Purchasers Must Be Engaged in Parity Discussions
Commentary
By Carol Girard
Blame for the limits on health-insurance coverage for substance-use is often laid at the feet of insurers and managed-care firms. But while these entities are no innocents, it is important to remember that purchasers have a huge voice and choice in the design of group health plans offered to employees.
The basis of all insurance coverage is a contract -- a legally binding set of terms agreed upon by two parties. In this case, the parties are the health plans or insurers and the purchasers -- employers, unions, or associations. Individual members of a group are not parties to the contract; they only get a health-insurance certificate and/or summary plan description detailing their health coverage.
Private health plans -- no matter the form -- are businesses, not charities. Coverage is not determined by whether insurers (or the public) believe something should be covered. It is determined by what is agreed upon by the two parties to the contract. Coverage can be changed, but the purchaser must negotiate it and pay for those services.
Coverage for substance abuse treatment was abysmal for a long time before managed care came along. Since the 1950s and 1960s, when coverage for alcohol and drug problems began getting tacked on to existing health-insurance policies, there have been extreme limits on the number of outpatient visits that were covered, serious calendar-year and lifetime dollar limits on benefits, and higher co-payments for addiction treatment. Some older plans even had separate deductibles for this chronic health problem.
Because the addiction treatment system is not thoroughly integrated into the larger health-care system, coverage for people with alcohol and other drug problems continues to be held separate and handled differently than that of other chronic illnesses. Some of the old stereotypes about both psychiatric and substance-abuse care have continued in newly designed managed-care plans -- the belief that people can will themselves to better health, and that they shouldn't need too many encounters with a professional to do it.
Pressure from purchasers can drive the design of all types of products, and health coverage is no exception. Managed care came into existence because the costs of all health-care services were skyrocketing, and because so many providers of all types of services took advantage of generous payments that the system became too expensive. Employers, unions, and associations told insurers to curb costs or they'd take their business elsewhere.
When the pendulum swung too far back towards restrictions on coverage, patients and families who had difficulty with managed-care plans were sometimes able to influence employers to re-think some of their decisions. The press got involved in reporting on the plans that had set up serious barriers to necessary treatment. The long-term result was that most managed-care plans relaxed some of their most egregious requirements.
Health care coverage is complex and can be difficult to navigate. The relegation of treatment and coverage for substance-abuse problems to sub-contractors may make the process even more difficult.
But if enough employers can be educated on the link between treatment for addiction and lower costs for treatment of other chronic diseases and traumatic injuries, and if enough brokers understand the importance of treatment for substance-use disorders in keeping other health and disability costs down, they will start demanding appropriate coverage on par with coverage for other diseases.
It remains important to push for parity through legislation and through pressure on the companies hired to administer plans. But it is equally important to bring those who decide which plans to buy and offer to their constituents into the conversation. Purchasers need to be educated about the importance of parity coverage, and should be encouraged to discuss costs -- and benefits -- with health plans during their negotiations.
Editor’s Note: Carol Girard is the project manager of Join Together's Demand Treatment! Project.
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