AHLA's Speaking of Health Law
AHLA's Speaking of Health Law
Payment Parity for Behavioral Health, Part 2: Perspectives from a Payer, Provider, and Parent Advocate
In a follow up to a podcast from February 2021, Gregory Moore, Dickinson Wright PLLC, speaks to Deepti Loharikar, Association for Behavioral Health and Wellness, Karen Fessel, Mental Health and Autism Insurance Project, and Alec Green and David Green, Sanford House, about behavioral health payment parity and other issues from the payer, provider, and parent advocate perspectives. They discuss whether recent guidance might make parity compliance more difficult, how to address requirements that function as barriers to accessing mental health care, and specific issues related to SUD treatment. From AHLA’s Behavioral Health Task Force.
To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.
Good afternoon, and welcome to the parody part, podcast, part two, perspectives from a payer, provider and Parent Advocate. Uh, this is a program put on by the Behavioral Health Task Force of the American Health Law, uh, association. And, uh, we have with us today three guests, um, obviously a payer, uh, a provider, and a parent advocate will hear, um, the perspective of each, uh, on parody. Um, jumping right into our first guest, deep t uh, LO Lok, uh, who is, uh, with the Association for Behavioral Health and Wellness. Uh, she's been there since January of 2020 as a Director of Regulatory Affairs. Uh, A B H W is the national Voice for specialty Behavioral Health Wellness Companies, um, is a member. Their member companies provide services to over 200 million people in both the public and private sectors, uh, in the mental health arena, uh, substance use and other behavioral health, um, uh, services. Prior to being at, uh, A B H W, uh, d t worked in both private and public sector, uh, health policy. Um, before shifting her focus to health policy, she practiced law focusing on civil litigation, insurance, defense, and health law. And so, to kick it off, dt, I'd like to, um, turn to you and, um, ask you a very general question. Where do payers stand on parody today?
Speaker 2:Yeah, no, thank you for including me in this really important discussion. It's really nice to be with all of you. Um, so I, I guess I'll just sort of start at the beginning. For the last two plus decades, A B H W has supported mental health and addiction parody. You know, we believe parody is a right. Um, everyone deserves access to equitable, affordable, medically appropriate, um, uh, you know, high quality mental health and addiction services and treatment. Um, our companies have worked very diligently over the course of the last two decades to make sure that there's consistent interpretation and enforcement of, um, the Mental Health Parity Act, um, across the US and, you know, we're, um, we were an original member of the Coalition for Fairness in Mental Illness Coverage, um, or the coalition as it was called, um, which was developed for the express purpose of achieving equitable coverage, um, for mental health treatment. Um, you know, we worked hand in hand with patient per, uh, patient groups such as the National Alliance for Mental Illness, as well as the, as Mental Health America, um, in this coalition. And we served as the chair of that coalition for the four years, uh, before the passage of the law. Um, we helped draft that legislation and we participated very actively in the negotiation of that final bill. So I say all of this to demonstrate that our involvement was deep as is our commitment to meeting the ultimate goal of parody. Um, so you, but we do run into some issues. Um, there's a sentiment out there that payers are trying to get out of parody requirements. Um, you know, this is not the case. Um, as you may know, we are the ones ultimately responsible for parody compliance. We have to provide. That comes through providing documentation and analyses that demonstrate that, um, we're providing the, we're providing access to those services. So where we run into issues, is it the requirements put out by the regulators, namely the Department of Labor, treasury h h s, um, are oftentimes unclear. So from our standpoint, we want to achieve parody, but the lack of regulations and guidance, um, and the, and the lack of tools, um, we lack those. We lack the tools to do that. Um, oftentimes there's a talking point, you know, that payers are complaining about the volume of documents and the amount of work needed to do a parody analysis. And, um, I understand that's not gonna garner much sympathy, but really it's not about doing the actual analysis or providing the, the documents, whatever the volume might be. Um, the frustration really lies in the fact that it's generally unclear what regulators actually want from us. You know, to date, we don't know what an analysis for a non quantitative treatment limitation. So these are limitations that are non-numerical limits on the scope or duration of a benefit. Um, this can include things like a pre-authorization requirement, formulary design, or geographic restriction just as examples. Um, you know, to date, we don't know what this N Q T L analysis actually looks like. We don't know what would pass muster with D O L on that. Um, so that makes it difficult to put one together. And on top of all of that, the federal requirements are different from state requirements and even within states, different regulators may, um, interpret the requirements differently. So having to do the same analysis, um, in a, in many different ways is also can get burdensome. And so, I'll just end with this on this at, at times there's the back and forth with regulators can kind of seem like an exercise on paper instead of achieving what, um, a set out to do, which is to ensure that mental health, um, ACC ensure access to mental health services. So we understand we all have our own issues around this in, on this panel with parody, but anyone who can help us carry that message to regulators about the need for uniformity, um, would be immensely helpful in moving towards a solution.
