By Joy Burkhard, MBA

In September 2022, the Department of Labor hosted a roundtable discussion on the Mental Health Parity and Addiction Equity Act (MHPAEA). The MHPAEA “was enacted in 2008 and requires insurance coverage for mental health conditions, including substance use disorders, to be no more restrictive than insurance coverage for other medical conditions.” 2020 Mom attended this discussion and submitted the following letter outlining the barriers to care and considerations for mental health parity.

Dear Ms. Rivers,

Thank you for the invitation to the Department of Labor (DOL) roundtable discussion on the Mental Health Parity and Addiction Equity Act in September. As the Department is considering how to move the needle with mental health parity, I’d like to offer the following written considerations:

Barrier: There are not enough behavioral health providers in the U.S. to meet needs. Health insurance plans often note this is the reason their mental health provider networks are not sufficient. Though there is more to the story, there is in fact a severe shortage. According to USAFacts, an estimated 122 million Americans, or 37% of the population lived in mental health professional shortage areas as of March 31st, 2021. 6,398 providers are needed across the United States to fill these shortage gaps.
Consideration: Plans should be investing in workforce development in order to deliver the product sold. When there was a severe RN workforce shortage in the 1990s, insurers like Cigna, invested in workforce development efforts in public-private partnerships. An entity like the DOL, could require plans to develop such efforts or contribute to a pool, to develop/implement a national mental health workforce development/deployment plan. Such a plan could build on the federal government’s fellowship, scholarships and loan repayment programs to stimulate workforce growth starting in HRSA workforce shortage areas. Such programs attract a greater number of, as well as more diverse, students to undertake specialty training and commit to practicing in high-need settings.
Barrier: Providers, particularly psychiatrists, don't want to join networks.
As the director from America’s Health Insurance Plans (AHIP) noted at the roundtable, providers are not interested in joining their networks and plans need help understanding what else to do. 2020 Mom has also learned of situations where providers, particularly psychiatrists, simply do not want to be bothered with the administrative hassles of billing, UM, and having to appeal UM/claim denials.
Consideration: Radical change is warranted. Plans should be asked to develop and test robust novel new delivery systems. For example, using a continuous quality improvement (CQI) framework, plans could be required to pilot capitated behavioral health medical homes (that are connected, in a formal way, to primary care provider offices to promote behavioral health integration (BHI). Capitating behavioral health services will allow Medical Directors (aka psychiatrists) to oversee and provide comprehensive behavioral healthcare with a multi-provider team (certified peers, LCSWs/Counselors, psychologists), without the administrative burden they will continue to avoid. Provider and patient satisfaction surveys (of patients and caregivers) should be a part of required feedback loops, to inform the CQI processes and to decrease provider administrative burden.
Barrier: There are shortages of in-network providers *and* behavioral health providers are being declined when applying to join insurer networks.
Plans are not yet monitoring the number of providers by specialty and therefore, are declining providers noting that there are enough LCSWs in zip code 9xxxx, for example. This approach is contrary to how medical networks are required to monitor the availability of providers. Medical plans review not only how many MDs they have in the network for example, but how many by specialty, such as how many dermatologists, cardiologists, etc.
Considerations: Plans/Insurers should look at subspecialties not just degrees when assessing network adequacy and through credentialing and recruitment processes.
Mental Health Plans’ Credentialing and Provider Contracting departments must implement policies to look at subspecialties, just as medical subspecialties are looked at when determining who should join the network and developing outreach strategies. Medical plans review not only how many MDs they have in the network, but how many MDs by specialty, such as dermatologists, cardiologists, etc.
Examples of specialties in mental health include child psychiatrists, certified addiction medicine specialists, and perinatal mental health certified providers for example.
Considerations: Subspecialties for which there are testing/credentials, should be monitored through ratio and geo-distance standards based on anticipated need.
Insurers/Plans should be assessing network adequacy by subspecialty by anticipating enrollee needs. Research on the prevalence of psychiatric disorders by sub-population (for example, children and perinatal women) could be paired with and plan enrollee data (children and child-bearing aged women for example) to determine whether there are enough subspeciality providers in the network to meet the need both by the ratio of members to providers and geo-distance analysis. Insurers/plans should be required to have an active and ongoing quality improvement plan in place for behavioral health network adequacy.
The DOL’s rules for network adequacy and availability (time/distance) standards, should tether to the federal marketplace network adequacy standards.
The DOL should review the insurer's network adequacy, availability, credentialing, and network recruitment policies against these standards. Further, the DOL should review the insurer’s recruitment plans to ensure that providers of specific subspecialties for which there are gaps are aggressively recruited to join the network at a fair market value/reimbursement rate.
Barrier: “Carving out” mental health insurance from medical insurance is part of the problem and should be part of the parity conversation. Efforts have been underway for years to support behavioral health integration (BHI) into primary care and medical hospital settings, such as California’s Integrated Behavioral Health Partners (IBHP) Program, yet, little traction has been made. This is in part because of the hidden and substantive barrier of mental health insurance being “carved out” of medical insurance. Though the field has taken some steps in the right direction, like all major medical insurance carriers now have a behavioral health company as a subsidiary, behavioral health insurance is still administered by those separate subsidiary companies. This poses significant challenges for both patients and providers. Patients must navigate not one complex insurer’s system, but two. Primary care providers and medical hospitals who wish to provide mental health services must do the same, contracting with not just medical insurers but also with mental health insurers. This process can be lengthy and arduous. We must ask ourselves, in the U.S. we don’t have separate insurance companies that cover heart care, why do we have separate companies providing brain care? Finally, leaders looking to put the right interventions in place to address equity between medical and mental health care via Mental Health Parity must consider insurance carve-outs as a mental health parity construct.
Consideration: The contractual parity gap should be closed: Medical Insurance plans should issue enrollee and provider contracts for mental health services. When medical plans provide contracts for mental health services like dermatology, cardiology, and other types of care, they take down barriers for PCPs and hospitals to provide mental health services, become accountable and invested in addressing the bi-directional relationship between medical and mental health, and increase the ability for behavioral health integration and incentive integration.
The time is now for leaders at the DOL and in Congress to provide and implement a bold platform for change. The future of America is counting on it.

We appreciate the DOL’s commitment and profound position to change the trajectory of mental health access in the U.S. through mental health parity rule-making and oversight. Insurers, Employers, Patients, and Providers are all eager for your leadership and forthcoming direction. We are here to support this critical work.

Sincerely,

Joy Burkhard, MBA
Founder and Executive Director
2020 Mom
2020Mom.org