Disparities in Access to Behavioral Healthcare for Employer-Sponsored Health Plans Worsening, Study Finds

For both in-network access and provider reimbursement rates, disparities between physical and behavioral healthcare is worsening for American families seeking affordable and available mental healthcare and addiction treatment, according to a report published this week by Milliman Inc.

The report titled, “Addiction and Mental Health vs. Physical Health: Widening Disparities in Network Use and Provider Reimbursement,” covered claims data from 37 million employees and dependents in all 50 states for hundreds of health insurance plans. The study sought to examine disparities for employees and their families seeking behavioral healthcare, which includes mental healthcare and addiction treatment, versus treatment for physical health issues over a 5-year period (2013-2017).

In the report, it was found that inpatient out-of-network use for behavioral health was 5.2 (520%) times more likely than for medical and surgical providers, showing an 85% increase from 2013’s rate of 2.8 (280%) times more likely. Outpatient facilities out-of-network use for behavioral healthcare additionally showed a growing disparity (90%) compared to medical and surgical healthcare from 2013 (3.0 times more likely; 300%) to 2017 (5.7 times more likely; 570%). Office visit disparities, which already had a stark 5 times greater likelihood in 2013, rose to 5.4 in 2017.

When pairing these growing out-of-network use disparities with diminished reimbursement rates, the current lack of efficiency for behavioral healthcare becomes increasingly concerning. In 2017, primary care office visit reimbursement rates were on average 23.8% higher than behavioral office visit reimbursement rates compared with Medicare fee schedule amounts, indicating a 3.0% increase in disparities from 2015 (20.8%). From 2013 to 2017, average behavioral health reimbursements have remained below Medicare allowed amounts.

In addressing spending on the 2 facets of behavioral care as a percentage of total healthcare spending, mental health treatment (excluding prescription drugs and substance use) ranged from 2.2% to 2.4%, and substance abuse treatment (excluding prescription drugs and mental healthcare) ranged from 0.7% to 1.0%. Overall, prescription drug spending for all behavioral health was shown to be 2% of total healthcare spending in 2017.

These relatively low spending figures are part of a growing issue in the United States, and reveal a lack of initiative from policymakers despite an epidemic of suicides and poor access to care:

• US suicides for all ages have risen from 41,149 individuals in 2013 to 47,173 in 2017, a rate increase from 13 to 14.5 per 100,000 individuals.
• Suicides for those under 18 years of age have risen from 1,645 individuals in 2013 to 2,337 in 2017, a rate increase from 2.1 in 2013 to 3.0 in 2017 per 100,000 individuals.
• Deaths of all types involving substance use increased from 75,472 in 2013 to 109,813 in 2017, a rate increase from 23.9 in 2013 to 33.7 in 2017 per 100,000 individuals.

Advisor to The Bowman Family Foundation, who commissioned the study, Henry Harbin, MD, a psychiatrist and former CEO of Magellan Health Services, stressed that “the study’s findings are beyond disappointing and disturbing” amid efforts to curb these disparities. “With the extensive efforts by multiple stakeholders, over the last several years, we were expecting to see significant improvements. Instead, we are going backwards,” said Harbin.

To combat this growing concern, study's authors provided recommended action steps and referenced an initiative titled, “The Path Forward for Mental Health and Substance Abuse,” which includes 5 priority strategies to drive change:

• Improve network access for behavioral health specialists
• Expand use of collaborative care to integrate behavioral health into primary care
• Implement measurement-based care to improve quality and outcomes
• Expand tele-behavioral health
• Ensure mental health parity compliance