Neurological misfires

This article is the second in a two-part series examining the challenges in achieving true parity for mental health benefits. This article addresses barriers to care due to lack of access and provider shortages. The previous installment, "Separate, but not yet equal," featured in EBN April 15, explores the history of mental health parity legislation, and is available online at ebn.benefitnews.com.

Deborah Serani has practiced psychology and psychoanalysis for more than 20 years. She doesn't accept insurance for her services because a few years ago, the pay rates for mental health stopped increasing with inflation, and she decided she had a large enough client base to sustain her business.

She still receives around 10 calls a month from prospective patients who ask, "Do you take my insurance?" She says she has tried many times to be removed from insurance networks, to no avail.

Elephant in the room

When she receives these calls, usually from people who are looking for help with a mental illness or life crisis, she tries to educate them about the thing the mental health community calls a "ghost network."

"It's almost like an elephant-in- the-room issue and unless you brush up against it personally, you don't realize it's going on," Serani says. Health insurance companies sell themselves based on comprehensive provider networks, and for physical health, she says, such networks are largely accurate. For mental health, though, while a network might have 100 therapists in a region who are actively taking clients, it might list 1,000 - thus the "ghost network" concept.

Employers uncertain about cost of parity

The Mental Health Parity and Addiction Equity Act of 2008, which says that health services must be equal for both medical and mental health, has yet to be fully executed by state insurance commissioners, the Department of Labor and the Department of Health and Human Services.

In the short term, enrollments in traditional models of managed behavioral health will continue to increase because employers are uncertain about the cost of parity and straining to control costs. But over the long term, current models for delivering mental health care likely will change.

Giving up the ghost

But for now, the issue of ghost networks remains. Much like Serani experienced, payment rates can be set too low to make participating within insurance networks economically viable.

Sara Mindel, a psychotherapist in private practice in Washington, D.C., rather than turning away people in crisis, cares for one-quarter of her patients on a sliding-scale basis.

An Aetna spokesperson told EBN the issue of network adequacy comes down to availability: "Providers may be fully contracted, credentialed and listed in directories as such, but at various times may not be available for new patients. That variable must be taken into account when building/expanding networks. There are also instances where providers may have changed location or contact information without notifying the carrier."

Although benefit professionals may feel powerless to improve provider networks, Serani says practitioners can be proactive now, during plan renewal season, to break down ghost networks. "Talk about the elephant in the room. Get them to tell you the true percentages," she says. "Contracts can be changed. It draws a line in the sand so the insurance company knows [it has] to be on its toes."

With all the talk of presenteeism and absenteeism, not treating mental illness, however mild, doesn't make sense.

"We had to fight in the passage of Parity and ... we got [the] Chamber of Commerce on board because they saw a business case to it," says Sarah M. Steverman, director of state policy at Mental Health America.

"It's not only right from a moral standpoint, it's a business case," she adds.

Hidden behavioral health care costs handcuffing companies' cost-saving efforts

While more companies today are focusing on wellness programs as a way to cut health care costs, Ed Jones, president of commercial division at ValueOptions, told attendees at the Institute for Health and Productivity Management conference that adding behavioral health clinicians to the mix can yield even greater returns on overall employer investments in health care and wellness.

An estimated nine million U.S. adults have serious thoughts of suicide each year, and one million make a suicide attempt, Jones said, adding that there is a strong link between depression and anxiety and chronic conditions.

There is at least a 50% increase in prevalence in chronic conditions like diabetes when paired with a mental illness, he said, which means "they're not taking care of their physical health. People who are dealing with comorbid conditions are far more costly, and the reason for that is that they're not getting effective care - it's fragmented."

"There are a lot of good efforts within corporate world to get people's extrinsic motivators going, like giving incentives," Jones noted. "That's fine, and that may get people started, but the goal is ultimately that you need to be tapping people's intrinsic motivation. The goal of health care isn't to reduce symptoms, but to have sense of well-being."

He said this is where a behavioral health clinician comes in because they can help workers reverse negative behaviors that can stunt effective management of chronic conditions. And with 20% of health care costs coming from behavioral health issues, according to the National Institute on Mental Health, Jones made the case that although companies might see behavioral health as only a small part of expenditures, there is in fact a behavioral health crisis.

"We have continued to fail to get people the help they need," he said. He cited anecdotal evidence that showed that for behavioral health employee assistance programs, 10% utilization is considered good, but with the number of people with mental illness in the country, it's just not enough.

"The technology will take us as far and as fast as we want to go, but the thing that holds us back - that is a brake economically and socially - is the performance of human capital," said Sean Sullivan, president of IHPM. "We cannot afford illness anymore. For all of those that have preached health and wellness forever, their time has come."