Patients Value Out-of-Network MH Care Option
Inclusion of an out-of-network benefit for mental health services along with an in-network parity benefit—even if the out-of-network benefit does not offer parity—appears to be essential to facilitating access to those services, according to data from a major parity study.
An analysis of patient and clinician participation in provider networks under the Federal Employees Health Benefits Program (FEHBP)—which has offered parity coverage of in-network mental health services to federal workers in the Washington, D.C., area since 2001—found that approximately one-third of surveyed clinicians participated in FEHBP networks, and only 44 percent of patients received care from in-network clinicians.
And an even smaller percentage of clinicians were participating in FEHBP health plan networks and also accepting new patients; many clinicians cited low fees and administrative burden associated with plan participation as a reason for not accepting new patients.
So a significant percentage of patients may have sought care out of network, either because they could not access in-network care, or because they were simply willing to pay more to go to a clinician of their choice.
“The out-of-network benefit, which was maintained at pre-parity levels [of coverage], was a very important form of coverage for a majority of patients who went for some kind of mental health service,” said Darrel Regier, M.D., M.P.H., in an interview.
Regier, executive director of the American Psychiatric Institute for Research and Education (APIRE) and APA's Division of Research, was lead investigator in the survey, which was published online in Health Affairs on December 18, 2007.
The finding that provision of an out-of-network benefit for mental health and substance abuse treatment was important for the successful cost-effective implementation of parity under the FEHBP could have implications for future parity policies. Regier believes that if some health plans are allowed to opt out of providing out-of-network mental health coverage, it could lead to adverse selection and diminished access.
“It is in the interest of the insurance industry not to have a few companies offering a good benefit, including out-of-network services [while others can opt out] because the good companies will experience adverse selection when beneficiaries with more expensive treatment needs flood those plans,” Regier explained.
He noted that that is what happened when Blue Cross/Blue Shield (BC/BS) offered full parity, beginning in the late 1960s, for mental health coverage.
Currently, legislators are considering two federal parity plans—the Senate Mental Heath Parity Act (S 558) and the Paul Wellstone Mental Health Addiction Equity Act of 2007, which was introduced in the House.
The language of the two bills differs with regard to provision of out-of-network coverage, though it is not entirely clear how those differences would affect coverage and access. And Regier notes that passage of either bill would be an important step forward.
“It is clear that either of the legislative plans would be a major advance over the current Mental Health Parity Act of 1996, which only provides for equal annual and lifetime payment caps for mental disorders with medical surgical conditions,” he said.
But the Senate bill does not require plans to offer an out-of-network benefit and leaves the definition of disorders to be covered under in-network parity to the plan—meaning that a plan could decide arbitrarily not to cover conditions, as has happened in Minnesota and New Jersey with BC/BS plans and some plans operating under North Carolina state parity laws that refused to cover eating disorders.
The House bill requires parity for both in-network and out-of-network services and does not allow health plans to opt out of providing an out-of-network benefit. Moreover, it uses DSM as its criterion for indicating covered disorders.
But Nicholas Meyers, director of APA's Department of Government Relations, cautioned against overly simplistic comparisons of the two bills, noting that neither bill mandates mental health coverage or out-of-network mental health coverage; rather, the bills operate on an “if-then” format—if a plan offers out-of-network medical-surgical benefits under the House bill, it must offer out-of-network mental health coverage at parity; if a plan offers out-of-network mental health coverage under the Senate bill, it must be at parity with medical-surgical benefits.
“As a result of changes made by Senators Domenici (R-N.M.) and Kennedy (D-Mass.), the Senate bill has moved much closer to the House bill,” Meyers told Psychiatric News.
Moreover, he said, both bills essentially defer to state law on coverage requirements and scope of benefits. If a state mandates that a plan provide out-of-network coverage using DSM inclusion as its definition of a covered disorder, the Senate bill would defer to that law, he said.
And it is uncertain how plans would respond to provisions in either bill.“ It is true that the House bill requires plans offering any out-of-network benefit to also offer an out-of-network mental health/substance use disorder benefit, while the Senate bill would permit plans to offer only an out-of-network medical/surgical benefit,” Meyers said. “That might encourage plans to drop out of network mental health coverage if the Senate bill prevails, but plans could also respond by increasing cost-sharing across the board for all out-of-network treatment, or they could increase use of managed care. That's just as true under the House bill.”
Three Clinician Groups Surveyed
In the survey, 661 psychiatrists responded with diagnostic and network information on 445 patients in the Washington, D.C., area, between April and October 2005. The survey was a collaborative effort with the American Psychological Association, which surveyed 375 clinical psychologists, and the National Association of Social Workers, which surveyed 169 social workers regarding their mental health treatment clients.
Clinicians were asked to report on general practice characteristics such as setting, size of caseload, health-plan involvement, network-panel participation, and availability to accept new patients. They were also asked to select a patient from their caseload within the last typical work-week and provide de-identified information on patient insurance coverage, treatment provided, and issues regarding access to treatment.
Some reported only network participation and did not provide detailed patient information.
A minority of mental health clinicians in the three professional groups participated in one or more FEHBP health plan networks. Rates of participation ranged from 26 percent for social workers to 38 percent for psychologists; 29 percent of psychiatrists participated in one or more FEHBP network.
And with regard to participation in any kind of managed care network—private, Medicare or Medicaid—only 38 percent (psychiatrists) to 49 percent (psychologists) of all surveyed Washington, D.C., clinicians participated in a network.
Patients Voting With Their Feet
From the sample of patients on whom clinicians provided information, it appears that just 44 percent of FEHBP beneficiaries receiving mental health care were treated by in-network clinicians.
The survey, the first to look at network participation as a variable in the provision of parity mental health benefits, underscores the importance of insurance coverage that includes out-of-network coverage.
“Since the parity benefit in FEHBP is available only if you are visiting a network clinician, it was important to know how many clinicians were in networks that patients would be able to access,” Regier said.“ The FEHBP population is 15 percent of the national capital area, so you might think that if 30 percent of clinicians are contracted with a network to provide care, that would be an adequate resource. But in fact, only 44 percent of the patients who are FEHBP beneficiaries went to a network clinician. Patients are voting with their feet.”
Regier noted that the cost of providing parity coverage for a managed mental health benefit is negligible: the Congressional Budget Office has said the House parity bill would increase premiums by just 0.4 percent.
“Most importantly, an evaluation of the FEHBP parity program since its implementation in 2001 to the present demonstrates that combined costs have not risen in response to the managed in-network parity benefit and the continued out-of-network nonparity benefit,” Regier and colleagues wrote in the Health Affairs report. “However, the safety valve for providing parity-level access to managed in-network service providers has been a continued out-of-network benefit that allows some access to and compensation for care that is not at parity levels. Maintaining previous benefit design ceilings that have controlled nonparity benefit costs for out-of-network services clearly has been affordable for the FEHBP.”
“Parity and the Use of Out of Network Mental Health Benefits in the FEHB Program” is posted at<http://content.healthaffairs.org/cgi/content/full/hlthaff.27.1.w70/DC1>.▪
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Published online: 4 January 2008
Published in print: January 4, 2008
Notes
It is not in the insurance industry's interest to have a few companies offering a good benefit, including out-of-network services, while others opt out, because the good companies may experience adverse selection.
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