Behavioral Health

A recent report from Morgan Health, JP Morgan Chase & Co.’s health care venture fund and consultancy, documents troubling disparities for health care access and outcomes among Black, Asian American and Hispanic employer-sponsored insurance plan members; lesbian, gay and bisexual (LGB) plan members; and ESI members with low incomes. Experts tell AIS Health, a division of MMIT, that plan sponsors and insurers must consider plan design and provider incentives, among other strategies, to close health disparity gaps.

Plan sponsors and insurers can take proactive steps to reduce health disparities among their plan members, experts say — and they add that there are clear business incentives for doing so.

Since integrating physical and behavioral health into its managed Medicaid program beginning in 2016, the state of Washington has not seen significant changes in utilization, quality measures or health outcomes, according to a recent JAMA Health Forum study. Experts tell AIS Health, a division of MMIT, that the study illustrates the challenges associated with integrating behavioral and physical health care that may not be fully apparent until the process begins.

K. John McConnell, Ph.D., the study’s lead author, tells AIS Health that Washington is just one of many states that in recent years have moved away from so-called carve-out models in Medicaid, where one health plan handles physical health and a separate behavioral health organization manages behavioral health. Most states now have carve-in designs where states contract with managed care organizations (MCOs) that are responsible for payment for all health care services for their members.

Self-funded health plans backed by large employers are expanding the amount and quality of behavioral health benefits available to their members, but a new report prepared by Milliman Inc. shows that those plans’ members will likely have a hard time using those benefits due to provider shortages. One expert says that to overcome entrenched, structural problems in behavioral health access, plan sponsors must employ creative solutions and be willing to boost reimbursement to behavioral health providers.

The Dec. 13 Milliman report indicates there is high demand and poor access to mental health care across the country, confirming what other research and anecdotal evidence has shown in recent years. Public health data compiled by the Centers for Disease Control and Prevention’s National Center for Health Statistics and analyzed by Milliman confirm that the most dire outcomes of untreated behavioral health conditions, deaths by suicide and overdose, respectively increased by 32% and 376% between 2001 and 2021.

Two recent surveys from KFF and WTW indicate employer-sponsored health plans are concerned with rising health care costs, driven by factors such as inflation, increased utilization and rising prescription drug expenditures. However, the results suggest that employers are becoming more hesitant to raise health insurance costs for workers at a higher rate than their salary increases.

While the average annual family premiums for employer-sponsored coverage increased 7% this year to $23,968 after not increasing a year ago, according to the KFF Employer Health Benefits Survey, workers’ average wages increased 5.2% and inflation was up by 5.8%. During the past five years, premiums increased 22%, while wages rose by 27% and inflation increased 21%.

Insurer and plan sponsor trade groups strongly oppose the Biden administration’s stepped-up mental health parity regulations, according to statements and public comment letters submitted in response to the latest rulemaking on the subject. Insurer groups AHIP, the Blue Cross Blue Shield Association (BCBSA) and the Alliance of Community Health Plans (ACHP) all lined up against the rulemaking, as did the ERISA Industry Committee (ERIC), a plan sponsor group.

According to the insurer and plan sponsor groups, the proposed rules, which were released in July, are unworkable. They argue that there are simply not enough providers available to meet the more stringent requirements set out in the proposed regulations. The current round of rules, if implemented, would expand the list of conditions covered by parity rules, require additional data reporting and establish stronger network adequacy standards. Both plan sponsors and carriers could be held liable for violations of most provisions in the Biden administration’s proposed regulations.

Prominent Democratic lawmakers have launched an investigation following an HHS Office of Inspector General (OIG) report citing high rates of prior authorization denials by Medicaid managed care organizations. That report, which reviewed 2019 claims data from seven multistate MCOs, found that those insurers denied 12.5% of all prior authorization requests — more than double the denial rate of Medicare Advantage plans that same year. Alarmed by the report, House Energy and Commerce Committee Ranking Member Frank Pallone, Jr. (D-N.J.) and Senate Finance Committee Chair Ron Wyden (D-Ore.) said they sent letters seeking information about prior authorization practices to CVS Health Corp.’s Aetna, AmeriHealth Caritas, CareSource, Centene Corp., Elevance Health, Inc., Molina Healthcare, Inc., and UnitedHealthcare. Among other questions, the lawmakers want “a description of all algorithms, including machine learning and artificial intelligence algorithms” that the companies use when considering prior authorization requests.

The latest round of mental health care parity regulations would require health plans to detail members’ access to mental health care and the extent of behavioral health networks in much greater detail than before — and a recent federal report says that most plans were not in compliance with previous reporting standards. Experts say that the reporting requirements are a drastic change from previous standards, and plan sponsors and insurers have asked the Biden administration for more time to review the proposed rule.

The Biden administration has made significant changes to regulators' mental health parity enforcement powers in the past, and the latest set may be the boldest yet. The latest proposed rules, issued July 25, include specific data reporting requirements around non-quantitative treatment limits (NQTLs) and more stringent network adequacy requirements. Indeed, insufficient network adequacy now could count as an NQTL for enforcement purposes.

Now that the COVID-19 public health emergency has ended, the health care system — including insurers — are grappling with how to proceed in the “new normal” amid shifted habits and utilization patterns. To that end, two new studies offer insights into the implications of patients’ growing use of telehealth for mental health care services.

“The COVID-19 pandemic has caused massive amounts of changes in health care delivery, but then also in terms of how individuals are dealing with the pandemic. There’s been extensive research about how anxiety has increased or [how] other mental health disorders have increased,” observes Jonathan Cantor, Ph.D., a policy researcher at RAND Corp. With that in mind, Cantor and his fellow researchers sought to build on a previous study and measure how both telehealth and in-person mental health utilization and spending has changed from 2019 to 2022.

When asked about the COVID-19 pandemic’s impact on their employees’ health and well-being, a whopping 77% of employers surveyed by the Business Group on Health said they are currently seeing increased mental health issues in their workforce. And based on other findings in the employer coalition’s annual survey, companies are counting on their health plan partners to help them address this growing issue.

According to Business Group on Health Vice President Brenna Shebel, “77% is a stark jump over last year,” when 44% of employers said they were seeing an uptick in conditions such as substance use disorders, depression and anxiety. This year, another 16% of employers said they anticipate seeing an increase in mental health issues in their workforces in the future, “so certainly a key finding here is the dire need for mental health services and supporting their employees as they’re navigating their myriad needs in the area of mental health,” Shebel added during an Aug. 22 virtual press event held to present Business Group on Health’s findings.

The Section 1115 waiver that allows states to provide limited Medicaid coverage to incarcerated people has drawn applications from 18 states, according to KFF data from Aug. 11. Most of those states have chosen to limit the coverage to specific populations, such as incarcerated people with positive HIV/AIDS diagnoses, substance use disorder (SUD) or serious mental illness (SMI) — and experts say that the varied scope of state uptake could, over time, show which interventions are most effective in helping the vulnerable populations that the waiver is meant to serve.

Per KFF, of the 18 states that have submitted waivers, four — California, South Carolina, Utah and Washington — have had their waivers approved. Fifteen have pending waivers. (Utah and Oregon have both submitted multiple waivers; both of Oregon’s are pending approval from CMS, while Utah has had one approved and one is still under consideration.)