Healio (8/2, Michael) reported, “For adolescents with severe mental illness, consistent access to a single primary care physician during the transition from pediatric to adult care could ensure improved long-term outcomes,” researchers concluded. The findings of the 8,409-patient study were published online Aug. 2 in JAMA Network Open.
Related Links:
— “PCPs essential during transition to adult care in adolescents with severe mental illness, “Erin Michael, Healio, August 02, 2019
Healio (8/2, Demko) reported, “Anxiety disorders in pregnancy and the postpartum period were more prevalent than previously believed, with about” one in five “women meeting diagnostic criteria for an anxiety disorder,” investigators concluded in a 26-study, “multivariate Bayesian meta-analysis.” The findings were published online July 23 in the Journal of Clinical Psychiatry.
Related Links:
— “1 in 5 women have anxiety disorders in pregnancy, postpartum, “Savannah Demko, Healio, August 02, 2019
The following summary was prepared by Meiram Bendat, J.D., Ph.D., head attorney in this case:
On March 5, 2019, in a nationwide class action suit, the United States District Court for the Northern District of California held that United Behavioral Health (“UBH/Optum”), the country’s largest managed behavioral healthcare organization, illegally denied mental health and substance use coverage based on flawed medical necessity criteria.
The federal court found that, although required by the class members’ health plans to make coverage determinations consistent with generally accepted standards of care, UBH developed restrictive medical necessity criteria with which it systematically denied outpatient, intensive outpatient, and residential treatment. Specifically, the federal court found that UBH’s internal guidelines limited coverage to “acute” care, in disregard of highly prevalent, chronic, and cooccurring disorders requiring greater treatment intensity and/or duration. The court was particularly troubled by UBH’s lack of coverage criteria specific to children and adolescents. Additionally, the court held that UBH misled regulators about its guidelines being consistent with the American Society of Addiction Medicine (ASAM) criteria, which insurers must otherwise use in certain states such as Connecticut, Illinois, and Rhode Island. (The court also found that UBH failed to apply Texas-mandated substance use criteria for at least a portion of the class period.)
Although the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 requires parity for mental health and substance use benefits, insurers are permitted to evaluate claims for medical necessity. By applying internal guidelines or medical necessity criteria developed by for-profit, non-clinical specialty associations, however, insurers can easily circumvent parity in favor of financial considerations and prevent patients from receiving the type and amount of care they actually need. The consequences to patients can be devastating.
In his detailed ruling, Chief Magistrate Judge Joseph Spero found the following to be the generally accepted standards for behavioral healthcare from which UBH’s guidelines deviated:
1. It is a generally accepted standard of care that effective treatment requires treatment of the individual’s underlying condition and is not limited to alleviation of the individual’s current symptoms;
2. It is a generally accepted standard of care that effective treatment requires treatment of co-occurring behavioral health disorders and/or medical conditions in a coordinated manner that considers the interactions of the disorders and conditions and their implications for determining the appropriate level of care;
3. It is a generally accepted standard of care that patients should receive treatment for mental health and substance use disorders at the least intensive and restrictive level of care that is safe and effective – the fact that a lower level of care is less restrictive or intensive does not justify selecting that level if it is also expected to be less effective. Placement in a less restrictive environment is appropriate only if it is likely to be safe and just as effective as treatment at a higher level of care in addressing a patient’s overall condition, including underlying and co-occurring conditions;
4. It is a generally accepted standard of care that when there is ambiguity as to the appropriate level of care, the practitioner should err on the side of caution by placing the patient in a higher level of care;
5. It is a generally accepted standard of care that effective treatment of mental health and substance use disorders includes services needed to maintain functioning or prevent deterioration;
6. It is a generally accepted standard of care that the appropriate duration of treatment for behavioral health disorders is based on the individual needs of the patient; there is no specific limit on the duration of such treatment;
7. It is a generally accepted standard of care that the unique needs of children and adolescents must be taken into account when making level of care decisions involving their treatment for mental health or substance use disorders; 8. It is a generally accepted standard of care that the determination of the appropriate level of care for patients with mental health and/or substance use disorders should be made on the basis of a multidimensional assessment that takes into account a wide variety of information about the patient.
The court acknowledged that accreditation by organizations such as URAC and NCQA does not entail substantive review of medical necessity criteria developed by insurers. Therefore, such accreditation does not guarantee use of medical necessity criteria that are consistent with generally accepted standards for behavioral healthcare or with the terms of insurance policies or any laws.
In light of the court’s findings, including that UBH’s experts (comprised of several of its own medical directors) “had serious credibility problems” and “that with respect to a significant portion of their testimony each of them was evasive – and even deceptive,” robust safeguards against abuses by managed behavioral healthcare organizations are clearly warranted, such as:
1. Legislation mandating exclusive adherence to medical necessity criteria developed by nonprofit, clinical specialty organizations such as the American Society of Addiction Medicine (ASAM), American Academy of Child and Adolescent Psychiatry (AACAP), and the American Association of Community Psychiatrists (AACP);
2. Formal recognition by the American Psychiatric Association that managed care psychiatric reviewers owe a primary ethical obligation to insureds, consistent with: a. AMA Principles of Medical Ethics: I,III,VII and AMA Code of Medical Ethics Opinion E-10.1.1 (https://www.ama-assn.org/delivering-care/ethicalobligations-medical-directors) and b. their fiduciary duties under ERISA (https://www.dol.gov/general/topic/retirement/fiduciaryresp).
