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Published Date: 11 March 2025

Disparities in Use of Out-of-Network Mental Health and Substance Use Treatment Versus Medical or Surgical Treatment

The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 requires that health plans not apply greater limitations on in-network access to behavioral health providers than on in-network access to medical or surgical providers. In this study, we used 2021 data from the Merative MarketScan Commercial Database to evaluate privately insured individuals’ use of out-of-network providers for mental and substance use disorder treatment as compared with medical or surgical treatment.
The Merative MarketScan Commercial Database included the deidentified health insurance claims data of 22.8 million individuals with private insurance in 2021. To measure disparities in out-of-network provider use, we compared the percentage of out-of-network claims for behavioral health providers with the percentage of out-of-network claims for medical or surgical providers. We examined these disparities by care settings: acute inpatient facilities, subacute inpatient facilities, outpatient facilities, and office visits to independent practitioners (not facilities). Using the primary diagnosis on the claims, we further separated treatment by behavioral health providers into mental disorder versus substance use disorder encounters. More information on our methods can be found in a report (1).
Patients receiving care from behavioral health providers for a mental or substance use disorder more frequently saw out-of-network providers compared with those receiving care from medical or surgical providers across all four settings (Figure 1). Furthermore, out-of-network provider use was consistently higher for patients with substance use disorders compared with patients with mental disorders. For example, the percentages of out-of-network encounters in acute inpatient facilities (e.g., hospitals) were 18.1% (N=115,181 of 636,359), 4.3% (N=52,861 of 1,229,316), and 1.5% (N=1,207,062 of 80,470,788) for substance use disorder, mental disorder, and medical or surgical treatments, respectively. The percentages of out-of-network encounters in subacute inpatient facilities (e.g., residential settings) were 35.9% (N=161,414 of 449,620), 31.7% (N=39,274 of 123,893), and 1.7% (N=14,801 of 870,649) for substance use disorder, mental disorder, and medical or surgical treatments, respectively.
FIGURE 1. Out-of-network provider use for substance use disorder treatment, mental disorder treatment, and medical or surgical treatment, 2021a
aOffice visits were defined as individually billed professional services in locations (often doctors’ offices) that are not designated as facilities. Acute inpatient medical or surgical facilities included inpatient hospitals and rehabilitation facilities. Acute inpatient behavioral health facilities included psychiatric hospitals and psychiatric care in acute care hospitals. Subacute inpatient medical or surgical facilities included nursing and intermediate care facilities. Subacute inpatient behavioral health facilities included residential mental disorder and psychiatric facilities. Outpatient medical or surgical facilities included outpatient hospital clinics, urgent care facilities, ambulatory surgical centers, and outpatient rehabilitation facilities. Outpatient behavioral health facilities included psychiatric facility partial hospitalizations, community mental health centers, and mental health clinics.
Our finding of greater use of out-of-network behavioral health providers versus medical or surgical providers is consistent with findings from other studies in which researchers used different methodologies (e.g., secret shopper calls, employer surveys, consumer surveys, and provider network analyses) that showed that consumers have limited access to in-network behavioral health providers (28). Note that the MarketScan data used in this study included only privately insured individuals; therefore, we do not know whether the results extend to individuals with Medicare or Medicaid.
Health plans have strategies to increase providers’ network participation, such as increasing reimbursement rates, reducing the administrative inconveniences of joining a health plan, and reducing the administrative burden of being paid by a health plan. In September 2024, the U.S. Departments of Labor, Health and Human Services, and the Treasury issued final regulations to strengthen the MHPAEA’s regulations to ensure network adequacy (9). Our analyses highlight the need for these regulations.

Footnote

These views represent the opinions of the authors and not necessarily those of RTI International or Johns Hopkins University.

References

1.
Mark TL, Parish WJ: Behavioral Health Parity—Pervasive Disparities in Access to In-Network Care Continue. Research Triangle Park, NC, RTI International, 2024. https://dpjh8al9zd3a4.cloudfront.net/publication/behavioral-health-parity-pervasive-disparities-access-network-care-continue/fulltext.pdf
2.
Busch SH, Kyanko K: Assessment of perceptions of mental health vs medical health plan networks among US adults with private insurance. JAMA Netw Open 2021; 4:e2130770
3.
Busch SH, Kyanko KA: Incorrect provider directories associated with out-of-network mental health care and outpatient surprise bills. Health Aff 2020; 39:975–983
4.
Claxton G, Rae M, Wager E, et al: 2022 Employer Health Benefits Survey. San Francisco, Kaiser Family Foundation, 2022. https://www.kff.org/mental-health/report/2022-employer-health-benefits-survey/. Accessed Oct 1, 2024
5.
Voice of the Purchaser Survey on Behavioral Health Report. New York, Path Forward, 2023. https://pathforwardcoalition.org/report/voice-of-the-purchaser-survey-on-behavioral-health-report/. Accessed Oct 1, 2024
6.
Inaccurate and Inadequate: Health Plans’ Mental Health Provider Network Directories. New York, Office of the New York State Attorney General Letitia James, 2023. https://ag.ny.gov/sites/default/files/reports/mental-health-report_0.pdf
7.
Zhu JM, Zhang Y, Polsky D: Networks in ACA marketplaces are narrower for mental health care than for primary care. Health Aff 2017; 36:1624–1631
8.
Slade EP, Wu RJ, Meiselbach MK, et al: Psychiatrist and nonpsychiatrist physician network breadth in dual eligible special needs plans. Psychiatr Serv 2023; 74:816–822
9.
Requirements related to the Mental Health Parity and Addiction Equity Act: a rule by the Internal Revenue Service, the Employee Benefits Security Administration, and the Health and Human Services Department, Sept 23, 2024. Federal Register 2024; 89:77586–77751. https://www.federalregister.gov/documents/2024/09/23/2024-20612/requirements-related-to-the-mental-health-parity-and-addiction-equity-act

Information & Authors

Information

Published In

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Psychiatric Services

History

Received: 14 September 2024
Revision received: 4 December 2024
Accepted: 11 December 2024
Published online: 11 March 2025

Keywords

  1. Health insurance
  2. Health care reform
  3. Mental health parity
  4. Behavioral health
  5. Mental disorder
  6. Substance use disorder

Authors

Details

RTI International, Research Triangle Park, North Carolina (Mark, Parish); Johns Hopkins University, Baltimore (Fujita).
Miku Fujita, B.S.E.
RTI International, Research Triangle Park, North Carolina (Mark, Parish); Johns Hopkins University, Baltimore (Fujita).
William J. Parish, Ph.D.
RTI International, Research Triangle Park, North Carolina (Mark, Parish); Johns Hopkins University, Baltimore (Fujita).

Notes

Send correspondence to Dr. Mark (tmark@rti.org). Tami L. Mark, Ph.D., and Alexander J. Cowell, Ph.D., are editors of this column.

Competing Interests

The authors report no financial relationships with commercial interests. Dr. Dixon, Editor of Psychiatric Services, oversaw the peer review of this column.

Funding Information

The research and manuscript preparation were supported by the Mental Health Treatment and Research Institute and RTI International.

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