Weeks of social distancing and economic uncertainty caused by COVID-19 coupled with the recent civil unrest over racial injustice is threatening to turn concerns over meeting demand for behavioral healthcare into a full-blown crisis.
Nearly half of U.S. adults reported their mental health was negatively affected due to worry and stress over the virus, according to a poll the Kaiser Family Foundation conducted in March.
Stakeholders fear the continuing effects of the pandemic will only accelerate the trend. “Prior to this pandemic, behavioral health conditions were already increasing significantly,” said John Boyd, CEO of mental health and addiction care for Sacramento, Calif.-based integrated health system Sutter Health.
While the increased demand for services has presented challenges, Boyd said it has also created an opportunity to examine how to expand patient access to care. Despite progress over the past decade in eliminating many of the more traditional barriers to accessing behavioral healthcare services, experts say many of the remaining issues can be traced to the yearslong battle to achieve insurance coverage parity with medical care. “We have a lot to do in terms of leveling that playing field,” Boyd said.
Demand for mental healthcare services has long exceeded the supply of clinicians. And stakeholders say many patients still face challenges accessing care more than a decade after enactment of the landmark Mental Health Parity and Addiction Equity Act of 2008, which was meant to address that issue.
The law was instrumental in ending many restrictions imposed on mental health and addiction treatment, such as stricter limits on the number of patient visits for such services and separate, often higher deductibles and out-of-pocket costs compared with other medical services.
But it remains difficult for those with commercial insurance to access mental healthcare services, according to Charles Ingoglia, CEO of the National Council for Behavioral Health. He said many patients with private coverage struggle to find a provider that accepts their health plan.
Studies have pointed to a widening access gap between behavioral health patients and those needing medical or surgical care.
Those seeking inpatient behavioral healthcare were 5.2 times more likely than medical patients to go out of network for services in 2017, compared with 2.8 times more likely in 2013, according to a report published in November by actuarial firm Milliman. Similar disparities were found for those seeking outpatient treatment; out-of-network use of behavioral services increased from being three times more likely than medical care in 2013 to 5.7 times by 2017.
“There’s really nobody looking at the state of network adequacy when it comes to private health plans,” Ingoglia said.
Consequently, as patients get more of their behavioral healthcare services from out-of-network providers, their out-of-pocket expenses for care grow.
While mental and substance use disorders were associated with lower total healthcare expenses than health conditions like congestive heart failure or diabetes, behavioral health patients had higher out-of-pocket costs, on average paying $341 more per year than patients with diabetes, according to a study JAMA Network Open published in November.
Ingoglia said commercial insurers’ low reimbursement rates for behavioral healthcare services gave providers little incentive to accept insurance for mental healthcare, further shrinking the number of mental health clinicians available to patients relying on insurance.
A Congressional Budget Office analysis that Health Affairs published in 2019 found commercial plans on average paid 14% less than fee-for-service Medicare for the same in-network mental healthcare services despite paying 12% more than Medicare for the same services when provided by other medical specialties.
Both problems have resulted in a smaller pool of healthcare professionals available to treat new patients. Behavioral healthcare providers have one of the lowest participation rates in health insurance of any medical specialty, with 55% of psychiatrists accepting commercial health plans, 54% accepting Medicare for payment and 43% accepting Medicaid in 2010, according to a 2014 study published in JAMA Psychiatry.
“That’s a parity problem in two different ways,” Ingoglia said.
Such issues have contributed to a system ill-equipped to handle any surge in demand. Only 43% of U.S. adults with mental illness received treatment in 2018, according to the National Alliance for Mental Illness. It can take an average of 11 years for a person who first experiences the onset of mental illness symptoms to finally receive treatment. “All of this is creating what people expect to be a crisis of mental health that’s within the pandemic of COVID,” said Angela Kimball, NAMI’s national director for advocacy and public policy.