Speaker 1:Thank you, dti. That was very, uh, informative. Appreciate those comments. So, uh, focusing in your comments mostly on mepe, let's fast forward to 2021 and the Consolidated Appropriations Act. There was quite a bit in there with respect to regulations, uh, in, when it comes to payers and payer reporting. Do you wanna fill us in on what those are all about? And will it make parody compliance more difficult for payers?
Speaker 2:Yeah, I think the short answer is that it may increase the burden on payers, but we think that it also gives us an opportunity to work with regulators to clearly define those boundaries that I was just talking about. Um, you know, we believe that the C A A provides us with a clean slate of sorts with the regulators. So under, uh, the Consolidated Appropriations Act, Congress expressly established a process to examine compliance with mapa, uh, which in turn triggers the Administrative Procedure Act. So under the a p a, agencies have to separately state and publish in the federal register. And I quote, rules of procedure, descriptions of forms available, or the places where those forms can be found, and instructions as to the scope and contents of all papers, reports or examinations. So, since Congress is directing the tri agencies to provide regulation, um, on the analysis of an N qtl, we hope to capitalize on that OP opportunity by making sure that our concerns are heard and they're incorporated into any regulations that may be forthcoming. Um, so while these regulations may be more burdensome, um, than current requirements, we think it's better to comply with many well-defined requirements than continuously guess at what the current requirements, um, mean. Um, so I think, uh, previously I touched on the need for clarification on N Q tls, um, but I just wanna be a little bit more specific on that. So what we're specifically asking from D O l, um, uh, treasury and H H s is for them to define a set of N qtl. So currently any aspect of plan design and operations can be considered an nq, T l and a regulator can ask for an analysis, uh, on any of it. Um, there's countless things that can be on this list. Um, so it's not really possible to have an analysis ready to go for each of them when they're asked for by the regulators. So being thoughtful about the N Q TLS that are actually moving parody forward, um, and, you know, increasing access to, um, mental health services should be identified and defined by the regulators. Um, we're also asking them to provide a comprehensive example of each of those N qls once it's, once they're defined, as I said before, we don't have a template. We don't have an example, we don't have any sort of document that we can look at our analysis, look at theirs and say, okay, we think this is close enough. Um, so it's a little difficult to know exactly what, what D O L is looking for. And the last thing that we'd like from them is a defined process of how that back and forth with the regulator should go. Once an N P T L analysis is requested, it would be great if they could, you know, give us a roadmap and then follow that. Right now, members are generally, they get a request for both documentation, which can be difficult, um, especially since the types of documents aren't clearly defined. Um, we believe that a defined list, providing those examples and then defining the process for the entire back and forth, would not only help us, um, but come into compliance with mape, but would also help the regulators more efficiently enforce that compliance. Um, you know, and I, we are using the C A A as to just restart these discussions, A B H W. And our members have been meeting with, um, D O L H J S and Treasury for, um, regularly for years to see where we can make changes. And born out of those discussions, you know, our members have improved, um, access to behavioral health treatment, um, services and providers. They've ensured that a behavioral health copays aligned with medical copays, they've eliminated arbitrary treatment limitations, adjusted prior authorization requirements, and integrated medical pharmacy and behavioral health benefits, which overall reduced medical costs. Um, so, you know, the, we've made progress, but we'd like just more uniform, um, regulations to make sure that, um, you know, we're doing exactly what's required. And I'll just, I'll end with this. There's also a consideration, I think that parity is a bigger, is, is a part of a bigger solution. So parity's really important. Um, we support it very much, um, and we want to comply with it, but we also need to focus on other things that affect access to care, um, such as workforce issues, uniform measures to ensure quality of care, um, access to medication assisted treatment, making sure providers have access to substance use disorder records so that they're providing the appropriate care. So there's this whole host of other issues where, um, you know, we also like to focus on, um, when it comes to, uh, increasing access to care for, for patients.
