What is the problem?

The cost of receiving behavioral health services is one of the largest barriers to patient access. The patient cost burden primarily stems from insufficient insurance coverage or an inability to find a clinician in network with availability and the appropriate expertise, leading patients to pay out of pocket for care.

What can health plans do?

Health plan leaders know they can impact on a member’s ability to afford behavioral health care via cost sharing arrangements. Some plans already offer an annual behavioral health wellness visit at no cost in order to encourage preventive care. But many plans overlook the impact they can have on affordability by encouraging more providers to even take commercial insurance. To do so, plans need to make it as easy as possible for provider organizations to partner with them.

For many plans, progress begins with meaningfully integrating their behavioral health and physical health teams, technologies, and processes. Integration makes it easier for plans to assess current practices, like utilization management policies, that may be inadvertently interfering with a member’s coverage of care. And because provider network availability directly impacts whether members can access covered care, review pages 7-9 of the accompanying PDF for more tactics on increasing the supply of behavioral health clinicians.

1. Fully integrate your behavioral health and physical health teams, technologies, and operations—which often starts with “carving in.”

Many health plans outsource their behavioral health operations to an external behavioral health organization (BHO) with deep subject matter expertise. However, this “carving out” to BHOs exacerbates the fragmentation of the field from the rest of medical care. Plans that outsource must usually manage two separate datasets for their members, making it challenging to understand the impact of behavioral health interventions on overall health outcomes and spending—and make the case for greater investment. Using a third-party vendor can also break down communication between plans and provider partners, frustrating providers who may want to be a part of commercial networks. But even plans that manage behavioral health in-house may still have separate databases or struggle with provider relationships.

Plans should aim to fully integrate their behavioral and physical health processes, which can inform better coverage decisions, strengthen provider partnerships, and ultimately reduce overall health care spend. But be prepared to devote considerable up-front time and resource investment to phase out vendor relationships, build internal expertise, integrate data sets and technology, and align team performance metrics with the physical health side.

Plans with a VP-level behavioral health leader and a well-resourced team are better positioned to achieve these goals. The leader should be included in broader strategic planning, operational discussions, and advocacy efforts to ensure major decisions align with organizational goals for behavioral health. Some plans find it helpful to devote staff time to serving as cross-department liaisons—this practice can help break down internal silos and extend behavioral health expertise across the organization.

2. Partner to evaluate current utilization management practices and reduce unnecessary coverage restrictions.

Provider organizations often report higher denial rates for behavioral health coverage compared to physical health. While plans aim to optimize the best clinical outcomes with the lowest possible spend, many clinicians believe that some limitations on care are unnecessary or lack clinical evidence (e.g., restricted lengths of stay in a detoxification unit).

There’s some reason for this concern. For example, one health plan noticed that while national guidelines offered approximate length of stay (LOS) recommendations for physical conditions, none existed for behavioral health conditions. In the absence of guidelines, the plan worried that they may be inadvertently undercovering behavioral health stays, resulting in more reviews per admission. The plan used retrospective claims data to create their own LOS guidelines by diagnosis, successfully reducing the number of authorizations required to extend LOS for behavioral health conditions.

Without insurance coverage for certain services, patients may have to fill in the gaps out of pocket. Health plans should regularly source feedback on utilization management practices to guard against unnecessary restrictions. Gather input from provider partners, academic experts, and government entities to come to a jointly agreed upon definition for medically necessary care, including preventive, maintenance, and pre-diagnosis care. Pair this feedback with a quantitative analysis of the clinical and cost outcomes associated with current utilization management policies. Use this data to reassess limits on duration of treatment or prior authorization requirements and adopt harm-reduction based policies around care coverage.

What is the problem?

