Almost 75% of insured Americans said they could easily access the mental health care they needed, according to a new survey by AHIP—but some patients who receive mental health care through their primary care physicians are seeing their claims denied, leaving them "with the short end of the stick."
In a nationwide survey of 500 insured adults who sought mental health care within the last two years, AHIP found that 73% of respondents said it was easy to get the mental health support they or someone in their household needed. In particular, 32% said getting mental health care was "very easy," while only 6% said it was "very difficult."
Most respondents (60%) also reported that their mental health care was fully covered by insurance, while an additional 33% said the care was partially covered by insurance. Only 3% of respondents said insurance did not cover their mental health care.
Overall, 91% of respondents said they were satisfied with the mental health care they received, with almost half reporting they were "very satisfied." The most frequently used mental health service was in-person counseling or therapy at 56%, followed by telehealth counseling or therapy at 38%.
"Mental health affects everyone, and the COVID-19 pandemic made that more true, impacting all of us in different ways," said Matt Eyles, AHIP president and CEO. "We know there are challenges, particularly as more people seek support than ever before. Health insurance providers are working hard on a variety of solutions – including expanding access to telehealth appointments, integrating mental health into primary care visits, and creating innovative programs to increase the number of mental health care practitioners available."
However, some patients who receive mental health care from their primary care physicians have seen insurers deny their claims, even if their physician is in-network. In these cases, patients often have to pay out-of-pocket for mental health care, if they receive it at all.
According to Kaiser Health News (KHN), many insurers have adopted "behavioral health carve-outs," where health plans contract with a different company to provide mental health benefits for their members. Policy experts say that this model aims to control costs and allow companies specializing in mental health to manage those specific benefits.
Because physical and mental health benefits are separated, patients often need to "navigate two sets of rules and two networks of providers and to deal with two times the complexity" to get the care they need, KHN writes.
However, many patients are not aware that their insurance plans have carve-outs until their mental health claims are denied. There have also been cases where both a primary insurance plan and a behavior health company will deny a patient's claim, arguing that a specific issue fits neither mental nor physical health requirements.
"It's the patients who end up with the short end of the stick," said Jennifer Snow, head of government relations and policy for the National Alliance on Mental Illness.
Although there is little data on how often these mental health denials are occurring, Sterling Ransone Jr., president of the American Academy of Family Physicians, said he has received "more and more reports" of such cases since the beginning of the pandemic.
In addition, while physicians can appeal these denials or contact the carve-out plan for payment, the administrative efforts may ultimately cost more than the reimbursement, particularly for those who run small practices.
"Everyone around the country is talking about integrating physical and mental health," said William Sawyer, who runs a family medicine practice in Cincinnati. "But if we're not paid to do it, we can't do it."
According to Kate Berry, SVP of clinical affairs at AHIP, many insurers are working on ways to support patients who receive mental health care through primary care physicians. This includes teaching physicians how to use standardized screening tools and explaining what billing codes should be used for integrated care.
However, Berry noted that "[n]ot every primary care provider is ready to take this [integrated care] on." For example, a 2021 report from the Bipartisan Policy Center found that many physicians "lack the training, financial resources, guidance, and staff" to combine physical and mental health care in their practices.
Overall, integrated care is "a chicken-and-egg problem," said Madhukar Trivedi, a psychiatry professor at the University of Texas Southwestern Medical Center. Physicians say they will provide mental health care if insurers pay for it, but insurers say they will only pay for mental health care if doctors provide appropriate care.
Ultimately, this back and forth on payment causes patients to lose out on the care they need, KHN writes. Many patients who cannot get mental health care through their primary doctors end up not getting any care at all. Some patients may also wait until they are in a crisis and end up in the ED—something that has become a growing issue for children and adolescents in particular.
"Everything gets delayed," Trivedi said. "That's why there are more crises, more suicides. There's a price to not getting diagnosed or getting adequate treatment early." (Pattani, Kaiser Health News, 6/8; AHIP press release, 6/7)
Digital therapeutics (DTx) are scalable software solutions built on clinically-proven approaches to behavior change that can be used for long-term disease prevention and management, and many DTx solutions are independent treatments that don’t require constant provider intervention, enabling a one-to-many treatment approach.
By involving patients directly in the management of their own care, DTx can promote higher levels of patient activation and foster meaningful behavior change over time.
Create your free account to access 2 resources each month, including the latest research and webinars.
You have 2 free members-only resources remaining this month remaining this month.
Never miss out on the latest innovative health care content tailored to you.