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RESEARCHING A BETTER FUTURE: STAR*D's Parity Implications

June 1, 2006
by David C. Guth Jr.
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STAR*D's Parity Implications

Behavioral healthcare research took an important step out of the laboratory and into the clinic with the latest phase of STAR*D. It is exciting to see the National Institute of Mental Health supporting a large study of “real-world” patients that can help us translate scientific findings into clinical practice.

As the largest research study of depression treatments, STAR*D provides objective data for making treatment decisions and assessing patient outcomes. For that reason, the study represents an important step toward placing behavioral healthcare on more equal footing with other medical specialties and overcoming the insurance disparity between behavioral and physical healthcare.

The findings from the second of STAR*D's four phases demonstrate that individuals whose depression resists initial treatment still can achieve remission when their medication regimen either is augmented or changed. One-third of depressed patients who had not entered remission while using their initial antidepressant medication were able to become symptom-free when an additional medication was added. Additionally, 25% of patients entered remission when switched to a different antidepressant.

STAR*D highlights the importance of measuring depressive symptoms, tailoring treatment to individual patients’ needs, and selecting medications from a range of proven medications at therapeutic dosages. Thus, our focus can move beyond treatment to remission. This knowledge will help the public understand that depression is a medical condition, not a character issue, and that it shouldn't carry a stigma.

STAR*D also addresses one of the fundamental reasons for the disparity in insurance coverage: the lack of understanding that behavioral disorders are illnesses that can be effectively treated. That lack of understanding encourages employers and insurers to place arbitrary limits on coverage. Treatments have evolved so rapidly that third-party payers often are not even aware of the types of available services—and the research that proves their effectiveness.

For example, recall the days when insurance paid for orthopedic surgery but not for physical therapy, which we now know is the key to a successful, faster recovery. That's a good comparison to where behavioral healthcare is today. It takes time for the insurance industry to catch up with advancements in medical knowledge.

The old notion is that providing behavioral health and substance abuse coverage on an equal basis with physical health coverage will drive up healthcare costs. STAR*D should encourage insurers to reassess that assumption. So should another research study commissioned by the U.S. Department of Health and Human Services. The study examined the results of the federal government's decision to provide mental health parity through the Federal Employees Health Benefits Program beginning in 2001. The study compared the federal plan with other insurance plans that did not provide parity. It concluded that mental health parity, when combined with care management, can increase fairness without increasing healthcare costs. Parity also significantly reduced consumer out-of-pocket spending.

Parity would help put STAR*D's lessons closer within our reach. Providers would be free to evaluate research-based treatments and address the next best step for each patient without arbitrary restrictions that render treatments less effective than they could be.

To be fully effective, however, this type of research-based care will depend on our willingness to embrace technology to get research results into the hands of practitioners much faster than is the case now. Today, it takes 17 years for research-proven best practices to become common clinical practices, according to SAMHSA. That is abysmal. We must shorten the science-to-service cycle.

We can no longer depend on the ability of dedicated clinicians to inform their practice by attending workshops and reviewing journals. In 2004, more than 500,000 healthcare journal articles were published, according to William W. Stead, MD, associate vice-chancellor for health affairs and chief information officer at Vanderbilt University Medical Center. It's impossible for anyone to read more than a tiny fraction of them.

To bridge this gap between research and clinical practice, Centerstone, the nation's ninth-largest behavioral healthcare provider, soon will implement our new electronic medical record system, which will be the spinal cord of our Knowledge Network. We have handpicked a group of leading mental health centers from around the country to be members of the Knowledge Network.

Our Knowledge Network will give top-tier researchers an opportunity to conduct research trials on an unprecedented scale, instead of having access only to a relatively tiny and isolated group of research participants. In addition, researchers will have access to a data warehouse of “real-world” client information (scrubbed of identifying information) compiling information on hundreds of thousands of records. Unlike the data warehouses currently available and populated by insurance claims data, this repository will hold information with all the rich detail contained within a full-scale medical record.

Because the system is built to support research-based clinical decision support, practitioners in the field will be able to use the results of this research, as well as other cutting-edge research, as a roadmap guiding them to proven treatments. That too should encourage insurers to embrace parity.

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