Will Mental Health Parity Laws Ensure Access to Psychedelic Medicine?
Mental Health Parity Laws Are Great in Theory
Will Insurance Companies Use the Same Old Playbook to Block Access to Psychedelic Medicine?
As you may have guessed, I don’t think that we can expect coverage for the first wave of Psychedelic Medicine from insurance companies and third-party payers.
The cost of many hours of psychotherapy provided by two therapists and the costs of clinical overnight stays combined with a schedule 1 molecule that opens the mind to allow one to “realize that all matter is merely energy condensed to a slow vibration. That we are all one consciousness experiencing itself subjectively. There is no such thing as death, life is only a dream and we're the imagination of ourselves” is too much the entrenched bureaucracies to handle.
If there is hope it is two-fold:
psychedelic-assisted therapy actually works (hopefully)
State insurance commissioners will grow a pair and enforce Mental Health Parity Laws
What are Parity Laws?
Mental Health Parity laws are designed to ensure that insurance companies cover treatment for mental health just as they would cover other conditions.
Parity is another word for equal or fair.
Insurance plans are said to have parity when they cover conditions like depression or schizophrenia to the same extent they would diabetes or cardiovascular disease.
If a plan offers unlimited visits for diabetes, and the plan had parity, it would offer the same level of coverage for the depression, though this is rarely the case and rarely enforced.
The laws at the federal level have come in waves after decades of advocacy.
The Mental Health Parity Act of 1996 was the first legislation of its kind, it required “annual or lifetime dollar limits on mental health benefits to be no lower than any such dollar limits for medical and surgical benefits offered by a group health plan or health insurance issuer offering coverage in connection with a group health plan. Prior to MHPA and similar legislation, insurers were not required to cover mental health care and so access to treatment was limited, underscoring the importance of the act.”
The Mental Health Parity Act was superseded by the Mental Health Parity and Addiction Equity Act (MHPAEA) in 2008. The MHPAEA extended the benefits of the first and was actually passed as part of the legendary Troubled Asset Relief Program (TARP) that ironically saved the asses of the largest insurance companies at the time.
The 2008 Act was then superseded by elements of the Affordable Care Act that covered Parity.
Each iteration of parity acts has been thought to be an improvement upon the previous, however, critics say that there are too many ways for insurers and employers to evade full parity.
An investigation by the Attorney General of New York found the denial of coverage is twice as high for mental health coverage than other claims and four times higher for addiction services.
This investigation also found a company that denied inpatient addiction treatment seven times more than they denied other forms of inpatient treatment.
Insurers fought this legislation through the confusingly named Coalition for Parity, an industry-sponsored organization that sued to block parity laws, a sign from the outset that Parity would be a long, drawn-out fight.
One way that insurers are getting around this legislation is by invoking pre-authorization, the requirement that patients need extensive exams, paperwork, signoffs, and other bullshit in order to be approved.
Another way is through a tiered treatment strategy in which shitty, useless and inexpensive attempts at treatment are required before plans will authorize more effective and evidence-based options.
United Behavioral Health, in the most visible case of parity negligence, was found guilty of “breaching fiduciary duty and denying benefits” in a class-action suit. The judge in the case admonished the company for considering its bottom line “as much or more” than the well-being of its members.
When patients are denied coverage in these cases, families usually take the financial hit. Rather than engaging in a protracted legal battle, the choice is obvious, just get the treatment and figure out how to pay for it later.
This, of course, is a recipe for disaster.
Further Reading: Patients need policymakers’ help to enforce mental health parity laws ; As Suicides Rise, Insurers Find Ways to Deny Mental Health Coverage ; 'Mental Health Parity' Is Still An Elusive Goal In U.S. Insurance Coverage
So that’s the Parity story.
Access to Care or Care that Actually Works?
Now, dear reader, grant me the space to stoke some ire. Rest assured we’ll return to the question at hand.
We can all agree that access to care is a problem.
A question that I have, which may be impossible to answer: is access to mental health care the key barrier to better outcomes?
Phrased differently, are conventional mental health treatments any good? Do they work?
I recently read a piece in the New Yorker about the rehab facility ‘scene’ in South Florida. The institutions, establishments, and professionals who serve the population suffering from mental health conditions are a series of revolving doors - rehab centers, halfway houses, psychiatric wards, prisons, even therapists offices are set up to extract value.
Is the organ of the mind is too complex for our primitive tools of inquiry to understand and therefore develop instruments of meaningful utility?
