Struggle to find affordable, in-network mental health treatment is real

Health insurers are failing to comply with mental health parity laws for Americans with employer-sponsored health coverage and their families, according to a recent report.

As a result, there are increasing disparities in access to behavioral health services for employees and their dependents who end up having to seek care from out-of-network providers at higher out-of-pocket costs.

The report “Addiction and Mental Health vs. Physical Health: Widening disparities in network use and provider reimbursement” outlines problems with access to affordable in-network care for mental illness and substance use disorders.

The report by the independent actuarial and research institution consulting firm Milliman was commissioned by the Mental Health Treatment and Research Institute LLC, a non-profit subsidiary of The Bowman Family Foundation.

The private foundation provides funding for projects designed to improve access to treatment for those who receive little or no mental health care because of financial or other barriers.
The Milliman report looked at third party administrative claims data from commercial preferred provider organization (PPO) health plans for 37 million employees and their dependents in all 50 states for the years 2013 through 2017.

It updated previous work that only looked at data through 2015 for a deeper dive to evaluate mental health and substance use treatment as a percentage of total health care spending.
Among the findings:

• Across all U.S. states, people seeking inpatient care for behavioral health issues were 5.2 times more likely to be treated by an out-of-network provider than for medical or surgical care in 2017 — up from 2.8 times in 2013. Maine residents were 37.7 times more likely — the highest proportion of behavioral out-of-network use in the nation.
• In 2017, a child was 10 times more likely to go out-of-network for a behavioral health office visit than for a primary care office visit.
• Substance use disorder treatment at an inpatient facility was over 10 times more likely to be provided out-of-network — up from 4.7 times in 2013.
• Primary care office visit rates were nearly 24 percent higher than rates for behavioral reimbursements in 2017, an increase from nearly 21 percent higher in 2015.

Federal law prevents group health plans and health insurers from imposing less favorable benefit limits for mental health or substance use disorder benefits than on medical/surgical benefits. The 21st Century Cures Act enacted by Congress in December 2016 strengthened mental health parity regulation and provided funding for states to address the national opioid epidemic.

So why are things getting worse, not better?

“Mental health parity is so clearly the right thing to do to improve population health that I suspect many professionals and community members had an optimistic hope,” said Jared Skillings, Ph.D., chief of professional practice for the American Psychological Association.

The access and reimbursement disparities highlighted in the report show that parity is a complex goal that is difficult to define and enforce, Skillings said.

In response to the Milliman report, APA joined a coalition of mental health and addiction organizations in calling for increased oversight by federal and state parity regulators. The coalition said health plans should be required to provide quantitative data comparing rates for out-of-network use, reimbursement, denial, pre-authorization requirements, and concurrent reviews.

The coalition also urged any insurers that believe the disparities in the report were in error or that their plans had improved since 2017 to publicly release data for its plans.

After parity regulations went into effect, there was great interest in ensuring that benefit designs were compliant with quantitative treatment limitations, such as number of visit or day limits for treatment, while interest lagged in non-quantitative treatment limitations, such as pre-authorization requirements, said Stoddard Davenport, MPH, one of the Milliman report’s three authors.
“Outside of this study, in the interactions that we have with health plans, we are seeing a growing interest in paying attention to these issues and self-compliance,” Davenport said.

Now Davenport said he is seeing interest in making improvements in access to behavioral health care coming from employers, regulators, and health plan.

“I see an awful lot of people that care deeply about improving the state of behavioral health and that gives me optimism,” he said.

The Bowman Family Foundation has not commissioned any follow up report for the future. But its president Matthew B. Bowman said the foundation is supporting several strategies for improving access to effective treatment outlined in a plan titled “Path Forward for Mental Health and Substance Use.”

The strategies include expanding adoption of the collaborative care model for delivering behavioral health in primary care settings, expanding telehealth, and ensuring mental health parity compliance.