N.Y. Consumers to Get Better Explanations When Coverage Denied

Back to table of contents Previous article Next article Health Care EconomicsFull AccessGatekeepers Aren’t Money Savers, RAND Study ConcludesKate MulliganKate MulliganSearch for more papers by this authorPublished Online:4 Jan 2002https://doi.org/10.1176/pn.37.1.0014The value of gatekeepers, one of the criticized tools in the repertoire of managed care, has been challenged by a new study conducted under the auspices of the RAND Health Program in Santa Monica, Calif.José J. Escarce, M.D., the lead study author, found that eliminating gatekeepers might not raise costs for health maintenance organizations (HMOs). Traditionally, HMOs have used gatekeepers to control access to medical specialists.To determine the role of gatekeepers in cost reduction, Escarce and his colleagues compared two plan types offered by a managed care organization (MCO) in the Midwest: a traditional HMO and a point-of-service (POS) HMO. Point-of-service HMOs have open physician panels, which allow patients relatively free access to various health professionals.Escarce said, “This is the first study to conduct a comprehensive analysis of spending in a POS compared with a more traditional HMO that uses primary care gatekeepers.” The researchers examined spending in categories including physician services, inpatient and outpatient hospital services, and prescription drugs.Costs were generally comparable between the gatekeeper HMO and the POS HMO.The authors speculated that the reason for similar costs is that enrollees might need to make numerous visits to their primary care gatekeeper to get specialist referrals, which would increase the HMO expenditures and offset any savings that occur because of restricted access to care. Another possibility is that the cost of monitoring primary care physicians and maintaining authorization procedures in gatekeeper HMOs might also offset savings.The researchers noted that as their survey was limited to one midwestern MCO, their findings might not apply to health care plans throughout the country. The trend toward decreased utilization of gatekeepers and other restrictive managed care strategies, however, has been documented in other studies.The 2001 Annual Survey of Employer Health Benefits, conducted by the Henry J. Kaiser Family Foundation and the Health Research and Educational Trust, for example, found that enrollment was shifting from HMOs to less-restrictive forms of care like preferred provider organizations (PPOs) (Psychiatric News, October 19, 2001).At “Emerging Health Care Market Trends,” a December conference convened by the Center for Studying Health System Change (HSC), Glen Mays, a health researcher at Mathematica Policy Research, told the audience that the “managed care backlash [had] come into full bloom over the past couple of years, with consumers demanding more choice and fewer restrictions on their health care decision making.”May cited gatekeeping and utilization-management techniques as one of four tools that managed care plans have used to manage costs and care. Health care insurance companies, according to Mays, are relaxing restrictions for referrals to specialists in their existing plans and introducing new products without those restrictions. United Healthcare is coming out with a new direct-access HMO, which allows patients to self-refer to specialists and eliminates precertification requirements for hospitalization.In his discussions with executives of health insurance companies, Mays found support for Escarce’s conclusion that gatekeepers might not be a source of savings. “Administrative costs associated with maintaining. . .utilization-management techniques had grown burdensome, and [companies] were not seeing the return in terms of cost savings,” Mays told the audience.Every two years HSC conducts on-site interviews with health care leaders in 12 nationally representative communities about emerging trends and presents the findings at a conference and in issue papers. Mays’s presentation was based on the most recent visits, which occurred 2000-01. An article about the conference will appear in the next issue of Psychiatric News.A copy of the RAND study is available by calling the RAND Corporation at (310) 451-6913. The Web address of the Center for Studying Health System Change is www.hschange.org. ▪ ISSUES NewArchived

