Lower Payments to Providers and Higher Out-of-Pocket Costs for Consumers as Compared to Medical/Surgical Treatment
(WASHINGTON, DC) A report, “Addiction and Mental Health vs. Physical Health: Widening disparities in network use and provider reimbursement”, released today found that the gap in disparities for individuals seeking mental health and substance use disorder (SUD) treatment versus treatment for physical health conditions widened in 2016 and 2017.
The study was conducted by Milliman, Inc and covered 37 million employees and dependents. It demonstrates, based on actual claims data in all 50 states for hundreds of health insurance plans, that “out-of-network” use of behavioral providers is dramatically higher than out-of-network use of medical and surgical providers – and the degree of disparity has grown substantially in recent years, despite state and federal efforts to promote the Mental Health Parity and Addiction Equity Act (MHPAEA). The study also documented much lower reimbursement rates paid by insurers to behavioral providers for “in-network” services, with the gap between behavioral versus medical/surgical providers widening.
"These access problems are about more than just reimbursements,” said Mark Covall, president and CEO of the National Association for Behavioral Healthcare (NABH) and Parity Implementation Coalition Co-Chair. “Our evidence shows that health plans limit in-network providers, do not credential new providers in a timely manner, pay significantly lower rates for in-network care, and apply extreme utilization-review tactics that are not based on medically necessary care.”
Parity Implementation Coalition (PIC) Co-Chair Marvin Ventrell, President and CEO of the National Association for Addiction Treatment Providers, said that these findings are particularly alarming amid the twin epidemics of suicide and opioid overdoses. Ventrell stated, “Unfortunately, this study shows that as the rates of Americans dying from overdoses and suicides have increased, provider reimbursement rate disparities have widened - in 11 states, reimbursement rates for primary care office visits were more than 50% higher than reimbursement for behavioral health office visits. The Parity Implementation Coalition calls on state and federal regulators to increase their oversight in key areas and require health plans to provide comparative quantitative and non-quantitative data covering factors such as out-of-network use and reimbursement rates so that these disparities can be addressed.”
“Peak spending for substance use disorder treatment accounted for only 1% of total healthcare spending during the last 5 years – that’s equal to $1 out of every $100. The numbers tell a story—and it’s a painful one for individuals and family members seeking treatment for substance use and/or mental health disorders,” said Justin Luke Riley, President and CEO of Young People in Recovery. “Behind those numbers are millions of Americans who can’t get the care they desperately need and families who are grieving the loss of their loved one to suicide or overdose” said Riley.
Key findings from the report include:
- Out-of-network use disparities
- From 2013 to 2017, the disparity between how often behavioral inpatient facilities are utilized out-of-network relative to medical/surgical inpatient facilities has increased from 2.8 times more likely to 5.2 times more likely, an 85% increase in disparities over 5 years.
- Over the same 5 years, the disparity for behavioral health office visits relative to medical/surgical primary care office visits has increased from 5.0 times (500%) more likely to 5.4 times (540%) more likely, an 8% increase in disparities.
- Reimbursement rate disparities
- In 2017, for 11 states, reimbursement rates for primary care office visits were more than 50% higher than reimbursement rates for behavioral office visits, an increase from 9 states in 2015. Another 13 states in 2017 had reimbursement rates for primary care office visits that were between 30% and 49% higher than reimbursement rates for behavioral office visits.
- Substance use disorder disparities analyzed separately
- Disparities in out-of-network use for SUD care compared to medical/surgical care are stark and have increased over the 5-year study period.
- The disparity between how often SUD inpatient facilities are utilized out-of-network relative to medical/surgical inpatient facilities increased from 4.7 times more likely in 2013 to 10.1 times more likely in 2017.
- Disparities for Children versus Adults
- In 2017, a behavioral healthcare office visit for a child was 10.1 times more likely to be to an out-of-network provider than a primary care office visit – this was more than twice the disparity seen for adults.
- By 2017, disparities in reimbursement rates between behavioral healthcare office visits for children and primary care office visits for children have narrowed, yet the out-of-network use for behavioral health office visits for children were higher in 2016 and 2017 than in 2015. This data highlights that reimbursement parity alone may not be sufficient to achieve parity of access to in-network care.
- Spending on mental health and substance use disorder as a percent of total healthcare spending
The Parity Implementation Coalition looks forward to working with Congress and the Administration to address these inequalities and ensure the Mental Health Parity and Addiction Equity Act is fully implemented and enforced as intended when the bill was passed by an overwhelmingly bipartisan majority of Members of Congress and signed into law by President Bush in 2008.
- Spending for mental health treatment (excluding prescription drugs), as a percent of total healthcare spending, has been consistent, between 2.2% and 2.4% in the study period.
- Spending for SUD treatment (excluding prescription drugs), as a percent of total healthcare spending, has increased from 0.7% in 2013 to 0.9 % in 2017.
- The percentage of total healthcare spending that is attributed to both mental health and SUD healthcare combined, including prescription drugs, was 5.2% in 2017, a slight decline since 2015.
The Parity Implementation Coalition includes the Depression and Bipolar Support Alliance, Mental Health America, National Alliance on Mental Illness, National Association for Behavioral Healthcare, National Association of Addiction Treatment Providers, and Young People in Recovery. The organizations advanced parity legislation and implementing regulations for over fourteen years in an effort to end discrimination against individuals and families who seek services for mental health and substance use disorders and remain committed to its effective implementation. More information about the Coalition is available at http://www.parityispersonal.org.