Compared to people with diabetes, those with drug-use disorders paid $1,242 more per year on average for out-of-network. (Image: Shutterstock)
People who need behavioral health treatment often need to go out of their insurance plan's network to receive care, and as such, they typically shell out more in out-of-pocket costs than those with other types of ailments, according to a study posted on JAMA Network Open.
The researchers, led by Wendy Yi Xu, an assistant professor of health services management and policy at The Ohio State University, examined commercial insurance claims from 3.2 million adults with mental health conditions, more than 321,500 with drug use disorders and more than 294,500 with alcohol use disorders. They compared those with claims from people with one of two common chronic conditions—diabetes and congestive heart failure.
Key findings include:
- Those with drug-use disorders were 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.
- 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.
- Compared to people with diabetes, those with drug-use disorders paid $1,242 more per year on average for out-of-network care and those 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 writes in the university's blog post about the study. "We saw that people with heart failure and diabetes didn't go out of network as often and didn't pay nearly as much for their care, probably because they were able to find care within the network," she writes.
Cost sharing for out-of-network care represents "a substantial financial burden" to patients with behavioral conditions, "and it may be an important sign of network inadequacy that requires more scrutiny from policy makers," the study concludes.
Policymakers apparently agree—both public and private.
On the same day (Nov. 6) the study was published, the Centers for Medicare & Medicaid Services announced the approval of a "first-of-its-kind Medicaid" demonstration project that broadens treatment services available to Medicaid beneficiaries living in the District of Columbia diagnosed with serious mental illness and/or serious emotional disturbance. At the same time, CMS is approving the District's request to begin providing new services for its beneficiaries diagnosed with substance use disorder.
"For too long, our system has failed to provide Americans with serious mental illness and their families the treatment and assistance that they need," HHS Secretary Alex Azar writes in the CMS 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."
Improving access to behavioral health services is also top of mind for private payers, according to Health Payer Intelligence. For example, Blue Cross Blue Shield of Rhode Island is partnering with Bradley Hospital in East Providence to mitigate pediatric psychiatrist shortages in their region.
"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," HPI writes.
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Katie Kuehner-Hebert
Katie Kuehner-Hebert is a freelance writer based in Running Springs, Calif. She has more than three decades of journalism experience, with particular expertise in employee benefits and other human resource topics.
