Here we summarize and discuss the work we conducted to assist ASPE in clarifying implementation of the IFR with regard to the requirement that NQTLs be applied no more stringently for behavioral health care relative to medical care. In particular, we note that the IRF requires that the “processes, strategies, evidentiary standards, and other factors used to apply NQTLs to MH/SUD benefits in a classification have to be comparable to and applied no more stringently than the processes, strategies, evidentiary standards and other factors used to apply to medical-surgical benefits in the same classification.”
Consultations with MBHO industry leaders provided insight into processes the industry uses to establish and apply NQTLs, and into industry views on challenges and uncertainties that arise in implementation of NQTL parity regulations. In the area of medical necessity definitions andformulary design, industry representatives did not raise significant concerns or challenges related to implementation. In the area of UM practices, however, industry representatives provided examples of lack of clarity in how to cross-walk and make comparisons between behavioral health and medical care in both outpatient and inpatient benefit classifications, as well as lack of clarity in how to consider intermediate levels of care in behavioral health (such as intensive outpatient and partial hospitalization). In the area of provider network management, some representatives expressed lack of clarity about whether supervised clinical experience qualifications for certain types of behavioral health providers to be included in networks were allowable under NQTL regulations, and representatives consistently raised the issue of not being able to use the same methods in setting fees for behavioral health providers as medical providers, because comparable data are not available to do so. In addition to the issues above, industry leaders whose MBHO included a significant carve-out business raised a broader implementation issue. From the perspective of these industry leaders, the task of coordinating with numerous medical plans to evaluate and implement parity was highly challenging.
Based on our discussions with industry leaders, we conclude that providing further examples that clarify NQTL regulatory guidance, particularly in the areas of UM practices, and provider network management, could facilitate understanding of and compliance with the regulations. Further clarifying examples are unlikely, however, to alleviate the concerns of carve-out MBHOs that arise from the burden of coordination with numerous medical plans managed by other organizations.
The panel of clinical experts convened by SAMHSA discussed processes, strategies and evidentiary standards relevant to evaluating parity in NQTLs, and provided examples of situations in which, in the view of the panel, NQTLs would and would not be in accordance with parity regulations. The discussion consistently reflected panelists’ views of NQTLs as a means to promote both clinically appropriate and cost efficient care. The panel discussed a number of processes, strategies and evidentiary standards -- related to both of these goals -- that were justifiable considerations for establishing medical necessity criteria, UM practices, formulary design, and network management practices. Considerations mentioned by the panel included: evidence for clinical efficacy, diagnostic uncertainties, unexplained rising costs, the availability of alternative treatments with different costs, variation in provider qualifications and credentialing standards, high utilization relative to benchmarks, high practice variation, inconsistent adherence to practice guidelines, identified gaps in care, whether care is experimental or investigational, and geographic variation in availability of providers.
Examples offered by the panel were drawn to show parallels between the kinds of clinical appropriateness and cost efficiency considerations used in management of both behavioral health and general medical care. If such considerations are applied consistently across management of behavioral health and general medical care, in the panel’s view, then the application of NQTLs meets parity regulations. While the panel focused on a number of examples in which the potential “uniqueness” of behavioral health care might make the comparison of behavioral health and other medical care NQTLs problematic, the discussion ultimately resulted in the identification of similar NQTL situations in medical care where comparisons could be drawn.
In conclusion, the Expert Panel meeting supported the view that parity of behavioral health care NQTLs with medical care NQTLs can be evaluated by comparing the processes, strategies, and evidentiary standards that are used to establish and apply the NQTLs. The specific examples provided by the panel should serve useful for clarifying the implementation of the NQTL regulations.