Americans are increasingly going out of network for mental health coverage

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Insurance coverage for mental health and substance-abuse care is worsening, suggests a new analysis of claim data from 37 million employees and dependents — despite soaring suicide rates, thousands of opioid overdose deaths, and rising teen depression and anxiety.

Americans are increasingly more likely to resort to out-of-network providers for behavioral health care than they are for medical and surgical care, according to the report by actuarial firm Milliman commissioned by the Bowman Family Foundation, which funds mental health-related projects. The report analyzed claim data from every state for “hundreds” of health-insurance plans over five years.

While patients were 2.8 times more likely in 2013 to use out-of-network inpatient care for behavioral health care than they were for medical or surgical care, they were 5.2 times more likely to do so in 2017. Use of out-of-network outpatient care for behavioral health was three times more likely in 2013, but 5.7 times more likely in 2017.

Meanwhile, out-of-network inpatient care for substance abuse was 4.7 times more likely than it was for medical or surgical care in 2013, rising to 10.1 times more likely in 2017. People were 4.2 times more likely to use out-of-network outpatient care for behavioral health in 2013, increasing to 8.5 times more likely in 2017.

Receiving health care from an out-of-network provider often comes with higher costs to a patient.

But it wasn’t smooth sailing in network, either, as the analysis also found mounting disparities in average in-network reimbursement rates between behavioral health office visits and medical and surgical office visits. Reimbursements for primary-care providers were 20.8% higher than they were for behavioral-care providers in 2015, and 23.8% higher in 2017.

The 2008 Mental Health Parity and Addiction Equity Act generally requires that health-insurance issuers and group plans that offer mental health or substance-use benefits ensure that coverage matches that of medical and surgical care. This equal treatment of behavioral health and physical health is known as mental health parity.

“Mental health parity is the law and must be enforced,” tweeted Andy Slavitt, who served as acting administrator of the Centers for Medicare and Medicaid Services under former President Barack Obama, in response to the Milliman report.

While the federal rules say that disparities don’t provide evidence of noncompliance on their own, “significant disparities, such as high out-of-network use of behavioral health providers and/or lower reimbursement for behavioral providers, could point to compliance problems,” the report said. Market forces could also be contributing to the results, the authors added, so additional analysis is needed.

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

As affordable mental health coverage grows more difficult to access, alarming mental health and substance-use statistics abound: The United States’ suicide rate increased 33% between 1999 and 2017, according to government data, while the suicide rate among Americans aged 10 to 24 increased by 56% from 2007 to 2017.

Meanwhile, the opioid crisis continues to claim lives. More than 700,000 people in the U.S. died from a drug overdose between 1999 and 2017, according to the Centers for Disease Control and Prevention, and opioids were involved in nearly seven in 10 of the 70,200 overdose deaths in 2017.

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