NEW, DIRECTIONS F

services, the member’s outpatient providers can be notified, and appropriate discharge planning is
coordinated and accomplished.

New Directions believes managing MH/SUD conditions based on clinically justified processes that
are unique to MH/SUD results in more appropriate access to services, more appropriate quality of
care being rendered, and better treatment outcomes. Imposing management on M/S conditions
when not clinically justified is inappropriate. Thus, there should not be strict parity required
because medical management processes are not inherently treatment limitations.

Thank you for the opportunity to comment on these Interim Final Rules and for considering our
suggested recommendations. If you have any questions, please contact me at jquick@ndbh.com or
913.982.8111.

Sincerely,
_—

John F. Quick, PhD
President and CEO


NEW DIRECTIONS f ]

BEHAVIORAL HEALTH

even be limited in what they can wear. Additionally, there is a significant stigma placed on
members who require inpatient treatment for MH/SUD conditions. As a result, there is an emphasis
on limiting the number of days that a member has to be hospitalized. The treatment goal is to
determine when it is appropriate to transition the member to an intermediate level of care, such as
partial hospitalization or intensive outpatient treatment.

e Impaired Ability to Navigate Health Care System
Members who have an MH/SUD condition are often impaired in their ability to think, to make
decisions, or to make informed decisions. This creates challenges in navigating the health care
system. The MBHO facilitates scheduling appointments for members with the most appropriate
provider and within a time frame that is based upon the urgency of the condition. Follow-up calls
are then made to verify that appointments are kept, whether medications are being taken, and to
assess how the member is doing. Home visits can be arranged as necessary or other assistance
offered so that treatment can be appropriately accessed.

¢ Coordination of Care
Many MH/SUD conditions are chronic or long term, with acute episodes along the way.
Depending on the stage of the condition, this may require inpatient treatment, intermediate level of
services, or outpatient treatment. Frequently, medications are prescribed by a psychiatrist. Because
many intermediate level and outpatient therapies are delivered by behavioral health therapists, such
as advance practice registered nurses, social workers, and licensed professional counselors,
coordinating care among the member’s primary care physician, psychiatrist, and behavioral health
therapist is critical, and a primary role of MBHOs.

If there are isolated cases of companies attempting to do so based on inappropriate processes, they
need to be held accountable. But where there is clinical justification based on outcomes and quality
measures, those management processes must be allowed.

e FEHBP Has Increased Management of MH/SUD Conditions
In 2001, the Federal Employees Health Benefits Program (FEHBP) implemented full parity of
MH/SUD benefits. Plans were encouraged to manage these benefits to expand coverage costs
effectively while maintaining quality services. U.S. Office of Personnel Management, Mental
Health and Substance Abuse Parity Frequently Asked Questions
‘http://www.opm.gov/insure/archive/health/consumers/parity/faq.asp). Initially, FEHBP required
preauthorization after the 8" outpatient visit for MH/SUD benefits. That was changed in 2009 and
now preauthorization is required for any MH/SUD outpatient visit, except for medical management
and psychological testing.

Recommendation: Modify Rule To Clearly Allow Clinically Justified Management of
MB/SUD Conditions

New Directions generally recommends requiring preauthorization after the 8" outpatient visit with a
behavioral health therapist since many acute episodes resolve within that number of visits, ard not
requiring preauthorization for medical management with a psychiatrist. Preauthorization is typically
required for inpatient services so that, along with determining the medical necessity of inpatient

3


REC NAVEFIA- 04 Page 1 of 1

LEGAL PROCESSING DIVISION d
PUBLICATION & REGULATIONS WAY 4 cord
BRANCH

As of: May 04, 2010
Received: May 03, 2010

. Status: Posted
PUBLIC SUBMISSION [rere ras dice
‘Comments Due: May 03, 2010)
Submission Type: Web

Docket: IRS-2009-0008
Request for Information for Paul Wellstone and Pete Domenici Mental Health Parity and Addiction
Equity Act of 2008

Comment On: IRS-2009-0008-0120
Interim Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and
Addiction Equity Act of 2008

Document: IRS-2009-0008-0157
Comment on FR Doc # 2010-02167

Submitter Information

Name: John F. Quick, Ph.D

Address:
New Directions Behavioral Health, LLC
2020 West 89th Street, Suite 200
Leawood, KS, 66206

Email: jquick@ndbh.com

Phone: 913-982-8111

Fax: 913-982-8201

Organization: New Directions Behavioral Health, LLC

——— —

General Comment

See attached file(s)

