A continuum of psychiatric
and chemical dependency services

May 3, 2010 EMAIL: http://www.regulations.gov

RE: Federal Rulemaking Portal

Dear Sir:

On behalf of Bournewood Health Systems which is a major provider of acute psychiatric inpatient,
partial hospital, and outpatient services in the Metro and Greater Boston areas of Massachusetts, | am
offering comments relative to File Code CMS-4140-IFC; Interim Final Rules Under the Paul
Wellstone and Pete Domenici Mental Health and Addiction Equity Act of 2008. Bournewood
Health Systems admits more than 3,800 inpatients, and close to 1,000 partial hospital patients per year.
Bournewood’s programs provide a full continuum of psychiatric and dual diagnosis care to adults and
adolescents and has been in continuous operation on its present site since 1895.

As a direct provider of behavioral health services, we at Bournewood Hospital see first hand the
challenges that face individuals with severe mental and substance use conditions when arbitrary
restrictions limit access to essential treatment. For example, many patients who are ready for discharge
from the inpatient level of care could benefit from participation in 5-10 visits in a partial hospital
program to ease their transition back to the community, and then to an even lesser intense outpatient
level of care. Unfortunately, some insurers do not provide coverage for the partial hospital level of
care, which ironically, can result in high costs when some patients inevitably relapse and require re-
hospitalization at a significantly higher expense to the insurance provider. More importantly though,
relapses and re-hospitalization are unnecessarily traumatic to patients’ mental and emotional health,
and disruptive to their personal, family, social, and professional lives. We strongly believe that
patients, who transition back to their normal lives through brief treatment in a partial hospital program,
are less likely to relapse.

The intent of the federal parity law is to give Americans access to mental health services on the same
basis as medical/surgical services. That is why Congress voted to require behavioral health treatment
and financial requirements that are no more restrictive than those that are placed on general healthcare
services. We at Bournewood join hundreds of other psychiatric care providers who applaud this step to
end longstanding discrimination. Mind and body are not separate; benefits should not be treated
differently. The interim final regulation understands this principle and provides good examples to help
ensure that treatment or financial requirements are not overly restrictive for behavioral health.

The requirement in the interim final regulations for a single combined deductible (vs. separate
deductibles for medical/surgical and behavioral health) is an important step toward the goal of truly
integrated health care. We support this requirement. The manner in which the mental health/substance
use benefit is managed can substantially restrict access to mental health/substance use services.
Therefore, the management of the benefit can be a form of a treatment limit, which the interim final
regulation confirms. We agree that mental health/substance use benefits can be managed, but they
should not be managed in a more restrictive way compared to medical/surgical benefits. We support
the language in the interim final rule confirming that managed care processes and strategies are a form

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of treatment limitation. For example, utilization management reviews are required on a daily basis for
psychiatric patients by some insurance companies. Patients therefore only know a day at a time
whether or not they will have coverage to remain in the hospital or partial hospital program for another
24 hours. It is unfair to these individuals to face the uncertainty and anxiety over the potential loss of
care every day they remain in treatment. As mentioned above, premature and abrupt loss of necessary
care often leads to relapse and re-hospitalization rather than a successful reintegration into the
community with decreasing intensity of treatment and support.

Medical necessity determinations through pre-certification and concurrent review are two areas that
have been particularly problematic for behavioral health patients. It is not infrequent for patients in
crisis to wait for preauthorization to receive treatment or to know only a day at a time what services
they may have coverage for. We support efforts to ensure equity in the way precertification and
concurrent review are applied to both behavioral and medical benefits. In Massachusetts, we believe
that the scrutiny for physical health is not nearly at the level of scrutiny for behavioral health. In fact,
the Massachusetts Association of Behavioral Heath Systems, an organization that represents 47
inpatient mental health and substance abuse facilities that collectively admit over 45,000 patients per
year and provide the vast majority of acute inpatient behavioral health services in Massachusetts, has
filed legislation which would balance the application of medical necessity determinations by providing
more authority for treating physicians than for insurance company reviewers. This is despite the
extensive experience in Massachusetts with parity laws, having passed the first parity law in 2000, and
then more recently, an expansion of that law in 2008.

Our association’s decision to file legislation is the result of realizing that removal of day and dollar
limits essentially does not lead to parity if the behavioral health services are going to be more
rigorously managed, scrutinized, and denied. Parity with medical/surgical benefit management would
be a major step forward in providing better access to needed services for the patients we serve, and
would help lead towards true parity which we believe the Congress intended.

We appreciate the opportunity to offer these comments and hope that the Interim Final Rules are
officially promulgated.

Sincerely yours,

Raymond F. Robinson
President
Bournewood Hospital

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