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News and Notes   |    
Psychiatric Services 2000; doi: 10.1176/appi.ps.51.8.1062
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A recent survey by the U.S. General Accounting Office (GAO) found that the majority of employers are in compliance with the requirement of the federal Mental Health Parity Act that their insurance plans offer parity in annual and lifetime dollar limits for mental health and medical and surgical services. However, fearing higher costs, many employers have taken advantage of loopholes in the law to impose more restrictive limits on services such as hospital days and outpatient visits for mental disorders than for other medical and surgical conditions. The result has been little improvement in access to mental health services, the survey report asserted.

GAO, the investigative arm of Congress, conducted the survey to assess the effects of the national parity law, which will expire on September 30, 2001, unless it is renewed by Congress. In a random sampling, 1,656 employers that were subject to the law in 26 states and the District of Columbia were contacted by mail. States selected for the survey had no state parity law or had laws that were less comprehensive than or similar to the federal law. Eligible responses were received from 863 employers, for an adjusted response rate of 52 percent.

The survey, conducted between November 1999 and February 2000, found that 86 percent of the respondents, representing 68,000 to 74,000 employers, were in compliance with the requirement for parity in annual and lifetime dollar limits, a substantial increase from 55 percent in 1996, before the law was enacted. More than 75 percent of employers that had changed their dollar limits cited the federal parity law as a major reason. Among the 14 percent of employers who reported that they were not in compliance with the law, most had lifetime limits for mental health coverage of $100,000 or less.

The federal parity law does not prevent an insurance plan from imposing more restrictive limits on services such as hospital days or outpatient visits for mental health services than for medical or surgical services, or from setting higher cost-sharing requirements. The survey found that 87 percent of employer plans that were compliant with dollar limits contained at least one more restrictive provision for mental health benefits. Most prevalent were restrictions in the number of outpatient office visits and hospital days. Nearly two-thirds of compliant plans had lower limits for mental health than for medical and surgical benefits; very few imposed any limits on office visits or hospital days for non-mental-health conditions.

Many employers in the states surveyed by GAO changed the design of their mental health benefits specifically to mitigate the more generous annual and lifetime dollar limits required by the parity act. About 65 percent of employers that changed dollar limits on mental health benefits to achieve parity also changed at least one other mental health benefit to be more restrictive. Of these employers, 51 percent covered fewer office visits, 36 percent covered fewer hospital days, 20 percent increased patients' copayments for outpatient office visits, 11 percent increased coinsurance for outpatient visits, and 18 percent increased the cap on the patient's out-of-pocket costs.

About 60 percent of the responding employers did not know whether compliance with the parity act increased their plans' claims costs, and about 37 percent reported that compliance had not raised their claims costs. Only about 3 percent of the respondents reported that claims costs rose as a result of the law. Less than 1 percent of responding employers have dropped coverage of mental health benefits or the health benefits plan altogether since the law was enacted. The law does not require any plan to offer mental health coverage.

The survey report said that as of March 2000, a total of 29 states had mental health parity laws that were more comprehensive than the federal law and required parity not only in dollar limits but also in service limits and cost sharing. Sixteen of these states required full parity; they mandated mental health coverage in all group plans sold and required parity in dollar limits, service limits, and cost sharing. Laws in six states essentially paralleled the federal law. Laws in eight states and the District of Columbia were more limited and might not conform to the federal law. Seven states had no laws addressing mental health benefits.

On the basis of the survey findings, GAO concluded that the federal parity law has resulted in only minor changes in mental health benefits. Consumers in the states studied have had little or no increase in their access to mental health services, and the costs associated with the federal law were negligible for most health plans. The report says that consumers in states without more comprehensive mental health parity laws are likely to remain in plans that continue to provide less coverage for mental disorders than for other types of illnesses.

The report, released in May, is entitled Mental Health Parity Act: Despite New Federal Standards, Mental Health Benefits Remain Limited. It is available on the Internet at www.gao.gov.

The Treatment Advocacy Center has developed a model law for assisted treatment that is designed to be the legal framework for providing care for persons who, because of untreated mental illness, become either dangerous or in need of treatment and incapable of making rational medical decisions.

