Medicare Advantage offers less access to psychiatrists than ACA plans, managed Medicaid: study

Medicare Advantage (MA) beneficiaries have less choice when it comes to finding a psychiatrist than Medicaid enrollees or those who buy coverage on the Affordable Care Act (ACA) marketplace do, according to a study published in Health Affairs.

That’s because the networks through which MA beneficiaries might find a psychiatrist are narrower, the researchers said.

Researchers with Johns Hopkins University, the University of Pittsburgh and Oregon Health & Science University examined data from 2019 and “found that nearly two-thirds of psychiatrist networks in MA were considered narrow, with MA having narrower networks than Medicaid managed care and the ACA Marketplaces. Further, more than half of the counties for which we had data did not have a single MA-participating psychiatrist.”

Researchers considered a network narrow if it contained fewer than 25% of psychiatrists in a service area. For MA, 64.5% of markets fit that description, compared to 43.1% for managed Medicaid and 39.5% for ACA marketplaces.

Researchers looked at the provider data in 1,905 of the 3,143 counties in the U.S. and pinpointed provider specialty information using National Provider Identifiers.

The study found that this dearth of psychiatrists in MA corresponds to a growing demand for mental health services among older Americans. Researchers also recognize that a shortage of mental health providers, including and perhaps especially psychiatrists, has blanketed the entire healthcare system for years for many reasons, including low reimbursements, workforce shortages, administrative hassles and barriers and high demand that often leads psychiatrists to decide not to participate in insurance networks.

Jane M. Zhu, M.D., the study’s corresponding editor, told Fierce Healthcare in an email that the findings “certainly highlight that there is a mental health professional shortage, which is a central problem.”

“However, we also find that MA psychiatrist networks are more restrictive than ACA marketplace plans and even Medicaid managed care,” Zhu said. “This suggests that within these broader supply constraints there is something additional going on with MA that is leading to less consumer choice, and less access for older adults needing mental health care.”

Zhu, a primary care physician and assistant professor of medicine at Oregon Health & Science University, said MA plans may pay mental health providers far more for out-of-network care than they do for in-network care, thereby possibly removing the incentive for providers to join the networks.

Jane Zhu
Jane M. Zhu, M.D. (Oregon Health & Science University )

“On the insurer side, it could be that MA’s capitated payment model incentivizes more limited provider networks in order to limit spending,” Zhu said. “These findings open up a whole can of worms in terms of what structures and incentives might be making things potentially worse in MA for enrollees with mental health conditions. These could all be potential policy targets that go beyond expanding the mental health workforce.”

The Centers for Medicare & Medicaid Services requires MA plans to include a certain number of providers for 26 specialties, including psychiatrists, within a specific distance for beneficiaries, and the agency now wants to expand what type of behavioral health care providers will be tracked, the study notes.

“However, existing regulations may be only weakly effective for a number of reasons,” the study said. “For example, considerable overlap in psychiatrists participating across markets may complicate efforts to define in-network capacity and activity at the plan level. Other factors challenging network adequacy have been well documented and include insufficient or poorly targeted measures of access, inadequate enforcement of network adequacy regulations, and an overreliance on provider directory data.”

Zhu added that access to psychiatrists might be less attainable than the study’s findings state because the data come from 2019 and do not take into account what impact the COVID-19 pandemic might have had.

“Demand for mental health services worsened during the COVID pandemic,” Zhu said. “What we can’t see from our data is what capacity and availability looks like—even if a psychiatrist is in-network for a patient’s health plan, if demand is high, that psychiatrist is unlikely to be available.”