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Assessing Availability, Financial Disparities of Behavioral Health Services


Going into the COVID-19 pandemic, previous studies by Milliman found a worsening over the past 5 years of access to inpatient intermediate levels of care and office-based care, said Henry Harbin, MD, leading behavioral health expert and adviser to The Bowman Family Foundation.

Going into the COVID-19 pandemic, previous studies by Milliman found a worsening over the past 5 years of access to inpatient intermediate levels of care and office-based care, with average payments for behavioral health professionals continuing to show disparities with Medicare allowables, said Henry Harbin, MD, leading behavioral health expert and adviser to The Bowman Family Foundation.


AJMC®: Hello, I'm Matthew Gavidia. Today on the MJH Life Sciences’ Medical World News, The American Journal of Managed Care® is pleased to welcome Dr Henry Harbin, a leading behavioral health expert who served as a key architect of a study by Milliman on how behavioral health conditions contribute to physical and total health care spending. Can you just introduce yourself and tell us a little bit about your work?

Dr Harbin: Okay, thank you. I'm Henry Harbin, I'm a psychiatrist by background. I've been in the behavioral field for 4 decades at least, and I used to, in my career, I've spent 15 years as an executive with and CEO of 2 national managed care companies, Magellan Health Services and Greenspring Health Services.

Most of the last decade, I've really been involved in kind of advocacy and policy work to try to reform the delivery of mental health and substance abuse services nationally. So, that's briefly my background and some ideas of the perspectives.

AJMC®: Amid the pandemic, several polls and studies have represented substantial rises in behavioral conditions such as stress, anxiety, and depression among US employees. Can you speak on the current availability of services and financial reimbursement mechanisms to address this intensifying concern?

Dr Harbin: Yeah, I think the data has been very consistent in the US and other countries actually, that there's a significant increase in the need for mental health and substance abuse services, and in some cases, significant reduction in access. Even though I will add 1 of the few positives to come out of this crisis is an expansion of the use of telehealth, especially telebehavioral health.

So, mental health and substance abuse services except for certain categories like inpatient care, lend themselves to either video or telephone therapies and interventions. So there has been expansion there, but still, what we've seen is an increase in the need—we don't know whether the prevalence of mental health and substance abuse problems have gone up, but certainly the demands for services at a time when it's hard for people to access specifically in-person services.

So, we've seen this spike, we suspect and there have been data about increase in suicides, increase of opiate or substance abuse related deaths, so we're concerned because we already had a shortage of access or difficulties in getting access to effective and affordable mental health subsidies care prior to the COVID crisis. So, that's why I think us and many other health policy people are concerned that this is going to be exacerbating an already existing problem.

To highlight this, in over the last decade, we've seen basically a huge spike in death rates from suicide and substance abuse related, opiates and other substances, to such a degree that we've seen for the first time in the last 5 years in particular a negative trend and life expectancy for the whole US health care population. It's mostly due to these what are called deaths of despair, and we have not seen a back to back yearly regression in life expectancy in the US since 100 years ago, actually, during the great flu epidemic of 1918.

So, going into COVID, we weren't in a good situation and now of course, we're worried it has been made worse and we're worried that it's going to be even worse coming out of this. So, the access issues are involved.

There were 2 Milliman reports that were funded by the Bowman Family Foundation, which is a small family foundation—I'm an advisor to them—in 2017 and 2019 that actually specifically measured disparities into in-network access for commercially insured individuals and beneficiaries. What both those studies showed, they measured the impact, the first one was for 3 years and the one in 2019, which was published in November 2019, was for 5 years, 2013 to 2017, about 40 million covered lives, looking at their claims in 2 large databases.

What that showed was actually a worsening over the 5 years of access to inpatient intermediate levels of care and office-based care—all categories. Substance abuse was the worst and mental health was next. So, what it showed was that, for instance, in for inpatient care, the access to in-network inpatient care for these individuals was say double digits, might be 15% or 20% depending on the state, where it might be 5% for people with all medical disorders. We saw the same thing for intensive outpatient services or office-based care. Those statistics of in-network access got worse from 2013 to 2017.

The second thing that was measured was reimbursement disparities. So, Milliman [examined] the same database in both periods of time measured whether or not psychiatrists, psychologists, and other mental health providers were paid the same as primary care doctors and other medical specialists for similar, or in some cases the exact same CPT codes. In general, on a national basis this varied a lot, but it's about a 20% differential with the behavioral professionals paid less than the medical professionals even for the same code.

The other kind of telling statistic on that is that over the 5 years in this most recent study, the average payment for behavioral professionals never got above Medicare allowables. Now, most physicians and I'm sure your audience knows that typically commercial payers pay a lot more than Medicare allowables for all doctors, hospitals, and everything. Yet, in this case on average nationally, the behavioral people never got above the Medicare allowables. Some states, some plans paid more but most didn’t.

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