What Does the 21st Century Cures Act Mean for Mental Health Care?



by Eric M. Plakun, MD, DLFAPA, FACPsych

Eric M. Plakun, MD, DLFAPA, FACPsych, Associate Medical Director and Director of AdmissionsPresident Obama signed the 21st Century Cures Act into law this week. This is an unusual piece of bipartisan legislation that has significant mental health components important to us at Riggs and to others who advocate for the importance of adequate funding for treatment of those with mental and substance use disorders. The law brings needed new funding to address the national opioid crisis that has developed over the last decade, as physicians were urged to prioritize alleviation of pain in ways that translated into too-easy access to powerful opioids that were sometimes misrepresented as much less addicting than they were by the pharmaceutical industry. Many psychiatric patients are in the unfortunate position of having been given opioid drugs for emotional pain or for physical pain for which less addicting and less mentally numbing drugs would be preferred. We applaud the new funding.

The law also strengthens and restructures SAMHSA, while improving integration of often fragmented mental health care across government agencies—especially for those with serious mental illness. These steps are most welcome and should make a real difference. 

The law also adds new funding for brain research. We hope the new NIMH director, Josh Gordon, changes NIMH policy so that much needed clinical trials research is again supported—the kind of research that teaches us which therapies work in the near term—unlike the basic brain research on underlying biological mechanisms and research on animal models the NIMH has favored—but that takes decades to lead to the development of new treatments that help patients. As an example of the need, the 2015 IOM Report on Psychosocial Interventions for Mental and Substance Use Disorders explicitly called for more research into which non-specific (i.e., shared) elements of therapies work, regardless of theoretical model. We need a “both/and” approach to spending research dollars, rather than the “either/or” stance that led the NIMH to stop funding for clinical trials research in favor of brain research.

The law also significantly bolsters and adds procedural substance to the parity law, which requires that insurance companies offer access to mental health and substance use disorder benefits in ways that are not more stringent or that set higher burdens to access than for medical or surgical benefits. The parity law forbids both “quantitative limits” (QTLs) (e.g., offering a fixed number of dollars, days or sessions for mental health disorders, but not medical disorders) and “non-quantitative limits” (NQTLs) (e.g., more stringent utilization management standards) to access care. I’ve recently spoken personally to several Riggs patients and family members who have faced denials of funding for Riggs residential treatment from their insurance company because the insurance company puzzlingly uses acute inpatient admission criteria to assess the need for residential treatment. To help advocate for the need for residential level care for these patients, we have begun to include the patient’s Level of Care Utilization System (LOCUS) score in the information we send with the patient’s consent to insurance companies. The LOCUS was developed by the American Association of Community Psychiatry as a way to assess the need for levels of care from outpatient to residential to acute inpatient by measuring six clinical dimensions that include acuity and safety as one dimension, but that also include attention to the patient’s other supports, concurrent or comorbid disorders, past history of response to treatment, and the like. We have found that including an objective measure (developed not by Riggs or by the insurance company, but by an independent organization concerned with accurately assessing the need for care) is often the best way to persuade an insurance company that residential care is medically necessary and appropriate to the patient’s needs. It is also especially helpful when the patient or family member who holds the insurance contract also works through their employer or insurance broker to let the insurance company know that they understand their rights under the parity law and will not tolerate NQTLs that appear to be in violation of it. Using acute inpatient criteria to justify the need for residential treatment seems comparable on the medical side to telling a patient with a stroke that, since they no longer need access to the lifesaving measures available in an ICU, they will be discharged to outpatient care even though they cannot yet walk, talk, or otherwise care for themselves. The law provides greater consumer access to information about parity and includes a provision to develop an action plan for improved parity compliance, with a particular focus on NQTLs.  Under the law, insurance plans that are found to have multiple violations of the parity law will face consequences. The law should make a genuine contribution to fuller parity implementation.

Finally, the 21st Century Cures Act streamlines FDA regulations for the development of new drugs. Although this may simplify bringing new drugs to market, many are concerned that such deregulation offers a windfall to a pharmaceutical industry already criticized for price gouging, and with a history of undue influence with psychiatrists that was a major cause of embarrassment in years past.

Like any bipartisan compromise, the law is in some ways a mixed blessing, but on balance the 21st Century Cures Act is a welcome piece of legislation—especially in terms of parity implementation.


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