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Report Shows Worsening Disparities in Access to Behavioral Health Care

Disparities between physical and behavioral health care for both in-network access and provider reimbursement rates are making it even harder for American families to find affordable and available mental health care and addiction treatment.


According to a report by Milliman, Inc. covering 37 million employees and dependents, and commissioned by The Bowman Family Foundation, indicated 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 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 and medical/surgical providers widening. 

“The study’s findings are beyond disappointing and disturbing,” said Henry Harbin, MD, a psychiatrist, former CEO of Magellan Health Services and advisor to The Bowman Family Foundation. “With the extensive efforts by multiple stakeholders, over the last several years, we were expecting to see significant improvements. Instead, we are going backwards.”

Out-Of-Network Use Disparities for Both Mental Health and Substance Use

  • Disparities in access to in-network behavioral providers compared to medical/surgical in all treatment settings continued to worsen in 2016 and 2017 compared to earlier years.
  • Inpatient out-of-network use for behavioral health was over 5x more likely than for medical/surgical, worsening from 2.8x (280%) more likely in 2013 to 5.2x (520%) more likely in 2017 (an 85% increase in disparities over five years).
  • Outpatient facilities out-of-network use was nearly 6x more likely for behavioral health, worsening from 3.0x (300%) more likely in 2013 to 5.7x (570%) more likely in 2017 (a 90% increase in disparities over five years).
  • Office visit disparities were already 5x higher in 2013 (500%) and worsened to 5.4x (540%) in 2017. 

These access problems are about more than just reimbursements. Our evidence shows that health plans limit in-network providers, do not credential new providers in a timely manner, pay significantly lower rates for in-network care, and apply extreme utilization-review tactics that are not based on medically necessary care,” said Mark Covall, president and CEO of the National Association for Behavioral Healthcare.

Substance Use Disparities (separate from mental health)  

  • Substance use out-of-network use 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 10x (1000%) more likely than for medical/surgical care in 2017, worsening from 4.7x in 2013 (a 113% increase in disparities over five years).  
  • Outpatient facility out-of-network use for substance use care was 8.5x (850%) more likely than medical/surgical care 2017, worsening from 4.2x (420%) in 2013 (a 102% increase in disparities over five years).
  • Office visit out-of-network use for substance use care was 9.5x (950%) more likely than primary care office visits in 2017, worsening from 5.7x (570%) more likely than primary care office visits in 2013 (a 67% increase in disparities over five years).   
  • Reimbursement rate disparities for substance use office visits compared to primary care office visits increased each year between 2013 and 2017.
  • Substance use 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 10.1x (over 1000%) more likely than for an out-of-network primary care office visit — this was more than twice the disparity seen for adults.

Reimbursement Rate Disparities

  • In 2017, primary care office visit reimbursement rates were on average 23.8% higher than behavioral office visit reimbursement rates compared to Medicare fee schedule amounts, an increase in disparities from 20.8% in 2015.
  • During the five-year period, average reimbursements for both mental health and substance use office visits have remained below Medicare allowed amounts.

Spending on Behavioral Care as a Percent of Total Health-Care Spending 

  • Spending for all types of mental health treatment (excluding prescription drugs and substance use), as a percent of total health-care spending, has ranged between 2.2% 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 1.0 %, never exceeding 1% of total health-care spending.
  • Prescription drug spending for all behavioral health was 2% of total health-care spending in 2017.

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

  • Suicides in the U.S. 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 2.1 in 2013 to 3.0 in 2017 per 100,000 individuals. 
  • Deaths of all types involving substance use increased from 75,472 in 2013 to 109,813 in 2017, a rate increase from 23.9 in 2013 to 33.7 in 2017 per 100,000 individuals.

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