Docket: EBSA-2009-0010 

Request for Information Regarding the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction 

Equity Act of 2008 

Comment On: EBSA-2009-0010-0001 

Request for Information Regarding the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction 

Equity Act of 2008 

Document: EBSA-2009-0010-DRAFT-0240 

Comment on FR Doc # E9-9629 

Submitter Information 

Name: Thomas G Goddard 

Address: 

10008 Wildwood Rd 

Kensington, MD, 20895 

Email: tgoddard@integralhs.com 

Phone: 703-879-8357 

Organization: Integral Healthcare Solutions, LLC 

General Comment 

May 28, 2009 

Centers for Medicare & Medicaid Services 

Department of Health and Human Services 

Attention: CMS–4137–NC, P.O. Box 8017, 

Baltimore, MD 21244–8010 

RE: Request for Information Regarding the Paul Wellstone and Pete Domenici 

Mental Health Parity and Addiction Equity Act of 2008 

I am grateful for the opportunity to comment on the MHPAEA of 2008. I am a 

healthcare consultant, a psychologist, and a lawyer with experience in healthcare 

policy and management in the public, private for-profit, and private non-profit 

sectors spanning three decades. My company, Integral Healthcare Solutions, 

PUBLIC SUBMISSION 

As of: May 28, 2009 

Received: May 28, 2009 

Status: DoNotPost 

Tracking No. 809bc380 

Comments Due: May 28, 2009

Submission Type: Web
LLC, has a Web site, at http://integralhs.com/, which provides more detail about 

my background and our current work with companies seeking to meet national 

healthcare accreditation standards. 

My comments will be limited to three areas of concern: 

1. utilization management (medical necessity determinations), 

2. cost-benefit calculations, and 

3. coordination between the behavioral health and medical/surgical domains. 

Utilization Management/Medical Necessity 

Your notice specifically requests information about utilization management: 

What information, if any, regarding the criteria for medical necessity 

determinations made under the plan (or coverage) with respect to mental health or 

substance use disorder benefits is currently made available by the plan? To whom 

is this information currently made available and how is it made available? Are there 

industry standards or best practices with respect to this information and 

communication of this information? 

This is an area of particular expertise for me and my firm, both because I have 

served as Chief Operating Officer and General Counsel of URAC 

(http://www.urac.org/), the premier accreditation organization in the area of medical 

management, and because my firm has specialized in assisting applicants for 

URAC accreditation since 2002. 

One of the most thoroughly worked areas in the world of managed health care is 

utilization management (“UM”), which is defined by URAC as the “evaluation of the 

medical necessity, appropriateness, and efficiency of use of health care services, 

procedures, and facilities.” URAC has promulgated national quality guidelines for 

UM since 1990, and has just recently released v. 6.0 of those standards, which 

apply to all organizations seeking the accreditation, whether or not they are mental 

health organizations. URAC’s standards provide explicit requirements for the 

development and approval of criteria for medical necessity determinations and the 

process for disclosing that information to patients and providers. In addition, 

URAC’s UM standards set forth exacting requirements for the qualification, 

supervision, credentialing, and available resources for the personnel involved in the 

review of requests for medical necessity determinations at every stage, including 

administrative, initial clinical review, peer clinical review, and appellate clinical 

review. 

In addition, I encourage you to take your inquiry into standards and best practices 

for medical management further than the relatively narrow world of utilization 

management. Much of the promising work of the last few years has been in the 

maturation of such medical management processes as case management (“CM”), 

disease management (“DM”), and in the rise of independent review organizations 

(“IROs”). Should your inquiry take you into these arenas, I again encourage you to 

tap the invaluable resource of accreditation organizations such as URAC. In 

addition to its two UM accreditation programs (“Health Utilization Management” 

and “Workers Compensation Utilization Management”), URAC operates 

accreditation programs for Disease Management Organizations, Case 
Management Organizations, and Independent Review Organizations. 

Accreditation programs are a dominant mode of establishing standards for 

healthcare organizations. Not only do purchasers of healthcare coverage often 

require accreditation, but both state and federal government agencies lean on 

national accreditation organizations like URAC, NCQA, and JCAHO as 

complementing federal regulatory standards. In doing so, regulators bring in the 

accreditors’ valuable expertise in healthcare business practices while helping to 

standardize requirements across jurisdictional boundaries. 

