More than half of Americans have health insurance plans through their employers, which often fail to include a sufficient supply of behavioral health services. Fewer than one-third of 200 large employers said they were satisfied with their employees’ access to behavioral health services. More than four of five employers (84%) felt that in choosing plans, behavioral health access and quality were as important as ensuring control of behavioral health costs. Offering behavioral health networks with an insufficient supply of providers also reduces the value of plans to employees, who must then turn to out-of-network behavioral health services, for which they pay out of pocket.
As the U.S. Government Accountability Office has noted, despite the efforts of several federal agencies to enforce accuracy of provider directories and provision of mental health services on a par with physical health services (as required under mental health parity laws), consumers experience challenges finding in-network behavioral health providers. One study of state legislation to address plan directories that include providers who do not accept the plan’s patients found that the insignificant penalties for violations are absorbed by insurers as a cost of business and have not led to improvements. The administration has recently issued stronger federal parity rules to help address these issues. Given how complex and entrenched this problem is, additional tools that use a market-based approach may also be needed.
Improving Transparency and Information
Employers and employees want plans to improve access to in-network behavioral health providers. However, employers don’t have the information to properly assess plans and demand improvements.
Some actions are already underway. The National Alliance of Healthcare Purchaser Coalitions and the HR Policy Association, an affinity group of chief human resource officers, have collaborated to develop behavioral health metrics. They developed a comprehensive template of questions to address network adequacy, quality of care, integration into primary care, and workplace mental health.
Although this is an important endeavor, it requires considerable effort by both employers and providers due to the length of the questions. One alternative would be requiring the collection and dissemination of key shared metrics that can be easily obtained from claims data and compared across plans. Claims-based information from an individual plan would be most useful if it could be compared to national and local median values. Because there are many employers and many providers, no single employer or plan is likely to develop, test, and implement metrics that would be useful in managing behavioral care. Instead, interested associations or federal policymakers can develop a set of claims-based metrics that would be useful to both employers and government programs, and could even include a star rating system, similar to the one Medicare uses.
Claims-based metrics, if carefully designed, can reveal key information about the adequacy of behavioral health benefits, including:
- percentage of overall health spending on behavioral health care
- number of providers that have billed the plan five times or more in the prior year per 1,000 covered lives (i.e., a measure of network breadth)
- share of total listed providers who have billed five times (i.e., an indication of real participation, as opposed to a “ghost network”)
- percentage of members who see an outpatient behavioral health provider and engage in a fourth visit to that provider (i.e., an industry standard indicator of continued engagement and quality of the providers)
- number of providers who billed last year but not this year (i.e., an indicator of provider network churn, which may indicate burdensome prior authorization requirements or low reimbursement).
- percentage of out-of-network claims (a common industry standard).
In addition to claims-based measures, employers might want to know whether an insurer has user-friendly processes, including the ability to make appointments electronically.
Recommendations for Policymakers and Purchasers
Knowing their own metrics as well as industry averages will strengthen employers’ ability to negotiate with their insurers, especially in self-funded plans. Employers can then seek to improve on these metrics or find other insurance companies to help them administer their health plans. Congress or the administration could ask a designated agency or standard-setting body (or, if necessary, develop a new one) to develop the standardized core metrics that third-party administrators (TPAs) — that is, insurance companies that administer health insurance for large self-funded health plans — would be expected to report on. There is some precedent: the Medicare statute’s requirement for CMS to contract with a consensus-based nongovernmental entity for performance management.
While requiring collection and reporting of metrics could be enough to shift purchasing decisions, legislators could go further. Under federal law (for self-funded plans) or state law (for fully insured plans), regulators could consider whether employers have reviewed metric information in assessing whether employer-provided plans are meeting their fiduciary duties. Plans could be required to report metric information to the U.S. Department of Labor, which could publish data by plan. The administration could also use this smaller set of claims-based metrics in its parity compliance work to identify insurers that merit more detailed review.
Representatives of employers and purchasers could designate a standard-setting body and require insurance brokers to report on a smaller set of claims-based metrics. They could also conduct and publish surveys where employers review their TPAs. The Health Purchasers and the HR Policy Association showed that it is possible to obtain this information and that there are meaningful distinctions between plans, but their initial efforts did not name the insurance companies. Future efforts by purchaser groups to assess TPAs should include names of insurance companies, although they could consider allowing the insurer a few years to improve before doing so.
The provision of behavioral health services in large employer plans is broken. Fixing it will require that employers have the tools to know what they are paying for. This will require the development of targeted and easily collected metrics of behavioral health access.
