Can we now please have a serious discussion about access to mental health and substance treatment?

Substance abuse and mental health conditions affect people of every ethnicity and culture, the rich, the middle class, the poor. We are all susceptible. Like any other illness, treatment should not only be readily available, but unimpeded and covered by public and private insurance plans. Yet despite passage of the Mental Health Parity and Equity Addition Act (MHPAEA) in 2008, which heralded the promise of a new era for those enrolled in insurance plans, enforcement of the act has been weak. The series of obstacles to treatment of substance abuse and mental illness that persist today would never be tolerated if applied to medical care.

Any one of us can fall prey to a range of substance use and mental health disorders. The pressure to perform, the drive to succeed, the desire to keep pain at bay, the pressures of unemployment or homelessness, and the unfair stigma attached to substance use disorders and mental illness, can lead people to need a short burst to a lifetime of treatment. But the most important question is, when people seek treatment, is treatment as accessible as it should be?

Whether it’s a lack of providers participating with insurance plans, a general lack of capacity of treatment locations like residential treatment centers or other programs, or repeated and unjustified refusals of insurers to cover medically necessary treatment that is too often based on inaccurate, outdated or just plain incorrect criteria, it is time to fix the problem. Our relative complacency in failing to aggressively pursue major improvements in ensuring access to care is baffling and unacceptable.

In 2011, the State of Connecticut Office of the Healthcare Advocate (OHA) received 407 calls for assistance with coverage or access to mental health and substance use disorders. These calls ranged from parents of children with eating disorders and major depressive disorder with multiple suicide attempts to children and adults with serious substance use disorders experiencing co-existing mental health disorders.  These calls are crisis calls from people trying to access treatment so they can get themselves, their children and parents back to school, work and sometimes, just to convince their loved ones to want to live. Some of the families took out second mortgages or even lost their homes, while some patients have sacrificed their freedom to get the treatment they needed because community treatment was not available.

An example of the issues facing consumers includes OHA’s identification of a pattern of denial of residential treatment coverage for individuals with substance abuse issues and/or mental health conditions. In deciding whether to approve treatment requests, one insurer regularly applied a set of medical necessity criteria to each enrollee request for service that were not founded on any professional guidelines and inconsistent with state law. The insurer did not impose comparable requirements for an individual seeking out-of-home medical treatment. The result of the insurer’s improper denials of coverage resulted in many consumers going without needed substance abuse or mental health treatment until OHA intervened and appealed the denials. Because the insurer insisted on using its criteria, many cases were not overturned until the external appeal level, where an independent agency affirmed the errors and supported the consumers’ claims.

At OHA’s request, the Insurance Department intervened to force the plan to change its criteria going forward. Notwithstanding the fact that the insurer, and in some cases, external reviewers, repeatedly used the erroneous criteria as a factor in denying individuals needed treatment, the carrier was not ordered to review previous cases for wrongful denials or to review previous cases of external reviews that relied on its flawed criteria and consequently jeopardized the physical, mental and financial health of affected consumers.

MHPAEA was enacted in recognition of the basic truth that people suffering from substance use and/or mental health disorders deserve equal access to treatment as those with physical illnesses. It is well past time that the state make substantial efforts to enforce true mental health and substance use parity by addressing head on the lack of capacity issues. It is also time to hold insurers accountable for imposing unreasonable barriers to access to care. We cannot reform health in Connecticut without reforming our mental health and substance use health treatment system.

Time has shown that traditional insurance does not do a good job of delivering mental health and substance abuse treatment and guaranteeing rights under the MHPAEA. The money going to carriers for these services could be better spent on a coordinated system of care that ensures access to necessary coverage and removes the onerous burdens on patients and providers of risk-based managed care.  Such a system might increase sorely needed capacity for inpatient and outpatient services. Our health reform efforts, including the Exchange, should include serious consideration of removing mental health and substance abuse treatment services from the carriers and the development of a system of delivering these services similar to that of the Behavioral Health Partnership under the Medicaid program or the Blueprint for Mental Health, authored by providers and advocates several years ago.  Such a system would guarantee access to medically necessary services as promised by the MHPAEA and eliminate the hurdles that insured individuals in Connecticut have had to try to jump over for far too long. We are past time to deliver on MHPAEA.

Vicki Veltri is the state’s Healthcare Advocate.