Objective. Concerns have emerged from two west coast communities that health maintenance organizations (HMOs) may deter their members from calling 911. One means of influence is retrospective denial of emergency department (ED) or emergency medical services (EMS) claims. The study objective was to systematically assess legal action taken to contest HMO denial of claims. Methods. Telephone survey of all state insurance commissioners (SICs). The specific question asked was: “What actions, if any, have been taken by the Office of Insurance Commissioner since 1990 against HMOs for denying claims for emergency department care or care provided by paramedics after a person has called 911?” Each office was contacted at least three times. Results. Representatives from 49 states were interviewed. Three states (6%, Oregon, Texas, and Virginia) have taken formal action since 1990. Oregon fined two HMOs a total of $25,000 for inappropriate systematic claim denial of ED care. Texas fined one HMO $1,000,000 for similar practices. Virginia, with no authority to fine, has issued citations. No action had been taken for denying EMS claims. Thirty-eight states (78%) reported no formal actions. Eight (16%) state SICs could not easily retrieve these data and did not report. Fourteen (29%) representatives reported receiving these complaints. Most of these complaints were resolved without formal SIC action. Conclusions. Three health plans in two states received financial penalties for systematic denial of ED claims. A fourth was cited. This may underrepresent the true incidence of appealed ED and EMS claim denials. While complaints occurred in 29% of states, recent actions by SICs are relatively rare (6% of states). These results speak more to the extent systematic claim denials are discovered by SICs than to the true incidence of this practice.

