RTI study on high rates of out-of-network care for behavioral health

The data are critical to supporting what we hear from individuals and families every day — it is too hard to find affordable mental health and addiction care, even with insurance. Obtaining care from out-of-network providers puts an enormous financial burden on patients who are often unable to pay higher rates to receive care. This report shows that insurance coverage for behavioral health care is broken. Insurers blame provider shortages for the disparities. However, primary care physicians are in shorter supply than behavioral health providers but have much lower out-of-network use because they are reimbursed at higher rates. More must be done to hold these insurers accountable; hopefully recently updated parity rules will help.

Based on its review of claims data, RTI found that in 2021:

• SUD office visits were out-of-network 4.2 times more often than medical/surgical office visits, while mental health office visits were out-of-network 3.4 times more often.
• Acute inpatient SUD care was out-of-network 12.4 times more often than medical/surgical care, while inpatient mental health care was out-of-network 3 times more often.
• In-network office visit reimbursement was 22% higher, on average, for medical/surgical clinicians than for behavioral health clinicians. Physician assistants and nurse practitioners receive higher reimbursements than psychiatrists and psychologists.
• It’s the same picture as 2013. Behavioral health office visits (where most behavioral health care is delivered) were 3.5 times as likely to be out-of-network than medical/surgical office visits, compared to 3.7 times in 2013, signaling no improvement between 2013 and 2021.

What it means:

• Patients are still far more likely to go out of network for behavioral health care than for medical/surgical care, creating significant financial burden for individuals and families.
• Behavioral health providers aren’t participating in plan networks because health plans pay them significantly less than medical providers.
• Little has changed in the past nine years, despite an increased need for mental health and SUD care.

The main point: Health plans are undervaluing behavioral health care and cost-shifting to patients.

• Too few people are able to access affordable treatment. Many have to forgo care because they can’t afford the cost, despite having insurance.
• Insurers need to stop finger-pointing at provider shortages and pay more to incentivize plan participation.
• Regulators must robustly enforce the Parity Act to force plans to expand their behavioral health provider networks.