December 2009: This Month's Highlights

Parity Lessons From California

On January 1, 2010, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act takes effect for most insurance plans. As the December issue goes to press, federal policy makers have not yet issued implementation guidelines. These officials and thousands of individuals in private industry and state monitoring agencies who will be charged with ensuring adherence to the guidelines might learn from California, where parity has been a reality since 2000. This month's lead article reports experiences of California health plans, providers, and consumers during the first five years of parity. From September 2001 through January 2006, Margo L. Rosenbach, Ph.D., and colleagues conducted interviews with nearly 150 state- and community-based stakeholders and led six focus groups that included 84 providers and consumers. The researchers found that although health plans eliminated differential benefits and cost-sharing requirements for the limited list of diagnoses to which the law applies, their use of medical necessity criteria to control costs led to concerns about access and quality, which in turn led to an increase in regulatory oversight five years after implementation. Health plan executives concluded that use of the limited list of diagnoses, which had some unintended consequences, was unnecessary. Lack of consumer knowledge about parity was widely acknowledged to be a critical problem ( Original article: page 1589 ).

Questionable Practices in New York State

The health care reform debate has drawn attention to the wide variation in physicians' practices. Participants on both sides have emphasized the importance of adhering to evidence-based practices to ensure quality and save health care dollars. In the second article in this month's line-up, Susan M. Essock, Ph.D., and colleagues describe an initiative by the New York State Office of Mental Health (OMH) to identify potential quality concerns in prescribing practices in the state's Medicaid program. A panel of 34 psychopharmacology experts convened by OMH in 2007 developed criteria to identify clinically questionable practices from claims data. Application of the criteria would trigger a clinical review to determine whether the concern was justified and feedback to "outlier" providers was warranted. Dr. Essock and her team then applied the criteria to the nearly 220,000 Medicaid recipients with an active psychotropic prescription on April 1, 2008. The researchers found significant rates of intensive polypharmacy among both adults (10% with more than four concurrent psychotropic medications) and children (13% with more than three). They also found that among recipients who received medications with a moderate-to-high risk of metabolic abnormalities, half of adults and nearly three-quarters of children had no record of a metabolic screen in the past year ( Original article: page 1595 ). In a commentary, John M. Davis, M.D., and Daniel J. Luchins, M.D., discuss the strengths and limitations of computerized prescription support systems ( Original article: page 1603 ).

Americans' Perceived Need for Alcohol Treatment

Most Americans with alcohol use disorders do not receive treatment, and accumulating evidence points to a major underlying reason: they do not perceive that they need it. To provide current estimates of the percentage of individuals with alcohol use disorders who perceive a need and, among those, the percentage who enter treatment, Mark J. Edlund, M.D., Ph.D., and colleagues analyzed data from two national epidemiologic surveys. They found that although fewer than one individual in nine with an alcohol use disorder perceived a need for treatment, two of every three persons with perceived need had received treatment in the past year. The findings suggest that steps forward in parity and health care reform that will make addiction treatments accessible to many more Americans will not achieve desired outcomes without accompanying efforts to increase perceived need ( Original article: page 1618 ).

First U.S. Randomized Controlled Trial

The illness management and recovery program incorporates empirically supported methods for teaching people how to manage their psychiatric disorders and achieve recovery goals. Aaron J. Levitt, M.S., and colleagues report on the first U.S. randomized controlled study of the intervention. In a supportive housing program in New York City, 104 persons with serious mental illness were randomly assigned to either the intervention or a waiting list, and multimodal follow-up assessments were conducted six months posttreatment. Intervention participants had significantly greater improvements in symptoms and functioning. Dropout patterns suggest that there may be merit in conducting separate classes for higher-functioning participants or those with more knowledge of mental illness and more years of education ( Original article: page 1629 ).