Managed Care - November 2008 - (Page 9)

LEGISLATION & REGULATION meyer. “Health plans are investing in the resources or contracting out. Because they are moving away from explicit limits, there will be more attention to managing the benefit.” Andrew Sperling, director of legislative affairs for the National Alliance on Mental Illness, says that the association expects plans “to aggressively use tools such as prospective and concurrent utilization reviews and prior authorization of high-cost services to avoid having costs spiral out of control.” To understand where health plans will have to make their biggest changes, you have to break the country down state by state, he adds, and look to see what they require in terms of parity. “If you’re in a state with one of the stronger parity laws — Minnesota, Maryland, Rhode Island — you’re not going very far in coming into compliance with this law,” says Sperling. “In Florida, where there is no parity and you’re imposing numerical limits on in-patients days and outpatient visits and you have a lot of people who come up against those limits, if you just take off the limits, your costs are going to go up substantially. “We expect the carve-out industry to flourish under parity simply because there’s a substantial part of the health plan market that doesn’t have expertise in managing behavioral health benefits,” he adds. Being allowed considerable latitude in managing the benefit, insurers say, was a key to coming up with widespread support for the final compromise. It is a big reason why the industry doesn’t expect to see large employers or the health plans that work for them simply abandon the benefit through the escape door built into the law. ical ailments, says Pamela Greenberg, president of the Association for Behavioral Health and Wellness, which includes behavioral health companies already providing coverage. Says Greenberg: “It’s more individualized.” Further complicating the field is the way providers react to managed care. Some mental health providers simply don’t want to contract with a managed care network, she says. “Part of the resistance is having to comply with practice guidelines or quality measurement tools that managed behavioral health care organizations are using,” says Greenberg. Those challenges may also spur some MCOs to contract it out. Waiting for the regs Advocates say plans won’t drop it. In a lot of states, Sperling notes, they can’t. “It may mean they have to raise cost sharing for the medical benefits to lower cost sharing for the mental health benefits,” says William Schiffbauer, a health care lawyer. “And for state-regulated insurance coverage, there may be a rush of mandates in states that don’t have them. Or they could reevaluate their existing mandates. This federal parity law will stimulate some new activity at the state level. That’s their prerogative. Mental health providers have had easy access to state lawmakers and influence.” Affordability was a key feature for gaining the support of groups like America’s Health Insurance Plans. To get there, negotiators who sat down together scrapped a controversial provision that would have required plans to cover a smorgasbord of mental health conditions outlined in the Diagnostic and Statistical Manual for Mental Disorders, published by the American Psychiatric Association. By reducing the overall financial impact, says one prominent managed care consultant, lawmakers gutted any chance of a sweeping new mandate. “The estimates on what this will cost are two tenths of one percent,” says Bob Laszewski, the consultant. “How much change are you going to get out of it? Zippo. That’s as low as I’ve ever seen. That tells you right there that there isn’t going to be monumental change.” MC A different world Once managed care organizations move past the arbitrary inpatient and outpatient limits they currently have in place for mental health and substance use disorders, they’re likely to find themselves confronted by a new set of practice guidelines and quality assurance measures that aren’t always the same as in the world of medical benefits. “It’s not as black and white” as treating phys- NOVEMBER 2008 / MANAGED CARE 9

Table of Contents Feed for the Digital Edition of Managed Care - November 2008

Managed Care - November 2008 Editor’s Memo Contents News and Commentary Legislation & Regulation Letters Medication Management Compensation Monitor Do It Yourself for Less Biomarkers Promise, but Do They Deliver? Oncologists Complain About Drug Payment Consider Blood Pressure Self-Monitoring Q&A: Keep Industry in the Game Formulary Files Plan Watch Tomorrow’s Medicine Outlook Respiratory Syncytial Virus Managed Care Considerations Contents Continuing Education Objectives RSV Disease in the Pediatric Population In the Trenches RSV Infection in the Adult Population Health Plan Medical Director Health Plan Pharmacy Director RSV Issues and Solutions Assessment/Evaluation/Certificate Request Post-Test

Managed Care - November 2008

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