Aetna 2001 Annual Report Download - page 21

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Mental Health Parity
 , ..
René Dubos University Professor of Behavioral Sciences, and Director, Institute for Health,
Health Care Policy, and Aging Research, Rutgers University
Mental disorders are among the most disabling of illnesses.
They destroy individual and family functioning; undermine productivity; and cause disruption in
the home, workplace and community. In recent decades, advances in treatment and rehabilitation
through improved medications, better focused psychotherapies and careful case management have
done much to increase function and reduce despair. Large gaps remain in access to effective treat-
ments. Major barriers are the lack and inadequacies of insurance coverage for mental health treatment,
the stigma of mental illness and limited public understanding of the benefits of treatment.
Resistance to parity in insurance coverage of mental disorders resulted from the lack of
clear treatment standards, the predominance of long-term psychotherapy as the preferred treatment
choice, and concern about “moral hazard,” the tendency for persons to seek more treatment when
care is insured. Since psychotherapy was a cultural source of self-actualization as well as a treatment,
it was feared that insurance coverage would induce unnecessary demand. The stigma of mental
illness also made it easier to impose greater deductibles, co-insurance, coverage limitations and
ceilings than those for other medical conditions, even medical conditions that had no clearer
treatment standards. In short, persons with mental illness faced and continue to face discrimination.
Many of the concerns used to justify discrimination have been substantially remedied. The
effectiveness of mental health treatments is now comparable to treatments for many medical
conditions. Medications have improved, and psychotherapies are now more focused and time
limited. Diagnostic assessment is now more rigorous, and practice standards have been clarified.
Moreover, the current evidence is persuasive that mental health coverage on the same basis as other
illnesses that are managed does not impose large or unaffordable cost increases. There is even basis
for the conclusion that the potential reduction of unnecessary medical treatment that people
with untreated mental illness receive, and the increase in function and productivity resulting from
appropriate treatment, substantially offset the costs.
Three issues must be kept in mind. Medical parity alone is not enough for the small subgroup
who have the most severe mental illnesses, and others who have the most profound and disabling
diseases and disabilities. These persons may require, in addition, services typically not covered by
insurance such as residential care, rehabilitation and housing assistance.
Persons with serious mental illness are commonly high-cost patients because they often have
co-morbidities and seek a variety of medical services. Plans and providers may limit coverage
to avoid such patients, who pose financial risks. Requiring basic mental health coverage in all
plans comparable to that for other medical conditions reduces risk selection. Improved methods
of risk adjustment for fair financing and reimbursement are also essential to reduce competition
to avoid risk.
Finally, the public must accept the necessity of expert management of the mental health
benefit based on sound diagnostic assessment and evidence-based standards. A well-managed
benefit offers an extraordinary opportunity to close gaps in treatment and improve the quality
of care at affordable cost.