Congress has passed legislation to increase enforcement of mental health and substance abuse parity rules and require health plans to apply parity standards to eating disorder benefits as part of a sweeping bill intended to spur development of new drugs and medical devices. The 21st Century Cures Act also includes provisions to let small employers use health reimbursement accounts (HRAs) to cover employees' costs for individual-market health insurance on a tax-free basis. The measure is expected to be signed into law by President Obama.
One part of the bill's mental health reforms focuses on the Mental Health Parity and Addiction Equity Act (MHPAEA). It directs regulators to come up with an "action plan" within six months of the bill’s enactment for improved federal and state coordination of enforcement of mental health parity and addiction equity requirements. The bill also seeks better compliance through clearer, more helpful guidance for employers and insurers.
Increasing public awareness of eating disorders is a key focus of the mental health reforms, and the bill mandates that parity standards apply to any eating disorder benefits, including residential treatment, covered by a group health plan.
The bill also would require HHS to clarify when it is appropriate for caregivers to share with others protected information about a patient's mental health or substance use disorder.
HRAs funded by small employers could cover employees' costs for individual-market health insurance on a tax-free basis under provisions in the bill. The provisions would apply to companies exempt from the Affordable Care Act (ACA)'s shared-responsibility provisions -- that is, employers with fewer than 50 full-time and full-time equivalent employees.
Under the Cures Act, only small employers not offering other group health plan coverage could reimburse health insurance costs through stand-alone HRAs. An employer's HRA contributions would reduce the relevant premium cost used to determine if an employee qualifies for any federal subsidies to buy coverage through a public exchange. Like other HRAs, small-employer HRAs could also reimburse qualified out-of-pocket medical expenses incurred by employees or their family members. Annually adjusted limits -- initially $4,950 for individuals and $10,000 for families -- would apply to small-employer HRA payments excluded from income.
The nonprofit organization Catalyst for Payment Reform is hosting a series of webcasts this month focused on “Addressing Today's Leading Challenges.” I was invited to cover behavioral health -- specifically, the changing behavioral health landscape for employers and the need to develop innovative strategies to bend the cost trend and improve care.
The issue: Just to put things in perspective, mental health is a bigger issue than most realize. One in five adults and 43.8 million people experience a mental illness each year in the US, according to the National Alliance on Mental Illness. Behavioral health issues are often not addressed and tend to exacerbate other health issues. About one quarter of patients with chronic conditions have undiagnosed depression. In addition, the US is seeing a rapid rise in opioid abuse (as discussed in an earlier post). Along with the cost of medical claims (direct and co-morbid spend), employers may also feel the effects of behavioral health issues in increases in absence and disability and worksite accidents or safety incidents.
Not easy to fix: To start with, there is a stigma associated with obtaining care. Those who need care are often hesitant or unwilling to seek help. But even if a person is ready to begin treatment, access to care can be challenging. There is a shortage of behavioral health providers such as psychiatrists, and only about 50% of providers actually participate in networks. In some cases, programs are not integrated and so it is difficult for the plan member to know which program to use and when. On top of that, poor member compliance with treatment strategies is not unusual.
Good news: There is a lot of innovation going on in this area. Greater awareness of the major barriers to accessing behavioral healthcare (such as cultural influence, access issues, and cost) have spurred the development of tools and services that address them. A myriad of apps, niche vendors, and targeted programs are available to fill gaps in care delivery and offer solutions across the continuum of behavioral health needs. ACOs and other integrated care models have emerged and continue to evolve.
What should employers do?
- Focus data-driven discovery on your existing workforce. How are current behavioral health issues affecting your organization? Are you getting the most out of the behavioral health offerings?
- Offer a variety of programs. Explore the latest innovations for options that may work better for your population and needs. Select programs that will maximize appropriate use of prevention and treatment services. Make access easy.
- Build a supportive work culture. Integrate emotional health with other pillars of well-being (e.g., physical and financial).
This last point is perhaps the most important of all. You can have great programs but if your people are not comfortable using them, not much will be accomplished. The challenge is to promote acceptance of the fact that we all have problems, that sometimes we need help, and that asking for help is the quickest, most courageous way to get better.
Mental health parity is nowhere close to the top of most lists of benefit concerns. After all, the Mental Health Parity and Addiction Equity Act (MHPAEA) is eight years old and has never received the attention paid to other laws. Its rules are complex, requiring comparison of mental health/substance use disorder benefits with medical/surgical benefits in six separate classifications.
