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Association for Ambulatory Behavioral Healthcare

247 Douglas Avenue Portsmouth, VA 22307

Phone 757‐673‐3741    Fax 757‐966‐7734

E-mail: aabh@aabh.org

 Web: www.aabh.org

May 27, 2009

Centers for Medicare and Medicaid Services 

Department of Health and Human Services 

Attention CMs-4137 – NC 

P. O. Box 8017 

Baltimore, MD 21244-8010 

Request for Information Regarding the Paul Wellstone and Pete Domenici Mental 

Health Parity and Addiction Equity Act of 2008 

Dear Sir: 

The Association of Ambulatory Behavioral Healthcare (AABH) is providing Public Comment by way 

of this letter on Issues Related to the Implementation of the Mental Health Parity and Addiction Equity 

Act of 2008. We thank you for the opportunity to comment on this issue. The AABH feels that the 

use of Partial Hospital Programs (PHP) and Intensive Outpatient Programs (IOP) to treat mental 

illness and substance use (M/SU) conditions are proven methods of care and money saving options to 

inpatient and emergency care for these individuals. 

A copy of the Standards and Guidelines for PHP and IOP, developed originally in the late 1970s and 

updated every few years since then by AABH Board of Directors and members, are attached to this 

letter 

The AABH is a national membership organization of Partial Hospital Programs (PHP) and Intensive 

Outpatient Programs (IOP), outpatient hospital treatment providers, free standing treatment providers, 

administrators, doctors, psychologists, nurses, program directors, and front line therapist and support 

staff who serve as educators, case managers, political advocates, and treatment providers of 

individuals with mental illness and substance use (M/SU). 

The AABH supports the PHP and IOP treatment programs concept within the M/SU continuum of 

care, flanked by outpatient/assessment services and inpatient/acute services. Medical necessity 

guidelines determine eligibility for PHP and IOP treatment and reflect an acuity level only slightly less 

severe than inpatient treatment. 

In general, PHP and IOP treatment is effective when deemed medically necessary by the treating 

physician to avert inpatient hospital treatment. The patient must be experiencing noticeable 

impairment in self-care and must be unable to fulfill expected life functions. Patients may also be 
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referred to PHP or IOP as a step-down from more expensive inpatient treatment to facilitate base-line 

functioning. PHP and IOP services are known for their ease of accessibility, and low cost treatment for 

individuals with acute and chronic mental illness. 

PHP and the less intensive IOP treatment, engages the patient in diagnostic assessments, symptom 

management and coping skills education, crisis intervention and relapse prevention, and relies on best 

practices and performance benchmarking to provide information as to the efficacy of the treatment 

programs. 

The inclusion of PHP and IOP services within the continuum of care is vital to the 

implementation of parity, as it allows for patients to be treated in the less restrictive and less 

costly level of care, to be treated in the community in which they live, and acts to prevent 

decompensation of symptoms and establishes a more positive quality of life. 

CURRENT STATEMENTS BY SAMHSA 

The AABH agrees with SAMHSA’s statement regarding their report describing the unique needs of 

M/SU individuals and how reform efforts can assist and establish the methods to integrate the best 

knowledge and expertise available for M/SU treatment and prevention services into the health care 

reform planning process. 

“While reform must successfully deal with the medical needs of the many healthy individuals, the 

greater challenge is to ensure that a reformed system better serves the medical and M/SU chronic care 

and prevention needs of a small fraction of the population that consumes a disproportionate number of 

services. Currently: 

• Providers are paid for providing services rather than producing desired outcomes; 

• Significant disparities in health and health outcomes exist across sectors of society; 

• Individuals, health practitioners, and policymakers make decisions based on a limited 

evidence base regarding which practices work effectively for which groups or individuals; 

• The current system focuses heavily on expensive acute care for physical and M/SU 

illnesses to the detriment of a mind/body wellness and proactive approach that can prevent 

and/or stabilize disease well before acute care is ever needed. 

The AABH fully supports SAMHSA’s position on utilizing the already proven and effective 

interventions provided through outpatient programs such as PHP and IOP for treating M/SU 

conditions while new and innovative interventions are being sought. M/SU treatment benefits already 

well exceed costs—for every dollar spent on M/SU treatment, seven dollars in future health care 

spending can be saved, compared to the widely accepted interventions such as pay-for-performance 

diabetes care that returns less than three dollars for every dollar invested. Preventive and proactive 

care will save money. 

PARTIAL HOSPITAL PROGRAMS AND INTENSIVE OUTPATIENT PROGRAMS 

Since as early as 1968, PHPs have been providing mental health and substance abuse treatment for the 

nation’s chronic and disabled mentally ill. Although not widely used until the mid 1990s, the PHP 

was developed as a less costly and more accessible treatment option to in-patient hospital care. As the 
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M/SU patient is treated in the environment in which he lives, he is able to live in a stable environment 

and receive outpatient treatment close to his home. The savings are significant when the efficacy and 

cost of a long term PHP care is set against the efficacy and cost of short term hospital or emergency 

care. 

Partial Hospital Programs (PHP), and the less structured Intensive Outpatient Programs (IOP), are 

ambulatory, active and time-limited M/SU treatment programs that offer therapeutically intensive 

coordinated and structured clinical services within a stable therapeutic milieu. “Partial Hospital and 

Intensive Outpatient” implies psychosocial milieu treatment with group therapy as the primary 

treatment modality. While specific program variables often differ, all PHPs and IOPs pursue the 

general goals of stabilizing clinical conditions, reducing symptoms and impairments, averting 

inpatient hospitalization, reducing the length of a hospital stay, and providing medically necessary 

treatment for individuals who cannot be effectively treated in a less intensive, strictly outpatient level 

of care. 

