Similar services for mental health are reimbursed differently according to the treatment setting, a report finds. Mental health services also involve more out-of-network coverage than other healthcare.
The setting in which mental healthcare is delivered has a significant impact on reimbursement for providers, even when the treatments are very similar, according a new report that suggests mental health professionals and their patients are not getting a fair deal from healthcare insurers.
In addition to the payment disparities found in 46 out of 50 states, "out-of-network" use of addiction and mental health treatment providers is extremely high when compared to physical health care providers, the report found.
The report was prepared by Milliman and released by a coalition of mental health and addiction advocacy organizations. It was based on three years of insurer claims data, 2013-2015, covering 42 million Americans, including inpatient and outpatient services, primary care office visits, and specialist office visits, comparing in-network and out-of-network claims in all 50 states and D.C.
The analysis “paints a stark picture of restricted access to affordable and much-needed addiction and mental health care in an era of escalating suicide rates and opioid overdose deaths,” the advocacy groups report. “Further, these disparities point to potential violations of federal and state parity laws, which require insurance companies to treat diseases of the brain, such as clinical depression and opioid addiction, the same way they treat illnesses of the body, such as cancer and heart disease.”
One of the most dramatic disparities outlined in the report is the low reimbursements paid to behavioral health providers when compared to physical health providers, a factor the report says is likely influencing network access and overall practitioner in-network availability. Physical healthcare providers were paid, on average, about 20% higher rates than behavioral health providers for the very same office visits billed under identical or similar codes. In many states, the disparities in payment rates were two to three times greater, the report says.
While payments to mental health and addiction providers were lower in comparison to physical healthcare providers, out-of-network visits for inpatient and outpatient behavioral health services were dramatically increasing, the report says.
The researchers also found that 31.6% of outpatient facility behavioral healthcare was accessed out of network, while only 5.5% of outpatient facility medical/surgical care was accessed out of network. In 2013, the out-of-network outpatient facility use for behavioral health was 15.6%, showing a doubling of access restrictions during three years of parity regulatory oversight, the report says.
For behavioral health, 18.7% of office visits were accessed out-of-network, while only 3.7% of primary medical/surgical office visits were accessed out-of-network.
Also, 16.7% of inpatient facility behavioral health care was accessed out-of-network, while only 4.0% of inpatient facility medical/surgical care was accessed out-of-network.
The numbers tell a painful story for those seeking treatment for mental illness or addiction, says Mary Giliberti, CEO of the National Alliance on Mental Illness.
"Behind those numbers are millions of Americans who can't get the care they desperately need,” she says. “We are confident that this Milliman analysis has uncovered a key barrier to network access—unfairly low reimbursement payments to mental health and addiction providers.”
As of 2015, out-of-network use of behavioral health inpatient care—as compared to medical care—was about 800% higher in California, New York, and Rhode Island, and over 1,000% higher in Connecticut, Florida, New Jersey, Pennsylvania, and New Hampshire, the report says. These states collectively had a population representing 30% of the U.S. population.
In 2015, there were 24 states with reimbursement disparities ranging from 30% to 69%, including Washington, Kentucky, and Virginia.
American Psychiatric Association CEO and Medical Director Saul Levin, MD, MPA, says the report indicates insurers are not maintaining adequate mental health provider networks and psychiatrists are reimbursed less than primary care doctors for the same services.
“We call upon state and federal regulators," he says, "to ensure that insurance companies are abiding by parity laws already on the books to correct what remains an unequal health care system for patients with behavioral health conditions."
Gregory A. Freeman is a contributing writer for HealthLeaders.