It is a mistake to ignore the MHPAEA, though, for at least three reasons.
First, mental health issues are abuzz in Washington. Witness increased public awareness of gun violence and opioid abuse. Several bills are pending, including HR 2646, a bi-partisan effort that would strengthen the MHPAEA. Also, earlier this year the President created a Mental Health and Substance Use Disorder Taskforce that will issue a report later this year that will identify gaps in parity implementation and discuss best practices.
Second, the regulatory agencies view mental health parity as a high priority. In May, DOL, Treasury, and HHS clarified in FAQ Part 31 that insurance companies or TPAs performing mental health parity testing cannot base the testing on their book of business. Instead, they must use plan-specific data when available. Also, in early June DOL and HHS provided a list of 15 red flags that indicate an issue with MHPAEA, including differing preauthorization requirements, likelihood of improvement provisions and written treatment plan constraints. DOL reviews mental health parity in its plan audits.
Finally, May’s final §1557 regulations have brought one mental health condition to the forefront: gender dysphoria. Health programs and activities receiving HHS funds cannot discriminate based on gender, among other protected categories. Blanket exclusions based on gender are prohibited -- this includes a broad exclusion of all items and services related to gender transition/re-assignment. Employers covered by final 1557 regulations will potentially have to cover gender reassignment benefits when deemed medically necessary. Mental health parity rules could limit design options as it prohibits stricter cost-sharing (e.g., a lifetime or annual limits) for mental health benefits than applies to medical/surgical benefits in the same classification.
Additional issues arise in varied situations, like carved-out behavioral health and autism spectrum disorder coverage. The challenge is that MHPAEA includes financial requirements, quantitative treatment limitations, and non-quantitative treatment limitations.
What should employers do? At least three things come to mind:
- Review current and future medical plan designs with legal counsel to determine if there are any mental health parity “red flags.”
- Address testing concerns with their insurance company or TPA to assess compliance with the recently issued FAQ.
- Work with a trusted advisor to determine if any other mental health parity issues are lurking “under the hood.”
The Golden State Warriors have started this year’s basketball season with a record-setting 16 straight wins. I watch all of the post-game interviews and I’ve noticed that the word “mindfulness” pops up more often than you might expect. It’s certainly not a new concept within sports (sports psychology dates back to the 1920s) but the use of meditation -- and, specifically, mindfulness -- is a growing practice.
Warriors coach Steve Kerr has shaped much of the current culture within the organization using the Mindfulness-Acceptance-Commitment approach to performance enhancement, along with experiences from his own playing career that shaped him. These include learnings from his own coaches -- the levity of Cotton Fitzsimmons, the Zen of Phil Jackson, and the tough love of Gregg Popovich.
After a loss to the arch-rival San Antonio Spurs early last season, Kerr said of his team, "They had the confidence. They had the swagger. The challenge is how to add the mindfulness. How do we add…the purpose?"
Apparently, he’s figured it out. In recent interviews, interim coach Luke Walton has described the core values that Kerr has instilled in the team: joy, mindfulness, compassion, and competition. “The first one and the most important one is probably joy -- he wants us having fun. It’s a long season, this game’s meant to be fun. There’s mindfulness. There’s compassion -- for each other and for the game of basketball. And then there’s competition. When we hit those four things, we’re not only very tough to beat, but we’re very fun to watch, we’re very fun to coach, we’re very fun to be around.”
A lot of athletes have the physical ability for competition but lack the mental training to support it. We’re beginning to see corporate America start to think about workforce performance and productivity similarly. For example:
- Salesforce’s Dreamforce conference featured an opening with Rick Welts and Bob Myers from the Golden State Warriors organization. What followed later in the event? A Mindfulness keynote with Donna Karan and Urban Zen. Coincidence?
- Talks at Google recently featured George Mumford discussing the Mindful Athlete and his work with Michael Jordan, Kobe Bryant, and the Warriors.
- Purpose is a key component within Dan Pink’s framework for motivation and drive, along with mastery and autonomy.
- Willie Mays was just presented the Presidential Medal of Freedom and once had this to say about mindfulness: “What you are thinking, what shape your mind is in, is what makes the greatest difference of all.”
- Companies like the Human Performance Institute and EXOS are taking learnings from athletics and bringing them to employers to help create “corporate athletes.”
Maybe, as you think about standard training programs for your employees around compliance and on-the-job functions, it’s time to think about mindfulness training as well.
When will the Golden State Warriors lose? Who knows, but I’ll be enjoying the entire season, mindful and appreciative of every fun moment that comes along the way.
