New Report Reveals Worsening Disparities in Access to Substance Use Disorder and Mental Health Care

Addiction Treatment Disparities for Inpatient, Outpatient Facility, and Office Visits are Stark Despite the National Opioid Crisis


Children’s Use of Out-of-Network Mental Health Office Visits is Ten Times Higher than for Primary Care Office Visits, Double the Disparities for Adults      

WASHINGTON, November 20, 2019 – Disparities between physical and behavioral healthcare for both in-network access and provider reimbursement rates are making it even harder for American families to find affordable and available mental healthcare and addiction treatment according to a new study. The report, published by Milliman, Inc., covering 37 million employees and dependents, and commissioned by The Bowman Family Foundation, reflects that conditions have worsened since a similar study was published two years ago.

The report, “Addiction and Mental Health vs. Physical Health: Widening disparities in network use and provider reimbursement,” shows the gap in disparities for employees and their families seeking mental health and addiction treatment versus treatment for physical health conditions widened in 2016 and 2017. The study, based on actual claim data in all 50 states for hundreds of health insurance plans, demonstrates that “out-of-network” use of behavioral providers is dramatically higher than out-of-network use of medical and surgical providers – and the degree of disparity has grown substantially in recent years, despite state and federal efforts to promote parity. The study also documented much lower reimbursement rates paid by insurers to behavioral providers for “in-network” services, with the gap between behavioral versus medical/surgical providers widening.

“These findings provide stark evidence that insurers are failing to meet the mental health and addiction treatment needs of their members. The fact that spending for addiction treatment only constitutes 1% of overall health costs in the midst of an opioid epidemic that is ravaging communities across the country is appalling,” says Ellen Weber, VP for Heath Initiatives at the Legal Action Center. “Moreover, the data show that inadequate reimbursement rates and insufficient provider networks are forcing patients to pay higher costs to get the care they need and are entitled to under the law. This report is a clear call to action to policy-makers and regulators that enforcing the Parity Law must be a priority.”

Key findings from the study can be found here and include:

Out–of-network use disparities for both mental health and substance use treatment

  • Disparities in access to in-network behavioral providers compared to medical/surgical in all treatment settings continued to deteriorate in 2016 and 2017 compared to earlier years.
  • Inpatient disparities are now over five times worse for behavioral health than for medical/surgical, increasing from 2.8 times (280%) more likely in 2013 to 5.2 times (520%) more likely in 2017 (an 85% increase in disparities over five years).
  • Outpatient facilities disparities are now nearly six times worse for behavioral health, increasing from 3.0 times (300%) more likely in 2013 to 5.7 times (570%) more likely in 2017 (a 90% increase in disparities over five years).
  • Office visit disparities were already five times higher in 2013 (500%) and have increased further to 5.4 times (540%) in 2017.

Substance use treatment disparities (separate from mental health)   

  • Substance use treatment out-of-network disparities compared to medical/surgical care are especially shocking, having increased for all treatment settings during the five-year period.
  • Inpatient out-of-network use for substance use care was over 10 times (1000%) more likely than for medical/surgical care in 2017, worsening from 4.7 times in 2013 (a 113% increase in disparities over five years).
  • Outpatient facility out-of-network use for substance use care was 8.5 times (850%) more likely than medical/surgical care 2017, worsening from 4.2 times (420%) in 2013 (a 102% increase in disparities over five years).
  • Office visit out-of-network use for substance use care was 9.5 times (950%) more likely than primary care office visits in 2017, worsening from 5.7 times (570%) more likely than primary care office visits in 2013 (a 67% increase in disparities over five years).
  • Reimbursement rate disparities for substance use care office visits compared to primary care office visits increased each year between 2013 and 2017.
  • Substance use treatment office visit reimbursement rates in 2013 were lower than Medicare allowed amounts and declined relative to Medicare during the five-year period.

Children versus adults 

  • In 2017, a child’s out-of-network office visit for behavioral healthcare was 10.1 times (over 1000%) more likely than for an out-of-network primary care office visit – this was more than double the disparity seen for adults.

Reimbursement rate disparities

  • In 2017, primary care office visit reimbursement rates were on average 8% higher than behavioral health office visit reimbursement rates compared to Medicare fee schedule amounts, an increase from 20.8% in 2015.
  • Reimbursement rate disparities have generally continued to widen during the entire five years.

Spending on behavioral care as a percent of total healthcare spending

  • Spending for all types of mental health treatment (excluding prescription drugs and substance use), as a percent of total healthcare spending, has ranged between 2% and 2.4% for the five-year period — essentially no increase despite an epidemic of suicides and poor access to care.
  • Spending for all levels and types of substance use treatment (excluding prescription drugs and mental health) has ranged from 0 .7% to 0 %, never exceeding 1% of total healthcare spending.
  • Prescription drug spending for all behavioral health was 2% of total health care spending in 2017.

“With this report, lawmakers and regulators need to step up their oversight and enforcement of the Federal Parity Law. The consequences of inadequate access to affordable behavioral healthcare can be lethal,” said former Congressman, Patrick J. Kennedy, founder of The Kennedy Forum and chair of Mental Health for US.

As shown below, death rates from mental illness and substance use have escalated dramatically over this five-year period (CDC, Dec. 2018):

  • Deaths of all types involving substance use increased from 75,472 in 2013 to 109,813 in 2017, a rate increase from 9 in 2013 to 33.7 in 2017 per 100,000 individuals. http://wonder.cdc.gov/ucd-icd10.html
  • Suicides in our nation for all ages have risen from 41,149 individuals in 2013 to 47,173 in 2017, a rate increase from 13 to 14.5 per 100,000 individuals
  • Suicides for those under 18 years of age have risen from 1,645 individuals in 2013 to 2,337 in 2017, a rate increase from 1 in 2013 to 3.0 in 2017 per 100,000 individuals.

This press release is issued by the Legal Action Center along with a coalition of America’s leading mental health and addiction organizations including:  Parity Implementation Coalition, Mental Health America, National Alliance on Mental Illness, The Kennedy Forum, National Council on Behavioral Health, National Association of Addiction Treatment Providers, The Treatment Advocacy Center, American Psychiatric Association, Meadows Mental Health Policy Institute, American Psychiatric Association Foundation’s Center for Workplace Mental Health, American Psychological Association, Mental Health Association of Maryland.

About the Report:

The report was developed by Milliman, Inc., an independent actuarial and research institution.  In the current study, Milliman researchers analyzed five years of insurer claims data from 2013 to 2017 covering 37 million U.S. employees and family members who receive health insurance coverage from their employer. The study covered all 50 states and D.C. and looked at four categories of treatment settings — inpatient and outpatient facility services, primary care office visits, and specialist office visits, comparing the level of out-of-network use of behavioral health providers versus physical health providers. The study also examined in-network office visit reimbursement rates, aggregate spending on behavioral health (mental health and substance use care) as a percent of total healthcare spending, and separate disparity details for substance use disorders, children versus adults, and various types of inpatient facilities.

A copy of the full report and tables can be accessed here.

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