As the need for mental health services grows across the United States, the push for greater parity between behavioral health and physical health services has never been more urgent. However, despite widespread efforts to ensure equal treatment for both types of care, new findings show that significant disparities persist—and in some areas, these disparities are actually widening.
A new report published by Milliman Inc., a Seattle-based actuarial and consulting firm, reveals some alarming trends in the access and reimbursement for behavioral health services in comparison to physical health services. The study, which was commissioned by the Mental Health Treatment and Research Institute LLC (a non-profit subsidiary of The Bowman Family Foundation), examined the data of 37 million U.S. workers and their dependents enrolled in commercial preferred provider organization (PPO) plans from 2013 to 2017. The findings show that the gap in access to in-network care and reimbursement between behavioral health services and physical health services is growing—despite the passage of the Mental Health Parity and Addiction Equity Act (MHPAEA) in 2008, which mandates that mental health and substance use disorder treatment be covered the same as physical health treatment.
The Widening Gap in Out-of-Network Behavioral Health Care
One of the most striking findings in the Milliman report is the increasing disparity in the likelihood that individuals will need to seek out-of-network behavioral health providers compared to physical health providers. In 2013, inpatient behavioral health facilities were 2.8 times more likely to be out-of-network than inpatient medical or surgical facilities. Fast forward to 2017, and this disparity had grown by 85%, with behavioral health facilities being 5.2 times more likely to be out-of-network.
A similar pattern was observed in outpatient care. In 2017, behavioral health providers were 5.7 times more likely to be out-of-network compared to their medical counterparts—a staggering increase of 90% since 2013. These numbers suggest a troubling trend: the more time passes, the harder it becomes for individuals seeking behavioral health care to find in-network providers, leaving them with fewer choices and, ultimately, higher out-of-pocket costs.
This growing gap in access to in-network providers raises important questions about the effectiveness of parity laws and the impact on consumers who rely on mental health care. As more behavioral health facilities fall outside of network coverage, individuals seeking care are faced with limited options for treatment that come with a higher financial burden.
The Discrepancy in Reimbursement Rates
The disparities don’t stop with access. The Milliman report also revealed troubling differences in the reimbursement rates for behavioral health care compared to physical health care. Across the board, between 2013 and 2017, behavioral health providers received lower reimbursements than their medical counterparts, and the gap has only worsened slightly over time.
For instance, in 2017, in-network reimbursements for primary care visits were nearly 24% higher than for behavioral health visits, marking a three percentage point increase since 2015. Additionally, in 2017, 11 states reported reimbursement rates for primary care visits that were more than 50% higher than for behavioral health visits, up from nine states in 2015.
This discrepancy in reimbursement rates is a significant concern, especially for behavioral health providers who are already faced with challenges related to reimbursement instability. Lower reimbursement rates can discourage providers from accepting insurance or even operating in certain regions, further limiting access to care for individuals in need of mental health services.
The financial strain placed on behavioral health providers, in turn, has far-reaching consequences for patients. Lower reimbursements can lead to fewer treatment options, longer wait times, and even the closure of clinics in underserved areas. For employees and their families who rely on these services, the financial burden can be overwhelming, forcing some to delay or forgo necessary care.
The Mental Health Parity and Addiction Equity Act: A Step Forward, but Not Enough
The findings in the Milliman report highlight a key issue with the enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA), which was designed to ensure that mental health and substance use disorder treatment are covered the same as physical health treatment under commercial insurance plans. While the MHPAEA has been a step in the right direction in terms of promoting equity, its implementation has been far from perfect.
Milliman researchers noted that while the MHPAEA federal rules state that disparities in reimbursement and out-of-network care are not definitive evidence of noncompliance, significant gaps—such as the high out-of-network utilization for behavioral health providers and the lower reimbursement rates for behavioral health services—could indicate problems with compliance. The report suggests that health plans need to carefully review their processes to ensure they are fully complying with MHPAEA and that any discrepancies are properly addressed.
However, Milliman also acknowledged that the issue of reimbursement rates is complex and influenced by many factors beyond the scope of the report. Despite this complexity, it is clear that the goal of parity between physical and behavioral health services has not been fully realized. The ongoing disparities in access and reimbursement point to systemic issues that require further attention from policymakers, insurers, and providers alike.
The Impact on Employees and Their Families
For U.S. employees and their families, the widening gap between behavioral health and physical health services has profound implications. The increased likelihood of out-of-network behavioral health care means that many individuals seeking mental health or substance use disorder treatment may face significant out-of-pocket costs, including higher copays, deductibles, and the possibility of paying for entire services out-of-pocket. This financial burden can deter people from seeking care in the first place, ultimately impacting their overall well-being and productivity.
Moreover, the growing difficulty of accessing in-network providers and the lower reimbursement rates for behavioral health services can exacerbate the stigma that often surrounds mental health issues. When individuals face barriers to getting the care they need, it reinforces the idea that mental health treatment is not as important as physical health treatment—a notion that runs counter to the principles of parity and equity.
Moving Forward: What Needs to Be Done
The findings of the Milliman report underscore the urgent need for continued advocacy and action to ensure that mental health and substance use disorder treatment are fully integrated into the healthcare system. Insurers, healthcare providers, and policymakers must take meaningful steps to address the widening disparities in access and reimbursement. This includes:
- Stronger enforcement of the Mental Health Parity and Addiction Equity Act: More stringent monitoring and enforcement of MHPAEA requirements are necessary to ensure that insurers are meeting their obligations to provide equal coverage for behavioral health services.
- Increasing the number of in-network behavioral health providers: Expanding the network of in-network behavioral health providers and reducing out-of-network utilization will improve access and lower out-of-pocket costs for patients.
- Addressing reimbursement disparities: Efforts should be made to close the reimbursement gap between behavioral health services and physical health services, ensuring that providers are fairly compensated for the care they deliver.
- Raising awareness and reducing stigma: Public education campaigns can help reduce the stigma surrounding mental health care, encouraging more people to seek treatment and access the resources they need.
In conclusion, while the U.S. has made significant strides toward parity in healthcare, the latest findings show that we still have a long way to go. The widening disparities between behavioral health and physical health services serve as a reminder of the work that remains to be done to ensure that all individuals, regardless of their health needs, have equal access to the care they deserve. Only through continued advocacy, policy changes, and systemic reforms can we truly achieve the parity that was envisioned when the MHPAEA was first enacted.