Attachments

IRS-2009-0008-0157.1: Comment on FR Doc # 2010-02167

https://fdms.erulemaking.net/fdms-web-agency/component/submitterInfoCoverPage?Call=P... 5/4/2010


NEW DIRECTIONS EI

2020 W. 89" Street. Ste. 200
Leawood. KS 66206

May 3, 2010
Submitted via Federal eRulemaking Portal: http://www.regulations.gov

The Honorable Hilda Solis

Secretary, U.S. Department of Labor

Office of Health Plan Standards and Compliance Assistance
Employee Benefits Security Administration

200 Constitution Avenue, NW

Washington, DC 20210

Attention: RIN 1210-AB30

The Honorable Kathleen Sebelius

Secretary, U.S. Department of Health and Human Services
Centers for Medicare and Medicaid Services

200 Independence Avenue, SW

Washington, DC 20201

Attention: CMS—4140-IFC

The Honorable Timothy Geithner
Secretary, U.S. Department of the Treasury
Internal Revenue Service

1111 Constitution Avenue, NW
Washington, DC 20224

Attention: REG-120692-09

RE: Comments on Interim Final Rules under the Paul Wellstone and Pete Domenici Mental Health
Parity and Addiction Equity Act of 2008

Dear Mr. and Mmes. Secretary:

New Directions Behavioral Health appreciates the opportunity to comment on the Interim Final
Rules under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act
of 2008, published in the February 2, 2010 Federal Register.

New Directions is a managed behavioral health organization (MBHO) that manages approximately
2 million lives throughout the country. Our company began in 1995, and we’ve experienced much
growth in our ability to manage members with mental health and substance use disorder
(MH/SUD) conditions. We are known for being very innovative in our practices as reflected by
several national awards, which have included URAC Best Practices in Health Consumer
Empowerment and Protection and NCQA HEDIS Update and Best Practices Improving Patient
Safety. The Vision of New Directions is to facilitate access to services, while focusing on
prevention as our predominant paradigm for management of care.



NEW DIRECTIONS im

BEHAVIORAL HEALTH

New Directions is concerned that the nonquantitative treatment limitation related to medical
management is being interpreted as restricting how MH/SUD conditions can be managed. We
believe the results will be devastating for members with MH/SUD conditions because of the
unintended consequences of this Rule.

¢ Uniqueness of MH/SUD Conditions
We perceive a lack of understanding of the unique qualities of MH/SUD conditions, and how
different they are from medical/surgical (M/S) conditions. The goal of managing care for MH/SUD
conditions is to insure that members timely access the most appropriate type of provider, e.g.,
psychiatrists for medication or behavioral health therapists for talk therapy, in the most appropriate
environment. In practice, medical management processes for MH/SUD conditions are typically
used to determine what is the appropriate level of care, not whether treatment is needed, and how
quickly treatment is needed.

Most plans don’t extensively manage M/S conditions because they are self-limiting. Visit limits
may be imposed as management on certain types of treatment, such as physical therapy. Significant
differences in the management processes reflect the distinct differences between these conditions,
not an intent to limit access to MH/SUD services.

¢ Management of MH/SUD Conditions Improves Access and Quality
And Is Not A Treatment Limitation

While managing MH/SUD conditions also lowers costs, this results from more appropriate
utilization of services and higher quality services being provided, not decreased access to services.
In fact, in the Supplementary Information to the Interim Final Rules for Parity, these statements are
made:

“Since the early 1990s, many health insurers and employers have made use of specialized
vendors, known as behavioral carve-outs to manage their mental health and substance: abuse
benefits. These vendors have specialized expertise in the treatment of mental and addictive
disorders in organized specialty networks of providers. ... They use information technology,
clinical algorithms and selective contracts to control spending on mental health and
substance abuse treatment. There is extensive literature that has examined the cost savings
and impacts on quality of these organizations. ... Also, it appears that the rate of utilization
in mental health care rises under behavioral health carve-out arrangements.”

75 FR 5410, 5422 (2010).

e Applicability of Least Restrictive Environment Principle
Utilizing the “least restrictive environment” principle requires that in determining the appropriate
level of care for members with MH/SUD conditions, they are placed in the least restrictive
environment. This is based on the premise that persons should not be deprived of their liberties or
freedom except when absolutely required and to the minimal level necessary. For example, when
patients are placed in an inpatient mental health unit, frequently the doors are locked, there are
limitations on visitors, time is very structured, they are deprived of personal possessions, and may

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