Brain with gears As of 2017,primary care reimbursements were 23.8 percent higher thanbehavioral reimbursements, which is an increase from 20.8 percenthigher in 2015. (Image: Shutterstock)


It's getting harder and more expensive for many people to getbehavioral health care, according to Milliman Inc.'s report,"Addiction and Mental Health vs. Physical Health-Widening disparities in network use and providerreimbursement."


The Bowman Family Foundation engaged Milliman to use third-partyadministrative claims data to assess non-quantitative treatmentlimitations associated with behavioral health care services. Theanalysis, covering 37 million employees and dependents, reflectsthat conditions have worsened since a similar study was publishedtwo years ago.


Related: A decade later, still no mental healthparity


"Based on the robust sample of commercial PPO plans, significantdisparities continue to exist between medical/surgical providersand behavioral health care providers with respect to out-of-network utilization levels, and providerin-network reimbursement rates," the authors write. "Behavioralproviders have lower reimbursement levels and higher out-of-networkuse. Most of these differences have increased since our priorreport."


Two of the report's top findings:

  • From 2013 to 2017, the disparity between how often behavioralinpatient facilities are utilized out of network relative tomedical/surgical inpatient facilities has increased from 2.8 timesmore likely to 5.2 times more likely, an 85 percent increase indisparities over five years.
  • Average in-network reimbursement rates for behavioral healthoffice visits are lower than for medical/surgical office visits(each as a percentage of Medicare-allowed amounts), and thisdisparity has increased between 2015 and 2017. As of 2017, primarycare reimbursements were 23.8 percent higher than behavioralreimbursements, which is an increase from 20.8 percent higher in2015.

"Our findings of payment disparities in this updated analysissuggest that plans should conduct a detailed assessment of providerpayment rate methodologies to assess whether there is compliancewith the Mental Health Parity and Addiction Equity Act MHPAEA andits NQTL non-quantitative treatment limitation regulations," theauthors write. "If a plan finds that it is not parity-compliant inthis area, it should increase its payment levels to behavioralhealth care providers.


That increase in payment rates could also lead to an increase inthe desire of behavioral health care providers to join the healthplan's provider network. This, in turn, could then lead to higheruse of in-network services for behavioral health care, therebyaddressing the other potential NQTL compliance issue of disparateout-of-network utilization rates between behavioral andmedical/surgical health care."


In the press release announcing the publication of Milliman'sreport, a coalition of leading behavioral health organizations alsorecommended several key initiatives "that could make a large impactimmediately:"

  • On Nov. 12, the initiative "The Path Forward for Mental Health and SubstanceUse" was announced by the National Alliance of HealthcarePurchaser Coalitions, the Meadows Mental Health Policy Institute,the American Psychiatric Association Foundation's Center forWorkplace Mental Health and the American Psychiatric Association.This is a five-year implementation plan that will partner withhealth plans (essential to helping address this public healthcrisis) and other key stakeholders to drive change.


    The Five Priority Strategies that will be executed are toimprove network access for behavioral health specialists; expanduse of collaborative care to integrate behavioral health intoprimary care; implement measurement-based care to improve qualityand outcomes; expand tele-behavioral health; ensure mental healthparity compliance.

  • Federal and state parity regulators should increase theiroversight in several key areas: (a) require health plans to providecomparative quantitative data covering parameters such asout-of-network use rates, reimbursement rates, denial rates,pre-authorization requirement rates, and concurrent review rates,and (b) specify detailed definitions and instructions for thesecomparative data analyses by using tools similar to the Model Data Request Form currently being used by theNational Alliance and employers ("MDRF").
  • The coalition urges any insurer that believes the disparitiesin the current Milliman report are not reflective of its plans, orthat its plans have improved since 2017, to publicly release datafor its plans obtained by using the MDRF. The definitions andmethodology in the MDRF are consistent with definitions andmethodology used in the analysis of the current Milliman report,and are used by the National Alliance.
  • Consumers and others are encouraged to visit to track parity legislation in all50 states, and, which offers education aboutconsumer rights under the Federal Parity Law.

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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.