health Subcommittee hearing will examine the
Federal mental health parity laws and regulations.
In 2008, Congress passed a bill requiring most group health
plans to provide more generous coverage for treatment of mental
illnesses, comparable to what is provided for physical
illnesses. This Mental Health Parity and Addiction Equity Act
(MHPAEA), which followed the Mental Health Parity Act of 1996
(MHPA), requires equivalence, or parity, in coverage of mental
and physical ailments.
Parity means that insurers need to treat copayments,
treatment limits, and prior authorization for mental health and
substance use disorder the same way they treat them for
physical health care.
The MHPAEA originally applied to group health plans and
group health insurance coverage, and then was amended by the
Affordable Care Act (ACA) to also apply to individual health
insurance coverage as well as Medicaid benchmark and benchmark-
equivalent plans.
With more than 11 million Americans who suffer with severe
mental illness such as schizophrenia, bipolar disorder, and
major depression, this issue is vitally important for
individual patients as well as families seeking appropriate
care for their loved ones.
Since there seems to be ongoing discussions on protections
as envisioned in the mental health parity laws previously
enacted, it is timely for this committee to consider ways to
streamline the mental health parity system.
Title VIII of the Helping Families in Mental Health Crisis
Act, authored by committee member Tim Murphy of my home State,
Pennsylvania, and Eddie Bernice Johnson of Texas, offers eight
provisions concerning mental health parity, such as improved
compliance guidance and disclosure support.
Of particular interest to our Democrat committee members is
a proposal by Rep. Joe Kennedy of Massachusetts, H.R. 4276, the
Behavioral Health Coverage Transparency Act of 2015. This bill
offers one of the many approaches to modifying parity
requirements.
Today, we have three expert panelists who will provide
testimony and answer questions on the strengths and challenges
of mental health parity standards.
Mr. Pitts. I yield the balance of my time to the vice chair
of the full committee, Mrs. Blackburn.
OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TENNESSEE
Mrs. Blackburn. Thank you, Mr. Chairman.
To our witnesses today, we thank you.
I want to thank the chairman for calling the hearing, and I
want to thank all of my colleagues for the great work that we
all did together as a team to pass that mental health reform
package through the House, get it through the House in July.
And I think it was significant that both sides came together on
what I see as a very important issue today.
As we talk with you all, I am going to want to highlight
some items pertaining to the Zika virus. I do have tremendous
concern about what we see happening here.
Wall Street Journal had an article, and I would like to
submit this for the record, Mr. Chairman. Researchers in the
FDA now are mentioning that, with the Zika virus, we could
potentially, probably will see an uptick in mental illness,
Parkinson's, diseases of that nature, dementia, et cetera. And
we know that the virus is fast-spreading, fast-growing--I think
16,000 cases now in the U.S. and our territories. And I am
quite concerned about the parallels between the virus and some
of the mental health issues that we have. So I do want to
highlight that. And, Mr. Chairman----
Mr. Pitts. Without objection, so ordered.
Mrs. Blackburn. I appreciate that, and I yield back my
time.
Mr. Pitts. Is anyone seeking time?
Mr. Shimkus. Mr. Chairman, just briefly.
I want to welcome the panelists. And I go to a local
healthcare provider in the mental health space, John Markley
from Centerstone, Illinois. And I asked him these very same
questions: What can be done to be helpful? And he listed just
three things real quick: The Federal Government should use
additional specific guidance to State regulators on plans on
how to implement the Federal parity law, identify parity
violations, and enforce the law in both public and private
insurance. The Federal Government should issue additional
guidance detailing the parity law transparency requirements and
modeling for issuers an appropriate disclosure of coverage and
plan design. And the Federal Government, Federal and State
regulators should robustly enforce requirements of the Federal
mental health, substance use disorder parity law prospectively
during plan approval and retrospectively through complete
investigations. And I will probably hear some of that from the
testimony from our panelists.
And I appreciate the time, Mr. Chairman, yield back.
Mr. Pitts. The Chair thanks the gentleman.
I also have a UC request. I ask unanimous consent to submit
the following letters from America's Health Insurance Plans to
the President's task force; a letter from the Eating Disorders
Coalition; a letter to Congress from 43 organizations
representing providers, professionals, patients, family
members, and consumers.
Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Pitts. The Chair now recognizes the ranking member of
the subcommittee, Mr. Green, 5 minutes for an opening
statement.
OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TEXAS
Mr. Green. Thank you, Mr. Chairman, for having this
important hearing.
To our witnesses, thank each of you for taking your time
out and being here this morning.
For too long mental health and substance use care has been
siloed from the rest of the healthcare system and stigmatized.
Perhaps the biggest barrier to accessing care has been higher
cost, lack of coverage for mental health, and substance use
care on par with the physical health care.
To begin to address this, Congress passed a Mental Health
Parity Act in 1996. The law prohibited employer-sponsored group
health plans from setting higher annual or lifetime dollar
limits on mental health benefits than any other benefits. The
Paul Wellstone and Pete Domenici Mental Health Parity and
Addiction Equity Act in 2008 built on this first step and
provided protections regarding equality of coverage for medical
and surgical benefits and mental health and substance use
benefits. This was further strengthened by the Affordable Care
Act in 2010.
While the progress has been made, there is much room for
improvement. Since MHPAEA was enacted in 2008, insufficient
enforcement, inconsistent compliance, spotty disclosure of
medical management information and other implementation
barriers to accessing mental health and substance use services
with equivalency to physical health services has mooted the
promise of the law for many. Today, we will be hearing with
witnesses from the current state of parity laws and on-the-
ground enforcement. Without strong enforcement of the parity
law, millions of people continue to struggle to get health care
they need.
I look forward to learning more about this critical,
important issue, and I thank you. And I would like to yield a
minute and a half to my colleague from California, Doris
Matsui.
Ms. Matsui. Thank you, Mr. Green.
What we really want to do today is treat mental illness as
a disease and afford the same prevention, early intervention,
and treatment that we strive to have for physical illnesses. We
are starting to make progress, but we have much more work to
do.
Mental health parity is an essential part of comprehensive
reform. Parity is designed to ensure that insurance companies
cover mental health benefits the same way they cover physical
health benefits. Congress started this effort with a Mental
Health Parity Act in 1996, and we have continued to build on it
since then. We have made great strides with the Affordable Care
Act by applying the concept of parity to more types of plans
and more types of benefits and adding mental health and
substance use disorder to the list of essential health
benefits. Yet we need to make sure that these laws are being
applied and enforced consistently.
We included provisions to strengthen the parity law and the
mental health reform bill this committee worked hard to pass
before the August recess.
I also support the ideas my colleague, Representative
Kennedy, has put forth to take these provisions a step further.
I look forward to hearing from the witnesses today and what we
can do moving forward to ensure that everyone has access to the
treatments and services they need.
I yield back to the ranking member.
Mr. Green. Thank you. I thank my colleague for her work.
The time has come now to actually enforce the mental health
parity laws. Over the last 20 years, as both a State legislator
and a Member of Congress, I have watched how we have tried to
improve it, but it has not been successful.
So, Mr. Chairman, I thank you for calling this hearing
today, and again, hopefully, if not this session, then early
next session, we can continue to work on making sure we provide
the parity that mental health has with our physical illnesses
in our insurance policies.
Does anyone else want time from my side?
I yield back my time.
Mr. Pitts. The Chair thanks the gentleman and now
recognizes the ranking member of the full committee, Mr.
Pallone, 5 minutes for an opening statement.
OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. I just want to thank you, Mr. Chairman, and
Mr. Green for this hearing on the state of mental health parity
in America, because current mental health parity law requires
that insurers treat mental health and substance use disorder
care the same way they treat medical or physical care, and that
includes copayments, treatment limits, and prior
authorizations.
Today, more than 41 million adults have some form of mental
illness, but in 2014, less than half of them received mental
health care. And more than 20 million people over the age of 12
have a substance use disorder, but only 2.6 million received
treatment at a specialty facility in 2014. Perhaps this can be
explained in part, because the majority of Americans do not
know that there are mental health parity protections in current
law.
This Congress, we have had several important conversations
on the challenges facing our mental health system. And we
recently passed a bipartisan mental health bill in the House,
and I am pleased that we are here today to continue that work
by having a more indepth discussion on mental health parity.
The last time we made major improvements to mental health
parity laws was in 2010 when we passed the Affordable Care Act.
The ACA expanded both parity protections and health insurance
coverage, making early treatment and prevention services more
accessible to millions of Americans. Under the ACA, all new
individual and small group insurance plans are mandated to
cover mental health and substance use disorder services as one
of 10 essential health benefits. In addition, the ACA expanded
parity protections for mental health and substance use disorder
services to individual health plans and certain Medicaid plans.
So this essentially means that these plans must provide
coverage for mental health and substance use disorder services
at the same level as coverage for other medical services.
So, today, I am interested in hearing from our witnesses
about how our current parity laws are being implemented and
enforced, because without proper enforcement, those laws will
not have the impact we hoped for them to have.
And, finally, I would like to thank Congressman Kennedy for
his strong leadership on this topic and for requesting this
hearing. He sponsored legislation this Congress that contains
important parity provisions that were not included in our
House-passed mental health bill. It is clear that we can and
should be doing more to ensure that Americans are able to
access necessary mental health and substance use disorder
services, and I hope this hearing will shed some light on what
steps we can take going forward.
So I would like to yield the remainder of my time to
Congressman Kennedy.
[The prepared statement of Mr. Pallone follows:]
Prepared statement of Hon. Frank Pallone, Jr.
Thank you, Mr. Chairman. Good morning and thank you to our
witnesses for joining us. We're here this morning to have a
discussion on the state of mental health parity in America.
