In light of the increasing demand for mental health treatment and simultaneous provider shortages, the private insurance industry is rolling out targeted initiatives to increase mental health support for members by mitigating many of the barriers to entry facing the mental health industry today.

Challenges Facing Mental Health Care

As the importance of mental health continues to become more clear, Americans are seeking mental health care that is timely, appropriate, and effective – an endeavor that is necessary, but difficult, considering the current state of the mental health industry in the United States. The national shortage of mental health professionals, combined with the urgency required to secure treatment for an at-risk population, places a significant strain on practitioners, specifically, and the mental health industry, at large. For example, an overwhelming sixty percent (60%) of recently-surveyed licensed psychologists reported having no openings for new patients, with many having a volume of patient requests that outweighs their ability to even maintain a waitlist.^[1] In addition to the challenges presented by provider shortages, even when patients are able to locate an available mental health provider, many are hesitant to engage in treatment due to cost uncertainties, which often arise due to limited availability for in-network care and the subsequent need to seek out-of-network care.^[2] Although federal laws, such as the Mental Health Parity Act (the MHPA), the Mental Health Parity and Addiction Equity Act (the MHPAEA), and the Affordable Care Act (the ACA), require private payors to recognize a certain degree of coverage parity between mental health services and general health services, and several states, including California, Oregon, and Connecticut, recognize mental health services as an “essential health benefit,”^[3] patients are up to six times more likely to pay out of pocket for treatment by behavioral health specialists than for treatment by general practitioners – underscoring the need for increased focus on parity by payors.

Leveraging Digital Health Resources to Increase Access to Care

With the threat to mental health care access presented by provider shortages and cost uncertainties, the mental health industry has begun to embrace digital health as a supplement, and even a replacement, to in-person care. In recent years, big-name insurers have expanded mental health treatment for members beyond the classic office-based therapy visit by offering on-demand virtual services, such as Blue Shield of California’s Wellvolution platform, Aetna’s Mindcheck platform, and Blue Shield of California’s CredibleMind care management tool. Digital health platforms like these go beyond the minimum coverage required by state and federal parity laws to give members round-the-clock access to tools that allow them to manage their own mental health between traditional appointments. Not only are these tools popular among members,^[4] they are proving to be an effective means to combat the current access-to-care issues facing the mental health industry. For example, a recent study published by the Journal of the American Medical Association (JAMA) associated one or more outpatient behavioral health treatments with lower healthcare costs for certain patients.^[5]

Continuing Limitations and Potential Expansion

Whether online or on-site, behavioral health support is only as sustainable as the resources supporting it. While digital health support tools provide essential supplemental care, payors continue to seek to address the indispensible need for licensed practitioners to provide mental health support to the growing number of patients in need of mental health care. In light of the behavioral health shortage, and now that these crucial digital health resources have been established, the most looming priority for private and government payors is to address workforce limitations, which directly lead to accessibility limitations for mental health patients. Private payors may learn from the strategies of state and federal leaders in crafting frameworks to support patient populations both virtually and in-person, despite the growing provider shortage.

The Kaiser Family Foundation surveyed forty-four state Medicaid officials about strategies to address behavioral health workforce shortages and found the following four categories to be most critical.^[6]

1. Increase provider reimbursement strategies. Health plans may promote outpatient health treatments by increasing the rate of reimbursement for particular providers or programs.During the pandemic, several state agencies leveraged increased Medicaid matching funds under the temporary American Rescue Plan Act to reinforce home- and community-based services. Since then, other states have increased reimbursement rates for specified providers, such as Applied Behavior Analysts, and particular programs, such as residential care for substance abuse disorders. For example, in Oregon, Medicaid coordinated care organizations increased rates by thirty percent (30%) for providers who receive more than half of their revenues from Medicaid and by fifteen percent (15%) for those who receive less than half of their revenues from Medicaid.

2. Redefining the workforce. By directing reimbursement to clinical social workers, peer/family specialists, and other mental health coaches who may bill as providers for non-emergent mental health services without a supervising practitioner, health plans can extend the involvement of more cost-effective personnel. This strategy was reinforced by the Consolidated Appropriations Act, passed in December 2022, which authorized funding for new psychiatry residency positions and increased the eligibility of providers authorized to prescribe medications for opioid use disorder.

3. Reducing the administrative burden. Digital mental health platforms with features that allow users to self-disclose information have the potential to lift some administrative weight from non-clinical staff and, ideally, pass on associated cost savings to patients. Physicians across the nation agree that prior authorizations create a major barrier in efficient care – for example, forty percent (40%) of physicians report employing staff exclusively dedicated to resolving prior authorizations to resolve medical encounters, basic imaging, and prescription refills.^[7] In alignment with this initiative, the Centers for Medicare and Medicaid Services (CMS) has recently issued a proposed rule to streamline the prior authorization process, which would purportedly decrease processing times from twenty-one (21) to seven (7) days. Please refer to our blog for more information on the proposed rule.

4. Incentivizing provider participation. Finally, private health plans may mimic state tactics to increase provider engagement through incentives such as prompt payment processes, referral assistances services, and direct financial payments for meeting specified performance benchmarks. Currently, thirty-three states link financial incentives to mental health disparity metrics, representing a concerted recognition of the strategy’s effectiveness in addressing the increasing need for mental health treatment.^[8]

Cristal Nova also contributed to this article.

FOOTNOTES

^[1] American Psychological Association. 2022 COVID-19 Practitioner Impact Survey. November 2022.

^[2] See, e.g., The Behavioral Health Care Affordability Problem, Center for American Progress (May 26, 2022).

^[3] California Department of Insurance, Health Insurance Benefits; Approaches in Implementing the MHPAEA: Best Practices from the States, Substance Abuse and Mental Health Services Administration (2016).

^[4] For example, approximately 110,000 Blue Shield of California members are enrolled in the Wellvolution program. See Why Blue Shield of California Made Its Wellvolution Platform Available to Medi-Cal Members, Med City News (Feb. 21, 2023).

^[5] Bellon, J., PhD, Quinlan, C., MPH, & Taylor, B., PhD, et al., (2022). Association of Outpatient Behavioral Health Treatment With Medical and Pharmacy Costs in the First 27 Months Following a New Behavioral Health Diagnosis in the US. JAMA Netw Open. https://doi.org/10.1001/jamanetworkopen.2022.44644

^[6] See also Approaches in Implementing the MHPAEA: Best Practices from the States, supra FN 3.

^[7] American Medical Association. 2022 AMA Prior Authorization (PA) Physician Survey.

^[8] State Delivery System and Payment Strategies Aimed at Improving Outcomes and Lowering Costs in Medicaid, Kaiser Family Foundation (Jan. 12, 2022).