The battle for parity in health insurance benefits was won at the federal level in 2008. This long struggle taught us the need for collaboration among all stakeholders to achieve big changes in policy. The parity in health systems that I will outline here requires a comparable commitment. However, it first needs a call to action.
The last campaign over parity involved diagnosis. The mandate was for insurance coverage to be on par for physical and behavioral health diagnoses. The new parity agenda presented here will not reference behavioral health diagnoses. There are three related reasons for this:
- Diagnoses are too narrow to capture the full range of psychosocial issues presenting within the primary care setting.
- Pre-clinical conditions with moderate symptoms (before meeting full diagnostic criteria) merit clinical attention because they impair functioning at lower levels of distress
- Health behaviors like diet and exercise are an essential part of consolidated behavioral health, and this domain is not diagnosis-based.
System is a term used here with two meanings. Medicine focuses on different organ systems within the human body, and the study of the brain has produced biological treatments. The behavioral health domain has produced a broad range of biopsychosocial solutions. This is the focus here, as distinct from studies related to physical health.
There are systems of care for treating physical and behavioral health problems. These systems are vastly different in size, and they are unequally valued both within the healthcare industry and society generally. This call for parity is to value physical and behavioral health equally, as well as to expand the behavioral health system of care to better meet existing needs.
Parity cannot be legislated
The federal parity law changed insurance coverage but not longstanding institutional practices or cultural beliefs. While many within our field have focused on the need for insurers to implement procedures that are compliant with parity legislation, the institutional practices of concern here are those relegating behavioral health to second-tier specialty status.
That status is reinforced by inadequate funding levels and fostered by negative cultural perceptions about the clinical effectiveness of the field. These barriers cannot be broken down with legislation. Achieving parity in the broad socioeconomic and cultural ways imagined here is a long-term undertaking that must begin by transforming the field from within.
The behavioral healthcare field has a great deal to contribute to population health. This cannot occur so long as it is offered as a second-class specialty. Behavioral health should hold a position of primacy alongside physical health, and services should be delivered on par with primary care services. This is not an argument for primary care integration.
Parity cannot be legislated, and its motivation is aspirational. The anchor and goal for all healthcare, both physical and behavioral, is its contribution to a sense of well-being. When we orient healthcare around the north star of well-being, we can start a dialogue about the enormous contribution of consolidated behavioral health to overall well-being.
This is a radically different conversation from that started by parity for insurance benefits. That focus on providing adequate coverage for acute and chronic care conditions remains. We are now shifting the focus to include how health-promoting behaviors drive our overall health and well-being. We are focusing on the diverse behavioral health needs of the population.
Finding a platform for parity
An effective call to action does not stop with ideas and passion. There must be a platform for launching a new way of doing things, and it is always best to leverage existing resources. Where can we find an existing investment for behavioral health that is not predicated on diagnosis, but is grounded instead in a prevention philosophy with wide support in corporate America? The answer is employee assistance programs (EAPs).
EAPs survive today because they are institutionalized, not because payers find them to be well utilized or effective. In fact, payers often value employer services – like efforts to address workplace crises – more than the provision of free employee counseling visits. EAPs are ripe for transformation.
EAPs can readily be aligned with parity’s goal of enhancing well-being. Many acknowledge the importance of well-being today, but the EAP can own this concept as foundational rather than incidental. EAPs contribute to well-being by addressing the consolidated behavioral health needs of a population. The EAP’s early intervention services function as a form of primary care.
The annual physical exam is an essential primary care service, and EAPs can become a platform for carrying out its complement, the annual consolidated behavioral health exam. This can be started with online assessment tools since self-report surveys are the gold standard of behavioral health assessment. These surveys are also the basis for understanding well-being.
There are several existing measures for well-being, and this would be one of the domains quantified by the EAP as part of its comprehensive annual assessment. EAP counseling services—addressing the mental health, substance use and wellness needs of the population—would be evaluated in relation to measurable goals for improving health and well-being.
Prevention and health promotion
All payers for healthcare services want effective care for acute and chronic conditions, but this focus has dominated our healthcare debates for too long. We will continue to have 50% or more of our healthcare dollars devoted to chronic care until we make a serious shift to prevention and health promotion.
The pathway for this shift is clear. It starts with a focus on mental health and substance use, and it culminates in the reinforcement of health-promoting behaviors. These are the three components of consolidated behavioral health. Genuine parity will have arrived when we recognize this focus as being equally important as that for physical health.
Parity must involve more than recognition. It must include funding and independence for the behavioral healthcare industry. Integration with the much larger, better funded industry for physical healthcare should be a very distant goal, only to be considered once parity has been achieved. Let us begin with a call to action for our next parity movement.
Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.