Current mental health parity law requires that insurers treat
mental health and substance use disorder care the same way they
treat medical or physical care. This includes copayments,
treatment limits, and prior authorizations.
Today, more than 41 million adults have some form of mental
illness, but, in 2014, less than half of them received mental
health care. And more than 20 million people over the age of 12
have a substance use disorder, but only 2.6 million received
treatment at a specialty facility in 2014. Perhaps this can be
explained in part because a majority of Americans do not know
that there are mental health parity protections in current law.
This Congress, we've had several important conversations on
the challenges facing our mental health system, and we recently
passed a bipartisan mental health bill in the House. I'm
pleased that we're here today to continue that work by having a
more in-depth discussion on mental health parity.
The last time we made major improvements to mental health
parity laws was in 2010 when we passed the Affordable Care Act.
The ACA expanded both parity protections and health insurance
coverage, making early treatment and prevention services more
accessible to millions of Americans. Under the ACA, all new
individual and small group insurance plans are mandated to
cover mental health and substance use disorder services as one
of 10 Essential Health Benefits. In addition, the ACA expanded
parity protections for mental health and substance use disorder
services to individual health plans and certain Medicaid plans.
This essentially means that these plans must provide coverage
for mental health and substance use disorder services at the
same level as coverage for other medical services.
Today I'm interested in hearing from our witnesses about
how our current parity laws are being implemented and
enforced--because without proper enforcement, our parity laws
will not have the impact we hope for them to have.
Finally, I'd like to thank Congressman Joe Kennedy for his
strong leadership on this topic and for requesting this
hearing. He's sponsored legislation this Congress that contains
important parity provisions that were not included in our
House-passed bill. It's clear that we can and should be doing
more to ensure that Americans are able to access necessary
mental health and substance use disorder services, and I hope
this hearing will shed some light on what steps we can take
going forward.
I look forward to hearing from our witnesses today--and I'd
like to yield the remainder of my time to Congressman Kennedy.
Mr. Kennedy. I want to thank the ranking member and the
ranking member of the subcommittee, Mr. Green.
I also want to thank Chairman Upton and Chairman Pitts for
allowing us to have this hearing today and for their leadership
on mental health and continuing to make mental health parity a
priority for this committee.
I also want to thank Mr. Selig for his work and the work of
Health Law Advocates, which has touched thousands of patients
and families across Massachusetts. It is a privilege to have
you representing our Commonwealth today, sir.
And to all the tireless advocates out there who have helped
inform our efforts in this committee, without your support, we
wouldn't be where we are today. I thank you.
When the House passed this committee's mental health bill
in July, it was a needed step forward in our efforts to fix a
deeply flawed system. But our work is far from over, because no
matter how many providers we train, grant programs we fund or
community health centers we expand, failure to ensure basic
insurance coverage for those services means the vast majority
of working and middle class families can't afford them, and
that is why I am grateful for today's hearing.
Parity, the simple idea that substance use disorder and
heart disease should be treated the same is the law. That is
not what this debate is, in fact, about. But without proper
enforcement and transparency, the law is little more than empty
words. It is meaningless to the patients and families who need
and deserve the access the Mental Health Parity Act, the Mental
Health Parity and Addiction Equity Act, and the Affordable Care
Act were intended to guarantee. And that lack of enforcement
and transparency has devastating consequences.
I recently read a story of a mother whose son Matt lost his
life after an insurance company continually refused to cover
long-term treatment for his substance use disorder. She wrote
that she, quote, ``used to wish that Matt had cancer, at least
he would have received timely, nonbiased treatment.''
Beneath the heartbreaking stories and anecdotes are
statistics to back them up. Claims for mental health care are
denied at nearly twice the rate as claims for physical health.
Twenty-four out of 25 insurance companies in California charged
higher copays or coinsurance for mental health care than
physical health care, according to investigation by State
regulators. Guided by those stories and statistics, I
introduced the Behavioral Health Coverage Transparency Act to
force insurers to disclose the rates and reasons for denials
for mental health care while holding insurers accountable for
any violations through random audits. Beyond those provisions,
it would create a portal where patients not only lodge
complaints but learn more about their coverage options. That
lack of accessible information is a major roadblock to health
care. My own legislative director, a health policy expert,
spent over 2 unsuccessful hours on the phone with her insurance
company last week trying to get the medical necessity documents
she is entitled to by law and still has yet to receive them.
Parity is a promise we made to millions of Americans who
suffer from mental illness. It is not just a legislative
technicality or regulatory minutia; it is their lifeline. We
haven't yet made good on that promise. We are allowing insurers
to hide behind a curtain of proprietary information and a broad
language of denial. Unless and until this committee becomes
serious about ensuring parity as a lived reality for patients
and the families who love them, meaningful mental health reform
will remain out of reach.
In this body, those reforms begin in this committee room,
and I hope that my colleagues will join me in calling for
parity to be included in any conference report that reaches the
President's desk.
Thank you. I yield back.
Mr. Guthrie [presiding]. Thank you.
The gentleman yields back.
All opening statements have been concluded, and all members
have the opportunity to submit statements for the record.
I would like to introduce the panel we have before us
today. First, I will introduce all three. Then we will have
their opening statements. Ms. Pamela Greenberg, president and
CEO, Association for Behavioral Health and Wellness; we also
have Dr. Michael A. Trangle, senior medical director,
Behavioral Health Division, HealthPartners Medical Group; and
Matt Selig, executive director, Health Law Advocates.
Thank you for coming today, and you each have 5 minutes to
summarize your testimony, and your written testimony will be
placed in the record. If you notice the lights, you will get a
yellow light when you get close, and then when the red light,
it would be time to sum up if you haven't concluded at that
point.
And I will begin with recognizing Ms. Greenberg for 5
minutes.
STATEMENTS OF PAMELA GREENBERG, MPP, PRESIDENT AND CEO,
ASSOCIATION FOR BEHAVIORAL HEALTH AND WELLNESS; MICHAEL A.
TRANGLE M.D., SENIOR MEDICAL DIRECTOR, BEHAVIORAL HEALTH
DIVISION, HEALTHPARTNERS MEDICAL GROUP, REGIONS HOSPITAL; AND
MATT SELIG, EXECUTIVE DIRECTOR, HEALTH LAW ADVOCATES, INC.
STATEMENT OF PAMELA GREENBERG
Ms. Greenberg. Good morning, Vice Chairman Guthrie, Ranking
Member Green, and distinguished members of the subcommittee.
Thank you for the opportunity to testify before you today.
My name is Pamela Greenberg, and for the last 18 years, I
have served as the president and CEO of the Association for
Behavioral Health and Wellness. ABHW is an association of the
Nation's leading specialty behavioral health companies. These
companies provide an array of behavioral health services to
over 170 million people in both the public and private sectors.
Since its inception in 1994, ABHW has actively supported mental
health and addiction parity. And we believe that it is
important to diagnose and treat mental health and substance use
disorders at an early stage. ABHW is an original member and at
one point chair of the Coalition for Fairness in Mental Illness
Coverage. In my testimony today, I will provide a brief
overview of MHPAEA, discuss compliance and enforcement, and
discuss some next steps as we continue to move forward with
parity implementation.
MHPAEA, as members have already said, expands upon the
Mental Health Parity Act of 1996 that created parity for annual
and lifetime limits between mental health and physical health
benefits. MHPAEA applies to plans with over 50 employees. It
does not mandate coverage for mental health and substance use
disorders. The law and regulations state that financial
treatment and nonquantitative treatment limits can be no more
restrictive than those on the physical side. Additionally, the
law requires the disclosure of medical necessity criteria and
the reason for denial. The law also provides that if out-of-
network services are available on the physical health side,
they must also be available on the mental health side.
It is important to note that parity was not intended to be
the panacea for all mental health and addiction issues. For
example, parity does not address our workforce shortage issues
nor does it look at the quality of care that is being provided.
The Affordable Care Act extended MHPAEA to individual
markets, small group, and qualified health plans. Parity also
applies in Medicaid and TRICARE.
Since MHPAEA's passage in 2008, our member companies have
had numerous meetings with the regulators to help us better
understand and operationalize the regulations. Our member
companies have teams of dozens of people from multiple
departments working diligently to exchange information and
perform the required analyses.
The analyses are complex. For example, in order to complete
the parity analysis, ABHW member companies review a variety of
documents, including summary plan documents, medical necessity
criteria, and medical management program descriptions. And then
they document the underlying processes, strategies, evidentiary
standards, and other factors considered by the plan. And then
they review these findings with the organization's legal team
and recommend any needed changes. Our members have been audited
for parity compliance at both State and Federal levels.
The DOL and HHS have been enforcing MHPAEA through
investigations and health plan audits. In its January 2016
report to Congress, the DOL reported that, since October 2010,
they have conducted 1,515 MHPAEA investigations and cited 171
violations. HHS has also received complaints and, to date, has
been able to avoid litigation by resolving the issues through
voluntary changes by the health plans. Regulating agencies have
also issued multiple sets of frequently asked questions and
fact sheets.
This year, President Obama established a White House Mental
Health and Substance Use Disorder Parity Task Force that is
going to--that is working to improve parity. I ask that our
comment letter to the task force be included in the record.
To say that parity is not being implemented and enforced is
a misrepresentation. It is important to recognize the strides
that have been made and work together to develop best practices
to move forward. We have to make sure that we are not so rigid
with our implementation of parity that we end up ignoring the
differences that exist between behavioral and physical health
and, as a result, compromise quality care.
Further discussion is needed on the disclosure issue.
