Health care providers, patient advocates and key lawmakers are targeting health insurers as Congress crafts a bill to tackle the mental health crisis, arguing that low reimbursement rates and coverage limits limit access to care.
Members of Congress are seeking to tighten enforcement of mental health parity laws and address a reimbursement paradigm that providers say undervalues behavioral healthcare.
Data show that Americans have experienced higher levels of depression, anxiety, and suicidal thoughts during the COVID-19 pandemic. Substance abuse and overdoses are also on the rise. According to federal data, more than a third of US residents live in areas where there are not enough psychiatrists.
But 14 years after Congress passed the latest legislation requiring most insurers to cover mental health as well as medical and surgical care, millions of people are still struggling to find treatments they can afford.
“Equality law is not a reality for many people with mental illness,” said Jennifer Snow, national director of government relations and policy for the National Alliance on Mental Illness. “There may be laws on the books, but health insurance companies don’t really provide fair coverage.”
Health insurance companies and providers agree on one key issue: Fewer behavioral health professionals are taking out private or public insurance, so their patients must pay out of pocket. Suppliers cite low rates, while insurers blame labor shortages and rising demand.
Payments and administrative burdens are pushing mental health providers away from private insurance and government programs, said Stephen Gillaspie, senior director of health care and health care financing for the American Psychological Association.
“More and more providers will say, ‘I’m not going to be on Medicare or Medicaid panels’ or ‘I’ll just go cash-only,'” he said. “Then the only people who can access mental and behavioral health services are those people who have the income to do so, so this is a huge health equity issue.”
According to the Milliman Research Report, between 2013 and 2017, patients were 5.7 times more likely to opt out of the network for outpatient behavioral care than for outpatient medical or surgical services. released in 2019 Patients seeking outpatient substance use disorder treatment were 8.5 times more likely to use an out-of-network provider. This means higher costs for patients, and even more so for those with insurance that does not include out-of-network benefits.
Dozens trade groups, health systems, healthcare providers and patient advocates have petitioned the Senate Finance Committee to improve access to mental health. Many recommend pay parity, or at least higher rates.
According to the 2019 Milliman Research Report, which analyzes the claims of healthcare providers, primary health care reimbursements were 24% higher than mental health payments in 2017.
“I need to make sure that all my psychiatrists get back into the system if they opt out, and for that it’s really important to ensure pay parity,” said Dr. Saul Levine, CEO and medical director of the American Psychiatric Association.
Insurers counter that suppliers have leverage and that Congress should avoid doing anything that could further tip the balance. “There are some good ways to get more providers into our networks, but you don’t do it by giving providers all the power,” said James Gelfand, executive vice president of communications for the ERISA industry committee, which represents large employers with funded healthcare plans. insurance.
“It’s not just about money. It is about the desire to participate,” Gelfand said. Mental health providers themselves prefer to stay out of the network and only take cash, he said. Instead of requiring payers to increase reimbursements, Congress should promote telemedicine and build a workforce in behavioral health, he said.
Higher payouts will not only encourage more mental health providers to take up insurance, provider groups say, but will also encourage more students to take to the field.
“The crux of these issues is that we are not getting reimbursed and behavioral health cannot cover our costs,” said Dr. Sabina Lim, systemic vice president of health safety and quality at New York’s Mount Sinai Health System. “One of the best ways to demonstrate that we will treat mental health the same as physical health is that we should pay the same for it,” she said.
According to Mental Health America, in 2019, about a quarter of adults with mental illness reported that they were unable to get the treatment they needed, a proportion that has been consistent since 2011. report.
Data for 2020 and 2021 is not yet fully available, but experts expect higher demand has led to more problems accessing care. Census Bureau survey found that almost a third of adults reported symptoms of an anxiety or depressive disorder in January and February this year.
Key lawmakers such as Finance Committee Chairman Ron Wyden (D-Oregon) have indicated that the payment reform will be part of pending legislation that could be introduced this summer and possibly passed later this year.
Sen. Michael Bennet (D-Colorado), chairman of the parity committee, called mental health payments “pathetic” and said reform should be the “cornerstone” of legislation. Congress could raise Medicare rates and hope that this would encourage private health insurers to follow suit, as they often do when the program raises or lowers benefits.
Senator Tina Smith (D-Minnesota) also proposed an increase in Medicaid reimbursement for these providers. In 2019, only 35% of psychiatrists said they would accept new Medicaid patients, compared to 71% of physicians overall, according to a study by the Robert Wood Johnson Foundation’s State Health Access Foundation Data Center.
Lawmakers are also considering giving the Department of Labor the power to impose civil monetary penalties on health insurance plans that violate parity laws and offer grants to state insurance regulators to increase oversight. In a recent report to Congress, the ministry explained that its ability to enforce compliance is limited without the power to impose fines.
The Mental Health Equity and Addiction Equity Act of 2008 does not specify that mental health services should be reimbursed at the same rates as medical and surgical care. Fee differences are only prohibited if the factors used to set rates are not comparable between services.
Providers also allege that insurers impose tighter restrictions on behavioral health care, such as prior authorization requirements that do not apply strictly to medical or surgical services, which would be in violation of parity laws.
In August, UnitedHealthcare settled a lawsuit with the Department of Labor alleging that the insurance company illegally slashed reimbursement for out-of-network mental health providers and flagged mental health patients for usage verification.