Today’s ruling stems from two consolidated class actions, Wit et al. v. United Behavioral Health. and Alexander et al. v. United Behavioral Health, brought by Psych-Appeal, Inc. and Zuckerman Spaeder LLP under the Employee Retirement Income Security Act of 1974 (“ERISA”) in 2014, certified in 2016, and tried in October 2017. While the certified classes encompass tens of thousands of ERISA insureds, non-ERISA insureds (such as governmental employees) adversely impacted by UBH’s defective guidelines must rely on state and federal regulators to intervene on their behalf.
Related Links:
In a piece directed to parents, HealthDay (8/1, Canter) reports, “Young” female athletes “who eat too little risk menstrual irregularity, weak bones and eating disorders.” Some sports appear to be “riskier than others” when it comes to eating issues, “namely those that involve endurance or weight-classes and those that emphasize appearance, especially thinness.”
In another parent-focused piece, HealthDay (8/1, Canter) reports, “Exercise has many health benefits for boys,” but “some sports come with cautions, especially those with weight classes that could lead to excessive dieting or even anorexia.” A physician’s “evaluation is important if you see signs for concern.”
Related Links:
— “Is Your Daughter, the Athlete, Eating Enough?, ” Len Canter, HealthDay, August 01, 2019
Healio (8/1, Miller) reports, “High remission rates were observed in patients with three or more follow-up visits after routine depression screening and treatment,” researchers concluded after utilizing “VitalSign6 – a software program that utilizes the PHQ-9 screening tool and supports treatment decisions – on a convenience sample of 25,000 patients (mean age, 40.88 years) who were previously screened with the PHQ-2.” The findings were published in the July/August issue of the Annals of Family Medicine.
Related Links:
— “Remission rates high among patients with multiple follow-up visits for depression, “Janel Miller, Healio, August 01, 2019
Medscape (8/1, Young, Subscription Publication) reports, “A coalition of health groups,” including the American Psychiatric Association (APA), “is continuing its legal challenge to the Trump administration’s policy that allows extended use of short-term medical insurance plans,” contending that such “‘junk’ plans put consumers at risk of being unable to afford care if they fall seriously ill, despite having purchased insurance.” On July 29, the coalition “filed an appeal to a July 19 ruling from Judge Richard Leon of the US District Court for the District of Columbia,” but the judge “found against arguments presented by…members of the coalition in a 2018 court filing.” The judge’s “ruling will put people with mental illness at risk, said APA president Bruce Schwartz, MD.” In a statement, Dr. Schwartz said, “These plans could be catastrophic for many Americans with mental illness or substance use disorders if these disorders are excluded from coverage.”
Related Links:
— “APA, Others Battle Trump Policy of Extended Use of ‘Junk’ Insurance, “Kerry Dooley Young, Medscape, August 01, 2019
NBC News (7/31, Edwards) reports on its website that researchers found about 10% of older adults engage “in binge drinking, putting them at greater risk for falls and other medical problems.” The findings were published in the Journal of the American Geriatrics Society.
Related Links:
— “One in 10 older adults binge drinks, increasing health risks, “Erika Edwards, NBC News, July 31, 2019
Healio (7/31, Demko) reports, “Clozapine was linked to an 18% lower risk for hospitalization and 27% lower risk for all-cause discontinuation compared with nonclozapine second-generation antipsychotics, despite greater illness severity in patients with schizophrenia receiving clozapine,” researchers concluded. The 63-cohort study meta-analysis also revealed, however, that clozapine use was “associated with a higher risk for cardiometabolic-related outcomes.” The findings were published online July 31 in JAMA Psychiatry. The author of an accompanying editorial observed, “The meta-analysis…supports evidence that clozapine is effective as it is used in the real world.” MD Magazine (7/31, Walter) also covers the study.
Related Links:
— “Clozapine tied to better effectiveness outcomes than other second-generation antipsychotics, “Savannah Demko, Healio, July 31, 2019
HealthDay (7/31, Preidt) reports, “Stigma about being overweight can cause physical and emotional harm to men,” researchers concluded after surveying some “1,750 men across the” US. The study revealed that “weight-related stigma (both internalized and from other people) was associated with higher rates of depressive symptoms and dieting.” The findings were published online in the journal Obesity.
Related Links:
— “Overweight Men May Feel Stigmatized, Too, ” Robert Preidt, HealthDay, July 31, 2019
Psychiatric News (7/31) reports, “Youth with bipolar disorder who take lithium may be less likely to attempt suicide than those who take other mood stabilizers,” researchers concluded after analyzing “longitudinal data collected from the Course and Outcome of Bipolar Youth…study, which included 413 youth aged seven to 17 who met criteria for DSM-IV bipolar spectrum disorders.” Next, investigators examined “data collected from 340 youth during 2,638 follow-ups to assess whether the youth who took lithium differed on these measures compared with those who took antimanic anticonvulsants, first- and second-generation antipsychotics, and/or lamotrigine.” The findings were published online July 29 in the Journal of the American Academy of Child & Adolescent Psychiatry.
Related Links:
— “Lithium Found Superior to Other Mood Stabilizers in Improving Outcomes in Youth With Bipolar Disorder, Psychiatric News, July 31, 2019