The COVID-19 pandemic has spurred—and aggravated—a range of mental health and substance use issues in the United States. In this episode of Critical Point, Milliman’s Stoddard Davenport discusses the rising demand for mental health services and how different populations are being affected. Stoddard also highlights recent statistics on the topic and what the road ahead may look like for mental health in America.
To listen to other episodes of Critical Point, click here.
Many social determinants of health have important effects on
behavioral health and can apply to all members of a family. Some research has
found that having a family member with a mental illness decreases family
functioning and is a general stressor for families. With that in mind, payers
and providers may find that the diagnosis of a behavioral health condition in
one family member could signal that it may be worth screening for circumstances
that might affect the entire household. This could provide an opportunity for
earlier diagnosis and intervention with other household members who may be at
heightened risk for similar behavioral health concerns.
In order to shed more light on how behavioral health conditions affect families, Milliman analyzed the prevalence of several conditions among family members in a national, commercially insured population in 2017. In this paper, Milliman’s Stoddard Davenport and Marissa North expand on existing research by analyzing the prevalence of behavioral conditions in parents of children with behavioral conditions versus those without as well as children of parents with behavioral conditions versus those without.
A federal judge recently ruled that a company administering mental health and substance use disorder benefits for ERISA-covered health benefit plans breached its fiduciary duty when it applied its own flawed medical review guidelines in rejecting plan participants’ claims for behavioral health services. ERISA requires fiduciaries to administer benefit plans solely in the interest of participants and beneficiaries and in accordance with plan documents.
Because the case, Wit v. United Behavioral Health (No. 14-cv-02346-JCS [as well as a related case, No. 14-cv-05337-JCS]), was decided by the U.S. District Court in the Northern District of California, it applies only to the parties involved. An appeal is possible, perhaps after the remedy phase of the case is completed and a final judgment is issued.
The court noted that the administrator abused its discretion when it adopted its guidelines in several ways, such as:
Having a conflict of interest because a large portion of its revenues came via pressure to keep expenses down
Not insulating the individuals who developed, revised, and approved the guidelines from financial considerations
Refusing to adopt generally accepted clinical guidelines despite the recommendations from clinicians to do so and against some states’ requirements stipulating standards of care
A key issue raised by the case was the coverage for behavioral and substance use disorders as chronic, rather than acute, conditions. Thus, the plaintiffs argued, the guidelines limited coverage once a patient’s symptoms subsided and did not cover services needed to stabilize his or her condition over a longer term. Furthermore, the court noted that the 2008 Mental Health Parity and Addiction Equity Act requires coverage of depression or addiction no more restrictively than other medical conditions. And yet, in the court’s opinion, the administrator’s guidelines adopted appropriate standards of care for medical conditions but not for the mental health conditions.
Employers that sponsor healthcare coverage should review the implications of the case and discuss any concerns with their behavioral management administrators.
For additional information about the court’s ruling, please contact your Milliman consultant.
Required cookies help make a website usable by enabling basic functions like page navigation and access to secure areas of the website. The website cannot function properly without these cookies.
Analytics & Performance Cookies
Analytics cookies are used to collect information about how visitors use our site. The information gathered does not identify any individual visitor and is aggregated. It includes the number of visitors to our site, the sites that referred them to our site and the pages that they visited on our site. We use this information to help operate our site more efficiently, to gather broad demographic information and to monitor the level of activity on our site. Performance cookies are used to enhance the performance and functionality of our services but are non-essential to their use. However, without these cookies, certain functionality like videos may become unavailable.
These cookies are used when you share information using a social media sharing button or “like” button on our sites or you link your account or engage with our content on or through a social networking site such as Facebook, Twitter or Google+. The social network will record that you have done this. This information may be linked to targeting/ advertising activities.