What Parity?

Parity Does Not Exist—Our Patients Deserve Better

Most of us believed in Santa Claus when we were young. In time, we grew into adulthood and left the innocent gullibility of childhood behind.

However, many of us still desperately cling to two concepts that are mythical in nature: insurance companies always cover medical costs when care is required and mental health equality exists in America today. 

It is still the case that if you break a leg, or get pneumonia, the cost is covered. That’s because the fractured femur or compromised set of lungs show up on x-rays.

Now imagine you fall victim to clinical depression—the soul-crushing sadness that keeps you in bed all day. Or your teenager wittingly or unwittingly becomes addicted to pharmaceutical opiates. With only a few misplaced moves on the great chessboard of life, each of these eventualities can occur—we see it every day.

But now, without empirical evidence such as a blood test or CT scan to confirm the depression or addiction, the future is decided by the seemingly innocuous term: medical necessity. Suddenly, it is incumbent on you to prove that treatment is required, and your insurance plan is responsible for the cost.

Now truth be told, the 1996 Mental Health Parity Act and the 2008 Mental Health Parity and Addiction Equity Act made substantial inroads in this area. Each piece of legislation forced insurance companies to address mental health and addiction diseases just as they treated other “medical” illnesses. 

But these advances are meager at best and true parity remains only a spec on a distant horizon.

All of us in the treatment field know the reality, which brings us back to the topic of medical necessity.  Unfortunately, the world of mental illness and addiction is not black and white, but many, many shades of gray. How do you specifically quantify thoughts, behaviors and cravings? Does a measurement exist to indicate the degree to which these intangibles are adversely affecting people’s lives?  Because such testing is not available, financial coverage is often denied.

Perhaps the most egregious situation is when an insurance company references how much care the person has already received. The implication is why should the provider throw good money after bad when treatment obviously isn’t working.

Last time I checked, we live in a country and culture that never gives up on people, even when they have terminal illnesses. Eleanor, my mother-in-law, is currently dying of stage 4 cancer. Yet, just last week, her medical team started her on another round of chemotherapy.   Although her death is likely imminent, the team is not giving up . This is due in large part to my wife’s tenacity, but also thank god because the doctors are not allowed to. Similarly, Illinois hospitals prolong life even when an individual is in a vegetative state, because to deny care would be criminal.

And yet, just this week SunCloud Health had a person present with a severe case of depression and bulimia. This person has been in and out of treatment in recent years, initially responding well, only to subsequently relapse. The information we collected, which included blood work and self-reporting measurements, clearly substantiated the need for this person to enter our partial hospitalization program.* We emphatically pointed out that without an immediate intervention, this person would probably die. Back came the ever-popular answer from the insurance provider: this person has received a great deal of therapy without “success”; therefore, the request was denied.

Did the data that we provided even matter? Not only did we show this person met medical necessity criteria, but we demonstrated that the person responded well to treatment in the past. The fact that the disease had come out of remission did not mean we should not try again, did it?

Health insurance companies are fixated on that word: success. Returning to the hypothetical example we provided above, no doubt, the broken leg healed, the pneumonia resolved. The treatment was successful.

But how is success evaluated when testing does not apply. If our live persons’s life was saved, the depression reduced to the point that her bulimia could be addressed, who is to claim that treatment failed? Statisticians in insurance offices thousands of miles from Chicago?

At SunCloud, we strive to tip the scales in our favor by translating subjective outcome data into objective data, hoping the reviewing team will extend coverage to our patients. But we are only one center in a vast sea of treatment programs. More must be done at the legislative level, to ensure that denial does not become synonymous with death.

·        Data: This person self-reported a score of 111 on the OQ45, 2, 19 on the PHQ, 8 and 138 on the EDEQ. All three scores are indicative of a person in a severe state of depression and an eating disorder and all three are well above the average score at which our patients generally enter some form of intensive outpatient treatment.