Speaker 1:So what I'm hearing you saying is that the, um, I don't wanna put words in your mouth, but the FAQs that were published by D O L in April didn't quite go all the way into giving enough guidance to payers.
Speaker 2:Yeah, I think it was a good start. And we're definitely using that to, you know, restart conversations with, with Department of Labor. We had sent them a letter in March, um, just, uh, reiterating that we think that the CAA is a asking is directing them to give us very specific guide, um, regulations. And the FAQs, um, took some steps in that direction, but we, there's still a lot that needs to get clarified. Um, mostly that process of the back and forth. And then defining that, they did define in one of the FAQs that in for the near future, they will focus on four nq tls. Um, but that's not permanent, right? So like, when that near future is over, we wanna know, um, you know, what is that list of eight 10, whatever that might look like. We just like to be prepared.
Speaker 1:Okay. Thank you so much. Deep t So I wanna turn our focus now to Karen Fessel. Um, Karen is a parent of, uh, proud parent, I should say, of two adult children, uh, one of whom is, uh, on the autism spectrum. Uh, when her son was young, she tried to work with, uh, particular health plan to get funding for treatments only to encounter a gauntlet of, uh, obstacles, appeals battles, and whatnot with state regulators, um, after, uh, securing a victory, uh, for her own family. And armed with a doctorate in public health and several years working, uh, for a California the largest California H M O, Dr. Fessel founded the nonprofit mental health and autism insurance project in order to help others in her health, in their healthcare battles. Uh, she served as the executive director of the organization since its founding in 2009. Uh, Dr. Fessel, um, was active in getting the California autism mandate, uh, that we all know as senate Bill 9 46 passed into law and recently worked on getting senate bill 8 55, uh, the landmark mental health legislation passed and implemented in California. So, welcome, Karen, and, um, thank you for having
Speaker 3:Me. I'm honored to be here.
Speaker 1:Okay. So I just wanna throw out there, we've been, we've been in the world of, uh, federal Mepe for nearly 13 years now. What has been some of the greatest challenges in realizing the promise of mental health purity from your perspective?
