MEDICAL FACULTY SENATE
Resolution to Provide Full Parity for Mental Health Services in University Employee Health Insurance Plans
The following resolution was adopted unanimously by the Medical Faculty Senate Steering Committee on July 14, 1998.
The Medical Faculty Senate Steering Committee strongly recommends that the University improve insurance coverage of mental health services for University employees to full parity with other medical services.
The Medical Faculty Senate Steering Committee urges the administration and the Personnel Benefits Committee of the University Council to re-address this issue during the coming academic year. Early in the deliberations, the Benefits Committee should invite the Department of Psychiatry and other knowledgeable constituencies of the faculty to present an argument in favor of full parity for mental health services. The Committee should also expect the University to provide an estimate of the actual cost of providing full parity for mental health care coverage that includes not only incremental expenses, but also likely cost savings associated with lower utilization of non-mental health services and fewer employee days lost from work.
The Medical Faculty Senate Steering Committee asks the Chair of the Personnel Benefits Committee to report to us again on this important issue in March or April of 1999.
The several health insurance options currently offered to University employees all place special limitations on coverage for mental health benefits that do not apply to other health care services. For example:
BC/BS Plan 100 and PENNCare limit inpatient mental health coverage to 30 days per year. Only locked wards are covered. Acute residential hospital stays (overnight care on unlocked hospital wards) are reimbursed only as outpatient services.
BC/BS Plan 100 and PENNCare cover only 50% of the discounted cost of outpatient mental health visits after deductible. All plans cover only 20 to 30 outpatient visits per year. "Outpatient visits" include overnight care on inpatient hospital residential units, treatment in day programs, neuropsychological testing and group therapy sessions in addition to outpatient visits with an individual physician or therapist.
For all plans, mental health drugs are covered at only 50% of cost after deductible. Mental health drugs include antidepressants, mood stabilizers, antipsychotics and other medications of proven efficacy for life-threatening psychiatric disorders such as major depression, bipolar disease and schizophrenia. This provision is unusual: most other local employers cover mental health drugs at the same level as other prescription drugs.
These and other provisions in our health insurance plans identify a group of employees for limited participation in a University-wide group benefit program based solely on the nature of their diseases. They conflict with the spirit, if not the letter, of the University's federally-mandated non-discrimination policy. *1*
During the 1997-98 academic year, in the context of the second phase of the Benefits Redesign Project, the Personnel Benefits Committee considered but then rejected recommending an increase in employee benefits for mental health services to provide full parity with other medical benefits. *2 * The committee was concerned that enhancements in mental health benefits would cost too much and that full parity in benefits "may not be accompanied by proportionate true benefits, even by those who use these services." Instead, the committee recommended only that the University should comply with recently enacted legislation by changing special limits on mental health coverage from annual dollar amounts to specified numbers of days or visits.
With input from a consultant, the University estimated that full parity would double the cost of mental health coverage (implying that current coverage for mental illness is at half-parity relative to coverage for non-mental illnesses).*3* That would increase the overall cost of employee health insurance by about 5%. This estimate apparently did not consider a potential reduction in non-mental health care insurance costs resulting from better mental health care, or the potential for a reduction in employee days lost from work.
Position of the Medical Faculty Senate Steering Committee
The Steering Committee is aware of no medical, scientific, or moral justification for distinguishing mental health services from other major types of medical care with respect to insurance coverage. Many major psychiatric illnesses are now known to have a genetic or acquired biochemical basis. Currently recommended drug therapies for mental illnesses are tested and approved by the Food and Drug Administration through the same rigorous process that applies to other prescription drugs. Modern cognitive and behavioral psychotherapy is also increasingly supported by widely respected, peer reviewed research.
The decision to continue non-parity for employee health insurance coverage of mental illnesses was made without substantial input from the Department of Psychiatry at Penn. No experts in the Department of Psychology or the Schools of Nursing or Social Work participated either. Had those groups been consulted, the University might have avoided several confusing or misleading statements that appeared in Almanac. For example, in justifying special benefit limits and maximums, mental health care was equated with other conditions where care is chronic or maintenance oriented such as "chiropractic treatment, immunizations, therapy services, hospice care and private duty nursing." In fact, mental health care is no more chronic or maintenance oriented than is care for many physical ailments that are covered at full parity, such as asthma, diabetes and hypertension. Any relationship between overall care within the broad category of mental illness and specific services such as chiropractic treatment, immunizations and private duty nursing is not apparent. The Almanac document further states that "Penn's mental health benefits are, for the most part, competitive with peer institutions" without revealing that Penn is unusual among local employers in placing special limitations on coverage for psychotropic drugs. Also in Almanac, the cost associated with mental health care was stated to be "very high," even though the 7% of benefit plan participants who use mental health services account for only 5% of the Penn's total claims cost.3 No comparison data were given for truly expensive physical conditions such as cirrhosis, HIV disease, cancer or heart transplantation that are covered at full parity.
In truth, the argument for perpetuating non-parity in employee insurance coverage for mental health can be boiled down to this: we have been making this distinction for a long time; other employers in our region do the same; our mental health insurance policies are allowable by law; there has been no sustained ground swell of pressure from employees to change our policies; full parity will increase our employee benefit expenses at a time when we are looking for every opportunity to contain costs.
These justifications for discriminating against the mentally ill are frankly embarrassing to a University that is internationally regarded for advancing social justice. The last two arguments are particularly vacuous. Aside from employees who are critically ill or comatose, no constituency of our University is less able or willing to lobby on their own behalf than individuals or close family members of individuals who are mentally ill. The actual net cost to the University of full parity is not known and is not relevant in any case to the issue of fairness. We no longer discriminate against physically handicapped employees because of the cost of ramps and lifts. Even if other benefits must be reduced proportionally to cover the incremental cost, the University should not distinguish among employees based solely on the nature of their diseases.
The harm done by special limitations on mental health insurance coverage extends beyond the imposition of an unfair financial burden on employees who incur mental health care expenses for themselves or their family members. Because other employers in Southeastern Pennsylvania also tightly restrict insurance coverage for mental health care, availability of many important mental health services is increasingly limited, even for those who can afford to pay out-of-pocket. Inpatient residential psychiatric care is a specific case in point. In Boston, where Harvard University and other major employers routinely pay for this proven modality, residential care is widely available to those who can benefit. In Philadelphia it is not. Instead, one world-famous Philadelphia psychiatric hospital has closed recently and another is threatened.
Special limits on mental health coverage also send a stark and painful message to people with mental illnesses. For example, a Penn employee with bipolar disease who takes bupropion and divalproex for mood stabilization soon discovers that special limitations on insurance coverage apply to the former drug but not to the latter because bupropion is used primarily for depression while divalproex is used primarily for seizures. After learning the reason for the difference, the employee might well conclude that her employer, the University of Pennsylvania, discriminates openly against people with "mental" as opposed to "brain" disorders, and might suspect that the true purpose is to discourage people with mental illnesses from working at Penn, regardless of their ability or performance.
Unlike most other employers, the University of Pennsylvania cannot plead ignorance on mental health insurance issues. We are national leaders in research on the causes and treatment of mental illnesses. Our University President is a clinical psychologist. Penn has an opportunity and an obligation to set a regional and national example for all major employers by insisting on full parity for mental health care in our employee benefit insurance plans.
Almanac, Vol. 45, No. 6, October 6, 1998