Many insured Americans go out of network, pay more for behavioral health

Americans are using more out-of-network care and paying more out of pocket for behavioral health care than for treatment of other conditions, despite efforts to increase coverage and access to mental health services, according to new research.

The study highlights access barriers to behavioral providers that lead to for patients, even for those who have , said lead author Wendy Yi Xu, an assistant professor of health services management and policy at The Ohio State University.

The study appears today (Nov. 6, 2019) in the journal JAMA Network Open.

Xu and her colleagues examined claims from 3.2 million adults with mental health conditions, more than 321,500 with drug use disorders and more than 294,500 with alcohol use disorders. They compared those with claims from people with one of two common chronic conditions—diabetes and congestive heart failure.

Those with behavioral health concerns were more likely to encounter out-of-network providers and to shoulder a greater burden of the cost of their care.

Key findings included:

  • Those with drug-use disorders were almost 13 percentage points more likely to have out-of-network hospitalizations and more than 15 percentage points more likely to experience out-of-network outpatient care than those with .
  • Enrollees with had cost-sharing payments for out-of-network care that were $341 higher per year on average than enrollees with diabetes.
  • Compared to people with diabetes, those with drug-use disorders paid $1,242 more per year on average for out-of-network care and those with alcohol-use disorders paid $1,138 more.

"Much of this disparity is likely due to the limited availability of behavioral health care providers in insurance plans—the participation rates by these providers are generally low, a problem that is fueled in large part by low reimbursement rates for clinicians, including psychiatrists," Xu said.

"We saw that people with heart failure and diabetes didn't go out of network as often and didn't pay nearly as much for their care, probably because they were able to find care within the network."

The 2008 federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act aimed to deal with disparities between behavioral health care and other medical care, Xu said.

"But our study included data from 2012 to 2017, years later, demonstrating that those disparities still exist," she said.

An estimated 57 million U.S. adults have behavioral health conditions, and people with these conditions also frequently have higher risks of poor physical health, according to the National Survey on Drug Use and Health from the federal Substance Abuse and Mental Health Services Administration.

"Policymakers need to address this," Xu said. "People with behavioral health conditions are not as likely to speak up about their lack of in-network coverage for these conditions because of the stigma that's still associated with mental illness and addiction in our country."

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Journal information: JAMA Network Open

Citation: Many insured Americans go out of network, pay more for behavioral health (2019, November 6) retrieved 13 May 2021 from
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