November 30, 2017
A recent Milliman, Inc., report found that individuals with behavioral health conditions are more likely than those with physical health conditions to use higher-cost, out-of-network care, and their providers are paid less than primary care providers for similar services. This report provides convincing evidence that patients have less access to behavioral health care than general medical care and the payment rates are significantly lower. Equal access to behavioral health and primary care is essential to achieve health care’s quadruple aim – improving population health, reducing costs and enhancing patient and provider experience.
Commissioned by the Mental Health Treatment and Research Institute, the report reveals that nationally, in 2015, the proportion of behavioral health care provided out of network was 3.6 to 5.8 times higher than medical/surgical care, depending on the setting. In 2015, primary care providers were paid more than 20 percent higher compared to behavioral health providers, even when providing the same low-to-moderate complexity evaluation and management services.
These two issues are closely linked. Behavioral health providers may be reluctant to join health plan networks if they are not adequately reimbursed for the cost of providing treatment. And the fewer providers a network has, the more often an individual may be forced to seek care out of network, which typically means higher copayments and coinsurance costs. Facing higher costs, some individuals may forgo treatment altogether. The result is lack of access to potentially lifesaving treatment and services for mental illnesses and substance use disorders.
These findings are consistent with the National Council Medical Director Institute’s Psychiatric Shortage: Causes and Solutions report on access to psychiatric services, which found that inadequate rates are a major reason for insufficient access to care. In addition to this, a survey of National Council members found that 70 percent lose money on psychiatric services because rates do not support the actual cost of providing care. Secret shopper surveys of network adequacy consistently show less availability for behavioral health than for primary care or other specialists. Inadequate rates are the greatest obstacle to keeping providers financially viable so they can provide quality services that keep their patients healthy. With rate disparities consistently high, the burden should be on payers to show that these differences do not reflect violations of the nonquantitative treatment limitations of federal parity law.
Parity is a critical lynchpin in providing access to quality behavioral health care. However, the National Council for Behavioral Health has long held that parity in benefit limits deductibles and copays is not the only solution to the issue of quality behavioral health. Parity of access, rates and treatment capacity are equally as important. We believe insurance companies can and must meet uniform standards for network adequacy and provider rates that are the same for behavioral health and general medical care. We also believe that state and federal regulators must systematically evaluate and enforce parity of network adequacy and rates to assure that patients have access to the behavioral health care they need.
Furthermore, we encourage health plans to create robust networks to address high levels of unmet need for behavioral health care and the high rates of comorbidity between behavioral health and physical health conditions. The Excellence in Mental Health Act established national standards of care with a corresponding Medicaid funding stream, reimbursing behavioral health providers the full cost of care for offering comprehensive, science-based treatment and recovery support services coordinated with primary care.
A recent National Council survey of Certified Community Behavioral Health Clinics (CCBHCs) created by the Excellence Act demonstrates that a prospective payment system that reimburses providers for the actual cost of providing care increases access to services. All respondents have added new staff, expanded treatment capacity and expanded services. As a result, 87 percent of CCBHCs have increased the number of patients they serve.
The Excellence in Mental Health and Addiction Treatment Expansion Act recently introduced in Congress would allow an additional 11 states to join the eight that have developed these state-of-the-art CCBHCs. The result, an increase in the number of behavioral health providers being paid a rate that relates to their actual cost of providing services.
The Milliman, Inc., report makes an important contribution to the national conversation about the adequacy of services for mental illnesses and substance use disorders. At the National Council, access to affordable, science-based prevention, treatment and recovery support services for mental illnesses and substance use disorders is our true north. The health of our patients and the well-being and economic security of our nation depend on us getting this right.
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The National Council for Behavioral Health is the unifying voice of America’s health care organizations that deliver mental health and addictions treatment and services. Together with our 2,900 member organizations serving over 10 million adults, children and families living with mental illnesses and addictions, the National Council is committed to all Americans having access to comprehensive, high-quality care that affords every opportunity for recovery. The National Council helped introduce Mental Health First Aid USA and more than 1 million Americans have been trained. For more information, please go to www.TheNationalCouncil.org.