Penn study: It's still harder to get insurance coverage for mental health, substance abuse treatment

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Though laws have tried to ensure parity in insurance coverage, it’s often not the case, a Penn study finds.

Despite years of efforts and multiple laws, insurance coverage for mental health and substance abuse still is not on a par with benefits for physical health, according to a new study of Affordable Care Act plans.

University of Pennsylvania researchers, analyzing details of insurance plans around the country, found that “narrow networks” were far more common for behavioral health providers, especially psychiatrists, than they were for primary care providers. Narrow networks — which mean a more limited selection of providers — have become more common as insurers look for ways to contain premium costs.

The average plan’s network in 2016 included nearly 25 percent of all local primary care providers, but just over 10 percent of all behavioral health providers. But there were major variations from plan to plan, and a narrow network for one type of care had no relation to network size for another.

Consumers tend to choose health plans based on premiums, which are clearly stated and easily understood. But for many people, a significant factor is the kind and amount of health care they are likely to need — especially, the new study suggests, if it involves mental health or substance abuse treatment. As the opioid epidemic has skyrocketed, so has demand for drug treatment.

“It is really important for consumers to check the provider directory before purchasing plans,” said Jane M. Zhu, an internist at Penn Medicine and lead author of the new studym published Tuesday in the journal Health Affairs. At the same time, she noted, getting accurate lists of behavioral health providers may be even more challenging than other types of care because many insurers “carve out” mental health and addiction treatment to a subcontractor.

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HEALTH AFFAIRS / Leonard Davis Institute of Health Economics’ analysis of data from Centers for Medicaid and Medicare Services, Robert Wood Johnson Foundation, and Vericred.

Receiving surprise charges from costly out-of-network providers, a practice known as balance billing, doesn’t come up much with behavioral health, because patients know whom they are seeing in advance. But they may have a hard time finding anyone to see within the network.

The problem isn’t limited to ACA plans; nearly everyone who has sought counseling or substance abuse treatment under any kind of health insurance will recognize the pattern. Use of out-of-network providers for mental health care is three times as common than for general medical care, previous research found, and is associated with higher out-of-pocket costs.

But the 2010 Affordable Care Act specifically required parity. Another federal law two years earlier had the same goal.

Those laws “have actually done quite a bit to promote parity. What we are looking at are the downstream effects of that,” said Zhu, referring to how the policy changes play out in the real world.

Various factors in the market have gotten in the way of change. Reimbursement formulas for psychiatrists, for example, tend to be less lucrative than for other physicians. At the same time, a shortage of psychiatrists gives them more market clout. About half of psychiatrists don’t participate in any Obamacare insurance plans, Zhu said. Participation by mental health providers who are not physicians —  psychologists, behavioral specialists, counselors, and others  — was even lower.

Some of the same researchers, affiliated with Penn’s Leonard Davis Institute of Health Economics, found this year that ACA plans in South Jersey and Southeastern Pennsylvania offered unusually broad access to primary care providers, with virtually no narrow networks, although so-called tiered plans were more common.

That level of analysis, which was done for the Inquirer, Daily News, and Philly.com, was not available for the newly released behavioral health networks.