Update to Parity Law Brings Potential Advocacy Win

Primary care physicians conduct “nearly 40% of all visits for depression, anxiety or cases defined as ‘any mental illness,’” the AAFP reminded policymakers, and they “play a crucial role in safe pain management prescribing practices, screening patients for opioid use disorder, and prescribing and maintaining treatment of medications for OUD.”

Given these facts, the AAFP called on the departments to

• implement guardrails to ensure that plans and issuers continue to improve access to primary care while remaining in compliance with the proposed rule;
• clearly establish metrics and recommendations for how plans should consider primary care physicians who provide mental health and substance use disorder care;
• limit administrative burden by removing the exceptions for medical standards and waste, fraud and abuse for application of nonquantitative treatment limitations;
• clarify that data collection and analyses should be separate for mental health; and
• finalize proposals to implement data reporting and analyses, including for nonquantitative treatment limitations, and penalties for third-party administrators. 

The letter reiterated some of the guidance the Academy sent CMS last year, which laid out specific steps the agency should take to “reinforce the health care safety net while moving toward better payment, mental health parity and administrative simplification for physicians.”

The AAFP has long pushed to improve parity for mental health services — including for non-quantitative treatment limits that increase administrative complexity, such as prior authorizations, step therapy and other coverage barriers and limitations — and better enforce existing parity requirements. The AAFP also has endorsed legislation that would reduce cost-sharing for preventive screenings, including depression, and streamline prior authorization and step-therapy requirements in Medicare Advantage.

“The AAFP strongly encourages the departments to use this proposed rule to advance behavioral health integration and value-based care,” the Oct. 2 letter added, echoing recent Academy advocacy to accelerate the integration of behavioral health services into primary care practices. The Academy is a member of the Behavioral Health Integration Collaborative, a coalition that has produced resources for clinicians, and has called on Congress to pass legislation supporting mental health services in primary care settings for children and adults.

“To better equip primary care clinicians to provide frontline mental health and SUD treatment, payments must move away from fee-for-service toward a well-designed value-based payment system that works best for primary care — one that provides prospective population-based payments that generate predictable and sustainable revenue streams,” the Academy wrote.

The letter cautioned against relying on Medicare payment rates when establishing parity benchmarks. “Medicare is not subject to the Mental Health Parity and Addiction Equity Act and may not be an effective comparison for mental health/SUD benefits without additional adjustments beyond those made for medical/surgical benefits,” the Academy wrote. “Medicare rates are also not meaningful for children and adolescents, since this population does not participate in the program.”

The AAFP also urged policy to ensure that “telehealth services patients are being connected to are safe, evidence-based and coordinated with a patient’s usual source of primary care.” Telehealth and virtual-only care companies should be allowed to deliver mental health and SUD care “only when in-person clinicians are not sufficient to the needs of the population,” the AAFP added.