The Biden Administration recently proposed a rule to refine, clarify, and expand the regulations implementing the Mental Health Parity and Addiction Equity Act of 2008. The nonprofit healthcare accreditation organization URAC has the nation’s only accreditation program for mental health parity. Shawn Griffin, M.D., the first physician to serve as URAC’s president and CEO, spoke with Healthcare Innovation recently about the proposed rule and other developments.
Before joining URAC, Griffin served as vice president for clinical performance improvement and applied analytics at Premier Inc. Before that, he served as the chief quality and informatics officer for the Memorial Hermann Physician Network in Houston. In that position, he directed the quality measurement and data collection programs for one of the largest and most successful ACO’s in the country with over 2,500 physicians enrolled from approximately 850 primarily independent practices.
HCI: Could you talk a little bit about the history of the mental health parity legislation, which passed in 2008? Why does work still need to be done on this issue?
Griffin: Just by its name, mental health parity says mental healthcare should be delivered at the same level as medical and surgical care. The law gets passed in 2008, but when you say something has to be equal, you get into all sorts of issues of how we are going to measure that and what's included and what's not included. Over the last 15 years, there has been regulatory guidance, there have been updated rules, there has been the Consolidated Appropriations Act, which have filled in some of the details.
Then there is how the payers and employers have responded throughout this. Back when this started, mental health and substance use disorder benefits were taken care of by an entirely different group of people within the insurance community. They might as well have been working in different companies. In 2008, the medical and surgical benefits were fairly well defined. Mental health was still fuzzy. Payers asked how the government wanted them to measure this. The government gave a little bit of guidance. If you look at this over the past 15 years, each of these subsequent regulations or updates has filled in the details more and more. With this new proposed rule, two important things that came out. There's a proposed rule around data — about analyzing the adequacy of certain things within the statute. And there's a report on all the work that's been done to investigate non-compliance.
HCI: Was one of the issues a lack of enforcement mechanisms or funding for enforcement?
Griffin: Yes, that's part of this. It was unclear how to enforce it. And this has gotten really complicated and detailed. You could probably get everybody in the United States who truly understands mental health parity into a large ballroom. And because of that, you have a lot of fear and a lot of confusion as to what's actually involved.
HCI: Are people who are mental health advocates frustrated that 15 years have gone by and they are still having to fight for this?
Griffin: Absolutely. You've got people who say, ‘Finally, I've got a hammer that I can use to get those insurance companies to do everything they're supposed to do.’ And you’ve got the insurance companies saying, ‘Oh, great, here comes a hammer, and you still haven't even told me exactly what I need to do.’
This proposed rule standardizes some definitions around benefits and whether they fall into mental health or not. That's 15 years after the law passed. These are supposed to be equal, and we're still figuring out the definitions. When the law got passed, there were some states that had very strong patient advocacy communities, and they have been pushing at the state level to move these things forward. And you have other states that say ‘maybe if we don't look at it, it will go away.’ If you're a nationwide payer, you now have 50 jurisdictions and 20 of them have different definitions, and you've been trying to solve it. You've got employers, especially small employers, who contract with benefit managers. All of a sudden, rules are coming out that talk about significant fines to plan providers.
HCI: You mentioned that the proposed rule has these tighter definitions. Is there anything else in the proposed rule that the insurance companies might be nervous about or oppose?
Griffin: There's a lot of talk about network adequacy. You hear talk from patient advocacy groups about what they call ghost networks or shadow networks, which is when an employer will list all of the providers who can provide mental healthcare. Then you call them and none of them are accepting new patients. In response to that, there are greater technical specifications on how to measure network adequacy.
HCI: Does URAC have enough confidence to say some organizations are meeting its standards in mental health parity?
Griffin: The standards that we accredit were built with consensus, where we had patient groups, provider groups, and payers all around the table to produce our program. Now we have organizations that are going through accreditation. No one has finally achieved accreditation. We have some plans that are going forward. Our standards reflect the rules as they sat before this proposed rule came out. We're going to have to update all of our guidance. We are convening a group to give feedback on what was proposed and our recommendations for going forward.
Payer organizations find parity a scary thing to be held accountable for, and now you've got employers who are nervous about their payers achieving parity. What we're trying to do is construct an independent standard reflective of the best guidance and the best practices that we see across the country. When this proposal came out, there was a lot of concern from the payers about network adequacy. They are asking where they are going to find the workers to constitute a robust network, because it's tough to find people in behavioral health. There are questions about telemedicine and whether that can that be used for network adequacy in some areas.
HCI: Let me switch gears a bit. I was talking a few weeks ago to Bob Sarkar, the CEO of the Arkansas Health Network, who was describing how they became the first organization to achieve dual URAC accreditations for clinical integration and employer-based population health. Could you talk about those accreditations? And are there other new ones you are coming up with to match the evolution in the industry?
Griffin: This employer-based population health accreditation came about because we were seeing employers who were trying to develop a population health strategy for their employees, and they were innovating. A clinically integrated network was new 25 years ago. ACOs were new 20 years ago. Employer-based population health was new four years ago. There are lot of elements of what you've seen before in CINS and ACOs; it has just been updated with what we're seeing now. So Bob and his group were the first ones to go through both the CIN and the employer-based population health accreditation. We really want to give providers a chance to distinguish when they're doing something innovative and new.
Looking ahead, we are getting ready to roll out a health equity accreditation. We have partnered with the National Minority Quality Forum and a number of other organizations that had been working on health equity for a decade or more.
With our health equity accreditation, we are saying we expect you to analyze your population and look for disparities in outcomes or in delivery and address those disparities. Now, in some parts of America, those disparities may be racial disparities in outcomes or delivery. In other parts of the country, they may be economic, or they may be geographic. We're not locked into health equity being only built around racial differences or economic differences or geographic differences. We're saying that your organization needs to look at the population that you serve and address whatever disparities you find within that population.