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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”



Access Issues in Behavioral Health Care

from Drug Benefit Trends®
Posted 10/28/2002

Jay M. Pomerantz, MD


The behavioral health marketplace is complex and confusing. Initial access to care is usually through a central telephone intake and certification process. Almost all MCOs use this method, especially the national behavioral health carveouts. The number to call is listed on the back of the subscriber's insurance card. The process seems simple enough, but let's look behind the scenes to see how things really work -- or don't work.

Patients usually ignore the fine print on the back of their insurance cards. They assume that their medical insurance operates the same way for behavioral health as it does for other specialties of medicine. After all, they have been referred for behavioral health services by a primary care physician and have been given the names of psychiatrists, psychologists, or psychiatric social workers to call. So the patients call these practitioners and wait for a return call, which is usually late in coming because most mental health professionals operate without secretaries. When the mental health professional finally returns the call, the conversation is primarily about which behavioral carveout network the patient's insurer has subcontracted with, rather than the patient's symptoms.

In most fields of medicine, the majority of practitioners participate in most networks; however, this is not the case in behavioral health care. Carveouts traditionally have kept their networks small to better control utilization, and many practitioners have either not joined or quit networks, which may underpay or hassle them. Moreover, many companies keep their network list private. In any event, the patient eventually must call the insurance company or carveout network to explain the need for services and to obtain the names of local, in-network behavioral health providers.



So the patient starts over again, often being greeted with the bad news that the practitioners in that particular network are all too busy to see new patients. When a therapist is finally obtained, often he or she is a psychologist or social worker who may need the assistance of a psychiatrist for medication consultation or if the case is complex. Once more, the patient must repeat the process of telephoning the MCO and mental health practitioners but is often greeted with a new complication. Even if the patient finds a psychiatrist in the network, that practitioner may not be willing to work with the patient's current therapist. (Psychiatrists fear malpractice lawsuits as a result of sharing treatment with unknown or questionably competent psychotherapists.) For the patient or anyone else trying to set up treatment covered by insurance, it is a mix-and-match scenario with many false starts and dead ends.

In a recent article, William Goldman, MD, the senior vice president of behavioral health services at United Behavioral Health (part of United Health Care), provides the industry's point of view. He complains, in particular, about psychiatrists. Even when psychiatrists join networks, they may choose to be unavailable to care for network patients.[1] Such a phenomenon, if present, would further complicate patients' access to psychiatric care. Before one could even suggest a remedy, however, one needs to explore the issue. Two questions jump out: why would a provider join a behavioral health network, yet not be open to its patients, and why would behavioral health networks tolerate such practitioners on their roles?

The answer to the first question is that most established practitioners have their own referral system, which primarily consists of self-referred former patients and their families and friends, primary care physicians, and other mental health professionals. Most of the patients being referred have insurance, and the behavioral health practitioner being on insurance panels makes treating these persons possible. Furthermore, one's long-term care patients often change insurance companies, sometimes yearly, as employers search out the low bidder or best value. In any event, behavioral health specialists find it convenient to be listed on several panels. There is little downside risk. If an insurer or behavioral health carveout does not pay well or provide correct paperwork or presents other major obstacles (eg, difficulty in hospitalizing high-risk patients), one merely turns down any new patients from that network, especially those referred by the central telephone intake personnel.



Although the insurance and carveout folks know what's going on, they have reasons for tolerating it. For one thing, they are constantly under pressure from purchasers and oversight bodies (eg, the National Committee for Quality Assurance) to show a large and diverse network, especially one including many psychiatrists -- the behavioral health specialty best able to prescribe medication and manage the care of difficult-to-treat and high-risk patients. Second, from a financial standpoint, the behavioral health budget benefits to the degree that potential patients never successfully access treatment that insurance covers. Insurance companies profit when patients resort to any provider who has an opening, even if that provider is not covered by the patient's insurance. Other patients return to their primary care physician with their tale of frustration and are treated with medication only, which may or may not benefit the insurance company (but does benefit carveouts). Still others give up on treatment altogether and do the best they can without it. This self-help may not be good enough, given the daily reports in newspapers of suicides, domestic violence, workplace shootings, and a rising prison population. While thesecosts to society are real, they are not easily measured or directly attributable to behavioral health access problems.

The quickest way to find out whether a behavioral insurance network is real or illusory is to measure a network's treated prevalence rate per year (usually termed "penetration rate"). Excellent behavioral health networks have penetration rates of 8% to 10% or greater, whereas average ones will have a rate between 5% and 6%. The latter figure is based not only on the experience of managed health plans but also epidemiologic and health services research on the rates of specialty mental health service use in the United States, which runs 5.6% to 5.9% per year.[2, 3] One can be reasonably sure something is amiss when a network reports penetration rates for behavioral health specialty treatment below those figures. Cuffel and Regier,[4] as well as Weissman and colleagues,[5] have found a direct and linear association between the spending in a managed behavioral health organization and the penetration rate. As usual, you get what you pay for -- behavioral health access is no exception.

Another way to determine the extent of access problems may be to collect instances of consumer complaints about access to both the managed health plan and any oversight agencies. Unlike penetration rates, these reports are anecdotal and may represent unreasonable consumer demands rather than system impediments to medically necessary behavioral health care. It is also difficult in many instances to separate legitimate manpower shortages of certain specialties in particular areas (eg, child psychiatrists in rural areas) from administrative or funding problems.

All that being said, some method of measuring the percentage of the insured population who end up paying out-of-pocket for ostensibly covered behavioral health treatment would be another way of determining and confronting access problems. Something is clearly amiss with insurance arrangements that persons pay for but "choose" not to use. For example, in an article studying predictors of outpatient mental health utilization by primary care patients, Simon and colleagues[6] report that among interviewed participants, 5.1% used mental health services within their HMO (mean, 2.92 visits) and 8.9% purchased outside mental health services (mean, 8.86 visits). Is that an access problem?



Dr Pomerantz practices psychiatry in Longmeadow, Mass, and is an assistant clinical professor of psychiatry at Harvard Medical School in Boston.