Harvard Medical School McLean Hospital

Department of Psychiatry
PRESIDENT

PSYCHIATRIST IN CHIEF

CHAIR
PROFESSOR OF PSYCHIATRY Scott L. Rauch, M.D. PARTNERS PSYCHIATRY AND MENTAL HEALTH

April 30, 2010

Centers for Medicare and Medicaid Services
Department of Health and Human Services
Room 445-G, Hubert H. Humphrey Building
200 Independence Ave., SW

Washington, D. C. 20201

Re: File Code: CMS-4140-IFC
Dear Sir:

On behalf of McLean Hospital , I am offering comments regarding File Code CMS-4140-
IFC; Interim Final Rules Under the Paul Wellstone and Pete Domenici Mental Health and
Addiction Equity Act of 2008. McLean Hospital provides a continuum of mental health and
substance use disorder services that comprise inpatient, residential, partial hospital and
outpatient services in Belmont, MA and in other community locations. McLean’s mission of
providing excellent clinical care, teaching and research allows for access to a diverse
population of patients and families and has given us a sense of the need for change in the
existing service system. We are very supportive of the overall direction of the Interim Final
Rules and the focus on clear delineation of how parity for these important mental health and
substance use disorder services will be defined.

These regulations are extremely important and we look forward to their successful
promulgation. In Massachusetts, we have had positive experience with Parity Laws creating
additional access to services for patients and families. The insurance treatment for
behavioral health was also greatly improved by removing arbitrary day and dollar benefit
limitations for certain conditions. However, these laws did not address the onerous and
arbitrary practices employed by many managed care organizations hired specifically to act as
managers of mental health and substance abuse services (Carve-Out firms).

The oversight from these specialized firms is far more rigorous for behavioral health than it
is for medical/surgical services in the areas of Pre-Admission Screenings; Concurrent
Reviews; and the application of Medical Necessity Standards. Hospitals and clinicians
continually struggle to get off-site Carve-Out firms to approve services that clinicians who
have seen the patient believe are medically necessary. Clinicians are constantly questioned
and micro-managed by Carve-Out reviewers as to the medical necessity of a given behavioral
health service.

McLean Hospital, 115 Mill Street, Belmont, Massachusetts 02478-9106
Telephone (617) 855-2201, FAX (617) 855-3880 Email srauch@partners.org
A Teaching Facility of Harvard Medical School / An Affiliate of The Massachusetts General Hospital / A Member of Partners HealthCare System, Inc.


The emphasis in the proposed federal regulations in the area of nonquantitative treatment
limits will greatly improve both access to and more efficient delivery of services to patients.
We hope that the federal agencies adhere to this language in the final regulations. Without
such a provision it will be impossible to achieve true Parity for mental health and substance
use disorder services.

Access to the appropriate level of care will be greatly enhanced if the final regulations clarify
that the plans must provide all levels of essential mental health and substance use disorder
services, as currently required for medical/surgical services. In order to have Parity, the
scope of services should include access to inpatient, residential, partial hospital and
outpatient services in order for mental health and substance use disorder services to be
comparable to the rehabilitation services included in medical/surgical services.

I appreciate the opportunity to offer these comments and would be available to answer any
questions.

Sincerely,

Sc ae Wi)

Scott L. Rauch, M.D.