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Consultants at Milliman Inc. have come up with hard numbers that may back up an allegation patients and providers have been making for years: that many health insurers have skimpy mental health and addiction treatment services provider lists.
The consultants tried to get a rough estimate of the size of the behavioral health provider network adequacy problem by comparing how often patients in preferred provider organization (PPO) plans use out-of-network providers for behavioral health care, and how often the PPO plan patients use out-of-network providers for other types of care.
The gap between the likelihood that patients would access in-network behavioral health care providers and the likelihood that they would access in-network providers for other types of care was huge.
The Millman consultants based their results on analysis of a batch of medical claim records, collected from 2013 through 2015, for about 42 million U.S. PPO plan members.
For inpatient care, PPO patients were between 2.8 times and 4.2 times more likely to use out-of-network providers for behavioral care than for other types of care.
For office visits, PPO patients were 4.8 times to 5.1 times more likely to use out-of-network providers for behavioral health problems than for other types of problems.
Reimbursement rates for primary care providers were about 20% higher, when compared with “Medicare allowed” amount benchmarks, than reimbursement rates for behavioral care providers.
The Milliman consultants acknowledged that variables other than network size might explain some of the in-network care access gaps.
“The observed differences between out-of-network utilization rates for behavioral and medical/surgical services point to possible inequitable design and standards for network providers for behavioral services,” the Milliman consultants write in their report. “While other explanations, such as supply-side issues or patient reluctance to switch providers to stay in-network, are certainly possible and likely contribute as well, further investigation is warranted to understand these out-of-network differences.”
An arm of the Bowman Family Foundation, a fund affiliated with Matthias Bowman, paid for the study. Matthias Bowman is a supporter of efforts to improve the U.S. mental health care system.
The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) was supposed to increase parity between behavioral health insurance benefits and benefits for other types of health care. The MHPAEA requires large group health plans that cover behavioral health care to offer parity in terms of “nonquantitative treatent limits,” such as rules for managing use of inpatient care, for behavioral health care and other types of health care.
While former President Barack Obama was in office, federal regulators required individual and small-group plans to offer behavioral health benefits.
Officials in the administration of President Donald Trump have sought to ease some Obama-era parity requirements, but they appear to support the general idea of parity.
(Related: Mental Health Payers Ask Trump Team to Ax Obama-Era Disclosure Rules)
The Milliman consultants found that the patients in their study appeared to be especially likely to go out-of-network for behavioral health care in some states in which lawmakers and regulators have been active at promoting parity, such as California and New York state.
Nebraska was the only state in which PPO enrollees were more likely to get behavioral care office visits in-network than to get other types of office care from in-network providers.
A copy of the full Milliman report is available here.
—Read Feds Investigate 191 Employers for Mental Parity Compliance on ThinkAdvisor.
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Six months of inpatient care for an eating disorder can cost $180,000.
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