Speaker 3:Um, I think it's just not trickling down to, um, to the regular families that need the services. And too often we see families that there's just not, um, adequate, um, networks of providers. And then, um, often they're, they're kind of forced to use out of network benefits, and then they hit huge, um, out-of-pocket payments. When they do that, sometimes we see that they're misled by, um, health plans who tell them, uh, things like, oh, well, you need to go out of bene out of network. That's why you have out of network benefits. And I tell them when they tell me that, well, you have out of network benefits when you want the choice, but if the network isn't adequate, they are obligated to provide a, an adequate network and you have to request a single case agreement. But, um, families are much more likely to need to go out of network, um, for mental health than for medical or surgical health. And this was, um, a study published by the Millman, uh, foundation, um, I guess about a couple years ago. And so this is, this is well known. And so that's a starter. And a lot of, um, uh, providers, uh, don't work with insurance because they present a lot of, um, hurdles that they must jump through in order to get paid. And the rates that they offer are much less than what they can get on the open market. So that's part of, um, the shortfall. It hasn't trickled down, um, to, to regular families. And it's not just because of networks. It's also because, um, with things like residential treatment, um, the plans often put up a lot of hurdles, making it really hard to get treatment such as they require, uh, round the clock, uh, 24 7 nursing care on, on site. Um, and it can't even be, if you have like two small buildings near each other, it has to be in the exact building. Um, they have to have accreditation from one of, of several, uh, accrediting bodies. Um, there has to be, um, there are several other, um, hoops that, that residential treatment centers have to jump through in order to be considered appropriate. And if they lack any of those, they need to have, um, they need to be directed. The clinical director needs to be a psychiatrist. I've seen that on some of these, um, with some of these organizations. And it can make very, very hard for residential treatment centers to meet the, um, high hurdle. And it also drives up the costs of, uh, mental health treatment unnecessarily. So those are just a couple of examples of how we haven't seen it, and we don't see those restrictions on the medical surgical side, for instance. Um, skilled nursing does not have the same level of requirements in restrictions. Um, and that is often residential treatment is often compared to skilled nursing facilities. When, um, you get right down to what's being offered, that's how the courts have been interpreting it. So, um,
Speaker 1:Thank you, Karen. I, few examples. Yeah. Mm-hmm.<affirmative>. Yeah, it's a, it's a very good, you know, I see that every day in my law practice. It, uh, network adequacy. Um, you know, it was a thing in the, in the early nineties when we were talking about managed care, uh, when it came, came to certain types of treatments on, uh, the physical health side, medical care side. Um, and we're really seeing that now with, uh, behavioral health as we try to mainstream that. Um, you know, it's, it's very rare that you see an acute care hospital that's not part of a payer network. Um, and, uh, certainly we don't see that with respect to certain classes or classes of, uh, uh, behavioral health providers. Right. So, um, just, just to move on away from that. So what can be done from your perspective, uh, to make, uh, behavioral healthcare more accessible and, and how do we improve the likelihood that families, uh, will be able to access quality, uh, mental health treatments as you refer to?
Speaker 3:I think we need to look closely at these, these, um, these requirements that, um, function as barriers to care. And we need to, um, we need to make them, bring them in line with what is expected on the medical and surgical side. Um, and so, and, and also that, um, if it's something that is overly, like, if it's not necessary to the given situation, I've seen situations where people don't need to be, um, assessed every week by a psychiatrist, and that's because of the individual circumstances of their case. And so to require them to see a psychiatrist, it drives up the care unnecessarily when it's not necessarily part of what they need. I'm talking about medication, specific medication. If they're not getting their medication adjusted, they may not need to be seen that frequently, but to have blanket requirements in there, they need to be, um, they need to ba be based on what is going on individually for that individual client. And so removing some of these restrictions and, um, spelling them out very clearly that, you know, these are not, uh, useful, uh, requirements. They are barriers to treatment. So, um, I think that that needs, so we need some better. As, as Deepti was saying, we need, uh, more explicit, uh, guidance on what is actually, um, uh, needed, um, to, for, for in, in various situations for plans to function appropriately. The other thing is, is that, um, medical necessity standards, um, each plan has been allowed to develop their own standards of what they consider is medically necessary. And, um, recently there was a court action wit versus UnitedHealthcare. And, um, what came out of that is the court, uh, realized that, um, that they needed to be, uh, relying on standards that were developed by, um, independent, um, uh, professional organizations rather than having each health plan set their own medical necessity standards. And so that made it so that that kind of legislation, like let we, and in California, we incorporated some of those changes into our law, which our mental health parity law, which was very recent, and, um, some of that is being replicated. The Kennedy Forum is, is taking that act on the road, and, um, they are bringing it out in other states. And, um, but to have to do it state by state by state is, is very onerous. If we could get direction on the federal level that incorporates some of those, um, medical necessity guidelines, it would be very helpful to, um, to making, uh, healthcare more accessible.
