Report: Wide disparity between mental and physical health coverage, payments

A new report found growing disparities in provider payments and network adequacy between physical and mental health despite a federal law demanding parity.

The report of claims data published Wednesday from consulting firm Milliman comes as stigmas surrounding mental health are eroding, but access to care remains an issue. Health plans also need to ensure they are not in violation of a federal law that mandates parity between behavioral and physical health.

Milliman found that out-of-network utilization rates of behavioral health providers were higher than medical and surgical providers from 2013 through 2017.

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In 2013, a behavioral health provider was 2.8 times more likely than a medical provider to see a consumer who was going out of network. That disparity increased to 5.2 times more likely in 2017, Milliman found.

In 2017, 17.2% of behavioral health office visits were to an out-of-network provider compared to 3.2% for primary care and 4.3% for a specialist, the analysis said.

Compounding the problem is that reimbursement rates for behavioral health providers were far below medical and surgical office visits.

In 2017, primary care reimbursements were 23.8% higher than behavioral health reimbursements, an increase from 20.8% in 2015.

“In 2017, for 11 states, reimbursement rates for primary care office visits were more than 50% higher than reimbursement rates for behavioral office visits, an increase from nine states in 2015,” the analysis added.

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The percentage of total healthcare spending in 2017 for mental health and substance abuse disorder care was 5.2%, a slight decline from 2015.

The Mental Health Parity and Addiction Equity Act of 2008 requires behavioral health benefits to be covered by most health plans and to be treated on par with physical health.

There are certain tests to determine whether a health plan is not in compliance, including a limit on copays, deductibles or coinsurance. There are also requirements for network adequacy and provider payments, and the report may indicate issues with compliance, Milliman said.

But it remains unclear whether market forces are the reason for the disparities, the firm added.

Insurers need to conduct a robust audit to determine if their plans meet the law’s requirements, according to the analysis, which was commissioned by the Mental Health Treatment and Research Institute, a nonprofit advocacy group that is a subsidiary of the Bowman Family Foundation.

“A health plan should evaluate its provider fee schedules to determine whether there are differences in payment levels between physical healthcare providers and behavioral healthcare providers,” Milliman added.

Plans also need to analyze their payment rate methodologies to ensure they are in compliance with the law’s guidelines.

“Problems will not necessarily be found in every situation, but this report demonstrates that disparities are common and generally increasing, such that close attention is warranted,” the analysis said.