In-Network Disparities for Mental Health

Kaysee Gruss

PGY-1 Managed Care Pharmacy Resident

Kaiser Permanente

In-Network Disparities for Mental Health

Concerns regarding adequate access to mental health care providers for members within health plan networks have been raised. From 2003 to 2013 there was a decrease in the number of practicing psychiatrists in the United States while there were increases in the numbers of primary care physicians and other specialties such as neurologists.¹ In addition, the amount of mental health care providers’ that participate in plan networks is low compared to primary health care providers, especially for psychiatrists. According to 2016 data of provider levels from the Affordable Care Act (ACA) Marketplaces, only 42.7% of psychiatrists and 19.3% of non-physician mental health care providers participate in any network.² Members who participate in narrow network plans are three times more likely to see out-of-network care for mental health services compared to primary health care providers. The use of out-of-network providers results in higher copayments, coinsurance, and deductibles for members. A higher financial burden may prevent members from seeking or being able to afford these services.² The patient population that is most effected by the limited in-network access to mental health services are those who are relatively poor and/or have a lower education level.¹

Mental health conditions are common in the United State with 25% of adults reporting having a mental health condition at any point in time. The need for mental health services is increasing due to improved treatment options, better defined diagnostic criteria, and expanded categories for diagnosis. Increased awareness of these mental health conditions has helped to reduce the stigma toward people with these conditions that may have been associated with the low amount of coverage of these services from insurance companies.³ Despite improvements in treatment options, the majority of people affected by mental health conditions do not receive help for these conditions. Untreated mental conditions can affect quality of life leading to morbidity and mortality. This population is at an increased risk of substance abuse, suicide, homelessness, and development of chronic diseases making the limited access to mental health services a public health concern.¹

One explanation for this discrepancy of care is the benefit of a narrow-network design for insurers. Approximately half of the plans offered in the Marketplaces in 2016 had narrow networks, defined as less than 25% of providers in any health insurance network. A narrow network design is a cost-containing strategy available to insurers, allowing for selectivity for providers in regard to performance. A narrow network may also help to prevent the inclusion of high-cost providers. Insurers can negotiate lower reimbursement rates with in-network providers. Narrow networks are also associated with lower premiums, which may influence member choice when choosing a health plan. This can further expand the problem. If members choose a plan solely based on the premium, that plan may not be able to provide affordable access to all the members’ health needs with in-network providers.²

Another explanation for this lack of participation of mental health professionals in plan networks is due to there being little incentive. Mental health providers receive low reimbursement rates from insurers regarding appointment length. Low reimbursement, on top of a growing demand for mental health care and a shortage of providers provides some insight into why mental health professionals may not wish to participate in plan networks. Only about half of number of practicing psychiatrists even accept health insurance.¹ This suggests that mental health professionals do not need to participate in a plan network due to a high demand for these services.²

Several regulations have attempted to account for the discrepancy in coverage and target the stigma surrounding mental health conditions. The Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 sought to reduce coverage gaps for mental health services by requiring benefit coverage to be similar to general medical services.² The Affordable Care Act (ACA) attempts to insert regulation by requirement mental health service be one out of ten benefits as well as requiring Marketplace plans to maintain a network that meets a sufficient number and variety of providers.² Components of these regulations have been left up to the states determination, creating inconsistency in coverage. Regulations have help to ensure that there is financial coverage for mental health services and increased awareness of the subject has helped to reduce the negative stigma surrounding these conditions, but the various interpretations of these regulations make it difficult to consistently regulate plan features and measure network quality.^2,3

Resources:

1     Bishop TF, Seirup JK, Pincus HA, Ross JS. Population Of US Practicing Psychiatrists Declined, 2003-13, Which May Help Explain Poor Access To Mental Health Care. Health Affairs. 2016; 35(7):1271-1277. Available at http://content.healthaffairs.org/content/35/7/1271.full.pdf+html. Accessed October 10, 2017.

2.     

         Zhu JM, Zhang Y, Polsky D. Networks in ACA Marketplaces are narrower for mental health care than for primary care. Health Affairs. 2017; 36(9):1624-1631. Available at http://content.healthaffairs.org/content/36/9/1624. Accessed October 6, 2017.

3.    

    McGinty e, Pescosolido B, Kennedy-Hendricks A, Barry CL. Communication strategies to counter stigma and improve mental illness and substance use disorder policy. PS in Advance. October 2017. Available at http://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.201700076?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed. Accessed October 6, 2017.