Speaker 1:So, Karen, I understand in your organization, one, one of the tasks that you, or one of the services you provide is that you assist, uh, families, um, in individuals, uh, in need of services, uh, either to get denied claims paid or services approved that have been, uh, been rejected. Um, what are some of the big biggest challenges in your work in that area that you find?
Speaker 3:Um, there's been a lot of stuff in the early years. Um, we did a lot with writing appeals and, um, uh, we had a lot of challenges with, with, um, getting a b a services covered for families with autism. And, um, we encountered a lot of barriers, um, from the health plans. And then, um, at the state level from the regulators. Um, once we got our legislation a lot changed, a lot improved. Now a lot of the battles are about how much treatment is needed. Um, and since that time, we've, um, expanded to include, to work with families with other mental health issues. Um, one of the things that we've most recently encountered is that, um, we help families with, um, a certain type of residential treatment called outdoor behavioral treatment, also known as wilderness therapy. And most recently we've encountered a lot of obstacles in just getting plans to, um, issue denial letters, because there have been a series of lawsuits and, um, they're very reluctant to issue denial letters. And so it can take six months and maybe, um, like eight or 10 phone calls to finally just get the denial letter so that you can move forward with the appeal. So we've had basically stonewalling from, um, some of the plans, um, that's been among the challenges. Um, and then, so once you get that letter, you can look at their reasons and you can write up an appeal letter addressing it. But until you do get that letter, it can be very hard to know what your, what you, what reasons you need to produce to, to respond to. And basically, the denial letter spa starts the appeal process, but until you get it, you're kind of waiting for it. You're kind of in limbo.
Speaker 1:Thank you for that. So, deep t in her comments, uh, spoke about the Consolidated Appropriations Act and the, uh, requirements, uh, under the caa. Uh, from your perspective, what kind of responses are you seeing from plans, uh, in providing these parody analysis? I know we're early on in the requirements, but, uh, tell us what your experience has been from your perspective.
Speaker 3:We've sent out about, um, 30 so far, we've been generally doing them, whenever we see a non qualita, non quantitative, any kind of treatment limitation that is parody related, we send them in, we've sent out about 30 to date, and we've gotten one response back. And it wasn't, um, it only a, it made a comparison, like a one-to-one comparison. It compared one treatment directly to another treatment instead of, like, the comparison is supposed to be substantially all, um, medical or surgical treatments. That's my understanding of the parody law. It can't just be that, yes, here's an example of how we discriminate again, or we, we don't provide a certain service, um, to someone in the medical field. But the, the way the parody act is written is that, um, the treatment limitation can be no more, uh, restrictive for mental health than substantially all medical or surgical, um, uh, uh, conditions. And so, w I think we all need more guidance 50. I think that that is correct, and I, I think that, um, we need better instructions from, um, the feds and also the states. And I know that, um, N A I C, that they talk about mental health parody a lot at their meetings, and it's a big issue. Um, and, and we, I work in many different states and, uh, how you, how things are handled by each state is very, very different. And you might be aware of that as well, that there's huge amount of variation. Um, so we need better, uh, conformity and, and I think really the feds have the ability to at least offer guidance that the states can, um, uh, incorporate, you know, if they want to. And so that would be helpful.
Speaker 1:I, um, just have to point out that we have, uh, a payer and a parent, uh, advocate, uh, on the panel who've spoken so far, and we have agreement between the two. And that agreement is we need more guidance.<laugh>. All right. I was able to extract at least one agreement between the parties. Uh, I think I've, uh, I think I could quit now, and the greens don't even have to talk
Speaker 3:<laugh>, but Well, the answer is we are not getting responses from the plans. So if you have any sway in at least responding, you know, even if it's a less than adequate response, it'd be helpful.
Speaker 2:I can't promise that, but
Speaker 3:<laugh> Okay.<laugh>.
Speaker 2:But I'll be thankful for the agreement. I think that was an important
Speaker 3:Point. Okay.
