-Addiction Treatment Disparities for Inpatient, Outpatient Facility, and Office Visits are Stark Despite the National Opioid Crisis

-Children’s Use of Out-of-Network Mental Health Office Visits is Ten Times Higher than for Primary Care Office Visits, Double the Disparities for Adults

Washington, D.C., November 20, 2019 – Disparities between physical and behavioral healthcare for both in-network access and provider reimbursement rates are making it even harder for American families to find affordable and available mental healthcare and addiction treatment according to a new study. The report, published by Milliman, Inc. covering 37 million employees and dependents, and commissioned by The Bowman Family Foundation, reflects that conditions have worsened since a similar study was published two years ago.

The report, “Addiction and Mental Health vs. Physical Health: Widening disparities in network use and provider reimbursement,” shows the gap in disparities for employees and their families seeking mental health and addiction treatment versus treatment for physical health conditions widened in 2016 and 2017. The study, based on actual claim data in all 50 states for hundreds of health insurance plans, demonstrates that “out-of-network” use of behavioral providers is  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 parity. 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.

“The study’s findings are beyond disappointing and disturbing,” said Henry Harbin, MD, a psychiatrist, former CEO of Magellan Health Services, and advisor to The Bowman Family Foundation. “With the extensive efforts by multiple stakeholders, over the last several years, we were expecting to see significant improvements. Instead, we are going backwards.”

“These results are profoundly worrisome in light of the recent decrease in life expectancy in the U.S. population due to so called ‘deaths of despair,’ especially suicide and opioid related death rates. We haven’t had a back to back two-year reduction in life expectancy since 1919 when the nation battled the influenza epidemic. What will it take to make the changes needed to turn this tragedy around?” said Tom Insel, Special Advisor for Behavioral Health to CA Governor Gavin Newsom and former Director of the National Institute of Mental Health.

Key findings from the study can be found here in the Executive Summary beginning at page six of the report, and include:

Out–of-network use disparities for both mental health and substance use

• Disparities in access to in-network behavioral providers compared to medical/surgical in all treatment settings continued to worsen in 2016 and 2017 compared to earlier years.
• Inpatient out-of-network use for behavioral health was over five times more likely than for medical/surgical, worsening from 2.8 times (280%) more likely in 2013 to 5.2 times (520%) more likely in 2017 (an 85% increase in disparities over five years).
• Outpatient facilities out-of-network use was nearly six times more likely for behavioral health, worsening from 3.0 times (300%) more likely in 2013 to 5.7 times (570%) more likely in 2017 (a 90% increase in disparities over five years).
• Office visit disparities were already five times higher in 2013 (500%), and have worsened to 5.4 times (540%) in 2017.

“These access problems are about more than just reimbursements. 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,” said Mark Covall, president and CEO of the National Association for Behavioral Healthcare.

Substance use disparities (separate from mental health)   

• Substance use out-of-network use disparities compared to medical/surgical care are especially shocking, having increased for all treatment settings during the five-year period.
• Inpatient out-of-network use for substance use care was over 10 times (1000%) more likely than for medical/surgical care in 2017, worsening from 4.7 times in 2013 (a 113% increase in disparities over five years).
• Outpatient facility out-of-network use for substance use care was 8.5 times (850%) more likely than medical/surgical care 2017, worsening from 4.2 times (420%) in 2013 (a 102% increase in disparities over five years).
• Office visit out-of-network use for substance use care was 9.5 times (950%) more likely than primary care office visits in 2017, worsening from 5.7 times (570%) more likely than primary care office visits in 2013 (a 67% increase in disparities over five years).
• Reimbursement rate disparities for substance use office visits compared to primary care office visits increased each year between 2013 and 2017.
• Substance use office visit reimbursement rates in 2013 were lower than Medicare allowed amounts and declined relative to Medicare during the five-year period.

Children versus adults 

• In 2017, a child’s out-of-network office visit for behavioral healthcare was 10.1 times (over 1000%) more likely than for an out-of-network primary care office visit – this was more than twice the disparity seen for adults.

“When a behavioral health visit for youth is 10 times more likely to be out-of-network than primary care office visits, it’s clear we have a serious crisis on our hands,” said Paul Gionfriddo, president and CEO, Mental Health America.
 
Reimbursement rate disparities

• In 2017, primary care office visit reimbursement rates were on average 23.8% higher than behavioral office visit reimbursement rates compared to Medicare fee schedule amounts, an increase in disparities from 20.8% in 2015.
• During the five-year period, average reimbursements for both mental health and substance use office visits have remained below Medicare allowed amounts.

Spending on behavioral care as a percent of total healthcare spending

• Spending for all types of mental health treatment (excluding prescription drugs and substance use), as a percent of total healthcare spending, has ranged between 2.2% and 2.4% for the five-year period — essentially no increase despite an epidemic of suicides and poor access to care.
• Spending for all levels and types of substance use treatment (excluding prescription drugs and mental health) has ranged from 0.7% to 1.0 %, never exceeding 1% of total healthcare spending.
• Prescription drug spending for all behavioral health was 2% of total health care spending in 2017.

“This analysis confirms that the U.S. mental health system is only getting worse, not better,” said Michael Thompson, president and CEO, National Alliance of Healthcare Purchaser Coalitions. “It will not fix itself and we need a course correction that requires the active collaboration of employers, regional coalitions, behavioral health and advocacy experts, health plans and providers.”

