Addressing Network Issues to Improve Mental Healthcare Access
The US is in the midst of a mental health crisis, exacerbated by the COVID-19 pandemic and other disruptive and stressful events. Given the chronic shortage of mental and behavioral health care providers, over the past few years it has become increasingly difficult for people to obtain the care they need. This is a problem with no easy solutions, but employers are focused on making a difference. In fact, the largest employers identified mental health as their top strategic priority in our latest National Survey of Employer-Sponsored Health Plans.
The provider shortage is so pressing that some employers have begun to explore enhancing coverage for out-of-network services, especially when mental health parity compliance is a concern. If you’re considering taking that leap, we’d recommend that you first assess the root causes and the full scope of your access issues. It makes sense to work with existing partners to improve network access before enhancing coverage for out-of-network outpatient mental health services – and to be prepared to evaluate new partners, if needed.
Your existing partner should be able to identify where the network is inadequate – and that includes assessing provider capacity. Understanding the carriers’ process for reviewing out-of-network care will be helpful. Will the carrier conduct recruitment of commonly used facilities to ensure that coverage at higher levels of care is adequate, and offer single-case agreements when the appropriate provider is not reasonably close to the member’s location? If not, that could be a red flag.
This type of assessment can serve as a starting point for sizing the problem and moving forward with actions. You might:
- Expand parameters when conducting network analyses to ensure that providers with specific specialties are in members’ geographic area. Are providers taking new patients, and do facilities have open placements? Does your EAP and medical carrier have virtual provider networks in place to augment traditional access, particularly for outpatient services in underserved areas?
- Review your EAP design and consider covering additional sessions. Ideally, your EAP will provide virtual options and self-directed tools that make it easy for people to get quick support for emotional well-being before their symptoms evolve into a more complex mental health need.
- Explore options for expanding provider access with your medical carrier – such as more aggressive provider recruitment or higher reimbursement rates. One approach is to increase reimbursement rates for both in- and out-of-network providers but reduce the member co-pay for in-network providers to encourage them to remain in-network whenever possible.
- Look for opportunities to contract directly with a local medical center to provide behavioral health services at a more favorable provider reimbursement rate. Ideally, claims would still be administered by your medical carrier partner, while you gain access to providers that typically don’t participate in carrier based networks
- Consider COE networks and support steerage to these providers/facilities. By covering travel to high-quality facilities, particularly those supporting members with substance use disorders, you may be able to redirect members away from out-of-network destination facilities that engage in aggressive direct-to-consumer marketing.
- Evaluate point solutions that specialize in improving access to mental health services and resources as well, as onsite supports such as yoga and meditation.
Do a deep dive with your medical and EAP carriers to assess how they determine which providers will be included in their networks and what licensing restrictions apply. You could suggest expansion of coverage for provisionally licensed clinicians that are operating under the license of a supervising clinician. At the same time, it’s important to ensure provider networks are diverse and able to to serve people with shared life experiences, and that the carrier is conducting cultural sensitivity/cultural humility training.
Weigh the risks and rewards of enhanced OON coverage carefully
If these efforts don’t result in better provider access, recognize that enhancing coverage for out-of-network claims comes with some significant concerns – but also that the benefits may outweigh the costs. The biggest risk to plan members is the financial burden of an out-of-network hospitalization. Make this a top consideration as you work through the process. There is increased risk of out-of-network leakage and increased employer costs, but again, the risk may be worth it if plan members can’t access in-network care when they need it.
One final consideration. Out-of-network providers may be less responsive to utilization management efforts, which can lead to denials of coverage. Before making a change, it’s important that you fully understand your carrier’s utilization management processes and look for ways to streamline the process to encourage provider participation and limit coverage denials. If you find the process is overly burdensome or lacks empathy or urgency, demand changes to ensure members get the care they need when they need it.