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Fax: 412-391-2528 • www.ireta.org 

 

 

 May 27, 2009 

Center for Medicare and Medicaid Services 

Department of Health and Human Sciences 

Attention: CMS-4137-NC 

P.O. Box 8017 

Baltimore, MD 21244-8010 

 RE: Paul Wellstone and Peter Domenici Mental 

 Health Parity and Addiction Equity Act of 2008 

Dear Sir/Madam: 

On behalf of the Institute for Research, Education and Training in Addictions (IRETA) we are grateful for 

the opportunity to submit the below comment as you proceed with this potentially historic legislation. 

IRETA is an independent 501© 3 organization begun in 1999 to help align science, service and policy in 

the addictions nationally. As such, IRETA works daily with policy makers, insurers (public and private), 

providers, research, consumers and their families. IRETA maintains an internationally frequented web site 

(www.ireta.org) and has offices in Pittsburgh, Pa, and Albany, NY. IRETA has been an active supporter 

of this legislation for nearly the entire 10 years of its being. IRETA is overseen by a national, prominent 

Board of Directors. 

We say “potentially historic legislation” because, as always, the truth of this Act’s relevance remains in its 

implementation. Five centuries ago the famous French philosopher Rene Descartes split the body and 

mind in his philosophy of science and medicine has remained in this chiasm of understanding ever since. 

Medicine was defined as the physical and the mind was left as separate and more often only a small 

component of illness. Science today regularly refutes the Cartesian split and points out that not only do 

80% of all illnesses have origins in behavioral and mental life but that the healing to reverse those 

illnesses can also come from using those same mental pathways as part of the remedy. In short, the mind 

and the body are inextricably connected as one in all illness. So you see why this new legislation offers 

some much “potentially” historical significance. It opens the door to tomorrow’s medicine, a door too 

long held closed by a partial understanding of what constitutes illness and healing and what can also be 

brought to bear in tomorrow’s approaches to societal health and individual wellness. 

Institute for Research, 

Education, and 

Training in Addictions 
Still, many say this Act is an illusion. Besides being a word to rally around “parity” must now be defined 

by those who pay for it. Further the belief is that if we reduce parity to payment those who do pay will 

keep us in the 15th century view. No greater threat to our evolution exists than defining what we see and 

know by old maps and telescopes that have only financial lenses. Columbus knew this and he had no 

maps. We do. Are we awakening to our modern science and re-defining a moment in history and the 

evolution of medical practice (e.g. integrating care) or are we reducing that hard won vision to an old lens 

that says if it can’t be paid for it isn’t real? This, for me, is the fundamental concern. As we implement 

“parity” we must agree first it is parity and not perpetrate an illusion to taxpayers and society in general. 

Once you affirm “parity” in approach to illness then have the discussion of payment. You will have 

already modernized the course for a 21st century medicine and not reduced it by its part, i.e. payment or 

medically restrictive definitions of medical necessity upon which payment is based. Let this Act set the 

course. 

A next concern lies with the correct cost evaluation of this Act in implementation. 

First, each health plan needs a clear benefit plan for consumers. As provided in the Act, OMB will study 

the cost of that utilization to assure any new costs do not exceed proscribed limits over the early years of 

implementation. Please be sure each plan has clear benefits and measures actual behavioral costs over the 

exact period of analysis compared to the charges and costs of those same plans over the previous five 

years. Research says good “parity” will reduce health costs in general for a less than 1% investment up 

front. Let’s also measure that. Still, in anticipation of parity it is not unthinkable for risk holders to build 

cost before implementation so as to offset anticipated new costs or to build increases beyond those 

provided by the numerous actuaries in testimony supportive of this Act. 

In this sense the terms “medical benefits” and “medically necessary” care demand clarity and a definition 

that works for a true evaluation of parity and for consumer access to modernized care. Medical necessity 

cannot be left to medical acuity or crisis care but should reflect a more modern understanding of the role 

of mind and body by ensuring access to a broad array of evidence based practices in prevention, 

intervention, treatment and recovery supports. Science and best practice along with the doctor/patient 

relationship should be the final determiner of medical necessity, not the payer. The payer has a specific 

role in working with the employer and best science and practice in advising what benefit should be 

promulgated and how it can be managed for optimal financial and clinical outcome. Management of care 

is critical to achieve full continuity of care, coordination of treatment and true efficiency. 

Fail first and step policies should not allowed unless indicated in the primary doctor-patient care. Nothing 

should transcend the doctor-patient relationship. Moreover, treatment panels and provider fees should be 

carefully monitored so as to protect both providers and consumers from profiteers, less than skilled 

practitioners and phantom panels or care that becomes inaccessible. All lessons learned painfully in the 

past ten years. Care should also be taken to not dismantle any pre-existing state legislation that may have 

earlier been established on “parity” and be working for that state in ways that meet or exceed the terms of 

this Act. If a benefit is denied, the patient and doctor should have at least two levels of timely appeal, the 

final one before non-financially involved parties. Care may then proceed with the potential of full 

retrospective payment or partial payment as determined in appeal. A particularly challenging element 

remains in the transfer of needed information to care-managers who are also holding financial 

accountability. Can care management be clinical first and only when determined to be not clinically 

necessary or appropriate care become both clinical and financial in review? Also, certain laws protecting 

patient confidentiality will need to be clarified (e.g. 42 CFR) as care management will also need to know 

enough information to make a determination of care appropriateness. Some states have even more 

restrictive confidentiality laws that despite their valid reason for existing cannot be used to preclude 

access to a clinically determined appropriate level of care. Finally, as an economic and patient safety 
concern, when a lower level of care is possible but not available the patient should be afforded continued 

care at the higher level until such care can be found and the benefit of the initial care can be sustained. 

I again thank you for the opportunity to have comment in this potentially historic Act and its 

implementation. Obviously many have work for years to have our health plans catch up to our science. 

This Act potentially opens the dawn of a new beginning of health care understanding for this Country and 

its citizens and we are honored to have had this opportunity and serve ready to assist further in more detail 

based on our experience, and knowledge of science and best practice today. 

Sincerely, 

Michael T. Flaherty, Ph.D. 

Executive Director