Public Payers News

Out-of-Pocket Costs Higher for Behavioral Health for Many Americans

Americans are using more out-of-network care and paying more out-of-pocket costs for behavioral health than for physical health, a new report finds.

Out-of-network

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By Samantha McGrail

- Insured Americans are spending more out-of-pocket costs on behavioral health services, such as treatment for substance abuse, than on conditions like diabetes and heart failure, according to a study published in JAMA Network Open

The study led by researchers at The Ohio State University found that insured Americans are using more out-of-network care for behavioral health services compared to other conditions, leading them to pay more for addressing their mental health.  

“Policymakers need to address this,” Wendy Yi Xu, lead author of the study and assistant professor of health services management and policy, stated in a press release. “People with behavioral health conditions are not as likely to speak up about their lack of in-network coverage for these conditions because of the stigma that’s still associated with mental illness and addiction in our country.” 

An estimated 57 million US adults have behavioral health conditions, and people with these conditions also frequently have higher risks of poor physical health, according to the National Survey on Drug Use and Health from the federal Substance Abuse and Mental Health Services Administration. 

However, millions of people in need of mental and behavioral health services fail to get treatment each year, Mental Health America reports. And it is not for a lack of trying. A 2018 survey conducted by the National Council on Behavioral Health found that 56 percent of patients wanted to access a mental health provider, but faced care barriers.

Specifically, the study from The Ohio State University looked at access barriers to behavioral health providers that led to high costs for patients, even those who have private insurance.  Xu and her colleagues compared claims from 3.2 million adults with mental conditions, more than 321,000 with drug use disorders, and more than 294,000 with alcohol use disorders with claims from people with diabetes and congestive heart failure.

Enrollees with mental health conditions had cost-sharing payments for out-of-network care that were $341 higher per year on average than enrollees with diabetes. 

Individuals with drug disorders were also almost 13 percentage points more likely to have out-of-network hospitalizations and more than 15 percentage points more likely to experience out-of-network outpatient care than those with congestive heart failure, according to the study.

In addition, those with drug-use disorders paid $1,242 more per year on average for out-of-network care than those with diabetes. And individuals with alcohol-use disorders paid $1,138 more. 

“Much of this disparity is likely due to the limited availability of behavioral health care providers in insurance plans- the participation rates by these providers are generally low, a problem that is fueled in large part by low reimbursement rates for clinicians, including psychiatrists,” Xu said. 

Since people with heart failure and diabetes had access to care within their networks, they didn’t go out of network as much, resulting in lower out-of-pocket costs for this group, Xu emphasized in the report. 

The healthcare industry has been working on improving access to mental health providers. For example, researchers cited the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act in 2008, which focused its efforts on addressing disparities between behavioral healthcare and other medical care.

“But our study included data from 2012 to 2017, years later, demonstrating that those disparities still exist,” Xu stressed.

Payers have acknowledged the barriers preventing members from accessing behavioral health services and many are addressing the problem.

In Medicaid, for example, Washington DC recently received CMS approval for a section 1115 demonstration that will broaden behavioral health treatment for Medicaid beneficiaries who have been diagnosed with serious mental illness (SMI) and/ or serious emotional disturbance, according to a recent press release. CMS also recently approved Alaska’s Section 1115 demonstration addressing behavioral health services.

“For too long our system has failed to provide Americans with serious mental illness and their families the treatment and assistance they need,” HHS Secretary Alex Azar stated in the press release. “Americans with serious mental illness too often end up homeless or in our prisons, when access to treatment could help them lead healthy lives.” 

Private payers are also seeking ways to improve access to behavioral health services.

BCBSRI and Bradley Hospital is approaching the problem of pediatric psychiatrist shortages through their strong partnership. A non-for-profit in the Lifespan health system in Rhode Island, Bradley Hospital hosts the PediPRN initiative, which provides a consultation team of child psychiatrists to provide telehealth support to pediatric primary care providers.