Introduced at the annual convention of the National Alliance for the Mentally Ill in June, the model law was drafted with assistance from persons with severe mental illnesses, their families, and medical and legal professionals, according to a statement from the Treatment Advocacy Center, based in Arlington, Virginia. It will be disseminated to policy makers, academicians, psychiatric professionals, lawyers, and families around the country to promote changes in state laws that currently restrict involuntary treatment on grounds other than dangerousness.

The center said the model law is a compilation of the most effective provisions of existing state treatment laws. It includes recommendations for both inpatient and outpatient assisted treatment and sets out four alternative criteria that justify assisted treatment: chronically disabled, gravely disabled, danger to others, and danger to self.

The "chronically disabled" criterion permits consideration of possible harm to a person with symptomatic mental illness in light of past psychiatric history and other factors. The "gravely disabled" criterion applies in cases where an individual is unable to provide for basic necessities or is likely to suffer significant harm without treatment. Both of these criteria require a finding that the individual is unable to make a rational decision about treatment.

The danger-to-others criterion incorporates a definition of dangerousness similar to that of most states, but makes clear that presenting a threat to a person in one's care, such as a child, or causing intentional damage to someone else's property is evidence of dangerousness. The danger-to-self criterion makes clear that past behavior will be considered when determining dangerousness to self.

The model law is available on the Internet at the Treatment Advocacy Center site, www.psychlaws.org.

A recent report by the inspector general of the Department of Health and Human Services questions the effectiveness of federal efforts to hold psychiatric hospitals accountable for patient care and makes a series of recommendations designed to strengthen and improve coordination of the external review system.

The report focuses on the role of the Health Care Financing Administration (HCFA) in ensuring that psychiatric hospitals meet the conditions required for participation in the Medicare program. Besides being subject to conditions that apply to all participating hospitals, psychiatric hospitals must meet special record-keeping and staffing conditions that Congress added because of concern that patients in these hospitals would receive only custodial care rather than active treatment. Psychiatric units in general hospitals are not subject to the special conditions.

HCFA relies on a panel of psychiatric surveyors to conduct reviews covering only the special conditions. These surveyors, who work part time under contract, are primarily psychiatrists and psychiatric nurses but also psychiatric social workers and pharmacists.

HCFA does not consider surveys by the Joint Commission on Accreditation of Healthcare Organizations to cover the special conditions, even though Congress provided that hospitals accredited by the Joint Commission were deemed to be in compliance with the conditions of participation in the Medicare program. HCFA contract surveyors take a regulatory but patient-centered approach to assessing whether hospitals meet the minimum requirements of the special conditions, reviewing the medical records of a sample of patients and observing the patients in different settings. Joint Commission surveys have tended to focus on staff education and improved performance across a broad range of standards.

Psychiatric hospitals wishing to participate in the Medicare program without accreditation must go through a Medicare certification process. HCFA funds state survey and certification agencies to conduct certification surveys at these hospitals. However, most of the 611 freestanding psychiatric hospitals are accredited by the Joint Commission; only 39 are currently not accredited, according to the report.

The report notes that between fiscal years 1993 and 1998 the number of HCFA-contracted surveys at psychiatric hospitals dropped by 65 percent, from a high of 413 to 146. The drop reflects the reduced resources available for the surveys, which declined from $3 million in fiscal year 1993 to $670,000 in fiscal year 1999. During that same period, the number of surveyors fell from 147 to 76.

As a result of reduced resources, hospitals are going longer without HCFA surveys. Since fiscal year 1993, the average time between surveys has tripled, from 14 months to 3.5 years. The inspector general's staff identified 37 hospitals that have not been surveyed for five or more years, including three that have gone ten years.

As fewer and fewer HCFA-contracted surveys have been conducted, HCFA's surveyors are finding more hospitals out of compliance with the two extra conditions of Medicare participation, the report states. In fiscal year 1993 they found 13 percent of the psychiatric hospitals out of compliance with one or both conditions. By fiscal year 1998, a total of 21 percent were out of compliance.

