Data Points to Potential Violations of Mental Health Parity Laws; Shows Higher Out-of-Pocket Costs for Consumers When Compared to Physical Health
(Washington, DC) – Physical healthcare providers are receiving significantly higher payments from insurers than addiction and mental health providers for the same types of services, finds a groundbreaking, independent report published today by Milliman, Inc. and released by a coalition of America’s leading mental health and addiction advocacy organizations. In the Milliman report, commissioned by the Bowman Family Foundation, researchers found that along with payment disparities, which occur in 46 out of 50 states, “out-of-network” use of addiction and mental health treatment providers by consumers is extremely high when compared to physical health care providers.
Milliman researchers used three years of insurer claims data from 2013 to 2015 covering 42 million Americans, and looked at inpatient and outpatient services, primary care office visits, and specialist office visits, comparing in-network and out-of-network claims in all 50 states and D.C. When taken together, the analysis paints a stark picture of restricted access to affordable and much-needed addiction and mental health care in an era of escalating suicide rates and opioid overdose deaths. Further, these disparities point to potential violations of federal and state parity laws, which require insurance companies to treat diseases of the brain, such as clinical depression and opioid addiction, the same way they treat illnesses of the body, such as cancer and heart disease.
“Clearly, these access restrictions fan the flames of the opioid crisis and suicide deaths, two of the most urgent public health challenges we face as a nation,” said former Congressman Patrick J. Kennedy (D-R.I.), member of the President’s Commission on Combating Drug Addiction and the Opioid Crisis, author of the Mental Health Parity and Addiction Equity Act, and founder of The Kennedy Forum, whose ParityTrack initiative includes state-specific data from Milliman, as well as a registry for complaints about insurance denials. “If nearly 300 people dying each day from overdoses and suicides isn’t sufficient to motivate insurers to take immediate action to improve access to the full range of in-network benefits, we have a real problem – and it’s time to start holding them publicly accountable.”
One of the most dramatic disparities outlined in the report is the low reimbursements paid to behavioral health providers when compared to physical health providers – a factor likely influencing network access and overall practitioner in-network availability. The researchers discovered that physical healthcare providers were paid, on average, about 20% higher rates than behavioral health providers for the very same office visits billed under identical or similar codes. In many states, the disparities in payment rates were 2-3 times greater.
While payments to mental health and addiction providers were lower in comparison to physical healthcare providers from 2013 - 2015, out-of-network visits for inpatient and outpatient behavioral health services were dramatically increasing. Nationally, Milliman researchers found that in 2015, on average:
31.6% of outpatient facility behavioral health care was accessed out-of-network, while only 5.5% of outpatient facility medical/surgical care was accessed out-of-network. In 2013, the out-of-network outpatient facility use for behavioral health was 15.6%, showing a doubling of access restrictions during three years of parity regulatory oversight.
18.7% of behavioral health office visits were accessed out-of-network, while only 3.7% of primary medical/surgical office visits were accessed out-of-network.
16.7% of inpatient facility behavioral health care was accessed out-of-network, while only 4.0% of inpatient facility medical/surgical care was accessed out-of-network.
“The numbers tell a story – and it’s a painful one for those seeking treatment for mental illness or addiction,” said Mary Giliberti, CEO of the National Alliance on Mental Illness. “Behind those numbers are millions of Americans who can’t get the care they desparately need. We are confident that this Milliman analysis has uncovered a key barrier to network access – unfairly low reimbursement payments to mental health and addiction providers,” said Giliberti.
The report and full data sets are available here.
"We look forward to working with insurers as they look at their data and call on them to lead the way in transparency and upholding the letter and spirit of parity,” said Paul Gionfriddo, President and CEO of Mental Health America. “Plans have a crucial role to play in eliminating the disparities hurting so many American families from all walks of life."
Other highlights from the Milliman report include:
As of 2015, out-of-network use of behavioral health inpatient care – as compared to medical care – was approximately 800% higher in California, New York, and Rhode Island, and over 1000% higher in Connecticut, Florida, New Jersey, Pennsylvania, and New Hampshire. These states collectively had a population representing 30% of the U.S. population.
In 2015, there were 24 states with reimbursement disparities ranging from 30% to 69%, including Washington, Kentucky, and Virginia.
“This report reflects what the APA has been saying for the past several years,” said American Psychiatric Association CEO and Medical Director Saul Levin, M.D., M.P.A. “Insurers are not maintaining adequate mental health provider networks, and psychiatrists are reimbursed less than primary care doctors for the same services. We call upon state and federal regulators to ensure that insurance companies are abiding by parity laws already on the books to correct what remains an unequal health care system for patients with behavioral health conditions.”
“Many insurers have stated that they have no control over market forces that lead to overall shortages of behavioral health providers, but this report signals the end of that faulty logic,” said Henry Harbin, MD, a psychiatrist and adviser to the Parity Implementation Coalition. “Despite overall shortages in primary medical care and many medical specialties, including surgical, insurers have successfully retained these providers in their networks. This report should motivate insurers to use these same payment practices and network access strategies to attract and retain mental health and addiction treatment providers.”
This release is issued by the following groups: Parity Implementation Coalition, Mental Health America, National Alliance on Mental Illness, The Kennedy Forum, National Association of Addiction Treatment Providers, American Foundation for Suicide Prevention, The Treatment Advocacy Center, National Association of Psychiatric Health Systems, the Legal Action Center and the American Psychiatric Association, all of whom have been working to support parity since the 2008 passage of the Mental Health Parity and Addiction Equity Act. Since 2008, there have been dozens of national and state reports documenting major compliance problems with this federal law, and severe access issues for consumers.
“This perfect storm of factors reveals that patients are being forced into more costly out-of-network care, and can mean that treatment is abandoned altogether,” said Ellen Weber, Vice President for Health Inititatives at the Legal Action Center.
In light of this new report from Milliman, the coalition urges the following immediate action steps:
Federal Regulators should issue more specific guidance on medical management practices with examples of compliant analyses and, based on this report’s findings, should immediately initiate audits of major insurers.
Employers should retain independent companies to conduct parity compliance audits of the insurance plans provided to their employees in order to measure reimbursements, out-of-network use, denial rates, and other key variables restricting access to benefits.
State-level agencies should conduct routine annual parity compliance market audits of all insurers in their state, for both commercial and Medicaid-managed care companies.
“This is the first national report of its kind that evidences, based on claims data, disparately lower reimbursement levels as well as far greater use of out-of-network providers for behavioral care compared to medical care,” said Steve Melek, Principal & Consulting Actuary with Milliman. “This data highlights the need for auditing by health plans to ensure compliance with all practices that may be limiting access to behavioral health benefits, including provider fee schedules.”
The report was developed by Milliman, Inc., an independent actuarial and research institution.