All PHPs and IOPs attempt to employ an integrated, comprehensive and complementary array of 

evidence-based treatment approaches. Programs are designed to serve individuals with severe 

symptoms and functional impairments resulting from M/SU disorders. They are also intended to have 

a positive clinical impact on the individual patient’s support system and therefore the individual’s 

recovery environment. Treatment services may be provided during the day time, evening time and on 

some occasions, on the weekends. 

PHPs and IOPs may be free standing, part of a mental health organization, or a department within a 

medical healthcare system. One of the unique strengths of a PHP or IOP is its applicability to a 

diverse array of circumstances such as clinical conditions, patient populations, treatment durations, 

treatment settings, etc. 

PARTIAL HOSPITAL PROGRAMS AND INTENSEVE OUTPATIENT PROGRAMS ARE 

INTENDED TO: 

• Provide the M/SU patient a way of managing their illness in an environment that allows 

them to remain in their homes and communities; 

• Provides Continuum of Care options, as these patients require psychiatric care of some 

type for their entire lives; 

• Provide options, other than inpatient hospitalizations, which are far more restrictive, far 

more costly, and far less effective; 

• Provide a cost savings, as untreated mentally ill patients will eventually end up in hospital 

emergency departments, jails, prisons, or become part of the growing homeless 

population. 

The concept of PHP and IOP is to maintain patients with chronic behavioral disorders in a controlled 

environment, providing psychotherapeutic and pharmacologic support on a daily basis, without 

requiring an inpatient hospitalization. Patients admitted to a PHP or IOP must be under the care of a 

physician; patients must provide written informed consent for treatment; must require comprehensive 

treatment due to a M/SU disorder which severely interferes with multiple areas of daily life, including 

social, vocational and educational functioning 

Patients appropriate for the PHP or IOP level of care comprise the following: 
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• Discharged from an inpatient hospital treatment program; 

• In lieu of continued inpatient treatment; or 

• Patients who, in the absence of partial hospitalization, would require inpatient 

hospitalization. 

Patients admitted to a PHP or IOP are provided comprehensive treatment and utilize the same services 

as inpatient psychiatric care at a greatly reduced cost; the treatment directly addresses the presenting 

symptoms and problems and consists of clinically recognized therapeutic interventions including 

individual, group, and family therapies and activities pertinent to the patient's illness. Medical and 

psychiatric evaluations and medication management are integral to treatment. 

ADMISSION CRITERIA TO A PHP AND IOP 

M/SU patients should be treated in the least intensive and restrictive setting that meets the needs of 

their M/SU illness. If patients do not require a 24-hour per day level of care, as provided in an 

inpatient setting, the PHP outpatient level of care is the perfect setting to prevent inpatient 

hospitalization. The M/SU patients being treated in a PHP or IOP receive active treatment through a 

combination of services such as psychotherapy, occupational, activity therapy and medical 

interventions as necessary. 

Patients admitted to a PHP or IOP must have an acute onset or decompensation of a covered Axis I 

mental disorder which severely interferes with multiple areas of their daily life and will have a degree 

of impairment that is severe enough to require a structured program 

SERVICES PORVIDED IN A PHP OR IOP: 

• Medically necessary diagnostic services related to M/SU 

• Individual or group therapy; Occupational Therapy 

• Drugs and biologicals that cannot be self-administered 

• Individualized activity therapies that are essential for progress toward treatment goals. 

• Treatment plans noting how each therapy fits into the treatment of the patients illness 

• Family counseling to assist the family members in helping the patient 

• Patient education where activities are related to the care and treatment of the patient 

• Diagnostic services for the purpose of identifying problem areas 

M/SU conditions are tied to physical health and can be addressed like other chronic and acute 

conditions in order to provide efficacious health care. Ignoring one is likely to compound the other. 

However, people that need M/SU treatment services and the services vary widely. An effective health 

care delivery system must provide: 

• Providers who are paid for providing services with desired outcomes; 

• A comprehensive range of services; 

• The full continuum of care, including PHP and IOP services; 

• Service to those with both acute and chronic condition 

• Service to a wide and varied population – some will present themselves, some will be 

delivered into the system, and some the system will need to seek out and serve. 
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SUMMARY 

PHPs and IOPs have evolved over the years until their current status as an instrumental part of the 

behavioral health continuum. Clients are referred both as an alternative to inpatient hospital care as 

well as a step-down from in-patient hospital care. PHPs and IOPs are particularly successful with first 

episode of care patients and utilize an educational format combined with group therapy, medication 

management, and specialized therapies to assist people in understanding their diagnosis and initiating 

a path toward recovery. Most programs are managed and adhere to strict medical necessity guidelines 

which determine individual eligibility for care. 

In conclusion, we want to make sure that parity includes the provisions of PHP and IOP services for 

M/SU in healthcare plans, as they maintain a fundamental alternative to in-patient care for the 

seriously ill M/SU patient in acute crisis, while providing a supportive community-based setting that 

maintains the continuation of family and community support. This gives the patient the opportunity 

to maximize treatment gains through completion of homework assignments, reconnect with 

community services, seek out employment options, and be involved in activities that develop strengths 

and enhance resiliency and recovery. 

 

Again, we would again like to thank you for this opportunity to share our comments. The AABH 

continues to work with other organizations and government agencies towards an integrated healthcare 

system where the M/SU patient will be able to receive a multitude of services including treatment in a 

PHP and IOP. 

We look forward to working with you on implementing the Mental Health Parity and Addiction 

Equity Act. 

Sincerely, 

Larry Meikel - President of the Board 

AABH Board of Directors 

Public Policy Committee