Achieving Mental Health Care Parity Might Require Changes In Payments And Competition

Abstract

One of the most prominent features of the Affordable Care Act has been the promotion of individual health plans chosen by consumers in the Marketplaces. These plans are subject to regulation and paid by risk-adjusted capitation, a set of policies known as managed competition. Individual health insurance markets, however, are vulnerable to what economists describe as efficiency problems stemming from adverse selection, and Marketplaces are no exception. Health plans have incentives to discriminate against services used by people with certain chronic illnesses, including mental health conditions. Parity regulations, which dictate coverage for mental health benefits on par with medical and surgical benefits, can eliminate discrimination in coverage but redirect discrimination toward hard-to-regulate tactics from managed care such as restrictive network design and provider payment. This article reviews policy options to contend with ongoing selection issues. “Better enforcement” of parity has less chance of success than more fundamental but feasible changes in the way plans are paid or in the way competition among plans is structured.

Health care demand elasticities by type of service

“…Demand response for mental health and substance abuse (MH/SA) services are of intermediate elasticities (−0.26). This may reflect the current trend that most people getting professional mental health treatment are getting drugs only or receiving MH/SA treatment in primary care (McGuire, 2016), which is consistent with the low level of spending on specialty mental health care observed in our data. Surgical procedures and Dialysis, two very expensive types of services, are of the wrong sign and not statistically different from zero.…”

Robust Machine Learning Variable Importance Analyses of Medical Conditions for Health Care Spending

“…Previous literature has also demonstrated that mental health and substance use disorders are substantially undercompensated in the current Marketplace risk adjustment system (McGuire ; Montz et al. ).…”

“…While further work is needed, I expand the evidence base that policy changes to risk adjustment formulas may be warranted. This could include altering risk adjustment methodology, such as adding HCCs or prescription drug flags to existing formulas (McGuire ; Montz et al. ).…”

“…). Of note, improvements in access to care and the health needs of individuals with mental health and substance use disorders over the last 50 years have been achieved partly through changes in financing rather than new treatments (McGuire ).…”

Trends in Mental Health Care Use in Medicare from 2009 to 2014 by Gender Minority and Disability Status

“…Access to mental health care, even under conditions of ostensible mental health parity, can be complicated further by issues that are difficult to regulate, such as narrow provider networks for those offering mental health services. 38 Considering that 50% of transgender patients in national surveys report that they need to educate their providers about gender minority care, 27 the ''effective'' network of mental health care providers prepared to provide high-quality mental health care to gender minority patients is likely much smaller than that available to the broader population. In focus groups of transgender women living with HIV who also had used mental health treatment, participants ''discussed the need for more readily available mental health services aside from psychotropic medications,'' 39 in particular, because there was a perception that medications were being used more often because they were ''more readily available than therapy, which participants viewed as a problem.''…”