The Mental Health Parity and Addiction Equity Act (MHPAEA or “parity”) – particularly in the context of the Patient Protection and Affordable care Act (PPACA or “reform”) – raises every conceivable question and concern in our field. As might be expected, health plans are wrestling with interpretation and procedural questions, employers are asking for delays in implementation, providers are either marketing at full-tilt or wondering where to start (or somewhere in-between), and policy-makers are trying to keep one eye on parity while the rest of their bodies are totally focused on reforms.  Parity feeds discussions concerning Behavioral Medicine, integration of mental health, substance use disorder providers and primary care, the continuum of care, practice guidelines and medical necessity criteria and whole host of other initiatives like Patient-Centered Medical Homes and Accountable Care Organizations. Rarely do I hear people ask: “How will parity impact consumers and their behaviors?” Bear in mind there are two facets to this question. The first is consumer behavior in terms of utilization and the second relates to healthy lifestyle and compliance with treatment plans. Both are viable aspects of the same question and speak to the need to engage and activate new consumer behaviors.

Behavior Rules

This question of behavior is critically important when you consider that the New England Journal of Medicine reports 40% of morbidity is attributable to and determined by people’s behavior. By comparison, 10% of morbidity is determined by medical conditions and only 20% is determined by social and environmental factors. The remaining 30% is determined by genetic factors. Our behavior is the most important factor in determining the quality of our life and whether we die too soon or live a long, high-quality life.

If history is of any value as a guide in answering this question, then the answer is: “Not very much.” By virtue of managed care practices and firmly entrenched treatment and coverage paradigms, experiments with the Federal Employee Benefit Plan and various State attempts at parity have produced results akin to treatment patterns that are quite consistent with pre-parity conditions. In some studies, utilization actually decreased. In almost every instance, utilization of services didn’t change much but cost-sharing requirements did so plan costs may have risen a modest 0.5%-1.0%. This trend is, in large part, why the law passed in late 2008. Most stakeholders believed that nothing much would change in terms of utilization and costs so they signed on in support.

It’s how you use the law that matters

MHPAEA reforms benefits and benefit management and creates new contracting conditions between health plans/issuers and providers. What happens next is a function of deliberate efforts at innovation in benefit management, reimbursement reforms, and novel approaches to higher quality care. Engagement and activation of consumers in the process is vital and has – in the past decade especially – given rise to peer and consumer-centered programs as well as peer-managed and supported services. How peer-involved programs manifest in a commercial managed care environment is yet to be seen but in the public behavioral health sector these initiatives are expanding by the day. The sections below explore the fundamentals of changing and impacting consumer behavior. What remains to be seen is how employers, health plans, managed care, Medicaid, and providers make the most of these highly interdependent tools with consumers.

Goals

The goals for engaging and activating consumer behavior include:

1. Greater activation of self-management (including self-regulation of medications)
2. Improved rate of engagement
3. Enhanced clinical and quality of life outcomes
4. Reduced hospitalizations
5. Increased value and reduced costs

Challenges

The traditional barriers or obstacles to ideal consumer behavior include:

1. Attitudes, values, and beliefs
2. Culture and language
3. Socio-economic status and social opportunities
4. Disability
5. Decision-making and problem-solving
6. Self-regulation and self-sufficiency
7. Experience, awareness and insight
8. Skills, knowledge and confidence
9. Availability of resources and natural supports

10.  Privacy and confidentiality concerns where data and information sharing are concerned

Strategies

There are a number of strategies that have developed and continue to be developed that aim to engage consumers in high-value, high-leverage behaviors. Each strategy can be tailored to align with the variety of needs associated with different segments of a population. People who require services for low-intensity adjustment disorders, for example, require different strategies than do people with serious and persistent mental illness (SPMI), serious emotional disturbance (SED) or multiple, co-morbid chronic conditions like diabetes, cardiovascular disease and substance use disorders. The following are examples of strategies that exist to address consumer behavior:

• Prevention and Wellness
• Outreach and Health Navigators
• Standardized Screening (ASI, GAF, SCID, etc.)
• Informed and Engaged Providers
• Standards-based Assessment & Diagnosis
• Coordinated Treatment for the Co-Morbid
• Chronic Illness Care Management
• Patient-Centered Medical Home Models
• Case Management
• Disease Management
• Discharge Planning
• Incentives that Motivate Consumers to Comply with Treatment
• Value-Based Benefit Designs that Steer Consumers Toward High-Quality Practices and Providers

Active Consumers

What does an active consumer look like? What kinds of behaviors do they exhibit? This question is tricky to ask with respect to mental health and substance use disorders wherein the nature of the disorder sometimes predisposes contrary attitudes toward engagement and compliance and challenges adherence to healthy choices and self-regulation. As is the case in substance use disorders, when you have a disease that tells you “you don’t have a disease”, engagement and active participation are strained in the early phases of treatment. This would explain the importance of Motivational Interviewing and conveying Stages of Change. Active consumers are:

1. Informed – active consumers are accurately and appropriately informed. They and their family members receive timely education into the nature of their condition(s) and are involved in care planning
2. Understand Role – active consumers buy-off on the notion that they play an active role in their own care and are engaged in goal-setting
3. Take Actions – active consumers voluntarily engage in or are willing to engage in Health Risk Assessments, healthy behaviors, smoking cessation, diet/nutrition, and exercise. Moreover, when directed as a function of treatment plans and case management, they follow-through on what’s expected of them.
4. Remain Compliant – active consumers follow care plans, refill prescriptions and take medication as prescribed and re-schedule appointments if they have to cancel them.

Parity creates new opportunities for consumers. Benefit limitations are lifted or modified, restrictions and exclusions have been addressed and reforms have banned denying anyone coverage on the basis of pre-existing conditions. The truth of the matter is that health plans and providers will need to cooperate in order to create and innovate upon strategies that activate new, healthy consumer behaviors. Some of us believe the sustainability and future of our healthcare system depends upon our success in this endeavor.