Transparency and disclosure of information to consumers is
important, but we also have to keep in mind the results of a
new research paper that found that 86 percent of participants
could not define deductible, copay, coinsurance, and out-of-
pocket maximum in a multiple-choice questionnaire. Recent
legislative attention in the area of disclosure has contributed
to the issuance of additional guidance. What is missing from
this discussion has been the volume and technical nature of
these documents. There needs to be a more concise option for
consumers to understand how their health plan has implemented
parity without burying them with hundreds of documents.
Some ideas to consider include the development of a
document that a plan would use to explain how they have
performed the parity analysis. Another idea is to provide
examples that would include scenarios of questions a consumer
might ask and then also the documents they may want to request
to answer those questions. A third area that needs additional
attention is education to all stakeholders as to what is and
isn't included in parity. HHS is working with States and the
National Association of Insurance Commissioners. DOL has issued
a compliance assistance guide and the check sheet to assist
employers, and SAMHSA has information on their Web site.
If I could just finish up. Our members are faced with
disparate and sometimes incorrect interpretations by State
agencies enforcing the Federal law, and we would like to see
more consistent enforcement. We also support the release of the
identified information that are found by the regulators.
And, finally, if I could just bring two issues to your
attention, and those are the disclosure of substance use
records related to 42 CFR in part 2 and meaningful use
incentives for behavioral health providers. We hope that the
committee considers those issues at a later date.
Thank you for the opportunity to testify today, and I look
forward to ongoing discussions as we move forward.
[The prepared statement of Ms. Greenberg follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Guthrie. Thank you for testifying.
Dr. Trangle, you are recognized for 5 minutes.
STATEMENT OF MICHAEL A. TRANGLE
Dr. Trangle. Thank you, Vice Chairman Guthrie, Ranking
Member Green, and all the committee members.
I am Michael Trangle. I am a practicing psychiatrist and
also a senior medical director for HealthPartners Medical
Group, one of our hospitals, and have been really actively
involved in kind of efforts we have been doing to make things
better. I am very involved in quality improvement, leading
initiatives to improve depression outcomes outpatient, reduce
readmissions for people coming from psych units, trying to
lengthen the lifespan of folks with serious mental illnesses in
our State, and just work hard on that.
I am from an integrated organization where there is a
health plan medical group of about 1,800 docs, hospitals. The
health plan covers 1.36 million lives. We have got 22,500
employees. I know that we are all working hard to try to
produce parity, both clinicians like me and administrators who
know the details of the law and the policy in a way that I
don't, to try to really make sure we understand and are fully
implementing it.
I want to talk about some of the efforts we are doing in
the real world at the ground level to try to make things
better. One initiative that we have been very successful with
is, with our public radio station and NAMI and other
organizations, doing a campaign to reduce stigma called Make It
OK, which actually helps access. There is so much shame
involved and avoidance of getting involved in treatment that,
if you can start conversations, people would be willing to
either listen to their primary care doc or bring it up and get
going. I know that, for our members, we measure closely and
look for improvements. We are at a 96 percent member
satisfaction of either very satisfied or satisfied for access
to behavioral health resources in our system.
We have come up with ways that we have offered--we think it
is so good to our employees as well as all of our patients,
whether they have our health plan or not and are health plan
members--where they can go online on the Internet and
participate in a cognitive behavioral therapy treatment program
at their leisure, at their own pace, to improve depression and
anxiety care.
We have created an algorithm, based upon claims, to look at
who is at high risk to not do well in the next 6 months. And I
can give you an example of one of my patients who is a 44-year-
old woman--married, three kids, lives in the burbs--who started
seeing me as an outpatient for depression and anxiety and,
despite my best efforts, wasn't getting better. Then I realized
she was probably abusing substances. And then when I talked to
her, she wasn't interested or willing to do treatment. She got
worse. She ended up getting drunk, passed out while smoking in
bed. Her house burned down. Thankfully, her kids and husband
got out safely, but she had between 20 and 30 percent burns.
She got hospitalized in a burn unit in a hospital that is not
integrated with our system but part of our health plan network,
was there for about 3 weeks, came out, and still was even worse
than before. She was still depressed, anxious. She had started
abusing opiates, because she had pain now, as well as drinking.
And we had a healthcare coordinator that was working with
this person because of our algorithm. And her job is to reach
out and talk to all the various places and people involved in
her care. She reached out to the hospital and found out that
the patient was actively suicidal there and had been civilly
committed and was under court order to undergo and participate
in psychiatric care, supposedly under my direction. She had not
filled out a release of information, lied to me about it, but
this care coordinator discovered this. And then all of a
sudden, I could have a real honest discussion with her. And we
got her into a dual-diagnosis CD treatment facility. And it is
about 2 years later now and she is still off opiates and
alcohol and not really depressed, still struggles with anxiety,
but her life is turned around. And it was all because of this
kind of extraordinary care coordination that spanned different
levels of care and systems of care that probably saved her
life.
I agree with the workforce shortage. You know, we find that
we are doing a lot of things to try and put psychiatrists and
therapists in our primary care clinics. And there is a shortage
of health psychologists. There is a shortage of psychiatrists.
We have been taking efforts, in partnership with NAMI, to do
extra training, to get physician's assistants and nurse
practitioners and clinical nurse specialists to increase our
pool of prescribers.
We are working hard to improve the flow of psychiatric
patients. We have patients accumulating in the ED waiting to
get into psych units, and people on psych units who can't get
out waiting to get into group homes and residential treatment
centers. And we need to partner with counties and States who
are responsible for those things, and they have budget
shortages, and there are not enough.
And I see I am going to run out of time. But one other
thing that we have been trying to work on, but it is hard, is
kind of payment reform so that we can flow our money to pay for
outcomes and can then afford to have care managers in our
clinics reaching out to patients between visits, reaching out
to make sure, ``It has been so long, you haven't rechecked, how
are you doing with your depression,'' and making sure they come
in and that they are getting into remission. And it requires
partnerships in ways that I don't think is usually talked
about. That is viewed as the public sector. We are viewed as
the private sector. And we have got to work together. And when
we do that, we can sort of get patients out of the hospital
sooner into group homes and then our EDs. We are overflowing
our safe space or locked space for psych patients. We can get
them into the inpatient unit.
And a lot of what we are doing really involves kind of
taking disparate partners and agreeing to a vision and then
trying to work together, but it is very hard because the
funding streams are not braided. I see I am going to be out of
time pretty shortly.
Mr. Guthrie. If you could just summarize. I mean, I will be
a little lenient, but if you could just summarize.
Dr. Trangle. You know, in a lot of ways, there are also new
models of care where we are trying to sort of really truly
integrate behavioral health resources with health plan
resources, both delivery system--and this care coordination is
another way of doing this. We have programs where, if I have my
patient and they don't get their refills for their
antipsychotics, I will hear about it because of the health plan
feeding that data to me. The patient hears about it. We can
reach out and try to capture them so they don't get psychotic
and really struggle. We do the same thing with depressed
patients. And it really helps a lot.
We have initiatives where we have got people like me going
or telemedicine going to primary care clinics. Primary care
docs will talk about their depressed patients and their issues
and their struggles. I will give advice. And for 2 hours a
week, I can sort of leverage what primary care is doing for
about 100 patients, so leverage the shortage of psychiatrists.
[The prepared statement of Dr. Trangle follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Guthrie. We also have the chance to reiterate some of
this during our question-and-answer period. We appreciate it
very much. Thank you. Thank you for that testimony. It is very
informative.
Mr. Selig, you are recognized for 5 minutes.
STATEMENT OF MATT SELIG
Mr. Selig. Vice Chairman Guthrie, Ranking Member Green and
members of the committee, thank you very much for the
opportunity to appear before you today as you examine the
parity law and regulations. I am grateful that you have
convened this hearing.
My name is Matt Selig, and I am the executive director of
Health Law Advocates. HLA is a nonprofit public-interest law
firm with a mission to improve access to health care for low-
income Massachusetts residents. We provide pro bono legal
assistance to low-income clients who have been denied needed
health care.
HLA has made mental health and substance use disorders
parity a priority for more than a decade. We try to improve
access to mental health and substance use disorders care by
making the protections of the parity laws, both Federal and
State, a reality for those we represent. HLA represents
approximately 70 clients each year who have been denied
coverage for treatment of mental illness or substance use
disorder. This work gives us an up-close look at the problems
consumers have when trying to access treatment. We also see how
current parity laws and regulations are implemented and
enforced. HLA works very closely with other advocates across
the country with a strong interest in parity. As a result, we
have a broader perspective on the insurance problems people
face when they need treatment and how the parity laws are or
are not addressing the problems.
While we and others believe there is much more important
work still needed to achieve true parity, I want to express
HLA's appreciation to you and as well as State legislators and
regulators across the country who have made significant gains
achieving parity already. We are particularly gratified that
parity has been very much a bipartisan issue in Congress, and
that has been true in Massachusetts as well.
In Health Law Advocates' experience with clients,
individuals have more difficulty accessing mental health and
substance use care than other types of care because of barriers
created by many insurers. Our assessment corresponds with the
findings of the National Alliance on Mental Illness report
issued last year, which found that twice as many families
reported that a member of their family was denied coverage for
mental health care as for general medical care.
Our lawyers have identified certain types of mental health
and substance use treatment that are particularly susceptible
to coverage denials. I will mention some, but this is not meant
to be exhaustive: residential treatment for substance use
disorders, eating disorders, and other severe mental illness;
applied behavioral analysis for autism spectrum disorder;
medication-assisted treatment; and outpatient psychotherapy
more than once per week.
