Advocacy

Parity in Insurance Benefit Structure...

Adoption Date:
October 1, 2002

Public Policy Statement on Parity in Insurance Benefit Structure Between General Medical Services and Services for the Evaluation, Management and Prevention of Behavioral Health Conditions, Including Addictive Disorders

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Background

For almost two decades, the American Society of Addiction Medicine (ASAM) has been concerned about payment for evaluation and management services for individuals with alcohol, nicotine, and other drug addictions and other substance related disorders. Payment for substance use disorders has always been less than payment for other chronic diseases in most private and public sector health insurance plans. In the public policy arena, there are increasing demands for parity of health insurance benefits, such that addiction care benefits, copays and deductibles would be equivalent to benefits, copays and deductibles for general medical care. ASAM is also concerned about payment for prevention services and case management services for addictive disorders, but the most intense recent debate has centered about payment for clinical diagnostic and treatment services.

One of the reasons that benefit structures have been inadequate is that addiction and other substance-related disorders are misunderstood and stigmatized conditions. Stigma is not unique to the addiction field. In the psychiatric field as well as in the addiction field, patients are faced with stigma about what their condition really is; how much of a biomedical basis there is for the clinical manifestations of their condition; the role of family and culture in disease etiology, presentation, and course; the extent to which treatments are effective; the availability of diagnostic and therapeutic interventions for the condition which resemble diagnostic and therapeutic interventions for general medical conditions; issues of relapse and chronicity; the impact of compliance and patient motivation on clinical outcomes; the appropriate role of mutual help in symptom reduction and functional improvement; and the nature of the recovery process itself. As a result, beliefs based on misunderstanding or bias have led to restrictions on access to third-party payment sources, leading in many cases to restrictions on access to affordable and effective care itself.

Political debate in the early part of the twenty-first century sometimes has focused on how to overcome political barriers to the attainment of parity. Some persons view parity for benefits covering mental health conditions to be a more attainable political goal than parity for benefits covering alcohol, nicotine and other drug addiction or other substance-related disorders. Thus, in some quarters, the political debate has suggested that parity legislation should omit reference to addictive disorders, and only address parity for psychiatric disorders.

ASAM has well established policy positions on economic issues related to addictive disorders. A clarification, re-emphasis, and elaboration of ASAM’s public policy recommendations follows:

1. ASAM recommends that primary care and specialty treatment for substance use disorders should be specifically included in any basic health benefit, rather than be subsumed under some other category, such as mental health. (This recommendation was previously made by ASAM in its 1993 Public Policy Statement entitled “Core Benefit for Primary Care and Specialty Treatment and Prevention of Alcohol, Nicotine and Other Drug Abuse and Dependence”.) Services by primary care and emergency room physicians to educate, motivate, and provide brief interventions for individuals with problems related to substance use, should be included in basic health insurance benefits. (New Recommendation.)

2. ASAM recommends that reimbursement for addiction medicine services should allow for appropriate patient placement into a comprehensive continuum of care delivery with patient placement based on objective criteria, such as the ASAM Patient Placement Criteria For The Treatment of Psychoactive Substance Use Disorders. This continuum of care should include professional assessment, detoxification, rehabilitation in intensive outpatient settings, non-hospital-based residential settings or hospital-based settings, ongoing rehabilitation in halfway house, three-quarter-way house, or long-term care settings, and ongoing outpatient care as indicated to maintain remission in the community setting. (This recommendation was previously made by ASAM in its 1992 Public Policy Statement entitled “Addiction Medicine and Health Insurance Reform”.) Services covered should include outpatient assessment and hospital consultation services; inpatient, outpatient, and home health care withdrawal management (detoxification) services; individual, group and family outpatient counseling; and office-based pharmacotherapy for alcohol, nicotine, and other drug dependence. (New Recommendation.)

3. ASAM recommends that benefit plans for the treatment of addictive disorders, in both the public and private sectors, shall be comprehensive; i.e., they should cover the entire continuum of clinically effective and appropriate services provided by competent licensed professionals, and should provide identical coverage and funding to those benefits covering physical illness, with the same provisions, lifetime benefits, and catastrophic coverage. (This recommendation was previously made by ASAM in its 1997 Joint Public Policy Statement issued together with the American Managed Behavioral Healthcare Association, entitled “Parity in Benefit Coverage.”)

3. ASAM recommends that coverage for alcohol, nicotine and other drug dependencies should be non-discriminatory on the same basis as any other medical care. Caps or limits on numbers of treatment visits, days or payments should be applied in the same manner as with any chronic disease. (This recommendation was previously made by ASAM in its 1993 Public Policy Statement entitled “Core Benefit for Primary Care and Specialty Treatment and Prevention of Alcohol, Nicotine and Other Drug Abuse and Dependence”.) Thus, there should be parity of health insurance benefits, such that addiction care benefits, copays and deductibles would be at-par with benefits, copays and deductibles for general medical care. (New Recommendation.)

4. ASAM recommends that provision should be made for simultaneous treatment of substance use disorders and their physical and psychiatric co-morbidity, wherever indicated. (This recommendation was previously made by ASAM in its 1993 Public Policy Statement entitled “Core Benefit for Primary Care and Specialty Treatment and Prevention of Alcohol, Nicotine and Other Drug Abuse and Dependence”.)

5. ASAM recommends that patients with physical or psychiatric co-morbidity may need additional care or consultation from other disciplines. Some patients with severe physical or psychiatric co-morbidity may require treatment in or referral to appropriate settings. Linkages among all service systems should be maintained and monitored. (These recommendations were previously made by ASAM in its 1993 Public Policy Statement entitled “Core Benefit for Primary Care and Specialty Treatment and Prevention of Alcohol, Nicotine and Other Drug Abuse and Dependence”.)

6. ASAM recommends that legislation be adopted that will assure parity of health insurance coverage between general medical conditions and so-called behavioral health conditions (psychiatric disorders and addictive disorders). ASAM supports the adoption of legislation that would establish parity between benefits for general medical conditions and psychiatric conditions only, with the understanding that such legislation would serve as a step towards the establishment of full parity of insurance benefits and coverage for all substance-related disorders. [New recommendation)

Adopted by the ASAM Board of Directors October 2002

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