AMA to Work With APA, Other Groups on Integrated Care

Improving Medication Management of Depression in Health Plans

The New Flexible Health Plans

Back to table of contents Previous article Next article ProfessionalFull AccessMembers Report Uptick in Plans’ Claims Denials, Scrutiny, and HasslesLinda M. RichmondLinda M. RichmondSearch for more papers by this authorPublished Online:24 May 2022https://doi.org/10.1176/appi.pn.2022.06.6.34AbstractAPA’s Practice Management Helpline is noticing an increase in the number of members with claims processing problems. A change in coding rules last year may be playing a role, and one legal expert weighs in on potential parity violations.APA’s Practice Management Helpline is fielding an increased volume of calls from members reporting greater scrutiny of psychiatric claims from commercial insurers. Problems include reduced claims payments, denials, and increasing administrative barriers. Some network-participating psychiatrists are also reporting contract offers for lower than Medicare payment rates.Ellen Jaffe, manager of APA’s Helpline, said APA is assisting several members with claims problems and encourages impacted members to contact the Helpline, either by email or phone. APA wants to understand the pervasiveness of these types of problems, she said. “We need to have sufficient documentation of this so we can put pressure on the plans to make some serious changes.”Psychiatrists are reporting a significant increase in utilization review by insurance plans, including prepayment review and postpayment audits, both in and out of network. Others are reporting insurers have “down coded” their evaluation and management (E/M) claims from level four to level three visits, lowering the amount paid with no request for documentation and no explanation.Marnie Neill, M.D., says administrative burdens, coupled with poor reimbursement, are making it increasingly difficult for psychiatrists to participate in insurance networks.Amy Joehlin-Price, M.D.Marnie Neill, M.D., clinical director of Silver Lake Psychiatry in Stow, Ohio, told Psychiatric News she participates in five insurance networks because she wants working families in her area to have access to mental health care. She said administrative difficulties with carriers are very labor intensive and, coupled with poor reimbursement, make it hard for her to cover her overhead. “Insurance companies are making it increasingly difficult for psychiatrists to stay in-network. I am very concerned about what this means for our communities and their access to mental health care.”Neill also cited problems with patient coverage for psychiatric illnesses. “A large proportion of patients at my practice have health insurance that covers certain psychiatric diagnoses—ones that their insurer deems ‘biologically based’ but provides far less coverage for other diagnoses. ... In reality, all mental illnesses are partially based on a person’s biology.”In addition, one national insurer in her area began cutting payments for telepsychiatry visits as of April 1 to the significantly lower “hospital facilities” rate. Unlike hospitals, however, practices such as Neill’s cannot bill a separate facilities fee to make up the difference. She said she’s heard rumblings that other insurers she participates with will follow suit.Neill said one national carrier is paying her only 50% to 60% of the Medicare rate in her jurisdiction. “I earned more than double that [rate] while moonlighting as a psychiatric resident, and I didn’t have the overhead,” she said. “We’re a tiny practice so plans won’t negotiate. … We have no choice but to leave that network. I have a lot of patients with that insurance, so I feel horrible about it, but we also want to keep our doors open.”Kamala Adury, M.D., says she wants to accept insurance, but some national insurers pay her only about two-thirds of the Medicare rate. “I want to accept insurance, and I keep getting calls from patients who I have to turn down; otherwise, I cannot stay in business.”Psychiatrist Kamala Adury, M.D., founder of the Center for Behavioral Health and Sleep Disorders in Medina, Ohio, told Psychiatric News she has similar challenges. Insurance problems are “a universal issue that no one talks about. Scores of private practices have become extinct or have been exterminated. The income of small practices has fallen drastically, which could lead to cramming more patients per hour to stay afloat—clearly compromising patient care,” she said.Some national insurers in Adury’s area pay her only about two-thirds of the Medicare rate. “They say ‘Take it or leave it.’ I want to accept insurance, and I keep getting calls from patients who I have to turn down; otherwise, I cannot stay in business.” One insurer paid Adury and then later billed her for hundreds of dollars, saying she had been overpaid and that she needed to return the money or face consequences.APA’s Jaffe said Medicare rates are considered to be the floor for physician reimbursement to allow practices to operate. Lower payments do appear to be outside the norm, according to a literature review by the Kaiser Family Foundation in 2020. That review found that private insurers’ payments to physicians for office-based care were 43% higher than Medicare’s, on average (with a range of 18% to 79% higher, across studies).Two psychiatrists in private practice in California said that carriers with whom they participate have made it difficult or impossible to reach their provider relations departments, compounding all the problems, John S. Smolowe, M.D., and Joellen Werne, M.D., told Psychiatric News in a joint interview. “There are many issues that claims reps cannot answer,” Smolowe said. Examples include requesting a reimbursement schedule, reporting a payment check missing, and needing to change an address. “Now these types of issues often drag on for months or go unanswered and unresolved.”Smolowe said another concern is carriers’ increasing use of subcontractors to manage behavioral health claims, which erects an additional barrier between the psychiatrist and the claims departments. “The patient is unaware of these subcontractors, and by design their contact information does not appear on patients’ insurance cards. Yet if we send the claim to the wrong entity, they disregard it,” he said. Oftentimes, determining who is managing a given patient’s claims takes longer than 90 days, at which time the bills are denied due to lack of timely filing.Psychiatrists in New York have also reported a significant increase in claims and administrative problems with insurers, Rachel A. Fernbach, J.D., deputy director and assistant general counsel of the New York State Psychiatric Association, told Psychiatric News. For example, several members have reported carriers declining to pay for the E/M portion of a bill. Rather, plans told these physicians they should be billing only for psychotherapy for most visits, Fernbach said. This is in direct conflict with the 2010 guidance issued by the Department of Financial Services (formerly the New York State Insurance Department) requiring all carriers to accept E/M claims submitted by all physicians, including psychiatrists, she added.Fernbach said she has found other problematic administrative barriers. Insurers request additional claims documentation for audits or prepayment reviews, and once the psychiatrists submit it, some carriers don’t acknowledge it. In some cases, members have faxed, emailed, and even overnighted the information—but insurers do not respond.Role of Billing Rule ChangesThe rise in psychiatric claims problems appears to have coincided with a major overhaul of E/M coding rules for office-based outpatient care that took effect in January 2021. There is now an entirely new framework for code selection and documentation of medical decision-making, which sometimes results in higher-level coding and more costly care for psychiatric patients, depending on their level of complexity and acuity presented. For example, during office visits when psychiatrists are treating unstable patients with at least one chronic illness and also managing medications during that same visit, it is now billed as a level four/moderate complexity visit versus a level three.“The New York State Psychiatric Association is working with the Department of Financial Services and carriers doing business in New York to ensure that insurers and health plans are aware of these recent changes in the coding rules and are appropriately adopting this new framework in their utilization review efforts,” Fernbach said.Rebecca Yowell, APA’s director of reimbursement policy, said the organization is in the process of further revising its educational materials about the coding changes, to add more clarity and provide additional psychiatry-specific examples. The revisions are aimed at helping members determine appropriate E/M billing levels and how best to document their services. For example, Jaffe said it is important for members to note that unstable patients are only those defined as “with exacerbation, progression, or side effects of treatment.”Budgets Driving DecisionsRobert Trestman, Ph.D., M.D. says, “What we would want, given this new pandemic of mental illness that is growing out of a consequence of the SarsCoV2 pandemic, is for insurers to do everything they can to expand access, reduce administrative burden, and encourage psychiatrists to join networks.”Rouse Photography Group LLC“So much of what we’re reacting to is anecdotal and not data driven,” Robert L. Trestman, Ph.D., M.D., told Psychiatric News. He is chair of APA’s Council on Healthcare Systems and Financing and chair of Psychiatry and Behavioral Medicine at Virginia Tech School of Medicine. However, such data are hard to come by because insurers are typically the ones who hold it. “Even if one could amass all the claims data from a given state, one could see which claims were denied, but not the reasons why.”Trestman said insurers’ administrative staff in billing and claims, who are focused on keeping within their budgets, are more likely to be making the day-to-day decisions than are the chief psychiatrists, who are focused on improving the quality of care. “So there’s a predictable disconnect.”Although the exact numbers are not known, it is estimated that as many as one-third of psychiatrists are already not accepting insurance. “What we would want, given this new pandemic of mental illness that is growing out of a consequence of the SarsCoV2 pandemic, is for insurers to do everything they can to expand access, reduce administrative burden, and encourage psychiatrists to join networks. Insurance companies could then track the data. They could see that our patients were getting better and that the investment was worth it.”Mental Health Parity EnforcementDisparities in claims processing or payments for psychiatrists may constitute a violation of mental health parity laws, particularly if the process is more stringent than for other physicians, according to Ellen Weber, J.D., senior vice president for health initiatives with the Legal Action Center. “Reimbursement for psychiatrists at levels significantly below Medicare rates is a red flag, particularly if the reimbursement for other physicians is higher than the Medicare rate for the same codes,” she told Psychiatric News.Weber added that prepayment claims reviews could also be a parity law violation if insurers are not requiring that same process for medical and surgical office visits. “The level of administrative work required to provide the information is an indication that is suggestive of a more stringent application, such as when practitioners must spend an inordinate amount of time responding to questions.”In 2021, Congress amended the Mental Health Parity and Addiction Equity Act to allow federal officials to put a greater emphasis on proactive enforcement. Now plans are required to begin providing detailed analyses of their non-quantitative treatment limitations (NQTLs). NQTLs are strategies used by health plans to limit benefits, such as prior authorizations, fail-first policies/step therapy protocols, and insurance network admission standards.A review by the departments of Treasury, Labor, and Health and Human Services in January of analyses of their behavioral health NQTLs submitted by health plans found that not a single plan complied with the law (“Government Steps Up Efforts to Enforce Parity Law”). Officials issued dozens of enforcement letters to health plans identifying plans’ mental health parity violations as well as deficiencies in plans’ reporting transparency. The report also recommended that Congress amend federal parity laws to ensure that MH/SUD benefits are defined in an objective and uniform manner, for example, using the most recent Diagnostic and Statistical Manual of Mental Disorders. ■ResourcesAPA members are encouraged to contact the Practice Management Helpline for assistance with claims issues at [email protected] and 800-343-4671.The Kaiser Family Foundation’s “How Much More Than Medicare Do Private Insurers Pay? A Review of the Literature”The Government Accountability Office report “Behavioral Health: Patient Access, Provider Claims Payment, and the Effects of the COVID-19 Pandemic”The 2022 MHPAEA Report to Congress ISSUES NewArchived