Speaker 1:Well, thank you, Karen. Thank you for, uh, your perspective from a, a parent, parent advocate, and, uh, certainly appreciate the work that both of you have done. Let's move on to try to get a, a perspective from, uh, a, uh, a provider in the community. And I wanna, uh, introduce our listeners to, um, David and Alec Green. Uh, Alec is the managing director of Stanford Behavioral Health and President of Greencastle Health, a billing company. Uh, David, uh, on the other hand, is the founder and c e o of Sanford. It's a growing behavioral health, uh, company, soon to have 130 beds, three outpatient programs, uh, serving, uh, the s u d community, uh, treating eating disorders, and of course, co-occurring disorders, uh, along the entire, uh, continuum of care. So, welcome to the Greens. And, um, I think I'll start out by asking, um, David and Alec, uh, you know, we focus so much on commercial, um, when we talk about parity, uh, but we know parity applies to government programs as well. And so I just wanna maybe throw a little curve ball. Do you, uh, gentlemen, ever, where do you see Medicare in all of this? Do you ever see Medicare paying for s u d uh, treatment anytime in the near future?
Speaker 4:Um, thank you, Greg, for, for having us on. We're, we're very appreciative. And, uh, and I do believe that is the case. Um, and, and it's something actually that the Kennedy Forum is working on. And, and our hope is, is that we can start serving, uh, individuals with Medicare under the normal, uh, way of billing for these services. So currently you wouldn't actually, uh, be paid by Medicare for a per diem rate, which is the normal way to, to do detox and residential and partial hospitalization and intensive outpatient services. So with, with that, I do believe that Medicare will, uh, pay for it in the future. I think it's something that the Kennedy Forum is working very hard on. Um, and, and I hope that that will happen. But, but with that, I think, uh, one thing that's tough for us as a provider is a lot of, uh, individuals when looking at rate structures and rates, uh, is looking at the way that we define them. And usually it's a percentage over Medicare. And so what we really would appreciate is some rates. So then we can, uh, can also look at the way that we're, uh, billing, um, so then we can be in line. Um, because what, what we've seen with certain health systems in Michigan is they can be billing, uh, quite a bit over Medicare, uh, compared to other health systems. And, and that can be very burdensome on, uh, on the patient. So, so yes, our hope is that will happen. I believe that with the force of the Kennedy forum, we'll, we, we will be able to do it. And, uh, I hope it's sooner rather than later.
Speaker 1:That's a really interesting perspective. I, you know, you, I talked to a lot of folks about, uh, s U D in the Medicare program. I've never heard that perspective that, uh, will be useful for providers in the community to sort of, uh, right size or normalize, if you will, not necessarily fix, but normalize within a certain range, um, uh, reimbursement rates, uh, based on where Medicare fee schedule might be. So, hey, let's turn back to, um, parity on its face and what you're seeing in the, uh, s U D treatment space. Uh, what I see from clients, uh, in the s u d treatment space is it's, it's, especially in residential, it's all about length of stay, um, and, uh, in the commercial world, uh, why do you think that payers, um, differ so greatly in their, uh, their pre-authorization length of stay, uh, in, in your, in your segment of the industry?
