Behavioral Health Services 3.5 Times More Likely to Be Out-of-Network than Physical Health Services

Despite federal parity laws, new research shows that behavioral health clinicians are reimbursed at rates 22% lower than medical and surgical clinicians.

A new study from nonprofit research institute RTI International may provide behavioral health operators with the evidence to meet with payers to boost reimbursement rates and increase patients’ access to behavioral health services.

“The idea that you would pay a mid-level, master’s level physician assistant more than an MD psychiatrist is very telling,” Dr. Henry Harbin, a parity expert and senior advisor to The Bowman Family Foundation, the non-profit that commissioned the study, told Behavioral Health Business. “It’s a statement of the priorities of the health plans.”


The study also found that non-behavioral medical services are vastly covered as in-network care. For behavioral health services, “it’s almost the exact opposite.”

Patients went out-of-network for behavioral health services 3.5 times more often than patients receiving medical or surgical care, leading to significant financial and clinical consequences, including thousands of dollars in medical bills.

For some behavioral health specialties, the disparities are even starker. Psychiatry appointments were 8.9% more likely to be out-of-network, psychology appointments were 10.6 times more likely to be out-of-network and sub-acute behavioral inpatient care, such as residential treatment care, was 19.9 times more likely to be out-of-network.


“It has a direct impact on the financial burden on patients and also their ability to get the treatment that they need,” Dr. Tami Mark, distinguished fellow and director of behavioral health financing and quality measurement at RTI said. “If it’s out-of-network and they say ‘I’m going to have to pay $1,000 to send my child to residential substance abuse disorder treatment,’ they’re not going to get the care.”

Mark and the study’s co-author, Dr. William Parish analyzed claims and enrollment data from more than 22 million people from 2019 through 2021 to determine out-of-network use and reimbursement rates across the country.

The research found that behavioral health clinician shortages, sometimes used to explain higher out-of-network rates for behavioral health appointments, are an excuse that does not explain the disparity.

“There’s a shortage in primary care, there’s a shortage in other specialists,” Mark said. ”If … we’re paying them equivalent, not 22% less, and there’s still a disparity, that would be more credible. But the whole picture together, the argument that this is driven by a shortage doesn’t hold water.”

There are 25% more shortage areas for primary care physicians than for mental health providers, according to the U.S. Health Resources and Services Administration. The study found that despite the primary care shortage, there was out-of-network use of only 2.2%, contrasted with psychologist visits, which had out-of-network use of 18.2% and psychiatrist visits, which had 15.3% out-of-network use.

The study also found that in-network vs. out-of-network disparities have persisted for almost a decade. The results of a previous study performed in 2013 were extremely similar, demonstrating a lack of progress on parity.

“One of the main goals of the parity law, the federal law and the state laws, was to equalize the financial burden on patients that have mental health problems and some substance use problems to be the same as medical,” Harbin said. “These results show you that for nine years there have been massive disparities. It hasn’t improved significantly, or at all in some cases.”

“This is a call for the regulators at the state and federal level that they’ve got to do more,” Harbin said.

The report outlined several recommendations to improve behavioral health parity.

Health plans and states should expand their behavioral health networks and offer higher reimbursements, the study’s authors wrote, to incentivize behavioral health providers to participate in-network and decrease out-of-network use.

The study’s authors recommended that federal and state agencies develop standardized templates with carefully worded definitions of terms to identify and remedy parity violations.

States and federal agencies should also get a “bigger stick” to enforce parity laws and transparency among insurance plans, Harbin and Mark said.

“How many years does it take to comply with a law that’s fairly clear?” Harbin asked.

Behavioral health providers can use the data from this report to potentially boost reimbursement rates and improve parity for patients.

“Hopefully [behavioral health providers] can take [the study data] to their health plans and say, ‘Look, I do want to participate,’” Mark said. “I want to be reimbursed fairly. Let’s get this done so we can help our patients get access and reduce their financial burden.”

Making appeals and complaints about parity is difficult, Harbin said, so the battle of making parity appeals should be led by larger behavioral health provider consumer groups. The study’s data will hopefully provide these groups with hope and motivation to do so, Harbin said.

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