HLA represents clients of all ages, but we devote
particular resources to helping children access mental health
and substance use disorder care. Over the years, we have seen
families struggle to obtain coverage for kids, especially for
services such as neuropsychological evaluations, wraparound
community-based care, autism services, and stepdown care from
acute treatment.
In our work, we have witnessed many different ways
insurance practices frustrate treatment for our clients that
appear to run counter to the parity laws. For example, we have
seen repeated early terminations of coverage for residential
substance use treatment, regardless of the severity of our
clients' symptoms; doctors being required to titrate
medication-assisted treatment as a condition of coverage, even
when mandatory titration is not the standard of care; treatment
providers subject to onerous requirements to justify care; and
termination of services arbitrarily based on age or alleged
lack of parental participation.
These examples involve clients who were fortunate enough to
have at least connected with a provider. We also represent
clients of all ages but particularly children who have great
difficulty finding a qualified and appropriate provider in
their insurer's network.
In closing, I wish to offer a few recommendations to
improve on current parity laws and their implementation. We
strongly support H.R. 4276, Congressman Kennedy's Behavioral
Health Coverage Transparency Act. There is no question that we
need greater disclosure of information by insurers. Detailed
information about how plans ensure that mental health and
substance use disorder claims are treated equitably and the
standards utilized to evaluate the medical necessity of
treatment should be made public and written in language
consumers can understand.
There should also be greater enforcement, including
enhanced penalties of requirements to provide detailed
information to members about the basis for coverage denials and
comparative information on medical management of physical
conditions. When HLA requests this information on behalf of our
clients, we rarely receive it. This prevents us from
determining whether our clients' parity rights have been
violated. An explicit private right of action in the parity law
would also allow consumers to enforce this right themselves.
Consumers should also have access to an easy-to-use process
for filing complaints when their right to equitable mental
health and substance use disorder coverage has been violated.
This would help consumers access the treatment they need and
identify trends in noncompliance. The complaint process and
consumers' rights under the parity law should be broadly
promoted by Government agencies to increase understanding among
consumers.
The Federal Government should also assist carriers'
compliance by publicizing and continually updating its
adjudication of parity complaints to create an administrative
common law for what constitutes a violation of the parity law.
Neither insurers nor their members should have to guess what
treatment limitation practices are illegal.
Finally, we recommend that Federal and State agencies
conduct random audits of health plans to ensure parity
compliance. These inquiries and other reforms will serve as a
check on self-reporting by plans and identify problem areas
where Federal or State enforcement is needed--more enforcement
is needed. That targeted enforcement will ensure that parity is
not only the law of the land but a reality for people suffering
with mental illness and addiction.
Thank you again very much for the chance to testify.
[The prepared statement of Mr. Selig follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Guthrie. Thank you very much.
I want to thank each witness for your testimony, and I will
begin the questioning and recognize myself for 5 minutes for
that purpose.
As Chairman Pitts discussed during his opening remarks,
there have been continued discussions on the safeguards
envisioned in previously enacted mental health parity laws.
Ms. Greenberg, one of the most recent documents ABHW
published is a letter in response to the President's task
force. You urge the administration's working group to engage
with stakeholders on clinical differences, additional tools for
States, release of the identified information, disclosure
clarifying guidance and parity and confidentiality rules.
I would like to focus on the clinical differences in
disclosure and confidentiality rules. In this letter, you
write, and I quote: ``Parity is important, but so is quality.
We have to make sure that we are not so rigid with our
implementation of parity that we end up compromising on quality
care of consumers,'' unquote.
Please help me better understand how clinical autonomy to
achieve improved quality outcomes in caring for patients with
mental health and substance use disorders can be impeded by
burdensome or, better yet, one-size-fits-all regulations.
Ms. Greenberg. Sure. Thank you, Congressman, for that
question. I think that our concern as we have moved forward
with parity implementation is we have behavioral health and we
have medical. And there are some things that are more clear-
cut, like the copayments and the coinsurance and things like
that. But then there are other things about the treatment that
is needed or when you check in with a provider to see how the
treatment is going. And those are things that differ based on
illness, and they are not so cookie-cutter that you say, oh,
exactly what you are doing on the medical side should be the
same thing that is done on the behavioral health side.
And we would just like to see some flexibility within the
parameters of clinical guidelines. So it wouldn't just be
because we say we should do it this way, then it is OK, but the
clinical guidelines may justify a difference in some areas on
behavioral health. And that language was included in the
initial interim final rule and then was deleted in the final
rule. And so I think just recognizing that there are some
differences that do exist and, when clinically appropriate,
those should be allowed.
Mr. Guthrie. Dr. Trangle, as a medical director, would you
like to comment on that?
Dr. Trangle. You know, I am not a policy guy. I am still
seeing patients, and I do a lot of quality stuff. So I can't
comment on the details of the law. But I know that, clinically,
all the time we are trying to improve talking to primary care
docs, seeing their lab results, making sure they can see what
we are doing. And in some sense, one of the things mentioned in
the prelude had to do with chemical dependency. And we are
struggling in our system with ED docs not seeing what meds or
what is going on in CD treatment parts of our facility or what
is going on in outpatient clinics and overmedicating people
because we are not sharing some of that data with each other.
It is just really important to be able to talk together.
It is an interesting place where stigma plays out. We have
primary care docs that, in some sense, will kind of be afraid
to talk about somebodyis depressed, you know, and shy away from
it. But if they can see that we have talked about it, because
we have a shared electronic medical record, they know it is OK,
all of a sudden they can help us follow up and they can help us
measure are they getting better or not.
Mr. Guthrie. OK. Thank you.
Let me get to my next question.
Ms. Greenberg, you note that certain transparency and
disclosure efforts may be well-intentioned but inadvertently
overwhelm patients with thousands of pages of documentation,
but other advocates have asked for even more access to benefits
details. Would you please share a more efficient and effective
way to help patients better understand parity, fairness?
Ms. Greenberg. Sure. The documentation that is available to
patients or should be made available to patients includes a lot
of information that health plans are using, either their
analyses or the documents that they had to look at to get to
what parity should include.
And while those documents are available, we would also like
to see some type of summary of the analysis instead of--our
concern is that if we hand the patient a box or two of
documents, that will overwhelm them. And, also, they are very
technical, and it will be a little bit difficult to go through.
So if we can talk about a uniform analyses that people would
hand out first to explain to patients how parity was determined
and then kind of go from there as more documents are needed
and/or provide guidance to patients as to what documents are
appropriate to ask for for their situation--not that they
couldn't have more but that at least at first they are getting
just the documents that they need.
Mr. Guthrie. OK. You, also, in the coordination that Dr.
Trangle was talking about--our committee is really looking at
coordination. We know that that is important. But in regard to
substance use disorders, you comment that multiple signed
patient authorizations are necessary to achieve true
coordination. How does this limit quality of care?
And then, Mr. Selig, would you comment on the fact that
there are so many multiple signed documentation, is that a wall
that the Federal Government should try to remove?
Actually, I am out of time. I don't want to go because we
are kind of against votes.
Mr. Selig. If you could clarify which signed documentations
you are referring to.
Mr. Guthrie. Well, you know what, if I get into that, I am
going to really get into that. I will put that in the record.
We will give you a question for the record. Otherwise, it is
going to take longer. We are running against--votes are going
to come sometime midmorning, I understand.
That concludes my questions.
I will recognize the ranking member, Mr. Green, 5 minutes
for questions.
Mr. Green. Thank you, Mr. Chairman,
Millions of Americans, as many as one in five, have a
mental illness. One in 10 Americans will have a substance
disorder in their lifetime. And 75 percent of them will not
seek treatment. The lives of these individuals and their
families and their communities will be significantly changed
for the better with access to the treatment they need.
Congress did our part. We passed a parity law requiring
health plans and Medicaid and Medicare and the private market
to cover mental health and substance use treatment to the same
extent as they do medical and surgical services. We passed the
Affordable Care Act, which significantly expanded access to
health coverage.
However, without strong enforcement of the parity law,
millions of people continue to struggle to get the health care
they need.
Mr. Selig, as a legal advocate, you are well aware of the
importance of strong parity implementation and enforcement. I
am sure you know how complicated and confusing insurance
benefits can be and how hard it is to fight with an insurance
company to get coverage for the benefits you need, especially
when you are sick and need it the most.
My first question is, how hard is it for consumers to get
the information they need in order to figure out whether their
insurer is meeting the requirements of parity?
Mr. Selig. Well, it can be very difficult, Mr. Green. As I
mentioned in my statement, when we are working with consumers
who have been denied coverage and they try to request
information from their plan explaining why the service has been
denied and providing the backup documentation comparing the
medical management techniques for mental health and physical
health, it is documents that really are rarely provided. And I
recall Mr. Kennedy mentioning a member of his staff having the
same experience.
So it is very difficult to get that information typically.
It is clearly requested by our team members at HLA, and we
don't get it. That being said, that information is difficult to
understand. And we would favor information being made much
clearer for the consumer. I think having boxes of information
that indicate the process for determining when services are
covered not only is complicated but it also I think speaks to
the extreme scrutiny that services are given when people are
trying to get coverage for them.
So we would definitely favor clearer information be given
to consumers and also clearer information on where people can
get help if they don't feel equipped to try to understand the
materials that they are given, so, as Congressman Kennedy's
legislation provides, a central portal where people can go and
indicate that they feel as if they have been, generally
speaking, unjustly denied coverage for care, and maybe they
don't feel equipped to go through the documents and do the
parity analysis themselves, but have an agency look at that
complaint for them in a systematic and general and uniform way.
Mr. Green. And I know with our mental health bill we
passed--it is still in the Senate--we didn't put that provision
from Representative Kennedy in, but it is one we intend to do.