In an effort to strengthen the external review system, the report recommends that HCFA determine an appropriate minimum cycle for contracted surveys. HCFA should take steps to coordinate survey activities—accreditation, state agency certification, and contracted surveys—among the external reviewers, the report says, so that the surveys do not impose an undue burden on hospitals and that some hospitals are not overlooked by the review system.

The report also recommends that the surveyors be trained in the full range of Medicare conditions of participation for hospitals and be available to respond to complaints and adverse events involving psychiatric care. Because of their special expertise, these surveyors should also be used for surveys in psychiatric units of general hospitals as well as in psychiatric hospitals. In addition, HCFA should hold surveyors more fully accountable for their performance by conducting periodic observations of the survey process, obtaining timely and useful performance reports, providing feedback and guidance, and increasing public disclosure of the survey results.

Another recommendation calls for HCFA to negotiate with the Joint Commission to achieve a more patient-centered approach in its surveys and to ensure a more rigorous assessment of discharge planning. HCFA is also urged to consider applying the Medicare special conditions of participation in psychiatric units of general hospitals, where most psychiatric patients are treated.

The report, entitled The External Quality Review of Psychiatric Hospitals (OEI-01-99-00160), is available on the Internet at www.hhs.gov/oig/oei/whats new.html.

A national survey by the American Foundation for Suicide Prevention (AFSP) found that 45 percent of Americans have had a close friend or relative who attempted suicide. Less than half of those who attempted suicide were reported to have undergone treatment or therapy to address the reasons for the attempt.

The survey results were released in early May at a symposium on suicide prevention sponsored by AFSP, a not-for-profit organization that funds research on suicide prevention and offers educational programs for survivors, mental health professionals, and the public.

Sixty-two percent of survey respondents correctly recognized depression as the leading cause of suicide. Seventy-six percent expressed sympathy toward those who attempt suicide. Twenty-five percent believed the person who commits suicide suffers from a mental disorder. Twenty percent said the condition is treatable, and 5 percent said the person could not be helped.

Survey respondents were a nationally representative sample of 1,026 adults age 18 and older who were interviewed by telephone between March 30 and April 2 of this year. Roper Starch Worldwide conducted the survey, which was funded by an education grant from Pfizer, Inc.

An AFSP statement announcing the survey results said that 75 percent of all persons who attempt suicide give some warning of their intentions to a friend or family member. Warning signs include previous suicide attempts; talking about death or suicide; planning for suicide, often by putting personal affairs in order; and depression. AFSP said that 30 percent of all clinically depressed patients attempt suicide, and half of them succeed over a lifetime. The statement noted that more than 30,000 suicides occur in the United States each year, making it the eighth leading cause of death. Suicide is the third leading cause of death among young people between the ages of 15 and 24.

More information about the survey is available from AFSP at 120 Wall Street, 22nd Floor, New York, New York 10005.

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News Briefs

Office-based treatment of opiate addiction: The Center for Substance Abuse Treatment (CSAT) of the Substance Abuse and Mental Health Services Administration has announced its intent to develop regulations that will allow physicians to provide partial-agonist treatment medications in office-based settings to patients addicted to heroin. New-drug applications for two new narcotic treatment medications, buprenorphine and buprenorphine-naloxone, are currently being reviewed by the Food and Drug Administration. If the new medications are approved, federal law requires that the Secretary of Health and Human Services develop standards for their use in treatment. CSAT envisions the new rule allowing office-based physicians to prescribe partial-agonist treatment medications for the treatment of opiate addiction, which is prohibited under existing federal regulations. A notice about the proposed regulations was published May 5 in the Federal Register.

New psychiatric administrators: The American Psychiatric Association's committee on psychiatric administration and management certified five psychiatrists in psychiatric administration and management at its meeting in May in Chicago. They are Namir F. Damluji, M.D., of Brookfield, Wisconsin; Thomas E. Jordan, Jr., M.D., of Bloomfield Hills, Michigan; Rose Yu-Chin, M.D., M.P.H., of Southbury, Connecticut; Kevin D. Moore, M.D., of Charleston, South Carolina; and Craig J. Wronski, D.O., of Long Beach, California.

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