Your request also seeks “best practices” in the development and disclosure of UM 

criteria. As valuable resource as any in identifying those best practices will be 

both the accrediting organizations and the companies, like Integral Healthcare 

Solutions, that have worked for years with organizations who have taken medical 

management beyond that required by regulators and accreditors to the realm of 

best practices. I encourage you to tap into both types of organizations to gain a 

rich view of the best practices you seek. 

Cost-Benefit Analysis 

The process that DHHS and DoL face in coming months is daunting. In particular, 

however, the questions you pose, “What direct or indirect costs would result? 

What direct or indirect benefits would result?”, are literally incalculable. What we 

know, or even can reasonably estimate, about costs and benefits of the 

implementation of MHPAEA is dwarfed by what we do not know. 

What is of particular concern, however, is that we are likely to know much more 

about the costs than we are the benefits, an imbalance of information that, I fear, 

may skew the discussion about costs and benefits. Existing claims frequency 

and severity data – the source of much of the “cost” side of the discussion – is 

plentiful and accessible, particularly when compared to information on the benefit 

side. We have been keeping track of what visits and treatments cost for many 

years. 

On the other hand, our efforts to understand the connection between mental health 

other areas, such as physical health and work productivity, are more recent and 

less robust. Yet, what “benefit” data are available nearly uniformly suggest that the 

benefits are likely to be huge. Every week, as new studies are published, the 

already strong case for the general statement that appropriate attention to mental 

health yields dramatic benefits in terms of somatic health and work productivity 

grows even stronger. As a trainer in stress reduction techniques, I am most 

familiar with the research connecting stress with a vast array of physical problems, 

from immune disorders to the healing of wounds to cancer, and I can tell you that 

the evidence is compelling. 

In sum, do not be misled by any imbalance of “hard” numbers between costs and 

benefits. A fair assessment of current data, filtered through the understanding that 

we simply have paid more attention to cost than to benefit, will be essential in your 

evaluation process. 

Coordination Across the Boundary Between Mental Health and Somatic Health
Much attention has been paid to the leveling of benefits between mental health and 

substance abuse (MH/SA) and somatic health (SH) that the MHPAEA seeks to 

attain. Less public attention has been directed to the flow of information across 

the invisible but real boundary between the world of MH/SA and that of SH. Yet, 

as any provider or health plan administrator on either side of that boundary can tell 

you, despite years of conversation, administrative reorganizations, and the 

emergence of new medical management approaches, the level of coordination of 

information and care across that boundary in this country is, for the most part, 

primitive. This is so despite the fact that the Institute of Medicine’s 10th Rule of 

Redesign is "Cooperation among clinicians is a priority." Specifically, the IoM’s 

2001 Crossing the Quality Chasm report notes that "Clinicians and institutions 

should actively collaborate and communicate to ensure an appropriate exchange of 

information and coordination of care." 

Certainly, the rapid emergence and maturation of case management and disease 

management systems and technologies in the last decade has done much to help 

make the boundary more porous. However, it is still generally true that the MH/SA 

and SH providers and plans pass too little information to each other, particularly 

given what we know about the intimate relationship between the two. 

The opportunity that the MHPAEA presents, therefore, is not merely about leveling 

the financial support for care between the MH/SA and SH side of the healthcare 

arena. It is a precious chance to support the true integration between the two, for 

there can be no true parity or equity for mental health and substance abuse care 

so long as those two domains exist in informational isolation as compared to the 

various modalities of treatment within the SH domain. 

The common theme, then, among these issues I raise today is that it is, and 

always has been, absurd to treat MH/SA and SH as distinct, unconnected realms 

of human health. That is the message of the MHPAEA, and it must be the 

methodology of the rule-making process to implement it. 

Again, thank you for the opportunity to weigh in on this vital issue. Please feel free 

to contact me at tgoddard@integralhs.com for further information or discussion. 

Sincerely yours, 

Thomas G. Goddard, PhD, JD 

Chief Executive Officer 

TGG/tac