One of the toughest challenges facing treatment advocates in the years between the passage of the MHPAEA in 2008 (and release of its interim final rules in February 2010) and the release of final federal rules in November 2013 was in documenting and presenting evidence to lawmakers that would convince them of the need for strong and detailed final regulations.
But advocates, including treatment centers, faced a dilemma: while parity’s rulemakers sought documentation of parity-related concerns and possible violations, treatment organizations hesitated to provide it. They learned that reporting possible violations would require them to publicly identify themselves, risking a confrontation with an insurance payer and, as Cumberland Heights CEO Jim Moore puts it, “biting the hand that feeds you.” The reporting rules offered no form of “whistleblower” protection to treatment centers, who feared that reports might incur an insurer’s wrath later on.
“We heard that the discussion in Washington D.Cs was that treatment centers had no issues with the interim rule. Lawmakers thought it was working fine,” recalls Nate Kasper, business operations manager at Valley Hope (Norton, Kan.). But NAATP leaders – and many member organizations – knew otherwise, so NAATP set out to create a means to make the needed data available while protecting patient and provider identities.
What resulted, after some months of effort, was a web-based tool, the NAATP Parity Reporting Survey. The brainchild of Bill Leech, healthcare reform analyst at Cumberland Heights (Nashville, Tenn.) and Kasper, the Survey offers NAATP members (and non-members, too) a means of creating structured reports about potential parity violations, complete with supporting documents, in a nationwide database. The database is “blind,” meaning that it contains no patient- or facility-identifying information.
Facility identifying information, the key to the database, is held by NAATP. By contacting NAATP and requesting access, any facility or organization can obtain a unique identification code, use it to log into the survey, and document parity concerns or possible violations. All reports from a particular facility are labeled with only with its unique identification code, then labeled sequentially by that facility upon submission.
The code/key structure enables both member and now, non-member treatment facilities to enter detailed reports without any patient or facility identifying information. Periodically, the Survey tool then automatically collates the reports according to user-specified criteria and can produce summary reports on a national or (coming soon) state-by-state basis.
To help state associations and national advocacy groups such as the Parity Implementation Coalition (PIC) with parity enforcement activities, Kasper says that NAATP is making Survey reports available to these groups as well, provided that group officials complete a Qualified Services Organization (QSO) agreement, a precaution against even inadvertent disclosures in the blind database. (Under CFR 42, Part 2, QSOs bar the redisclosure of patient-identifying information by business associates of addiction treatment organizations.)
The beauty of the blind database is that, should regulators request additional details about a reported parity issue, or seek information direct from a treating professional, patient, or patient family, all they have to do is contact NAATP. Based on such a request, NAATP then can use its key to identify and contact the reporting facility confidentially and explain the request, leaving the decision to provide additional details solely in the hands of the facility, professional, or patient.
How the NAATP Parity Survey works
The language of the MHPAEA describes parity for mental health and addiction treatment as a circumstance in which access to, authorization of, payment for, and ranges of treatment are “comparable to, or no more restrictive than” similar categories of medical or surgical treatment. The design of the NAATP Parity Survey (www.parity.naatp.org) reflects that intent. To date, Kasper says that the Survey has recorded more than 600 submissions of two major types:
- Issues relating to limitations or exclusions in health plan design. These issues relate to health plans that appear to exclude particular categories or types of addiction treatment without having similar restrictions on medical or surgical treatment.
- Issues related to the actual denial of treatment. These issues arise when a course or type of treatment recommended by an addiction professional is denied to a patient.
After choosing the type of issue involved, the reporting center is then asked to indicate whether the issue involves “quantitative” or “non-quantitative” treatment limitations. To date, Kasper says that issues involving NQTLs comprise about 70 percent of the reports and of these, “the majority of reports involve denials based on either ‘fail first’ or ‘medical necessity’ criteria.
The Survey display adapts based on the user’s choices, offering screen-based listings of NQTLs, for example, to help users categorize and then complete their reports, all of which include a brief, non-identifying text summary. An “attach document” feature allows users to upload supporting document files.
The nomenclature used in the Survey is important, Kasper explains. “We’re not saying that these reports are actual violations of the parity law, but that they are documented issues that patients and treatment centers are facing. The Survey enables us to isolate each situation, document the examples, and start the conversation. We’re saying to insurers, ‘Let’s get to the table and talk about this. Let’s see if there’s a way to resolve it.’”