1001 South George Street Gary B. Zimberg, M.D., M.H.A., M.P.H.
P O Box 15198 Executive Director

York, PA 17405-7198 WellSpan Behavioral Health
717.851.2672 Tel

717 851.2479 Fax Professor of Clinical Psychiatry
e-mail: gzimberg@wellspan.org The Pennsylvania State University

School of Medicine

www.wellspan.org ‘WELLSPAN

HEALTH

May 18, 2009 NO

Department of Health and Human Services
Centers for Medicare & Medicaid Services
Department of HHS

P.O. Box 8017

Baltimore, MD 21244-8010 .

RE: MENTAL HEALTH PARITY AND ADDICTI TION EQUITY ACT OF 2008
To Whom It May Concern:

Passage of the aforementioned Act has been lauded in the mental health community.
While most states have moved in the direction of mental health parity for years,
federal regulation has lagged, and the many exclusions included in prior federal
statutes have made life difficult for patients and providers alike. Managed care, often
criticized for:its particularly harsh treatment of mental health, must be:credited-to .
somé degree for! allowing:the 2008 Act to come to fruitions.Managed care:made the
provision of mental health coverage quantifiable, and.by extension, subject. to:accurate
pricing.. Managed care.companies have become adept at managing the mental-health :
benefit, affording primary medical insurers the opportunity to offer mental health as a
covered benefit on an actuarial sound basis, commensurate with all other medical and
surgical conditions. Primary health insurers will undoubtedly continue to rely upon
mental health managed care companies for benefit design, treatment criteria, network
development, etc. I have no doubt that mental health “carve outs” can rise to the task,
as most have played both sides of the fence at some point, providing management
services and some degree of clinical services simultaneously.

éThe single greatest problem encountered to date with mental health managed care eee
“companies has been establishing, and reliably enforcing, criteria for approving or

disapproving treatment. In fact, clinical reviewers for managed care companies
frequently point out that they are not actually denying treatment, but rather, coverage
for treatment. This is obviously more than a matter of semantics considering the fact
that most consumers are unable to afford treatment without use of their insurance
benefits. Having also worked both sides of the fence, as the Mental Health Medical
Director of a Blue Cross plan, I can honestly say that most of the low-hanging fruit
with respect to cost containment has already been picked. Long-term psychiatric .
hospital stays‘are a relic of the past. Regional and national shortages.of mental:health
( ikeésover-treatment” exceedingly unlikely. To that end,’burdensome :
.d'6f‘mental:health providers prior to and:during the delivery of
an'‘unténable.burden; quite dissimilar from that required of non-. .
mental health:providers.: As the Act does not specifically address this, mental health .

os



Page Two
Mental Health Parity and Addiction Equity Act of 2008
May 21, 2009

providers are appropriately concerned that the practice will continue, creating an
unequal burden on mental health providers relative to those outside of the field. TM
Additionally, the appeal process for denied claims has often been unfair. Internal
appeals are typically reviewed by employees of the managed care company, and
external appeals are usually reviewed by either individuals or committees receiving
regular and at times substantial income from the managed care company. Truly
objective reviews are difficult to come by.

I would support the continued use of mental health managed care companies as
intermediaries for primary insurers in their delivery of mental health benefits. I would

also give them ktidos for est'ablishirig 4 sound“actuarial basis for primary insurers to" ~*~

offer mental health benefits widely. That said, I would recommend that paperwork
required of mental health providers be no different than that required of all other
providers. I would also recommend that the appeal process be conducted by
independent entities with no financial ties to the managed care company or primary
insurer. State medical societies might provide an alternative for appeals, or perhaps
employed physicians of federal and state government. Both would be relatively
insulated from the financial pressures ordinarily felt by reviewers paid directly by the
insurer.

Thank you for allowing the public the opportunity to comment upon this Act before
implementation.

Sincerely,

Gary B. Zimberg, M.D., M.H.A., M.P.H.

Sur TGBZ/tksy + et

q

“w