“With this report, lawmakers and regulators need to step up their oversight and enforcement of the Federal Parity Law. The consequences of inadequate access to affordable behavioral healthcare can be lethal,” said former Congressman, Patrick J. Kennedy, founder of The Kennedy Forum and chair of Mental Health for US.

As shown below, death rates from mental illness and substance use have escalated over this five-year period (CDC, Dec. 2018):

• Suicides in our nation for all ages have risen from 41,149 individuals in 2013 to 47,173 in 2017, a rate increase from 13 to 14.5 per 100,000 individuals.
• Suicides for those under 18 years of age have risen from 1,645 individuals in 2013 to 2,337 in 2017, a rate increase from 2.1 in 2013 to 3.0 in 2017 per 100,000 individuals.
• Deaths of all types involving substance use increased from 75,472 in 2013 to 109,813 in 2017, a rate increase from 23.9 in 2013 to 33.7 in 2017 per 100,000 individuals. http://wonder.cdc.gov/ucd-icd10.html

Immediate Recommended Action Steps: The findings in this report, as well as the prior Milliman Report published in 2017, support the need for significant actions from all stakeholders to address what has been a decade of increasing mortality and morbidity from these diseases.  A coalition of leading behavioral health organizations issuing this press release highlight and recommend several key initiatives that could make a large impact immediately:

• On Nov. 12 a new and exciting initiative “The Path Forward for Mental Health and Substance Use” was announced by the National Alliance of Healthcare Purchaser Coalitions, the Meadows Mental Health Policy Institute, the American Psychiatric Association Foundation’s Center for Workplace Mental Health and the American Psychiatric Association. This is a five-year implementation plan that will partner with health plans (essential to helping address this public health crisis) and other key stakeholders to drive change. The Five Priority Strategies that will be executed are:
  •    Improve network access for behavioral health specialists
  •    Expand use of collaborative care to integrate behavioral health into primary care
  •    Implement measurement-based care to improve quality and outcomes
  •    Expand tele-behavioral health
  •    Ensure mental health parity compliance
• Federal and state parity regulators should increase their oversight in several key areas: (a) require health plans to provide comparative quantitative data covering parameters such as out-of-network use rates, reimbursement rates, denial rates, pre-authorization requirement rates, and concurrent review rates, and (b) specify detailed definitions and instructions for these comparative data analyses by using tools similar to the Model Data Request Form currently being used by the National Alliance and employers (“MDRF”).
• We urge any insurer that believes the disparities in the current Milliman report are not reflective of its plans, or that its plans have improved since 2017, to publicly release data for its plans obtained by using the MDRF.  The definitions and methodology in the MDRF are consistent with definitions and methodology used in the analysis of the current Milliman report, and are used by the National Alliance.
• Consumers and others are encouraged to visit www.ParityTrack.org to track parity legislation in all 50 states, and www.DontDenyMe.org, which offers education about consumer rights under the Federal Parity Law.

This press release is issued by a coalition of America’s leading mental health and addiction organizations including:  American Foundation for Suicide Prevention, American Psychological Association, American Psychiatric Association, American Psychiatric Association Foundation’s Center for Workplace Mental Health,  BrainFutures, Columbia University Department of Psychiatry, Legal Action Center, Meadows Mental Health Policy Institute,  Mental Health America, Mental Health Association of Maryland, National Alliance on Mental Illness, National Association of Addiction Treatment Providers, National Association for Behavioral Healthcare,  National Council for Behavioral Health, Parity Implementation Coalition, The Kennedy Forum, Treatment Advocacy Center.

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About the Report:

The report was developed by Milliman, Inc., an independent actuarial and research institution.  In the current study, Milliman researchers analyzed five years of insurer claims data from 2013 to 2017 covering 37 million U.S. employees and family members who receive health insurance coverage from their employer. The study covered all 50 states and D.C. and looked at four categories of treatment settings — inpatient and outpatient facility services, primary care office visits, and specialist office visits, comparing the level of out-of-network use of behavioral health providers versus physical health providers. The study also examined in-network office visit reimbursement rates, aggregate spending on behavioral health (mental health and substance use care) as a percent of total healthcare spending, and separate disparity details for substance use disorders, children versus adults, and various types of inpatient facilities. The Milliman study does not provide an opinion on whether any particular reimbursement rates are appropriate or fair.

A copy of the full report and tables can be accessed at www.milliman.com/bowman

Media Contact:
Ed Emerman
609.275.5162
eemerman@eaglepr.com

About The Kennedy Forum
Founded in 2013 by former Congressman Patrick J. Kennedy (D-R.I.), The Kennedy Forum leads a national dialogue on transforming the health care system by uniting mental health advocates, business leaders, and government agencies around a common set of principles, including full implementation of the Federal Parity Law. Launched in celebration of the 50th anniversary of President Kennedy’s signing of the landmark Community Mental Health Act, the nonprofit aims to achieve health equity by advancing evidence-based practices, policies, and programming for the treatment of mental health and addiction. The Kennedy Forum’s “Don’t Deny Me” campaign educates consumers about their rights under the Federal Parity Law and connects them with essential appeals guidance and resources. To learn more about The Kennedy Forum and donate, please visit www.thekennedyforum.org.