In the United States, commercially insured patients are struggling to find in-network mental health providers, forcing many to seek out-of-network care at rates above those for other conditions—despite the federal mental health parity law, according to a report published recently by Milliman.

Just released: Your behavioral health access playbook

Findings

The report, which was commissioned by the Bowman Family Foundation (BFF), examined the claims data of 37 million workers and their dependents from all 50 states with commercial PPO health plans from 2013 to 2017. The latest report updates Milliman's previous research on the subject, which assessed claims data from 2013 to 2015.

According to the new findings, out-of-network utilization rates for mental health care providers were higher than such rates for medical and surgical providers across all five years. Specifically, the report found that people seeking:

• Inpatient care for mental health in 2017 were 5.2 times more likely to use an out-of-network provider than they did for inpatient medical or surgical care, up by about 85% from 2013, when they were 2.8 times more likely to do so; 
• Outpatient mental health care services in 2017 were 5.7 times more likely to use an out-of-network provider than they did for outpatient medical or surgical care, up by 90% from 2013, when they were three times more likely to do so; and
• Mental health office visits in 2017 were 5.4 times more likely to use an out-of-network provider than they did for medical or surgical office visits, up by 8% from 2013, when they were five times more likely to do so.

The disparity was particularly glaring for substance use disorder treatment, the report found. Overall, people seeking inpatient care for substance use disorders were 10.1 times more likely to use an out-of-network provider than they were for inpatient medical or surgical care in 2017. According to the report, that figure marks a stark increase from 2013, when such patients were 4.7 times more likely to use an out-of-network provider.

Additionally, the report identified substantial disparities in reimbursement rates for mental health care compared with medical or surgical care. For instance, in 2017, reimbursements for primary care were, on average, about 23.8% higher than for mental health care—and in 11 states, reimbursement rates for primary care office visits were more than 50% higher than mental health office visits.

Moreover, the percentage of total health care spending "attributed to both" mental health and substance use disorder treatment was 5.2%, marking a "slight decline" from 2015, the report found. 

Recommendations

According to Milliman, the findings "indicate that disparities exist in both network use and provider reimbursement … when comparing behavioral health care to medical/surgical health care." The report authors noted that those disparities persist despite the passage of the Mental Health Parity and Addiction Equity Act (MHPAEA), which requires insurers to provide equal access to mental and physical health care, more than 10 years ago.

Milliman recommended that insurers "carefully review their processes … to ensure compliance" with the law.

Comments

"The main disparity is that consumers with any mental health or [substance use disorders] have to go out of network" at a rate "many times higher than a person with any medical condition," said Henry Harbin, a psychiatrist and advisor to BFF.

Michael Thompson, president and CEO of the National Alliance of Healthcare Purchaser Coalitions, said employers have noticed the way the coverage gap affects employees, as well. "This has become a situation that they can't deal with anymore. When their people try to get appointments with network psychiatrists, they can't even get a phone call returned," Thompson said.

According to Harbin, the problem exists because insurance plan networks refuse to adjust to address the shortage of behavioral health clinicians in their networks and instead continue to reimburse behavioral health providers at lower rates than physical health providers.

Harbin noted that, if an insurance plan had too few oncologists or cardiologists, the insurer would increase reimbursement rates to attract more providers to the network. "It can be done pretty quickly," he said, adding, "Just raise rates in the areas where you're short, like they do on the medical side."

But Cathryn Donaldson, a spokesperson for America's Health Insurance Plans, said, "Health insurance providers regularly assess the adequacy of their provider networks so patients have timely access to behavioral health care" to ensure compliance with MHPAEA. According to Donaldson, the disparities reflect a national shortage of behavioral health providers. She added that a lot of mental health clinicians do not want to participate in insurance networks.

However, Thompson conceded that it is the responsibility of employers and insurers to "lead efforts to improve access and accountability," especially as rates of suicide and substance misuse increase. "It's clear that our mental health system is broken and it's not going to fix itself," he said (Kaiser Health News/U.S. News & World Report, 11/20/19; Jaspen, Forbes, 11/20/19; Owens, Axios, 11/21/19).