Let me use another, more esteemed writer, David Brooks, to make my point:
Mental diseases are not really understood the way, say, liver diseases are understood, as a pathology of the body and its tissues and cells. Researchers understand the underlying structure of very few mental ailments. What psychiatrists call a disease is usually just a label for a group of symptoms. As the eminent psychiatrist Allen Frances writes in his book, “Saving Normal,” a word like schizophrenia is a useful construct, not a disease: “It is a description of a particular set of psychiatric problems, not an explanation of their cause.”
The problem is that the behavorial sciences like psychiatry are not really sciences; they are semi-sciences. The underlying reality they describe is just not as regularized as the underlying reality of, say, a solar system.
Steven Hyman, director of the Stanley Center for Psychiatric Research and a member at the Broad Institute of MIT and Harvard, goes even further:
The scientific issues facing translational psychiatry—the application of basic discoveries in neuroscience, genetics, and psychology to understanding disease and to advancing therapeutics—are daunting. The molecular and cellular underpinnings of psychiatric disorders remain unknown; there is broad disillusionment with the animal models used for decades to predict therapeutic efficacy; psychiatric diagnoses seem arbitrary and lack objective tests; and there are no validated biomarkers with which to judge the success of clinical trials.
I believe we have a three-pronged issue:
Restricted Access - Mental health is in shambles because people can’t access care because they can’t afford it and insurance companies do everything in their power to evade payment.
Treatments don’t work - A prescribed drug, a style of therapy, a strategy, an intervention are best guesses. Unlike a torn knee ligament which is easily diagnosed and requires a straightforward, yet a technical solution, mental health conditions are not easily diagnosed and treated. Somes they work, sometimes they don’t.
The Hard Problem of Consciousness - Treatments don’t work because they are not easily diagnosed, they are not easily diagnosed because they are not easily understood, they are not understood because the mind is the organ of subjective experience and the tools that we have to understand the natural world, brains, and minds seek to quantify and make sense of phenomena objectively. See the hard problem of consciousness.
While there’s certainly a reason to be upset with insurance companies, and hospital systems and, restricted access to care, I wonder how much improvement we would see if access to the current best practices was guaranteed.
What About Psychedelic Medicine Coverage?
Now that I have that out of my system, let’s get back to the question of coverage for Psychedelic Medicine
Here’s what’s going against it:
The stigma of history and schedule 1 classification
The time requirement
Two therapist protocols
Here’s what’s going for it:
It offers a different approach than a chronic, longterm care option of ameliorating symptoms, ie. it works. (hopefully)
The three conditions that the early psychedelic compounds have been tested to treat, Post Traumatic Stress Disorder, Major Depressive Disorder, and Treatment-Resistant Depression are considered chronic conditions, they’re considered chronic because treatments don’t work.
It is a classic chicken or egg situation.
They are treated with a patchwork of interventions, drugs, counseling over a lifetime to manage symptoms rather than address the root cause.
This is no way to live.
The hope of psychedelic medicine is that it can be a savior for the field of mental health, like some Tim Tebow raising a beleaguered Denver Broncos from the depths of mediocrity but with actual staying power (probably not the best comparison for this crows).
For the first time, there is hope that these patterns can be undone and extinguished and not merely managed.
If this turns out to be the case and the results of trials to date continue in Expanded Access and the early days of psychedelic medicine then there is hope that insurers recognize the value.
Secondly, and this addresses both the access issue and the efficacy issue, psychiatry hasn’t seen a novelty in a long time. Advances have been incremental at best.
Steven Hyman’s assessment that “no new drug targets or therapeutic mechanisms of real significance have been developed for more than four decades” is perhaps about to change.
Could such a change breath new life into the issues of access and efficacy in some kind of Phoenix rise from the ashes?
Let’s hope so.
Perhaps MAPS, Compass and Usona have thought of this, perhaps they are speaking with insurers, with Parity Advocacy groups and State Insurance Commissioners. Hopefully, the emergence of psychedelic medicine marks the end of a drought in psychopharmacology that will promote reinvestment in the space, that will galvanize new research.
I suppose we’ll find out.
The G.O.A.T. of modern psychedelic science, Roland Griffiths, spoke at the National Institute of Health yesterday.
This is a big deal. Many see it as a softening of the federal government’s stance on funding psychedelic research. I haven’t watched the lecture yet but curious to see if there are any major revelations such as an announcement of funding - if you happen to know please holler at me.
Secondly, while it is not news, I did happen upon a post from Scott Alexander of the legendary Slate Star Codex, the legendary blog that inspires The Trip Report, titled Is there a case for skepticism of Psychedelic Therapy? Scott is a psychiatrist in addition to knowing everything and writing with clarity, wit, and humor about high falutin concepts and ideas. (I’m not jealous, you’re jealous)
Here’s a list of essays from Slate Start Codex that deal with psychedelics.