How Payers Can Help Reform Behavioral, Mental Health Parity

January 16, 2020 - Henry Harbin, MD, a psychiatrist and an advisor to The Bowman Family Foundation, and his team were somewhat hopeful in 2017 after publishing their report on mental health parity and disparities from 2013 to 2015.

Their optimism stemmed not from the results of the 2017 study—those were deplorable—but from the fact that they believed the behavioral healthcare disparities of those two years would show progress when the study was expanded to a five-year timeframe.

“We thought with the ACA having expanded access to behavioral benefits and with what many employers and health plans and others were saying they were trying to do, we would have seen some improvement from the first study,” says Harbin, who recently spoke with HealthPayerIntelligence.com. “When we took it to a five-year, we thought surely there would be some improvement.”

Instead, he saw access to behavioral and mental healthcare as well as provider reimbursement get worse.

The first study found a 20.8 percent difference between primary care reimbursements and behavioral healthcare reimbursements. Two years later, the difference was 23.8 percent.

READ MORE: Payers Do Not Enforce Behavioral Healthcare Payment Parity

The likelihood that patients seeking mental or behavioral healthcare treatment would resort to an out-of-network facility in comparison to when they required inpatient medical attention rose 85 percent between 2013 and 2017. In other words, patients who need mental and behavioral health were more likely to be forced to access out-of-network care than those who needed physical health attention.

By 2017, patients were 5.2 times more likely to obtain out-of-network care for mental or behavioral healthcare than traditional medical healthcare.

The result was an increasing death rate in behavioral and mental healthcare when medical diseases were seeing a decrease in mortality. Mental and behavioral healthcare are largely responsible for bringing down the nation’s overall life expectancy.

Payers can meet the quantitative requirements for parity—as established by law—and still not achieve mental and behavioral healthcare parity.

Now, Harbin says he has spoken with providers who are willing to take a pay cut to provide behavioral healthcare in-network. But when these providers offer their services to health plans, they are told the health plan’s network is full.

READ MORE: Out-of-Pocket Costs Higher for Behavioral Health for Many Americans

“To be telling providers that you don't want them, that you're full, defies reality,” Harbin argues. 

“And then to say it takes six months to eight months or a year to get in makes it pretty clear that's an administrative action. It may or may not be a parity law violation, but it's an administrative action that you could do if access was a priority. Given the shortage of access that we hear from everybody, including the health plans and the employers, the least you can do is accelerate your acceptance into the network.”

The study identified a broad trend of limited behavioral and mental health parity. Within that trend, Harbin indicates, some payers may have improved their pay and access parity. But on the whole, the industry has taken strides backwards. 

 “The payers and the employers, they're the only hope to fix this,” Harbin emphasizes.

For next steps, he points to the Path Forward initiative.

READ MORE: CMS OKs Demo to Expand Behavioral Health Treatment in Medicaid

Launched in November 2019 by the National Alliance of Healthcare Purchaser Coalitions (NAHPC), along with other healthcare partners, the Path Forward for Mental Health and Substance Use initiative aims to strengthen mental health parity through stakeholder collaboration.

“What we have developed is an approach that is thoughtful and comprehensive in terms of how we need to approach rebuilding a health system that can support people with mental health and substance use,” says Michael Thompson, NAHPC president and chief executive officer. 

“It’s basically about making sure that we are taking the same rigor in the treatment of mental health as we would with any other health condition collaborative care, which is providing better support and improving the treatment that is provided through primary care physicians and telebehavioral health.”

The Path Forward initiative is a five-pronged approach using evidence-based, cost-effective, and strongly endorsed methods:

• Improve behavioral healthcare network access
• Integrate behavioral healthcare into primary care through collaborative care
• Improve quality measurement in behavioral care
• Use telehealth more effectively to produce telebehavioral solutions
• Ensure mental healthcare parity laws are recognized and pursued

The approach hinges on mobilizing all relevant stakeholders—from payers, providers, and employers to regulators and advocates—and striking the obstacles from all angles, instead of adhering to a single reform.

“The goals of this project will be achieved through a market-driven implementation plan leveraging the influence of employers and regional employer coalitions motivated for change, supported by the technical expertise and guidance of our nation’s leading behavioral health experts,” the executive summary explains.

The methods will be advanced by stakeholders in six regions the initiative says are ripe for reform. The reforms achieved in these regions will raise the bar for behavioral and mental healthcare across the nation through market-driven means.

The summary visually lays out a chain of reactions starting with a national steering committee and moving into a national technical resource team, eight Regional Employer Stakeholder Engagement Teams (RESET), and over thirty non-RESET coalitions. 

The technical resource team will promote education about behavioral and mental healthcare parity. It will focus its efforts on national stakeholders through advising and supporting the coalitions and providing resources on websites, tools, and speakers.

The eight RESET regions will start by establishing a regional baseline. Through stakeholder collaboration, they will come up with a plan and enact it.

The non-RESET coalitions serve as on-the-ground educators and change motivators in areas outside of the reform regions. They focus on educating consultants and employers.

“We're really looking to drive measurable improvement region by region and then take the lessons learned from those RESET regions and apply them across the country through our other coalitions as well to actually create the market pressure for the industry and the profession to solve their problems together and move the country forward in this area,” Thompson explains.

Payers tend to point to provider shortage as justification for the low access to behavioral and mental healthcare. But Harbin, a psychiatrist himself, rejects that proposition.

The minimum step to solving provider shortage, he says, is to raise reimbursement rates, a point Thompson agrees with.

In all fifty states, the average mental healthcare reimbursement was never above the Medicare reimbursement threshold, says Harbin. While payment for medical care is well above Medicare reimbursement levels, mental healthcare reimbursement, on average, hovers at the main level.

NAHPC’s Thompson agrees that payment parity is a necessary step but by no means is it the finish line for overall behavioral and mental healthcare parity.

“Frankly, it may require us to get out of the box and rethink how we're paying for mental health and substance use disorder,” Thompson explains. “We're actually looking at a potential bundled payment type arrangements or other more advanced approaches that allow us to kind of jump into the future and solve for the issues on a more sustainable and thoughtful way while again creating an accountable system that is centered on patients and outcomes.”

Like Harbin, Thompson characterizes the payer role as “critical” to achieving behavioral and mental healthcare parity. And while new technologies and investments may be steps toward solving certain issues, such as using digital solutions in areas with provider shortages, that is not ultimately what NAHPC is looking for in its payer partnerships.

“We want material activation of payers working with the other stakeholders, including employers,” Thompson summarizes.

Stakeholder collaboration is not a simple request but, Harbin and Thompson express, it is the most durable and effective solution.