When the Cure Is Not Worth the Cost

Maia Szalavitz weighs in against parity in today's NYT.

On its face, providing equal coverage for mental and physical illnesses sounds like a good idea, something only a managed-care bean counter could oppose....Unfortunately, this change would not be as benign as it appears. Unless mental health parity is tied to evidence-based treatment and positive outcomes, generous benefits may become a profit bonanza for providers that does little to help patients.

Thanks to research by the National Institutes of Health and academic scientists during the last three decades, we now have proven treatments for depression, addiction and other mental disorders. But all too often clinicians do not use them.

...

Without financial incentives to provide treatments that are known to work, many mental health professionals stick with what they know, or pick up on the latest fad, or even introduce their own untested innovations — which in turn are spread by testimonials and credulous news media coverage.

According to a review by the Institute of Medicine in 2006, only 10.5 percent of alcoholics received “care consistent with scientific knowledge” of the disorder; similarly, 43 percent of children in psychiatric hospitals are given antipsychotic medication despite not suffering from psychosis. Tough boot camps for troubled teenagers — which have been proven to be ineffective and potentially harmful — thrive, while “multisystemic family therapy,” which effectively treats teenagers at home, is available only through the juvenile justice system.

Hmmm, where to begin? Let's start with "generous benefits may become a profit bonanza." While we still need to pass federal parity laws, we have a lot of experience with parity in this country. Some states have passed sweeping parity laws, some large employers have implemented it and federal employees have had parity since the 1990s. I haven't seen any studies of provider profit, but there is a lot of research on increases in spending following the implementation of parity. The impact on spending for mental health and substance abuse services ranges from a 9% decrease in spending to a 4% increase in spending. Current estimates of increases from the Wellstone Mental Health and Addiction Equity Acts hover around 1%. Hardly a bonanza. The truth is, when parity is implemented, managed care practices are implemented to limit costs.

As for use of evidence based practices, I went to the Institute of Medicine review she mentioned. The quote she pulled was from a New England Journal of Medicine article reporting on a RAND study. The study based its ratings on compliance with quality indicators. There were 5 quality indicators for alcohol dependence and only 2 were offered as examples: "Assessment of alcohol dependence among regular or binge drinkers" and "Treatment referral for persons given a diagnosis of alcohol dependence". The problem with both was "underuse."

I was unable to find the other 3 indicators, but this paints a different picture than the NYT Op-Ed suggests. First, these indicators seem to assess primary care providers, not specialty treatment providers. Second, one could argue that the compliance problem with both of these indicators might be caused or worsened by the absence of parity. Local primary care physicians often don't assess and make referrals because adequate care is out of reach for many of their patients.

Finally, offering the TV show "Intervention", forcing patients to identify as alcoholics, and teen boot camps as examples of modern treatment is a bad faith argument. It's a little like characterizing journalists by talking about Stephen Glass, Jayson Blair and Jack Kelley.

The interventionists I know describe "Intervention" as hopelessly old school and dated, which makes for much more entertaining TV. No treatment program I know of in our area "force[s] [patients] to identify themselves as alcoholics." In fact all heavily rely on Twelve Step Facilitation, Motivational Enhancement Therapy, and Cognitive Behavioral Therapy--all evidence-based practices. Finally, I don't know of any treatment provider or social worker referring a child to a boot camp.

One more thing. While treatment could undoubtedly be improved with greater emphasis on demonstrating outcomes or utilizing evidence-based practices (I won't get into the politics of evidence-based practices.), we know that treatment, even "treatment as usual", helps people and is cost-effective.