ERISA: Supreme Court Holds ERISA Does Not Preempt Illinois Independent Review Law-Rush Prudential HMO, Inc. v. Moran1-The U.S. Supreme Court, a 5-4 decision, held that the Employee Retirement Income and Security Act (ERISA)2 does not preempt the Illinois Health Maintenance Organization Act (Illinois Act).3 In response to widespread employer mismanagement of employee pension funds, Congress enacted ERISA to create a uniform system of federal law to regulate private sector employee benefits programs, including employment-based health coverage.4 By alleviating the administrative burden of complying with an amalgam of state laws, Congress intended to encourage and enable more employers to provide benefits for their employees and to increase access to these benefits.5 To effectuate these goals of uniform regulation, Congress expressly dictated that ERISA preempts all state laws that relate to ERISA plans.6 ERISA's unbridled preemption raised federalism concerns about the respective roles of the state and federal government. Traditionally, states have regulated insurance; to preserve some role for state authority, ERISA provides a narrow exception to its preemptive power over state laws. Under this savings clause, state laws that regulate the business of insurance are saved from ERISA preemption even if such state laws relate to ERISA plans. ERISA was enacted 1974, before the advent of health maintenance organizations (HMOs). As many commentators have noted, the emergence of HMOs as the primary providers of healthcare and health insurance the U.S. has muddled the question of ERISA preemption. The ERISA preemption quandary results from the fact that many HMOs perform multiple functions, including management and provision of healthcare, and administration of ERISA plans. Moran is the most recent Supreme Court case to address where ERISA regulation ends and state regulation begins under ERISA preemption. Writing for the majority, Justice Souter aptly surmised the general issue that has plagued ERISA jurisprudence, namely the interpretation of the difficult language of ERISA that seems simultaneously to preempt everything and hardly anything.7 In Moran, the Court addressed another issue stemming from this underlying quandary, which is whether the Illinois Act was a permissible state regulation of insurance or whether the Act was preempted by ERISA. Section 4-10 of the Illinois Act requires HMOs to submit benefit denials to an independent physician reviewer in the event of a dispute between the primary care physician and the [HMO] regarding the medical necessity of a covered service proposed by a primary care physician.8 Under the Act, an independent physician reviewer must be unaffiliated with the HMO and jointly selected by the HMO and the patient. If the independent reviewer decides that the treatment is medically necessary and is a covered service under the contract, the HMO must provide the covered service. Respondent Debra Moran was a beneficiary of petitioner Rush Prudential's health plan, which was sponsored by her husband's employer. Under its Certificate of Group coverage issued to plan beneficiaries, Rush promised to provide its participants with medically necessary health services. Under Rush's plan, each participant selected a primary care physician from a group of physicians who had a contract with Rush. According to its contract, Rush was obliged to pay for medical services performed by an unaffiliated physician only if the services had been authorized by both the primary care physician and Rush's medical director.9 Moran suffered pain and numbness her right shoulder. Her primary care physician's attempts to alleviate her discomfort through conservative treatments were unsuccessful. Moran's primary care physician recommended that Rush approve surgery by an unaffiliated specialist who had developed an unconventional treatment for Moran's condition. Despite her physician's recommendations, Rush denied Moran's request for coverage of the surgery because it found that the procedure was not medically necessary. …