Since 2010, we know there are only 140 cases in which the
Federal Department of Labor has found parity violations. It
seems unlikely that the parity has been implemented so
comprehensively nationwide that there are only 140 violations.
What steps can we take to ensure the law is fully enforced?
Mr. Selig. Well, thank you for that question. I would say
several things, and many of them are embodied in Congressman
Kennedy's bill, which I think is on the mark in many ways. We
do feel like Federal reporting requirements for health plans
are important, for health plans to be required to demonstrate
how they are complying with parity and have that information
public.
We also think that random audits of health plans are
important as a check on the self-reporting that insurance
companies do. We also, again, believe strongly that there must
be a simplified consumer complaint process and much greater
public education that will help people understand what their
rights are under the parity law and how to vindicate those
rights and understand when a denial is inappropriate or maybe
when it doesn't violate parity.
I also support some of the provisions for sure in the
legislation that the committee did pass. The compliance program
guidance document that was included in that legislation I think
would provide a very valuable, as I said in my opening
statement, kind of common law, a record of how the Government
has interpreted certain limits by health plans and to give
health plans and insurers a greater understanding of what are
appropriate denials and what aren't.
Mr. Green. Thank you. We are out of time. But we even have
problems with the physical health, because I have folks who
think they have insurance, and they show up at the hospital
that is on their network, and all of a sudden they find out--
nowadays, the practice of medicine, there are different
providers that are not part of that system. So when they leave,
they find out they are out of network. And so it is confusing,
both--the mental side probably worse than the physical side,
but we have those problems there.
Thank you, Mr. Chairman.
Mr. Guthrie. Thank you.
I am going to try to stick to the 5 minutes as much as
possible so we can get more questions in. There is actually a
memorial service for 9/11 coming up this morning as well.
Dr. Bucshon from Indiana, you are recognized for 5 minutes.
Mr. Bucshon. Thank you very much, Mr. Chairman.
First of all, I would just like to outline, you know,
again, the problem, and it goes across all socioeconomic
statuses. I have a high school friend in my class who recently
died at age 54. She had schizophrenia. Their life expectancy is
shortened. She had two children and her husband divorced her
and changed the children's names. And she ended up on the
street because of really probably a multitude of factors, but
one of those was her ability to get treatment.
I also had a high school friend who came home for Christmas
break in college and broke up with his girlfriend and a couple
weeks later committed suicide at college. No other indication.
But the question in my mind is, you know, on college campuses,
was there any indication that he was struggling?
And that is true, because my son, one of his fraternity
brothers who graduated in May and who had a job just committed
suicide at age 22.
So this is really something we need to address. Twenty-two
veterans a week we are losing. I just wanted to outline the
problem, as we all know, but for the record.
And it is important to know that most mental health
patients have other medical issues. In Indiana, there are a
couple centers close to my district--Centerstone in
Bloomington, Hamilton Center in Terre Haute--that coordinate
both traditional medical problems and mental-health-related
issues, including substance use disorder.
So, Dr. Trangle, this is a subject that is really--also, I
was a medical doctor before I was in Congress. I was a surgeon.
So I understand this.
Why do you think it has been so difficult to get mental
health parity and treatment for mental health issues? I mean,
they can be chronic problems, I understand. But, you know,
diabetes, congestive heart failure, these are all chronic
problems. Why? I mean, I think we all know probably the answer.
But, in your experience, why are we still struggling to be able
to have parity in how people are treated because they happen to
have a mental health issue?
Dr. Trangle. I think the tradition in medicine is to have
things siloed up, you know, and not thinking holistically, not
having people be physically in the same place, not sharing the
same EMR, and not talking about these things.
Some of the examples you mentioned--diabetes,
cardiovascular disease, heart failure--have a significantly
increased incidence of depression. If somebody has an AMI and
they are depressed and you don't recognize it, they will have
higher mortality, not because of the physiology, because they
don't do their cardiac rehab. We need to screen for depression
throughout all of primary care, throughout health plans'
members, and then make sure for those that are screening
positive we follow up. Ideally, you follow up in primary care
clinics where you don't have to get somebody to get over their
own stigma and go to a more embarrassing place of a mental
health clinic. You need to be able to virtually talk to the
primary care docs and help them with advice, with
recommendations, with consults, things like that.
Mr. Bucshon. Mr. Selig, maybe you can help, because you are
involved in dealing with trying to help people get coverage. I
mean, as a healthcare provider, still for years I have had this
issue. I mean, I had patients that were inpatients that I did
open heart surgery on that clearly had mental health issues. I
diagnosed a number of people who were bipolar and depressed and
everything and had a hard time getting--there is a physician
shortage, which we can address.
But, in your mind, what is your opinion, what is the
impetus for difficulty getting coverage for, say, depression
versus diabetes? I mean, it doesn't make a lot of sense,
really. I mean, do you have any insight into that?
Mr. Selig. Well, I have a couple of thoughts about why the
parity law, which is, you know, a landmark law, why it is hard
to--has been hard to implement. First of all, there is a
patchwork of agencies that have to enforce the law. So we have
the Federal Government, which directly enforces it with self-
insured plans and also can provide guidance to State agencies.
And then you have 50 State agencies, divisions of insurance,
and also Medicaid offices that all have to enforce the law in
all different ways. So there is a patchwork of interpretations
of the law.
Mr. Bucshon. I guess the question is, why would you need to
have to interpret it? Why do you need a parity law in the first
place? You see what I am trying to get at? I don't know if we
can answer that question today.
Ms. Greenberg. Dr. Bucshon.
Mr. Bucshon. Yes, Ms. Greenberg, do you have any insight?
Ms. Greenberg. If you don't mind for a second, Mr. Selig.
I think part of the issue too is that there is a great
stigma associated with mental health and addiction. And so we
have treated typically mental health and addiction in our
healthcare system differently than behavioral health. That is
not the right answer, not the right thing to do. But people are
afraid to talk about their mental health and addiction for fear
of being ostracized or----
Mr. Guthrie. We are going to have to get more questions in,
so hopefully you will have the opportunity to answer further
through some other questions moving forward.
But I would like to recognize Ms. Matsui from California.
Ms. Matsui. Thank you very much. And I would like to thank
all the witnesses for being here today to testify on such an
important issue.
One of the main reasons that I have heard with parity
enforcement stems from the fact that there are different
Federal and State agencies responsible for overseeing and
enforcing the parity law. This patchwork is a little bit of the
nature of the game. The Federal law sets a standard, and States
can make more strict parity laws, which California does. And
States are also responsible in large part for making the rules
for their own Medicaid programs.
Mr. Selig, can you give an overview of the patchwork of
State and Federal enforcing agencies?
Mr. Selig. Sure. I will pick up and repeat a little bit of
what I was just speaking about and try to do it quickly. So
there is a patchwork of enforcement agencies that enforce the
parity law. So you start with the Federal Government, which
enforces the law for self-insured plans directly, because those
aren't under the regulatory purview of the States. Each State
has a division of insuranceand an office of Medicaid that
enforces the law for those respective plans. You also have the
TRICARE agency also, as Ms. Greenberg indicated, has a separate
enforcement mechanism too. So there are several different
agencies that have responsibility for making sure the parity
law is implemented and enforced.
Ms. Matsui. OK. Well, because much of the enforcement tends
to be at the State level, especially for Medicaid, it follows
that the States should learn from one another about best
practices to ensure consistency for consumers. SAMHSA put out a
report regarding best practices from seven States. For example,
the California Insurance Commissioner's Office worked closely
with California's exchange, Covered California, to design
benefits under the parity law.
Ms. Greenberg, is the SAMHSA report helpful to your member
companies? And what else can we be doing to share best
practices, such as interagency coordination, across the
country?
Ms. Greenberg. Sure. Yes. The SAMHSA document, which was
released quite recently, is very helpful. We were actually
interviewed as a part of that report. And I think sharing of
the best practices is one of the most helpful ways to assist
with parity implementation. And one of the other things that
can be done, as has been mentioned by I think all of us, is the
sharing of the identified information.
So whether it be a problem that is found or something
positive that is found by any of the agencies that Mr. Selig
suggested that are doing the implementation, if they can let
people know, this is a problem that we found, and this is how
it should have been treated; or this is how the change was made
to become parity compliant; or this is an instance where a plan
is parity compliant, and these are the things that they are
doing that we, the auditors, have found helpful. I think that
information and those best practices or, in some cases,
unfortunately, worst practices would be helpful to us.
Ms. Matsui. But how can we encourage more sharing of
information at a level where actually things get done?
Ms. Greenberg. I think to talk--reports like the SAMHSA
report, to talk with States and encourage them to release the
information, and also to talk with the Federal agencies, which
we and other stakeholders have, to encourage them to share that
information.
Ms. Matsui. OK. Well, thank you.
There are today up to 30 million Americans experiencing
eating disorders during their lifetimes. However, one in 10 of
these Americans will receive treatment due to a lack of early
identification and treatment coverage.
You know, the Paul Wellstone and Pete Domenici Mental
Health Parity and Addiction Equity Act was designed to ensure
health insurance plans covering mental disorders and substance
use disorders would provide the same favorable level of
coverage as they would for medical/surgical benefits. Since the
law has been finalized, we have heard that there are still gaps
in coverage for mental health disorders, especially for people
with eating disorders.
With my colleague, Congressman Lance, we led the effort to
include provisions to clarify coverage of eating disorders
benefits, including residential treatment, within the mental
health bill that passed the House before the August recess.
Dr. Trangle, in your experience, what is your understanding
of how private health insurance contracts handle eating
disorders?
