Behavioral Health Parity and the System of Care
Finding & Paying for Care
If your child breaks their leg, you know you should take them to the emergency room, and that’s usually easy to find. It’s also normally in-network with your insurance. Once you get there, an x-ray will show the fracture, making a pretty hard-and-fast case that your insurer needs to pay for the treatment they need to recover.
If your child is struggling with anxiety or depression, it’s much harder to find appropriate care in-network with your health insurance. The issue of ghost networks in mental health care has grown in prominence in recent years. Last year, when Senate Finance Committee secret shoppers called a range of health plans, they found that 33% of listed numbers were inaccurate or inactive, and they could only make appointments 18% of the time. Up to 45% of psychiatrists do not accept any form of insurance. Even when you do find a provider willing to take insurance, the subjective, variable nature of many mental health conditions means that it’s much harder to make a case to your health plan that they should cover quality treatment for an adequate time.
This example simplifies the distinction between medical-surgical and behavioral health care, but it points to an issue that policymakers have struggled with for decades. It provides some context for why only 70% of children with mental health needs receive treatment. For children experiencing poverty, this figure falls to just 15%.
Parity
In 2008, the Mental Health Parity and Addiction Equity Act (MHPAEA) was the first attempt to restrict health plans from imposing limits on access to mental health care greater than those imposed on medical-surgical care. Since then, in 2013 and 2020, there have been subsequent attempts to strengthen this legislation and its enforcement.
In September 2024, the Biden administration announced a further attempt to enforce parity. As a result:
Health plans are required to do thorough comparative analyses of their use of non-quantitative treatment limitations (NQTLs) in behavioral health
Prior authorization and other medical management techniques (including narrow networks) should not be used more restrictively for behavioral health
Non-federal government health plans must now comply with MHPAEA.
These are all welcome changes, but it’s important to remember that parity is only one tool for improving access to behavioral health care in a functioning system.
Expanding Networks Means Expanding the Workforce
Take, for instance, the issue of narrow networks. While insurers can and do use narrow networks to restrict access to care, this is not the only issue in accessing treatment.
Mental health care is experiencing a profound workforce shortage. The Health Resource and Services Administration (HRSA) estimates that more than 6,000 new providers are needed nationally to meet demand. In rural areas, 45% of counties do not have access to a psychologist. For networks to become less narrow, we need investment in training and retaining providers regionally and nationally.
Especially in underserved rural areas, telehealth can be a vital tool for increasing access to care and expanding networks. But with post-pandemic telehealth flexibilities set to expire for Medicare (with the risk that commercial insurers follow suit) in December 2024, the future of telehealth as a means of expanding access to care remains uncertain.
Reimbursement Rates
Rates of reimbursement underlie the issue of workforce supply and retention. While parity matters, to individual mental health providers, the rates they are reimbursed at matter far more. Low reimbursement rates in Medicaid in particular are restricting access to care for the most disadvantaged populations. Research shows that commercial plans pay psychiatrists between 13-20% less than non-psychiatrist medical doctors for similar evaluation and management services. The American Counselling Association cites low reimbursement, and therefore low wages, as a key factor for retention issues.
Every day, both public and private payors limit access to treatment by reimbursing below what’s economically sustainable. The MHPAEA’s requirement to include reimbursement rates in analyses is welcome, but given differences in underlying costs it may not be that informative. Most of all, we need commitment from public and private plans to reimburse sustainably for behavioral health care.
Different Treatment Options
In the continuum of care in behavioral health, options like intensive outpatient programs and partial hospitalization programs can play an important role in stepping down from inpatient care, and from preventing patients who are escalating from reaching higher levels of care. Residential treatment facilities also play an important role for some children and families. For autism spectrum disorders, insurance coverage for applied behavioral analysis (ABA) has become a growing issue. All these treatments have no direct analogy in medical-surgical care.
The final MHPAEA rule does not change the six existing benefit classifications and does not permit plans to create new sub-classifications. Instead, it equates residential facilities with skilled nursing facilities and ABA with home-based care in the medical-surgical world. In many ways, this is a step forward. But to build a functioning system of care in pediatric behavioral health, it’s important to understand the nuances of mental health, rather than seeing the system as a mirror image of medical-surgical levels of care.
It’s clear that mental health is equally as important as physical health. In that sense, parity is vital. Yet it’s important to remember that equally important doesn’t necessarily mean the same.
