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Mental Health America

July 27, 2017

Laurel Fuller, MPH
Office of the Assistant Secretary for Planning and Evaluation
U.S. Department of Health and Human Services
200 Independence Avenue, SW, Room 424E.21

Re: Parity Public Listening Session

Dear Ms. Fuller:

Mental Health America (MHA) thanks the Department of Health and Human Services (HHS) for hosting this listening session, and commends the extensive efforts of HHS, the Department of Labor, and the Internal Revenue Service to give full meaning to the words of the Mental Health Parity and Addiction Equity Act (MHPAEA).

While MHA certainly echoes many of the comments to be made throughout this listening session, MHA would like to focus on an emerging and increasingly important issue – parity in the context of alternative payment models (APMs), and especially advanced primary care APMs.

Advanced primary care APMs, like the Centers for Medicare and Medicaid Innovation’s (CMMI’s) Comprehensive Primary Care Plus model, empower primary care providers to become population health managers – maximizing health outcomes and reducing care costs across an attributed population, both inside and outside of the office.1 With the work of HHS, innovative commercial payers like Blue Cross Blue Shield of Michigan, and purchaser coalitions like Catalyze Payment Reform, advanced primary care APMs will begin to make up a growing share of all care in the coming years.

Primary care is also the critical site for early intervention in behavioral health. Screening for mental health and substance use conditions can detect needs when they first arise, and approaches like the Collaborative Care Model (recently given G-codes in the 2017 Medicare Physician Fee Schedule) offer ways of addressing these needs through primary care.2 The opportunities grow further with the transition to population health management, which will support individuals in tracking their behavioral health with online screenings and creating the possibility of follow-up with telehealth. In cases where the complexity or severity is beyond what can be treated in primary care, advanced primary care APMs provide primary care financial incentives to ensure that individuals get their needs met effectively with high quality specialty care providers. Advanced primary care APMs, along with similar emerging payment and delivery reforms, offer tremendous potential to overcome long-standing workforce limitations and offer individuals effective behavioral health treatment when they first need it.

Parity will be essential to the success of these advanced primary care APMs. MHA does not advocate for a compliance and enforcement frame for promoting parity in APMs, however – parity in these contexts is legitimately complex. To date, CMS and others have worked thoughtfully to incorporate behavioral health as a key feature in the APMs, including depression remission as a quality measure in Comprehensive Primary Care Plus (CPC+) and a special focus on behavioral health integration. The work needed is challenging. For example, there is evidence to show that payment methodologies based on past payer experience fail to adequately incentivize effective behavioral health treatment, because behavioral health care was historically under-reimbursed or not covered before MHPAEA, distorting claims patterns and in turn distorting the primary care payment methodology for behavioral health.3 Expert analysis and consensus will be needed to appropriately calibrate reimbursements and incentives for behavioral health to improve outcomes while continuing to bend the health care cost curve.

MHA recommends the development of a collaboration between regulators, payers, purchasers, providers, and the individuals served, through a mechanism like a Health Care Payment & Learning Action Network working group, to begin to resolve emerging issues in parity as it applies to APMs. By providing clear guidelines on parity as it applies to emerging APMs, payers will be better equipped to provide consistent incentives for the providers they contract with, and ultimately promote improvements in behavioral health outcomes.

Thank you for your time and consideration. Please do not hesitate to reach out to Nathaniel Counts, J.D., Senior Policy Director at MHA, at ncounts@mentalhealthamerica.net with questions at any time.


Nathaniel Counts, J.D.
Senior Policy Director
Mental Health America
500 Montgomery St, Suite 820
Alexandria, VA 22314

Back to complete list of written comments

1 Sessums LL, McHugh SJ, Rajkumar R. Medicare’s vision for advanced primary care: New directions for care delivery and payment. Jama. 2016 Jun 28;315(24):2665-6.
2 Press MJ, Howe R, Schoenbaum M, Cavanaugh S, Marshall A, Baldwin L, Conway PH. Medicare payment for behavioral health integration. New England Journal of Medicine. 2017 Feb 2;376(5):405-7.
3 Montz E, Layton T, Busch AB, Ellis RP, Rose S, McGuire TG. Risk-Adjustment Simulation: Plans May Have Incentives To Distort Mental Health And Substance Use Coverage. Health Affairs. 2016 Jun 1;35(6):1022-8.
Content created by Assistant Secretary for Public Affairs (ASPA)
Content last reviewed on October 17, 2017