Dr. Trangle. Thanks for the question. I think it is a great
one. As my organization has grown, we combined with another
organization, and we now own something called Melrose Eating
Disorder Center. And our organization is really intent upon
trying to simultaneously improve the measure of the quality,
patient satisfaction, and making it more affordable.
As we kind of integrated this eating disorder place into
our hospital, into our system, we looked at it from all
different directions. What is the quality? Were they measuring
outcomes? They weren't. What was the expense? It turned out our
employers were complaining about the expense and the number of
high-buck cases and were thinking about excluding eating
disorders from their benefit sets, the self-insured employers.
We looked at it and basically said: We want to shift this a
bit. And we created levels of care, like intensive outpatient
treatment teams, to be mobile and work with them and much more
intensive. It helped us reduce the length of days for
inpatient. We created more outpatient resources. Ultimately,
people are in care longer, but it is at less expensive levels
of care. The cost has gone down, and the outcomes have gone up.
Mr. Guthrie. Thank you.
Ms. Matsui. Thank you.
Mr. Guthrie. You might want to submit more of that to the
record. If you want to answer more, you can submit that to the
record. I appreciate it very much.
Mr. Collins of New York, you are recognized for 5 minutes.
Mr. Collins. Thank you, Mr. Chairman.
Dr. Trangle, if you could speak closer. When I ask you a
question, I am going to maybe 4 inches from the mike, because
that is how sensitive they are.
Anyhow, I want to thank the witnesses for coming, and I
don't think there is a family in America that is not impacted
by mental health at one stage or another. It is such a
multifaceted problem, I think. Unlike some traditional medical
issues, I actually believe mental health is almost
individualized to so many contributing factors. It is hard to
take six patients that may seem similar and say that it is all
the same thing. So, again, I think this is a very useful
hearing to kind of deep dive: What is going on? How we can do
better?
Just as a point of interest, my district includes the only
veteran suicide center in the United States. So every veteran
who would have that unfortunate urge to commit suicide, when
they call in, they end up at a call center in Canandaigua, New
York. So I have spent a significant amount of time there
talking to those who are answering the phone calls. And it just
became clear that the problems ranged from opioid abuse to PTSD
to then PTSD leading to more opioid abuse and substance abuse.
It is such a tragic thing that is going on in this country and,
in some cases, with the youth.
So, again, I appreciate all your testimony. But I also know
there is a balance between State regulations, Federal
regulations, more regulations that we have to address.
So, Dr. Trangle, I will just maybe ask my first question to
you.
Mr. Collins. As a clinician, would more Federal rules, more
Federal disclosures, and more Federal audits, because that is
what we are here, the Federal Government, would this help in
any way streamline care, or as a clinician do you feel that
more regulations at the Federal level would potentially burden
a system that is already pretty highly regulated, as Mr. Selig
pointed out?
Dr. Trangle. Yes. Let me try and answer that. I almost feel
like I am living in parallel universes. I think about what----
Mr. Collins. If you stand a little closer, like 4 inches--
--
Dr. Trangle. It feels like I have these conversations with
patients and families--I am going to eat it while I talk.
Mr. Collins. That is--we will use that.
Dr. Trangle. I feel like I live in a world where I am
talking with patients and families kind of in the clinic, and
the kind of information they want is really sort of--like last
week there was a social worker seeing someone. And the patient
was someone who was chronically depressed and I think beginning
to get a little bit manic and having some kind of thought
disorder. And we talked about what do we need to do. You know,
there was not necessarily a clear suicidal thought, a little
vague thought about a bridge. And the discussion was, does this
person need to be in an inpatient unit, which means being
locked up and much more restricted? Do they need to continue to
see somebody once a week? No. Ultimately, we came up with the
idea this person should go to a partial hospital program where
they would see a psychiatrist every day, they would get started
on an antipsychotic, talk about suicide, make sure they were
safe. And it was not all or nothing.
You know, you need to have some checks and balances, and
people that are making the recommendations know what the
resources are and what is the right care at the right level of
care at the right time.
We have similar checks and balances that we struggle with.
Somebody came to me and said: I read about Ketamine and I know
it works for depression and I want you to change--and our
depression scores showed that she was actually getting better
but not fast enough for her. And she said: I want you to order
Ketamine and I want the health plan to pay for it. And this
didn't even go to the health plan review. I said: I am up on
this literature. And Ketamine has a number of individual
studies showing rapid response for depression, but it doesn't
last. As soon as you stop getting the IV Ketamine, you get
depressed again. It is not going to be a good solution long
term.
You know, how do you have checks and balances to make those
decisions and not have people like primary care docs who don't
necessarily know all the details saying: This is what I am
recommending, but somebody with more knowledge is involved and
gets the right care at the right time for the patient? It is a
separate issue. But more is not always better. It is what you
share and what you communicate.
Mr. Collins. Yes. Thank you.
I guess, Ms. Greenberg, let me ask you kind of a similar
question. There are so many State enforcement laws, as
Representative Matsui, you know, alluded to a Federal, State,
et cetera, et cetera. Do you think that the State enforcement
laws at that level are adequate for the oversight and parity
standards or do we need more Federal intervention?
Ms. Greenberg. I think what we need is more uniformity in
the enforcement. Whether you are a State or whether you are the
Federal Government, the parity laws should be enforced
consistently and uniformly. And if there can be some direction
in that area in terms of education and what are the questions
that an enforcer, no matter where they sit, should be asking to
determine whether or not a plan is parity compliant, that would
be very helpful. I don't know that it has to be legislative. I
think the regulators are working to get there.
Mr. Collins. Yes. Well, again, my time has expired. I want
to just thank all the witnesses. This is such a complicated
issue. And I thank Representative Kennedy for asking that we
hold this hearing. And I think it is being useful. And I yield
back.
Mr. Guthrie. Thanks for that. I appreciate it.
Mr. Kennedy from Massachusetts, you are recognized for 5
minutes.
Mr. Kennedy. Thank you. And I appreciate the kind words
from Mr. Collins.
A couple of quick points here. First, for Mr. Selig, I want
to thank you again for your tireless work on behalf of the
patients and their families. We hear anecdotes time and again
about patients who struggle to get access to the care that they
need. In your experience, what is the greatest barrier to that
care, and is it insufficient reimbursement, inadequate
networks, shortage of suppliers? And we will start there.
Mr. Selig. Thank you, Mr. Kennedy, very much. And thank you
for your very hard work on this issue.
I think that there are many barriers to mental health and
substance use services. And insurance barriers are certainly a
leading one, and that is obviously the topic of today's
hearing. That being said, there are other barriers to mental
health and substance use care that I think are worth noting.
Workforce shortages, which has been mentioned today----
Mr. Kennedy. Can I push you on that one.
Mr. Selig. Sure.
Mr. Kennedy. And I just ask just because the timing is
brief, we have restrictions here. But all of you have mentioned
workforce shortages in your testimony. And, Dr. Trangle, you
went into this in some detail.
For programs that you put forth, loan forgiveness,
reimbursement rates, would you support movement on all of those
to address the workforce shortages issues? Ms. Greenberg.
Ms. Greenberg. Would we support--yes.
Mr. Kennedy. Yes. Dr. Trangle?
Dr. Trangle. Absolutely.
Mr. Kennedy. And Mr. Selig?
Mr. Selig. Oh, 100 percent. Absolutely. Loan forgiveness
and better reimbursement would be critical for that.
Mr. Kennedy. Great.
Ms. Greenberg, my cousin Patrick served in the House, and
he worked tirelessly to pass a groundbreaking mental health
parity law. And again, I want to thank you for your early
support for that legislation and for ABHW's work. Years later,
we worked to try to implement the spirit and the letter of the
law. And the final rule for mental health parity clearly
indicates that it, quote, ``requires the criteria for planned
medical necessity determinations with respect to mental health
or substance use disorder benefits be made available to any
current or potential beneficiary or contracting participant
upon request in accordance with regulations,'' end quote.
One of the challenges we hear over and over and over again,
including from my legislative director who spent, again, 2
hours on the phone with an insurance company whose folks,
representatives, had no idea what she was talking about, to the
extent that they said: That information doesn't exist. And she
said: Well, then you are not in compliance with Federal law. I
can go through the minute-by-minute readout.
I understand the fact that this is very complex, and most
experts in this room would still struggle with that level of
complexity. But the complexity can't be the barrier to
information for a patient to be able to get access to that
care. So how can we--how can parity be strengthened--the
enforcement of parity--and the legislation that we have
authored doesn't try to touch the actual requirements around
parity. It merely says: Shine a spotlight on it to make sure
that the information is available so that we can ensure that
parity is being complied with.
So if the issue is complexity, and it has been 10 years
since this law has been passed, can't we find a way to simplify
some of the information so that consumers can digest it?
Ms. Greenberg. Yes. I would like to work with you and
others that are interested in this topic to try to find what is
that kind of concise document that we can give out. And I think
that would help insurers understand, OK, what are the
components that should and need to be given and also help with
consumers, because they would have then an understandable
document.
I will say that I agree with you, the medical necessity
criteria should be disclosed. That is part of the law. Many of
our member companies have it up on their Web site. And in that
specific situation, if that is still an issue, I would like to
help with that as well.
Mr. Kennedy. Great. And great that that was one specific
company. And, you know, there is obviously many plans and
challenges out there. But one of the challenges that we also
hear over and over and over again is that there should be a
central clearinghouse for--essentially, a database for issues
and complaints that arise so that information again can come in
a centralized location so that regulators, advocates, patients
can understand what services they can get, what is covered,
what isn't, given the complexity of this law, and the
challenges for it. That is part of what is contemplated in our
legislation.
