Provider Not Found: Contributions and Solutions to Inadequate Provider Networks for Behavioral Health Care

• Jurisdiction: United States,Federal
• Publication year: 2022
• Citation: Vol. 38 No. 3

404 Provider Not Found: Contributions and Solutions to Inadequate Provider Networks for Behavioral Health Care

Travis Williams
twilliams121@student.gsu.edu

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404 PROVIDER NOT FOUND: CONTRIBUTIONS AND SOLUTIONS TO INADEQUATE PROVIDER NETWORKS FOR BEHAVIORAL HEALTH CARE

Travis C. Williams^*

Abstract

Despite the efforts of policymakers, access to in-network behavioral health care services has continued to lag relative to other types of health care. Many psychiatrists, for example, do not accept insurance, limiting access to their services to only those individuals who can afford to pay out of pocket. Several factors contribute to insurance networks' paucity of behavioral health care providers, including low insurance reimbursement for behavioral health care services, inadequate regulation and enforcement, provider shortages, and a lack of access to telehealth services. To maximize the utility of existing regulatory structures, states should take an outcome-oriented enforcement approach that principally monitors appointment wait times to evaluate how well insurance networks meet their enrollees' behavioral health needs. Additionally, policymakers should aim to strengthen internet infrastructure, broaden scopes of practice to encompass telehealth services, establish quantitative reimbursement minimums for some services, foster early interest in behavioral health careers, and adjust federal loan repayment programs to maximize recruitment to the behavioral health care workforce. Finally, lawmakers should create tax incentives to encourage behavioral health care providers to accept insurance.

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CONTENTS

Abstract................................................................................989

Introduction.........................................................................992

Background...........................................................................995

A. The Push for Parity: The Historical and Social Context of Legislative Efforts..................................................996
B. A Backdrop of "Narrow Networks"..........................999
C. The Problem of Network Inadequacy........................1001

II. Analysis.........................................................................1006

A. The Inadequacies of Network Adequacy Regulations ..................................................................................1007

1. Qualitative Standards.........................................1009
2. Quantitative Standards.......................................1010

a. Geographic Criteria ..................................... 1010
b. Appointment Wait-Time Requirements.........1011
c. Provider-to-Enrollee Ratios or Minimum Number of Providers....................................1013
d. Lingering Flaws in Quantitative Standards and Their Enforcement........................................1014

3. "Any Willing Provider" Laws............................1015
4. Behavioral Health Care Providers' Low Reimbursement Rates and Network Participation ............................................................................1017
5. Inaccurate Provider Directories........................1022

B. Provider Shortages .................................................. 1024

1. Scholarships and Loan Repayment Programs for Medical Students ................................................ 1026
2. The Use of Telehealth Services and Integrated Care Models................................................................1029

C. The Sum of Provider Shortages and Inadequate Network Adequacy Regulations .............................................. 1034

III. Proposal.......................................................................1034

A. Strengthen and Enforce Network Adequacy Regulations for Behavioral Health...............................................1035

1. Establish Quantitative Reimbursement Requirements ............................................................................1035
2. Strengthen Existing Network Adequacy Regulations and Their Enforcement.......................................1038

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a. Take a More Active, Outcome-Based Approach to Enforcement.............................................1038
b. Strengthen Provider Directory Accuracy Standards......................................................1041

B. Incentivize Psychiatrists to Accept Insurance..........1043
C. Bridge the Gap Between Behavioral Health Care Providers and Patients.............................................1044

1. Bolster Workforce Recruitment in Behavioral Health Care....................................................................1044
2. Foster Interest in Behavioral Health Care Early in Education............................................................1048
3. Remove Barriers to Behavioral Telehealth and Continue Integrated Care Models......................1050

Conclusion..........................................................................1054

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Introduction

In the days before April 18, 2019, Kristi Bennett and her family called more than a dozen mental health facilities.¹ Desperate to find help for her, they tried establishments both in and out of her home state of Kansas.² According to her family, however, the facilities and Bennett's insurance company, Blue Cross and Blue Shield of Kansas, blocked them at every turn.³ Before going to bed on April 18, Bennett took fifteen Wellbutrin.⁴ She never woke up.⁵

Kristi Bennett's tragic story provides a bleak example of the human costs of a behavioral health care system that lacks the capacity to adequately care for people who need its help.⁶ unfortunately, stories that illustrate the shortfalls of behavioral health treatment in the United states remain all too common.⁷ Many people suffering from a mental health crisis encounter a system generally ill-equipped to meet their needs.⁸

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The system's failings have led politicians to call for a greater focus on behavioral health in recent years.⁹ The broader scale of behavioral health problems in the United States, which has been exacerbated by the COVID-19 pandemic since 2020, justifies these calls for greater awareness.¹⁰ In today's troubling landscape of behavioral health care delivery, access to care continues to pose the most significant challenge.¹¹

Some of the trouble with access to behavioral health care stems from providers' low participation in insurance networks compared with other types of care.¹² Legislators have sought to counter this and other

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insurance disparities with laws that mandate "parity" between the terms of coverage for behavioral health care and other types of care, such as medical and surgical benefits.¹³ To that end, statutes and regulations passed at both the state and federal levels aim to remedy coverage disparities by targeting network adequacy for mental health and substance use disorder (SUD) services.¹⁴

Although parity legislation has achieved many of its goals, significant gaps remain.¹⁵ Network adequacy issues provide a particularly cogent example of this ongoing discrepancy: a disproportionate number of patients turn to out-of-network providers for behavioral health care compared to medical or surgical care.¹⁶ High rates of out-of-network care matter because out-of-network care often entails higher out-of-pocket costs, variable provider quality, and limited availability of services, all of which compromise access.¹⁷

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Thus, even though mental health parity laws have mandated that coverage for behavioral health care services be on par with other medical coverage, access to behavioral health care services continues to fall short of the promise of parity because of inadequate networks of participating behavioral health care providers. This Note discusses the complex framework of state and federal laws governing network adequacy and the market conditions that contribute to underrepresentation of behavioral health care providers in insurance networks. Part I provides a brief history of the legislation to date that affects access to mental health care, expanding on the significance of network adequacy by framing the problem within its broader social context.¹⁸ Part II analyzes the shortcomings of network adequacy regulations, the system of variable state-to-state enforcement of those regulations, and the provider shortages that complicate efforts to expand access.¹⁹ Finally, Part III proposes strengthening regulations and enforcement; expanding educational programs, "telehealth" services, and scopes of practice to address provider shortages; and incentivizing behavioral health care providers to join insurance networks.²⁰

Background

The fight to ensure parity for coverage of behavioral health conditions has been incremental.²¹ Before encountering the problems presented by disparate coverage of behavioral health conditions, however, individuals must seek care in the first place, and social issues like the stigma surrounding behavioral health conditions and a lack of health insurance inhibit people from doing so.²² Social barriers and the

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lag of legislation contribute to inadequate insurance networks, which negatively impact people seeking behavioral health care.²³

A. The Push for Parity: The Historical and Social Context of Legislative Efforts

Prior to the passage of the Mental Health Parity Act (MHPA) in 1996, many plans either lacked coverage for mental health services entirely or imposed significantly more restrictive limitations on those services than other types of health care.²⁴ The MHPA took the first steps to remedy these issues by requiring parity in annual and lifetime dollar limits for mental health benefits relative to medical or surgical benefits.²⁵ The legislation, however, left many other disparities intact and did not include provisions for SUD treatments.²⁶

Over a decade later, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)...