Americans are finding it increasingly difficult to access in-network care for addiction and mental health issues, according to a new analysis.
The report, released November 20 by actuarial and consulting firm Milliman and commissioned by the Mental Health Treatment and Research Institute LLC (a not-for-profit subsidiary of The Bowman Family Foundation), relies on claims data from 37 million employees and dependents with commercial preferred provider organization health insurance plans in all 50 states.
It updates a previous look at specific nonquantitative treatment limitations (NQTL) associated with behavioral health care services. The latest iteration adds analyses of claims for calendar years 2016 and 2017 and builds upon the prior report to include details of mental health and substance use treatment expenditures as a percentage of total health care spending.
The most recent findings are consistent with the previous analysis, showing significant disparities between medical/surgical providers and behavioral health care providers regarding both out-of-network utilization levels and provider reimbursement rates.
Most of these differences have worsened since the prior report was released, the authors point out, which may point to compliance issues with the NQTL requirements of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)—a law passed by Congress to improve access to mental health and substance abuse care.
The data revealed that for all five years examined, consumer out-of-network utilization rates were higher for behavioral health care providers than for medical/surgical providers, and disparities for out-of-network utilization were more significant in 2017 than in 2015 for all services analyzed.
Differences between out-of-network use for substance use disorder (SUD) care versus medical/surgical care "are stark," the report points out, and have risen throughout the five-year timeframe covered by the study.
The gap between how often SUD inpatient facilities are used out of network compared to medical/surgical inpatient facilities grew from nearly 5 times more likely in 2013 to over 10 times more likely in 2017. That same metric more than doubled for outpatient facilities, rising from 4.2 to 8.5.
Notably, spending for SUD treatment (excluding prescription medication) fell from 2015 to 2017 even though the opioid epidemic escalated during this stretch.
The average in-network reimbursement rates for behavioral health office visits are lower than for medical/surgical office visits, according to the report, and this difference has widened in recent years. As of 2017, primary care reimbursements were nearly 24% higher than behavioral reimbursements, and in 11 states, reimbursement rates for primary care office visits were more than 50% higher than rates for behavioral office visits.
Because the findings indicate disparities in both network use and provider reimbursement level, the authors suggested that health plans review their processes to ensure compliance. If a plan discovers that it is not adhering to the rules governing network adequacy and provider payment rates, increasing payment levels to behavioral health care providers could encourage practitioners to join the health plan's network, which may lead to greater use of in-network services.
The issue is clear, according to Patrick Gauthier, director of healthcare solutions at research and consulting firm Advocates for Human Potential Inc (AHP). Mental health and substance use disorders are treated differently than primary care by payers, he explained, and while plenty of progress has been made, there’s still a long way to go.
“What’s alarming about this latest spate of data,” Mr Gauthier told First Report Managed Care, “is that providers increasingly represent a parity challenge in their own right. While it is true that some managed care organizations apply unfair medical necessity guidelines and make seeking out-of-network care difficult and more costly for behavioral health sufferers, many behavioral health providers themselves no longer contract on an in-network basis.”
This exacerbates the problem and increases out-of-pocket costs for patients. Far too many mental health providers practice on a cash basis only, for example, refusing insurance payment—particularly Medicaid enrollees. “The result after a decade,” he says, “is a widening of the gap between primary care and behavioral health care.”
What’s needed “is a concerted and coordinated effort on the part of managed care entities and health systems” to integrate both disciplines, noted Mr Gauthier, who has previously held management positions in a variety of mental health and substance abuse treatment settings, served as COO and CMO for a national managed behavioral health care organization, and led the implementation of mental health parity in group health plans.
To bring behavioral health into the folds of primary care and medicine in general, he believes three main changes need to take place: (1) alter billing rules and policies to allow same-day billing; (2) get to integrated care faster by pursuing more mergers and acquisitions; and (3) normalize reimbursement for behavioral health services.
Health systems (knowing they could bill for behavioral services on a same day basis) need to merge with or acquire behavioral health practices, and managed care organizations need to encourage and reward that practice, Mr Gauthier explained.
“As an industry, we have never calculated reimbursement consistently where mental health and addiction treatment providers are concerned, and that’s especially true when accounting for Medicare and Medicaid,” he added. All payers ought to agree to a process that both modernizes and standardizes payment for services.
These steps, pursued in a way that moves in the direction of an integrated delivery system, value-based reimbursement, and population health are both necessary and urgent, Mr Gauthier added. Those wondering if the disparity is consequential need look no further than the latest statistics on life expectancy. The US has experienced a decline for a third straight year, due at least in part to alcohol-related illness, drug overdose, and suicide.