After the events in Paris and Beirut last week, every one of your screens – from TVs to tablets, phones to laptops – was probably like mine, filled with stories and images of tragedy and human loss. For better or worse, the speed and connectedness of our social world allow us to feel and experience events throughout the globe, via tweets, timelines and newsfeeds, all updating around the clock. As we process and digest the events, we’re asked to try to continue normal daily life in our homes, our workplaces, and our communities.
Tara Haelle wrote a nice piece for Forbes, talking about the effects of disaster news fatigue and pointing to examples from the Oklahoma City bombing, Hurricane Katrina, September 11th, and the Boston Marathon. She also addresses the importance of knowing how to speak to children about these events, and the images they may be witnessing for the very first time in their lives. And Carol Harnett discusses appropriate employee communications in HRE Online.
Much of health care innovation has been focused on physical health, but we’re seeing a number of interesting trends and developments within the emotional health space:
- A new behavioral health start-up called Lyra Health (launched by former Facebook CFO David Ebersman), focused on helping those with depression, anxiety, or substance abuse issues.
- Wearables like Spire, which analyze breathing rates to determine levels of tension, calm, or focus.
- New technology companies like Lantern, Calm, and Cope, all aiming to increase access and digitize therapies for emotional health.
- Virtual reality therapy to help treat anxiety, phobia, addiction, and PTSD.
And Alphabet, the parent company of Google, has hired the former Director of the National Institute of Mental Health (NIMH), Thomas Insel, for its Life Sciences group. We’ll be interested to see where that leads.
We’re hearing more companies speaking out about holistic wellbeing, which includes physical, mental, and financial aspects. As you think about the dynamic world around us, do you think that social attitudes and stigmas towards emotional health are changing? Are we more receptive to therapy, resiliency, mindfulness, and meditation? Do you see regular practice of these activities within the workplace? Please leave a comment with your thoughts.
In a review of claims data for almost 100 Mercer employer clients, representing approximately 2.5 million members, we found that the Mental Health and Substance Abuse per member per year cost trend (for allowed charges) rose nearly 11%, in stark contrast to overall medical PMPY trend of 3.5%. And while MH/SA claims represent a small percentage of the overall medical claim costs (4%), a spike in the cost may be a symptom of a larger issue – and an opportunity for employers to get out in front. What’s driving this trend?
- More people – 3.4% increase in the MH/SA unique claimants.
- More claims per person – 7.5% increase in MH/SA claims per claimant.
- Fewer claimants are using out of network (OON) MH/SA providers but the total OON visits are increasing by 7.5% -- and the average allowable amount per visit is twice as high for OON providers ($2,097) than for in-network ($1,019).
One factor behind the increase in OON utilization may be adult dependents added under the ACA, who tend to live outside the primary member’s area and use OON services at a higher rate.
But the biggest driver of increased OON utilization may simply be limited access. Mental Health Parity has increased both visibility and pressure to increase access. We are seeing members access care more than ever before. And more employers are recognizing the importance of behavioral health in the benefit offering; they are increasing the number of EAP visits allowed and adding onsite counselors. Some specialty areas in particular experience access issues, such as psychiatry – both adult and child/adolescent.
The shortage of providers has led a growing number to choose not to join networks -- because they don’t have to. With access to in-network providers limited not just in rural markets but also in busy urban areas, more plan members may be making a choice to use out-of-network providers, albeit at a lower benefit level.
What are the possible interventions?
- If the underlying cause is access, collaborate with your networks about their strategy for contracting with providers; promote and leverage the EAP; and explore mental health resources available through telemedicine vendors.
- If the underlying cause is literacy, focus on member education, particularly if there are patterns by region or for covered adult dependents where in-network providers may not be evident or readily available. Also promote EAP and other resources that may be available to support members with mental health, substance abuse and/or stress related needs.
- Engage care management and advocacy support vendors in promoting in network and EAP resources; also validate their attention to the co-morbidities of mental health in their engagement contacts.
But before you start down any of these paths, look at your data to find out:
- Is your MHSA spend increasing?
- Is it MH or SA or both driving the increase in trend?
- Is it unit cost, number of claimants and/or number of claims per claimant?
- Are there patterns by location, job type or relationship to the covered employee?
- Are current resources such as the EAP being optimized?
- Are there employee surveys that suggest high rates of stress?
The more answers you have, the better equipped you will be to develop an approach that strikes the right balance between what people need and how the plan meets those needs.