And I would love to get your thoughts on, again, how we can
ensure that the transparency requirements--we shine a greater
light on that transparency.
Ms. Greenberg. Sure. And we do support the idea of a
consumer portal that I know is in your legislation. And also we
would say, and I think you do as well, deidentified
information.
Mr. Kennedy. Of course.
Ms. Greenberg. And people always remind me to say not just
the problems but also deidentified but show the good things
that have happened and where there have been success stories in
parity, because there are some of those as well.
I don't know, Congressman, whether legislation is necessary
to do this. I think, you know, that strict and strong
conversations with the regulators. And, frankly, we have
already seen, as a result of the attention you have brought to
this issue, guidance issued in the last few months on the--more
guidance issued on the disclosure topics. So you are shedding a
sunlight on it.
Mr. Guthrie. Thanks. We are going to--I hate to----
Mr. Kennedy. No, Mr. Chairman.
Mr. Guthrie. Mr. Kennedy, do you have other things----
Mr. Kennedy. I have a number of documents I would like to
introduce for the record. And, again, I appreciate the time.
But a letter from a number of advocacy organizations, testimony
from former Representative Patrick Kennedy, and a couple of
letters from other advocacy organizations that I would like to
submit for the record.
Mr. Guthrie. Without objection, so ordered.
Mr. Kennedy. Thank you.
[The information appears at the conclusion of the hearing.]
Mr. Guthrie. Thank you, Mr. Kennedy. And I will compliment
you on your passing of this as well.
Mr. Schrader from Oregon is recognized for 5 minutes.
Mr. Schrader. I yield my time to Representative Kennedy.
Mr. Guthrie. Representative Kennedy is recognized.
Mr. Kennedy. Mr. Schrader, you are a good man.
So let's focus a little bit, since I have a couple more
minutes, on the reimbursement issues.
My understanding--again, Mr. Selig, we can start there--
well, actually, Dr. Trangle, we can start with you.
Particularly issues around Medicaid. If you could talk a little
bit about how low reimbursement rates affect, in your opinion,
the access to care that professionals are able to provide for
the poor.
Dr. Trangle. You know, I know I read an article that came
out just this past week, I think it was in JAMA, where they
talked about--it did document some variability there, as well
as sort of variability in how many psychiatrists were
participating in what plans. So I know there is data out there
nationally of how that plays out.
In our area, I don't think we necessarily--what we have are
psychiatrists that opt out of the system totally and will take
cash only and take nobody with insurance, is the bigger issue
in our area versus not taking one versus the other.
Mr. Kennedy. Generally----
Dr. Trangle. Workforce issues for general population,
especially the mentally ill.
Mr. Kennedy. So generally speaking, looking at insurance
rates, reimbursement rates, private insurance generally
reimburses at a higher rate than Medicaid would. Fair?
Dr. Trangle. Correct.
Mr. Kennedy. So one of the challenges that we have faced,
even over the course of the past couple years, is that we have
been searching for information about Medicaid's reimbursement
rates for mental health services. Not the joint Federal/State
program, CMS actually doesn't compile a national database of
what those rates are.
So I was wondering, Ms. Greenberg, is there some
information that, given the companies that you represent and
the scope that--the number of States that your companies
practice in, that data clearly exists, it is just that the
Federal Government doesn't have access to it because, in our
conversations even with CMS, they have indicated the nature of
a joint Federal/State program, that information is lodged in
the States and many of those States aren't--they are not
required at all to divulge that reimbursement rate information
to CMS or to the Federal Government.
You guys obviously deal with those issues on a daily basis.
Is there a way that we can try to ascertain, that this
committee can ascertain, what reimbursement rates look like for
Medicaid across the country? Can you help with that?
Ms. Greenberg. I would be happy to try. To be honest, it is
not an issue that I have--or the question that I have asked
before of our member companies. But I certainly would be happy
to ask them that question and see--or maybe they don't--they
don't have it or can't give it out, but maybe they know someone
in the State level that can help with that. So yes, I would be
happy to look into that.
Mr. Kennedy. It just strikes me as we have heard some of
the challenges of parity, but we have also heard from all of
you today the struggles with workforce. If we are looking at
struggles with workforce and Medicaid is the largest payer of
mental health services in this country, that if we are not
looking at reimbursement rates as one of the drivers for
workforce shortage, then it is tough to address that issue for
workforce if we are not looking at the compensation mechanisms
for those professionals.
Ms. Greenberg. Sure. Yes.
Mr. Kennedy. Do you want me to keep going?
Mr. Schrader. Sure.
Mr. Kennedy. Great.
So if I can continue, Ms. Greenberg, so insurance companies
often state that they are making efforts to comply with the
law. And in your testimony with mental health parity, your
testimony, you indicated that. Why is it that given a good-
faith effort to comply with the law, why is it that 10 years on
we are still struggling with the actual receipt of that
information and struggling with patients being able to gain
access to the care that they need when they need it and even
understand what services are available to them?
Ms. Greenberg. There are so many reasons. You know, it is,
as I think everybody knows, it is a complex law and regulation.
The regulations came much later than the actual law did. So
enforcement of the law began--or, sorry--of the final
regulations began in 2014. So while the law passed in 2008, the
regulations haven't been in effect for as long a period of
time.
I think also we have seen some things, like some of the
larger disclosure issues have come later through guidance that
has been issued by the regulators versus the initial disclosure
that specifically was around medical necessity criteria and
reasons for denial. And through guidance we have seen that
expand a little bit. So trying to get our head around, OK, what
are those documents that you are talking about, what format,
you know, as we have discussed here today, are you looking for
that information? And it is--as I mentioned in the testimony,
we have had dozens of meetings with regulators. There are gray
areas, as there are with all regulations, that we have spent
countless hours trying to understand.
Mr. Pitts [presiding]. Thanks.
Mr. Kennedy's time has expired. Dr. Schrader, we have a 9/
11 memorial service at 10:30 I know some of us are trying to
get to.
But Ms. Castor from Florida, you are recognized.
So I apologize for cutting you off.
Ms. Castor. Thank you, Mr. Chairman. I want to thank
Congressman Kennedy and Congressman Green and all of my
colleagues for continuing to focus on mental health parity for
our neighbors back home. And thank you to the witnesses.
There have been many significant changes to mental health
parity and substance abuse parity over the past decade. And as
a legislator, it is important to know what is happening in the
real world, how does this play out for families.
Mr. Selig, your organization, Health Law Advocates,
represents Massachusetts residents in mental health and
substance abuse disorder parity cases. You also communicate
with other advocacy groups across the country that are engaged
in similar work. Based upon your experience, what is the most
common type of potential parity violation you encounter? Or are
there a few different ones?
Mr. Selig. Thank you for the question. There is no
question, as I said, that among the people we represent, mental
health and substance use care is harder to access than other
types of care. That is our experience, and that is the
experience that is communicated to us by other advocates and
providers out across the country.
The insurance limits that we see most frequently are things
like arbitrary limits on things like residential stays for
substance use disorders. You know, we have seen several
patients, for example, who have lost their coverage for
residential substance use treatment, regardless of their
condition, after 2 weeks. It is like a hard stop and then that
is it and then services are stopped. So that is something that
we see as a significant barrier.
The full range of scope of services is also something that
we see not being provided to consumers. So especially
intermediate services, intensive outpatient services. Again,
residential care and other types of services that aren't acute
and aren't outpatient are very common.
As I mentioned, we also see unusual limits on medication
assisted treatment that seem to be arbitrary and don't
necessarily align with what our review of the medical necessity
requirements are. So those are some. Also----
Ms. Castor. But when you raise the issue with insurance
providers, typically is it remedied or is it a fight?
Mr. Selig. So, you know, it really runs the gamut. When we
talk to health plans on behalf of our consumers, sometimes we
are able to remedy the problem. We will be able to provide a
certain amount of information or provide some clarity on the
situation or an analysis of the parity law, in some cases,
where we may say we think that this process counters the parity
law and the health plan will change its course. In other
situations, we will go to appeals internally with the health
plan, externally, and we will raise the issues that way. And in
a good portion of the cases, those appeals do result in an
overturning of the decisions that are made by the health plan.
So we have a pretty good record, I think, a very good
record, actually, when insurance denials occur in changing the
outcome.
Ms. Castor. It is really too bad that folks need an
advocate at all, because they are dealing with the personal
issues every day. And thank you for what you are doing.
Congressman Kennedy raised the point of Medicaid
reimbursement rates. And I know my colleague, Mr. Green from
Texas, would agree that the fact that Texas and Florida have
not expanded Medicaid at all is a real barrier to so many of
our families receiving the care they need. Do you have an
opinion on what Medicaid expansion has meant for families and
mental health treatment across the country?
Mr. Selig. Well, I think the Medicaid expansion really has
provided just incredible financial stability and support for
State Medicaid programs which enable them to support the, you
know, really the entire range of services that members are
entitled to, but specifically mental health and substance use
services, which are typically, you know, and historically
shortchanged. So I think it has been just hugely successful in
that way.
More people are enrolled in insurance, obviously, because
of the expansion. People have better coverage. And so I would--
you know, undeniably, the expansion has, in all sorts of
different ways, helped people throughout the country access
mental health and substance use services.
Ms. Castor. I hope they hear that back home in my State
capital. The most important thing for the mental health of a
lot of my neighbors would be for the State of Florida to expand
Medicaid. So thank you very much.
And I yield back.
Mr. Guthrie [presiding]. Thank you, Ms. Castor.
I recognize Mr. Lujan from New Mexico for 5 minutes.
Mr. Lujan. Thank you very much, Mr. Chairman.