Back to table of contents Previous article Next article Government NewsFull AccessCongress’s Psychiatrist Still Says Single-Payer System NeededKate MulliganKate MulliganSearch for more papers by this authorPublished Online:19 Dec 2003https://doi.org/10.1176/pn.38.24.0010Rep. Jim McDermott, M.D. (D-Wash.), calls the recently passed Medicare legislation a “turkey” because of its diversion of funds that could have helped seniors rather than pharmaceutical and insurance companies.Rep. Jim McDermott (D-Wash.), the only psychiatrist in Congress, takes no pleasure in his prophetic abilities. In 1994 he warned APA members and anyone else who would listen about the potential hazards of managed care and urged support for a single-payer system of financing health care.McDermott told the audience at the William C. Menninger Memorial Convocation Lecture at APA’s annual meeting that year, “The wildfire of managed care competition is sweeping across the landscape of medical practice.” He also quoted health care economist Uwe Reinhardt, who had predicted that in five years all doctors would be “serfs of the insurance industry.”Earlier that year, McDermott, the only psychiatrist in Congress, urged APA’s Board of Trustees to support single-payer legislation, arguing, “[I]t is the only way you are going to have any chance in the future to have a say about health policy.”In a recent interview with Psychiatric News, he discussed the political and economic factors that affect the current debate about health care reform and his single-payer legislative proposal.“Everywhere you turn, there is another problem,” McDermott said. “The same tide that led to managed care in the early 1990s is building.”The number of people without health insurance is increasing, as is the cost of health care. Now, however, little or no hope remains that managed care can solve the fiscal and access problems of the health care system.“Our ability to deal with access problems is limited because there is no real health care system,” he said.As in the 1990s, health care reform has become an important political issue. According to an analysis in the September 30 New York Times, “[As] the plight of the uninsured becomes more of a middle-class issue, . . . it is more politically potent.”According to a September Gallup poll, 43 percent of Americans cited a candidate’s position on health care as “extremely important,” ranking just below terrorism and the economy.With the failure of managed care to reform the health care system, there appears to be increasing receptivity to proposals for a single-payer system of financing care.An ABC News-Washington Post poll released in late October found that by a margin of 62 percent to 32 percent the public favors a “universal health insurance program, in which everyone is covered under a program like Medicare that’s run by the government and financed by the taxpayers,” as opposed to the “current health insurance system, in which people get their health insurance from private employers, but some people have no insurance.”That change is welcome news to McDermott, who introduced the American Health Security Act (HR 1200) last March. The bill, which has 40 cosponsors, would establish a national and universal health program that would be funded by the federal government and administered by the states (Psychiatric News, October 3).McDermott looked back to the 1960s when asked to consider the bill’s chances of passage. He said proposals for what would become the Medicare program had been “kicked around for a long time,” but had been defeated by forces that included strong opposition from the AMA and health insurance carriers.But ultimately, in 1965, McDermott said, pressure on politicians from constituents became too great to resist, and the legislation was passed.McDermott voted against the Medicare legislation that passed the House of Representatives on November 22, charging that its “real goal” is to privatize Medicare (see Original article: page 2).He added, “The bill is designed to protect and increase drug companies’ and insurance companies’ profits. The pharmaceutical industry will reap about $140 billion in profits if this becomes law. The bill explicitly prohibits the secretary of Health and Human Services from negotiating lower drug prices on behalf of America’s 40 million Medicare beneficiaries.”McDermott cited stigma and ignorance as factors that have prevented passage of federal legislation promoting parity in benefits for mental illness with those for other forms of illness.“The idea that one must pull oneself up by the bootstraps still has a lot of power,” he said. Unless people have had direct contact with mental illness, they often do not understand that it is a chronic, but treatable disease.“Get to know your local politicians. Become active in the community in visible ways,” McDermott urged APA members. “Education about mental illness must be a constant process.”He praised the work of APA in helping to establish the Mental Health Caucus in the House of Representatives, which has worked to provide that education. ▪ ISSUES NewArchived