Speaker 5:Yeah, we're, uh, uh, in, this is David Green. Um, so we deal with 15 in-network contracts, uh, insurance companies around the country. And I think part of it is, um, you know, there's been some motivation by certain insurance contracts to really focus on their compliance with parody. And that motivation, unfortunately, has come through the court system rather than what was discussed earlier, which was maybe some clarification from the departmental labor or other governmental entities, um, state law potentially. But it's, it seems like it's, our habit in America these days is that our legislation might be written loosely. It may not have a lot of, uh, detail to it. It's left to the regulators, uh, there's not a lot of teeth in it, which is what the case was with the 2008 parody Act. And then everyone spends a lot of money running off to court and defending those cases. So, um, I, I, we see a big difference between the different, uh, approaches to criteria lengths of stay, and quite honestly, as a provider, um, while we, uh, uh, you know, as a former lawyer, I, I read all the cases and I find them very intriguing. Um, but as a provider, we really have to, um, do our best, um, to work with all 15 insurance companies. We have to interpret all of their criteria. We have to deal with all of their bureaucracies and their forms, et cetera, which we do. We have quite a big, uh, department that Alec operates, um, which raises the cost, obviously, to us. Um, and, and so we see a, we see a wide range of rates. We see a wide range of authorizations. Um, but we, we really feel like there's a bigger picture here, right? Not only do we want to treat people in a quality fashion, we want them to get well, um, not only is it the right thing to do, but the financial windfall to the insurance companies to get somebody in recovery versus active addiction in the case of substance use disorder is absolutely amazing. The physical health ailments, uh, issues, chronic issues, uh, I'm not saying they all go away, but they diminish dramatically. And the savings to the insurance industry, uh, to, to, to medicine generally is, uh, if you can take, uh, a, a more than a, you know, the next minute view of things and look at the long haul, that's really, uh, where we think that there should be a different approach to mental health generally. I think also, um, we just got our renewal for our company for insurance and went up five, 10%. I can't even remember. Well, that insurance company is competing with other insurance companies for our business, and it's all about what your renewal rate is, right? And I'm not really sure mental health has been totally baked in to the cost of insurance. Um, once again, I think if it is properly baked in and it's financed and it's supported, the physical health aspect is gonna improve dramatically. Employers actually, if you look at the data, are gonna have more reliable employees. Uh, they take, uh, fewer personal days, um, et cetera. There's a lot of data out on that. Um, and we've written, uh, white paper on that. Um, so I, I think I'm rambling now, Greg, but, um,<laugh>, that's a long, long way of trying to answer your question.
Speaker 1:So let me ask you this, David, as a former, uh, or still a lawyer, but former practicing lawyer, I'm sure you, um, um, take great, uh, interest in, in many of the, the, what I would call landmark cases in the area, uh, in, uh, Karen mentioned wood versus United Health, um, care. Do you believe that things like the WIT case, uh, will drive more uniform criteria, uh, for s u D providers, uh, such that things like length of stay will normalize over time?
Speaker 5:Yes, I believe it will. I think, um, um, you know, we're in, we're in Michigan, we're close to eastern part of the United States. I guess we're mid Midwest. Um, you know, a lot of'em, a lot of those cases, the federal cases come out out out from California. So it's kind of nice when they get cited across the country. We all know that wit is being cited across the country. It's gonna become law regardless of what the regulators in Washington DC do, uh, until Congress might change the legislation. So I, I do believe it will have an impact. Um, I'm quite surprised when I'm dealing with various insurance companies that, um, some of the people I'm dealing with may not have a little more education on the ramifications, uh, of wit and, uh, you know, the legal jeopardy that can, uh, flow from wit. Um, but I think it's all gonna catch up. I do think it will, um, create a standard. And fundamentally, and this was referred to a few times as, um, I actually, when I read wit, I basically took away from it that that particular judge, um, I think annoyed AAM as the voice for the standard of addiction treatment in America. AAM was formed in the eighties, and the goal of as a m was to come up with a national standard, a national criteria for substance use disorder. Now, there's, um, you know, there's a lot of, you know, we're dealing with 15 insurance companies, right? They all have their little twists and turns. Um, some our, you know, way out there, and some of them, you know, putting their own signature on, on as a m do pretty much follow as a,
Speaker 1:So let's, uh, let's turn the dialogue, uh, uh, for the greens and the payer perspective to, uh, a little bit more philosophical. David, I know you and I and Alec have had conversations about whether we're in the right payment model. Uh, you know, if we look at the history of behavioral health, uh, on the public side, fee for services is not the gold standard. Uh, many, uh, capitated contracts, sub capitated contracts, and, uh, where, where providers were held to quality, uh, providers went out of business and they couldn't deliver care for a certain price. And, you know, along comes the Affordable Care Act, which makes behavioral health, uh, an essential health benefit, and providers are thrown into this fee for service world. Um, just wondering what kind of tension that creates from where you sit, uh, is it the right payment model? Uh, and can we start, uh, uh, looking at, uh, different types of payment models that, uh, might have a better set of goals for cost of effective delivery of care?