But insurers say they have expanded access during the pandemic. Maria Gordon Shydlo, a spokeswoman for UnitedHealthcare, said the company has taken a number of actions to expand coverage to those needing mental health support during the pandemic. Those actions have included waiving cost-sharing for behavioral health and substance use disorder telehealth services and virtual visits while providing additional supports through its mobile app. Since March UnitedHealthcare’s Optum subsidiary has added 45% more providers available to offer virtual mental healthcare, she said.
“We continue to enhance access to mental and behavioral health services to help support individuals’ health and well-being,” Shydlo said. “We want members to have ready access to clinically effective mental health and substance use disorder treatment and support when they need it.”
Sutter’s Boyd said the expanded use of telepsychiatry and videoconsulting is a key component of what he called “the new normal” for delivering behavioral healthcare services during the outbreak.
Sutter inpatients had more than 1,600 telepsychiatry consults from January to May, up slightly from the same period last year despite an overall drop in inpatient volumes since the outbreak began. And since mid-March, Sutter has handled more than 12,000 video visits with outpatients seeking mental healthcare.
Like Sutter, many healthcare providers have taken advantage of CMS temporarily waiving regulations that limited the use of and reimbursement for telehealth services during the public health emergency; the move allows providers to expand their telehealth offerings for mental health services.
Some of the regulatory changes include allowing traditional Medicare to cover telehealth services, as well as waiving restrictions that prevented providers licensed in one state from providing telehealth services to patients in another.
Many say such changes are needed to fulfill telehealth’s potential for expanding care access. But some also say the regulatory rollback will help providers use telehealth to address parity for mental healthcare.
“I think we are seeing throughout the country there is such pent-up demand for telehealth,” said John Snook, executive director of the Treatment Advocacy Center, a national not-for-profit that works to eliminate barriers to treatment for those with severe mental illness. “It’s disappointing that it took a global pandemic for these steps to happen, but now that they are, I can’t imagine us going back.”
Paul Gionfriddo, president of Mental Health America, said the expansion of telehealth is changing people’s perceptions of what mental health parity could look like. He said the question won’t be whether the pandemic sped up progress toward parity, but rather whether the technologies used are delivering the kind of care services patients need and want.
“When you’re talking about more services that are provided remotely and less desire for people to be in congregate settings of any kind, I think all of this is just going to be different,” Gionfriddo said. “The metrics that have been used are not the same metrics that people will have to use to decide whether or not we are providing services at parity.”
Much of the debate on achieving greater parity has focused on strengthening enforcement of the rules for insurers. Critics have argued a lack of oversight and enforcement by state regulators has limited efforts to achieve greater parity.
States’ varying compliance standards have prompted patient advocates to call for a more uniform national set of standardized rules to reduce such disparities.
Problems related to enforcing compliance with parity rules proved there was a need for alternative approaches focused on giving payers more incentives, said Matt Miclette, senior manager of clinical operations at NeuroFlow, a mental healthcare remote management platform. “We know that somebody with a chronic health condition and a concurrent mental health disorder is two to three times more expensive to treat than a person without a mental health disorder,” Miclette said. So giving insurers opportunities to treat both concurrently is going to save money, he said.
Medicare, one of the single-largest payers of behavioral healthcare services, presents another complication. While it often greatly influences what services commercial health plans cover, parity rules don’t apply to it.
“All of that sets a tone where there is no incentive then for plans to really comply with parity because that can put them at a financial disadvantage compared to plans that are not even trying,” NAMI’s Kimball said.
For now many providers are focused on just trying to keep pace with the increased demand for telehealth mental healthcare services they’ve experienced in the past several weeks, said Peter Carlson, president of behavioral health services for the Advocate Aurora Health system.
He said a big concern is that many or all of the regulatory waivers around telehealth will expire once the pandemic emergency ends. Carlson said the emergency telehealth waivers need to become permanent to avoid severely limiting providers’ ability to meet demand for mental healthcare services now and in the outbreak’s aftermath.
“My sense is that this is the wave of the future,” Carlson said. “Hopefully we don’t go backwards.”