Doctors across the country say that health maintenance organizations (HMOs) routinely limit their ability to talk freely with patients about treatment options and HMO payment policies, including financial bonuses for doctors who save money by withholding care. In interviews over the last 3 weeks, many doctors said such restrictions interfered with their ethical and legal duty to provide patients with information about the benefits, risks, and costs of various treatments. Ill feeling over the restrictions is growing as more and more Americans join HMOs and employers encourage their use to control costs. The doctors' complaints illustrate the tension between them and HMOs as health plans try to monitor and regulate the doctors' behavior. Dr Daniel A Gregorie, president of Choice Care in Cincinnati, defended the confidentiality clause as a way to prevent doctors from sharing their frustrations with patients. "Physicians are angry, frustrated and, to some extent, depressed because the world as they've known it is changing rapidly and radically," Dr Gregorie said. "But physicians should not take out that frustration in a nonconstructive way by sharing it with patients. That does not help the patients. It just makes them more anxious about the care they are receiving."

Economic Grand Rounds: A Pay-for-Performance Program for Behavioral Health Care Practitioners

Independent foundations' primary focus is grant making.In general, their assets come from the gift of an individual or family.Community foundations' assets usually come from many donors rather than a single source, and grant making is limited to a particular region.Community foundations are usually classified as private charities under the tax law and are subject to different rules and regulations than are other private foundations. Access To CareAccording to 1988 Census Bureau estimates, over thirty-one million Americans are without health insurance.The demographics of these people are diverse, and their ranks continue to grow as the service industry burgeons and as competition in health care increases.Regional disparities in access also exist.Foundation funding in this area ranges from economic analyses of the problem to direct provision of care.