Speaker 5:I have a quick answer, and then I'll, I'll hand it over to Alec. Uh, no,
Speaker 1:<laugh>
Speaker 5:<laugh>.
Speaker 4:So, so, yeah, Greg, you know, I think the, the, the big piece that you're hitting on is that the fee for service model, uh, makes, uh, payers and providers butt heads. So how can we come together collaboratively to get somebody healthy? And I think the answer is value-based and it is capitation. So I, I think it could even be a mixture of the two. Uh, but I, I think we need to get away from the fee for service model. I think it is going to help with some of the NQ TLS that we're seeing right now that are based on length of stay. Um, but we see other nq tls, and I do wanna just speak on that for one second to kind of talk about some of the things that DT and, uh, Karen said. And, and one thing is, is I totally agree that we need more standardized N Q tls, but when I see certain NQ TLS that are stating that 15 people need to be in treatment at a time for this individual to get paid, or, uh, or another one being you can only have 2 28 day stays in a, in a year period of time, those are inexcusable. And I think we really need to come together as providers and payers and say, let's work together. Let's be collaborators. How can we make this cost effective for both sides? Uh, you know, there is, in, in a lot of cases too, there should be a psychiatrist involved, but do they need to be there 24 7 7 days a week? Uh, so I think there's different pieces that we need to look at when looking at payment and when looking at the NQ tls, because I would, I would really love more description of what those look like. Uh, but some, some of them that we see are, are, uh, very, very burdensome on the patient that needs that care. Um, and, and if you are not a provider that has that knowledge base and knows that you might, uh, appeal that on the backend based on unreasonable N Q tls, you know, you're not gonna bring that patient in. And they might, you know, who knows, they might die. So it's, it's a tough thing that we don't, uh, we don't wanna mess with. And I think that it's something we need to see some pretty immediate change on.
Speaker 1:Thank you Alec, for, uh, that perspective. Uh, dt did you have a, a comment?
Speaker 2:Yeah, no, I guess I'll give you another point of agreement. You know, we, uh, our members also are very pro, um, integrated care. I mean, that is something that we, um, advocate for. It's something that we want to see. I think this past year, especially with covid, we've seen that mental, mental health and um, and physical health are indeed intertwined. So, you know, we wanna make sure that they're being treated, um, appropriately. Um, and so we are, um, you know, the, I think C M S has, uh, there's the collaborative care model that they've put out a few years ago, and, you know, we're, um, we think that there should be, they should look for ways C M M I should look for ways to incorporate that elsewhere. And so, um, you know, we do advocate for that. So I think there, this, you know, we've, we found a couple of places where we might have some overlap for, we can actually work together on that. I think that's great,<laugh>, thanks.
Speaker 1:That is excellent, excellent to hear a second area of agreement. And I'll tell you, I wanna thank everyone for tuning in and listening to, uh, our parody podcast, part two Perspectives from a payer, uh, provider and parent advocate. And while we're talking about that pea soup, I will just, uh, throw in there that, uh, perhaps, uh, I should be tagged the peacekeeper<laugh> because I was able to keep, uh, what could have been a fisticuffs, uh, and find a couple of areas of agreement between everyone on, on, uh, our podcast today. So thank you all for your time and, uh, for those listeners, uh, thank you for listening. And, uh, if you haven't, if you felt like you stepped into the middle of a moving, uh, target or a motion picture, please make sure you tune into part one of the Parody podcast where Anna Anna Whites, uh, was able to talk to a few regulators in the area and, uh, set the stage really for this part too. So thank you all on behalf of the Behavioral Health Task force of the, uh, A H L A, we appreciate you tuning in today.