It's been nearly a decade since Congress passed the mental health parity act, with its promise to make mental health and substance abuse treatment just as easy to get as care for any other condition. Yet today, in the midst of the opioid epidemic and a spike in the rate of suicide, patients still struggle to access treatment.
That's the conclusion of a report published last week by Milliman Inc., a national risk management and health care consulting company. The report was released by a coalition of mental health and addiction advocacy organizations.
Among the findings:
-- In 2015, behavioral care was four to six times more likely to be provided out-of-network than medical or surgical care.
-- Insurers pay primary care providers 20 percent more for the same types of care as they pay addiction and mental health care specialists, including psychiatrists.
-- State statistics vary widely. In New Jersey, 45 percent of office visits for behavioral health care were out-of-network. In Washington D.C., the figure was 63 percent.
The researchers at Milliman examined two large national databases containing medical claims records from major insurers for PPOs -- preferred provider organizations -- covering nearly 42 million Americans in all 50 states and the District of Columbia from 2013 to 2015.
"I was surprised it was this bad. As someone who has worked on parity for 10-plus years, I thought we would have done better," said Henry Harbin, former CEO of Magellan Health, a managed behavioral health care company. "This is a wake-up call for employers, regulators and the plans themselves that whatever they're doing, they're making it difficult for consumers to get treatment for all these illnesses. They're failing miserably."
The high proportion of out-of-network behavioral care means mental health and substance-abuse patients were far more likely to face the high out-of-pocket costs that can make treatment unaffordable, even for those with insurance.
In a statement issued with the report, the coalition of mental health groups, including Mental Health America, the National Association on Mental Illness, and The Kennedy Forum, called on federal regulators, state agencies and employers to conduct random audits of insurers to make sure they are in compliance with the parity law.
Harbin, now a consultant on parity issues, said the report's finding that mental health providers are paid less than primary care providers is a particular surprise. In nine states, including New Hampshire, Minnesota, Vermont, Maine and Massachusetts, payments were 50 percent higher for primary care providers when they provided mental health care.
Because of such low reimbursement rates, he said, mental health and substance abuse professionals are not willing to contract with insurers. The result is insurance plans with narrow behavioral health networks that do not include enough therapists and other caregivers to meet the demands of patients.
For years, insurers have maintained that they are making every effort to comply with the Mental Health Parity and Addiction Equity Act, which was intended to equalize coverage of mental health and other medical conditions. And previous research has found that they have gone a long way toward eliminating obvious discrepancies in coverage. Most insurers, for example, have dropped annual limits on the therapy visits that they will cover. Higher copayments and separate mental health deductibles have become less of a problem.
Still, discrepancies appear to continue in the more subtle ways that insurers deliver benefits, including the size of provider networks.
Kate Berry, a senior vice president at America's Health Insurance Plans, the industry's main trade group, said the real problem is the shortage of behavioral health clinicians.
"Health plans are working very hard to actively recruit providers" and offer telemedicine visits in shortage areas, said Berry. "But some behavioral health specialists opt not to participate in contracts with providers simply because they prefer to see patients who are able to pay out of their pocket and may not have the kind of severe needs that other patients have."
"This is a challenge that no single stakeholder in the health care infrastructure can solve," she added.
Carol McDaid, who runs the Parity Implementation Coalition, countered that insurers have been willing and able to solve provider shortages in other fields. When there was a shortage of gerontologists, for example, McDaid said, insurers simply increased the rates and more doctors joined the networks. "The plans have the capacity to do this; I just think the will hasn't been there thus far," she said.
The scarcity of therapists who accept insurance creates a care landscape that is difficult to navigate for some of the most vulnerable patients.
Ali Carlin, 28, said she used to see her therapist in Richmond, Va., every week, paying a copay of $25 per session. But in 2015, the therapist stopped accepting her insurance, and her rate jumped to $110 per session.
Carlin, who has both borderline personality disorder and addiction issues, said she called around to about 10 other providers, but she couldn't find anyone who accepted her insurance and was taking new patients.
"It's such a daunting experience for someone who has trouble maintaining their home and holding a job and friendships," said Carlin. "It makes me feel like no one can help me, and I'm not good enough, and it's not an attainable goal."
In Virginia, the Milliman report found that 26 percent of behavioral health office visits were out-of-network -- more than seven times more than for medical care.
With no alternative, Carlin stuck with her old therapist but must save up between sessions. She has just enough to cover a visit once every few months.
"I make $30,000 a year. I can't afford an out-of-pocket therapist or psychiatrist," said Carlin. "I just can't afford it. I'm choosing groceries over a therapist."
Angela Kimball, director of advocacy and public policy at the National Alliance on Mental Illness, said she worries many patients like Carlin simply forgo treatment entirely.
"One of the most common reasons people give of not getting mental health treatment is the cost. The other is not being able to find care," she said. "It's hurting people in every corner of this nation."
(Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.)
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