Well, I am a cosponsor of Congressman Kennedy's legislation
and I applaud all the work that Congressman Kennedy is doing in
this space to continue much of the work that has been done by
the Kennedy family and carrying on with the work that was done
by both Senator Paul Wellstone and Senator Pete Domenici,
senior Senator from my home State of New Mexico.
In New Mexico, right now, we have an issue before us where
the State of New Mexico under Governor Susana Martinez
unnecessarily suspended payments to 15 behavioral health
providers, claiming fraud. And the system was thrown into
chaos. Now, even though every provider has been exonerated by
the attorney general of the State of New Mexico, many of these
providers have been forced to close their doors. And we all
know who is left out. It was patients. It was the people that
needed help the most.
And so, Mr. Selig, can you talk to us about what such a
disruption means for someone struggling with mental health
issues? If their provider is suddenly gone, the trust that is
established to try to get back in that door, what does that
mean to someone that is struggling with mental health issues to
try to get the support they need?
Mr. Selig. Well, that sounds like a very regrettable
situation, and I am sorry to hear about that situation in New
Mexico. We represent, again, a lot of people who have mental
health services. And when they are denied coverage, their
services are interrupted. And we have seen really catastrophic
effects for people. Their conditions get much worse. Someone
with a eating disorder, for example, which is a high priority
for us, who needs a particular level of treatment and is denied
that level of treatment and is only provided access to a much
lower level of care, really, their life is going to be in
danger. And that person is really gravely at risk. Also, there
is absolutely a connection between lack of addressing mental
health and substance use services and deterioration of other
health conditions. So when people aren't getting mental health
services, other health conditions will suffer too. So people
aren't as able to attend to situations like perhaps heart
disease or diabetes.
So really, there is a cascading effect when people aren't
able to access mental health and substance use care that I
think is really life threatening and disruptive, you know, to
their lives and livelihoods for sure.
Mr. Lujan. Well, along the same questions that
Congresswoman Castor was asking that Congressman Green had put
on the table with concerns of States that did not have Medicaid
expansion. In New Mexico right now, what we are seeing is the
State recently made a decision to cut provider Medicaid
reimbursement by $400 million. And especially with the shakeup
with the mental behavioral health system, we have grave concern
and we are looking for some support.
But specific to the reimbursement rates, Mr. Selig, is a
low reimbursement for behavioral health providers in the
Medicaid program an impediment to ensuring robust access? And
how can we encourage more participation of behavioral health
providers in the Medicaid program?
Mr. Selig. I mean, I think thereis no question. I mean,
that is what we hear from providers. They would love to be able
to provide the services, be reimbursed through insurance. I
think the rates are an important factor alongside the other
burdensome kind of criteria that health plans place upon them.
But going back to the rates, I think that it is absolutely
connected to the inability of consumers to access providers
because they are not in the network, because providers choose
not to accept insurance because of low reimbursement rates. In
Massachusetts, we have recently been able to increase,
actually, reimbursement rates for outpatient providers. So we
really applaud our State government for doing that. I think
there is more work to do in that area, but that has been very
well received by the provider community in Massachusetts. And I
think it is going to have some impact going forward. So we
would encourage other States to do the same.
Mr. Lujan. I appreciate that. And, Mr. Selig, the other
question I had for you you actually addressed, which was the
impact to someone's physical health if they are not able to get
the mental health care that they need. And you described
exactly that impact. So I appreciate you addressing that.
And, Mr. Chairman, you know, while I hope that the
committee and the Congress will move forward to support
Congressman Kennedy's legislation, I think the aspects that
Congressman Kennedy also raised, which was brought up by our
panelists today, about the importance of making sure that we
have enough providers available to see everyone that needs care
is something else that we need to take seriously. And the
mental and behavioral health bill that passed the United States
House of Representatives currently still needs to be funded.
And I think everyone on this panel would support full funding
of that legislation. And so I look forward to working with our
colleagues to get that done.
Mr. Guthrie. Thank you.
And Mrs. Capps from California, you are recognized for 5
minutes for questions.
Mrs. Capps. Thank you, Mr. Chairman. And thank you all for
your testimony. And I want to echo the thanks to our colleague
Joe Kennedy for making sure this topic is received in this
hearing. I hope it won't be the last one. I hope it is the
first of really getting into this issue and doing some of the
work we haven't done yet. Because for too long we have
artificially looked at behavioral health as totally separate
and unrelated to physical health. My previous questioner just
made that point. But I want to go into it.
Because we know that the two are so intrinsically linked,
we need to ensure that our public policy recognizes the
important fact that if we ever really want to help our Nation
become more healthy and productive, this topic needs to be
addressed. I am proud of the work that Congress has done over
the years to address parity between the behavioral health and
physical health services. And I want to be clear. We have come
a long way, but that is not enough. What we have done is not
enough.
Too many individuals are still falling through the cracks.
Too many communities, as we have heard, are unable to support
those in need of affordable behavioral health services, even
though the treatments are there and the results have been
documented. I believe we have missed an opportunity to take the
next necessary steps to address this issue in mental health
legislation we considered here in this committee earlier this
year.
So today's hearing is a chance to reinvigorate this
conversation, help guide this committee to do what is necessary
to ensure that individuals get the care they need when they
need it.
Mr. Selig, I know you have been questioned, but you see the
shortcomings in this current system so well. And while we know
that these issues affect all in need in one way or another, I
wonder if you would speak a minute about the compounding
effects on more vulnerable and underserved populations like
children.
It is estimated that at least 13 percent of children are
affected by mental disorders in a given year. Unfortunately, we
know that pediatric specialists are few and far between. So in
your experience, how does this lack of coverage affect
children? Are there any unique access issues faced by children?
You mentioned eating disorders, and that is just one. Is there
a difference for children in Medicaid and CHDP and those with
private insurance?
Mr. Selig. Well, thank you for raising that, and
particularly, Mrs. Capps, for highlighting the needs of
children. There is, you know, no higher priority for our
organization than trying to access mental health and substance
use services for children. We do see specific types of services
that are harder--that children have difficulty accessing. I
mentioned a couple of them.
Children with autism, very difficult to access, especially
applied behavioral analysis services. Eating disorders you
mentioned, another. And there are also, I would mention, many
children, simply there is a long wait for services.
Authorization for coverage may be in place, but--and this
particularly speaks to children on Medicaid in our State. There
can be lengthy waits for services, and I think that also
connects to the issue of the availability of providers.
So I would say that, you know, children, as much as any
other population, are impacted by this kind of thing. They have
very special needs. They see different providers than other
people, obviously, and their needs are complex and they are
intermingled with school concerns and family concerns. And so
we are very cognizant of the needs of children and pay very
close attention to them.
Mrs. Capps. Thank you. You know, I so agree. I noticed so
many--the many years that I worked as a school nurse, having a
child on a waiting list is--in Congress in so many ways,
because they change so dramatically over the months. Sometimes
it is years. And by the time they can be treated and seen,
those symptoms they had have exacerbated and become so much
worse. And so the impact is so much more than their health. It
affects their education, their ability to learn and work. It
sets them on a pathway that is destructive, not opportunity
challenging.
And it is clear to me that any barriers to getting the care
they need are not only harmful for the child, they really
impact our society as a whole. The whole family is affected by
it. It is really an urgency. And that is why we have to make
sure that these services become more available.
Again, I want to salute my colleague Joe Kennedy, and
pledge my support for making sure this topic stays on the table
and that it actually goes somewhere further. Thank you very
much.
And I am yielding back.
Mr. Guthrie. Thank you.
I also want to thank Mr. Kennedy and Chairman Upton and
Vice Chairman Pitts for working together to make this hearing
come together. I thank the witnesses for being here. I think
that concludes all of our questions.
Mr. Kennedy. I will take them if I got time.
Mr. Guthrie. Well, no, the 9/11 memorial is coming, and as
of now--I want to remind members they have 10 business days to
submit questions for the record. And I ask the witnesses to
respond to the questions promptly. Members should submit their
questions by the close of business on Friday, September 23.
So you have an opportunity to submit more questions, Mr.
Kennedy.
And the subcommittee stands adjourned. Thank you for being
here.
[Whereupon, at 10:31 a.m., the subcommittee was adjourned.]
[Material submitted for inclusion in the record follows:]
Prepared statement of Hon. Ben Ray Lujan
The Paul Wellstone and Pete Domenici Mental Health Parity
and Addiction Equity Act was a signature achievement of New
Mexico's longest sitting Senator, Pete Domenici. It was through
his perseverance and that of Senator Ted Kennedy and
Representatives Ramstad and Patrick Kennedy that Congress
finally passed The Parity Act.
But it was just a first step. I thank my colleague and
friend, Congressman Joe Kennedy, for his efforts to build on
his family's legacy and I look forward to working together to
secure passage of more robust legislation that expands coverage
for some of our most vulnerable citizens.
As we all know, parity laws are undoubtedly a crucial step,
but laws mean very little without access to mental health
service providers and mental health facilities.
In my State, we do not have a functioning mental and
behavioral health system. When the State of New Mexico decided
to unnecessarily suspend payments to 15 behavioral health
providers claiming fraud, the system was thrown into chaos.
Now, even though every provider has been exonerated of the
charges leveled against them, the damage has been done--
providers have been forced to close their doors and continuity
of care has been disrupted for vulnerable New Mexicans.
I hope today's hearing will bring light to the many
challenges faced by our mental health system and will serve to
educate all of my colleagues on the importance of strengthening
mental health parity laws and expanding access. Everyone
deserves to live their healthiest lives, and mental health is
no exception.
This should not be a partisan issue--it is simply the right
thing to do.
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