Back to table of contents Previous article Next article Government NewsFull AccessDB Efforts Help Pass Mississippi Parity BillChristine LehmannChristine LehmannSearch for more papers by this authorPublished Online:18 May 2001https://doi.org/10.1176/pn.36.10.0004Mississippi is the 32nd state to enact mental health parity legislation. To ensure the law’s passage, the Mississippi Psychiatric Association (MPA) and its coalition partners worked with key legislators, and Gov. Ronnie Musgrove (D) signed the bill last month.APA President Daniel Borenstein, M.D., said in a press release, “We applaud the Mississippi legislature and Gov. Musgrove for breaking down the barriers for the people of Mississippi from receiving treatment and recovery from mental illness.”APA’s Commission on Public Policy, Litigation, and Advocacy approved funding for MPA’s advocacy efforts last month, subject to approval by the Board of Trustees.APA’s Division of Government Relations held a one-day advocacy training session last year for MPA members and provided resource materials on parity.Sudha Madakasira, M.D.: “We were told by politicians that a parity bill would not pass given the opposition by key legislators.”MPA President Sudha Madakasira, M.D., said in an interview with Psychiatric News, “We were told by politicians that a parity bill would not pass given the opposition by key legislators. We decided not to ask for full parity and met with insurance committee chairs in the House and Senate and the insurance industry. Once we agreed on the provisions, the chairs sponsored the bills and shepherded them through their chambers.”Madakasira estimated that the law, which becomes effective next January, will affect 500,000 individuals in group health insurance plans. The legislation requires employers with more than 100 employees to provide mental health coverage for “clinically significant mental illnesses.” The law doesn’t list or define those illnesses.The mental health coalition also succeeded in not having lifetime caps on mental health benefits included in the bill.Specifically, HB 667 mandates that group health plans provide the following mental health benefits:• A minimum of 30 days of inpatient services annually• A minimum of 60 days of partial hospitalization annually• A minimum of 52 outpatient visits annuallyThe group health plans must cover a minimum of 50 percent of the cost of outpatient visits but are not required to pay more than $50 a visit. Group health plans can opt out of the new requirements if they result in increasing the plans’ costs by more than 1 percent.MPA lobbyist and executive director Angela Ladner told Psychiatric News, “In addition to having a 15-member mental health coalition that included the state psychological, medical, and hospital associations, we had representatives from the state department of health insurance giving us advice.”Ladner said the coalition took the department’s advice to craft a bill based on the mental health benefits in the health insurance plan for state employees. “We decided the state’s benefits were pretty good and that we could argue persuasively that everyone else should have the same benefits as state workers.”Ladner praised Mary Ann Stevens (D), chair of the House Insurance Committee and a previous opponent of parity, with meeting with the mental health coalition and agreeing to sponsor the bill.“Once we had the insurance industry on board, she did everything in her power to ensure the passage of this legislation.”Ladner credited Senators Billy Thems (D) and Robert Huggins (R), as well as Lt. Gov. Amy Tuck (D), who presides over the Senate, with pushing the bill through the Senate.Madakasira added that the law is a good first step toward full parity and that the mental health coalition plans to work toward having its provisions expanded. ▪ ISSUES NewArchived

After US Congress failed to enact legislation in the summer of 1998 that would have ratified the June 20, 1997 deal to settle lawsuits filed by state attorneys general (AGs)...

To summarize for the California Legislature the evidence on the medical effectiveness of pediatric asthma self-management training and education (PASMTE), including the use of peak flow meters, spacers, and nebulizers and the impact that mandated coverage of these services and devices under Assembly Bill (AB) 2185 would have on total health care expenditures, monthly premiums, health services utilization, and the public's health. The review of the literature finds that PASMTE is medically effective and has favorable effects on the health of children with symptomatic asthma, as well as reduces asthma-related emergency room visits and hospitalizations. There was inadequate evidence to assess the effectiveness of the three medical devices independently of PASMTE. One-hundred percent of children in health maintenance organization (HMO) plans in California are already covered for PASMTE, with fewer having coverage for the specific medical devices. However, despite full coverage of PASMTE in HMOs, these services are underutilized. We expect that the enactment of AB 2185 would increase utilization of PASMTE among children who are currently covered by 10 percent as a result of increased awareness of current coverage by all HMOs and increased awareness of the importance of these services. We estimate that this increased utilization by children who are already covered may result in a total statewide premiums increase of $170,000 or 0.006 percent, equal to one to two cents per member per month (PMPM). It is estimated that the public health impact of the mandate, as a result of new utilization of PASMTE by 10 percent of children who are already covered, would reduce the number of school days missed because of asthma per year by 158,000; the number of children reporting restricted activity days by 6,020; the number of emergency department visits by 350; and the number of hospitalizations by 1,105. AB 2185 passed the legislature after being amended six times. The bill as it was signed into law did not mandate coverage for PASMTE, as all HMOs in California presently reported covering these services. However, the bill retained the mandate for coverage of the three medical devices, as their coverage was not as universal across health plans.

BackgroundIn the USA, chlamydia screening of all sexually active women aged ≤25 years is recommended, but screening rates are low. The Healthcare Effectiveness Data and Information Set (HEDIS) performance measure...