Many patients struggle to access the “right” behavioral health professionals—practitioners who match the patients’ geographic location, are accepting new patients, have the right expertise, can provide care with cultural humility, offer affordable rates, and accept patients’ insurance. The overall shortage of behavioral health practitioners makes it difficult for anyone to find care, but it can be particularly challenging for patients who require specialized care or want a clinician with a specific demographic profile. It’s also uniquely challenging for patients who are low-income, as many health plans do not have robust, high-quality networks of behavioral health professionals with availability, forcing individuals to go out-of-network or forgo care altogether.

What can health plans do?

Health plans can improve members’ access to the right professionals and differentiate themselves from competitors by expanding the number of qualified providers in their network and investing in the behavioral health workforce pipeline.

1. Regularly assess behavioral health reimbursement rates to ensure they meet parity requirements, market standards, and provider partner needs.

Many clinicians and provider groups choose not to join insurance networks because they feel reimbursement rates are too low, and there is sufficient demand from patients who will pay out of pocket for care. Raising reimbursement rates can encourage providers to join your network and attract more professionals into the behavioral health field.

a) In addition to meeting parity requirements, ensure your rates at least meet your market’s or Medicare’s baseline. Historically, commercial and Medicare Advantage plans have paid an average of 13% to 14% percent less than fee-for-service Medicare rates for the same behavioral health services.

b) Come to consensus with providers on how to adjust reimbursement for specific codes by clinician type, including market factors like inflation and cost of living. Many providers are interested in accepting insurance—if it’s sustainable. Partner with providers to assess how much various services cost to provide and set rates accordingly so provider organizations can at least break even on behavioral health services. Seek additional feedback from providers not currently in-network to understand what rates would motivate them to join.

2. Address providers’ administrative pain points to encourage professionals to join and stay in your network.

Many providers choose not to join the private insurance network because they feel it’s not worth the hassle of navigating the administrative and documentation requirements—which often differ by plan. To avoid this, regularly collect feedback from providers in your network to understand which documentation or process changes would most improve providers’ experiences, with a special focus on prior authorization. Work with other local plans to standardize administrative processes as much as possible.

3. Regularly review your provider network’s true availability to streamline members’ experience scheduling care.

When seeking in-network care, many plan members must call each in-network provider individually to determine availability. Often, these providers are not taking new patients, have long wait times, have moved locations, or are no longer practicing. These seemingly large networks of providers who are not actually accessible are called “phantom” or “ghost” networks. Not only do they make it difficult for members to access care, but they also frustrate employer partners who are increasingly prioritizing behavioral health investments. To avoid this, plans should regularly collect and share information about provider’s geographic location, openness to virtual visits, current licensure status, wait list time, and capacity to take on new patients.

4. Expand coverage to include services provided by a broader range of behavioral health professionals, including expanded care team members like community health workers (CHWs) and peer specialists.

When deployed effectively, these team members can expand patient access by filling in care gaps and enabling other providers to work top-of-license.

a) Gather input from partner provider organizations to identify which additional roles are most important to begin supporting via reimbursement. Work with state and federal legislators to update coverage rules if necessary.

b) Work with provider partners and other plans to agree on the least-restrictive licensure and/or certification requirements possible for expanded care team members. Streamlining these requirements for reimbursement across different plans makes it easier for providers to hire and support these roles.

c) Offer competitive market rates to expanded care team members. Plans can reimburse these team members at lower rates compared to other behavioral health providers, making them a cost-effective option. However, plans must offer rates that are at least on par with the market in order to attract a high-quality, diverse workforce. Use federal benchmarks when possible as a starting place.

d) Help your provider partners hire and deploy members of the expanded care team. Use internal data to quantify the impact of these roles on members’ health outcomes and costs and share this information to help provider partners understand the benefits. Use your position as a liaison with many provider organizations to identify, share, and scale best practices across your provider network.

5. Build a diverse candidate pipeline to grow the behavioral health workforce.

Health plans should invest in building sustainable workforce pipelines with their partner organizations to provide great in-network access to behavioral health professionals. For more information on these strategies, see our publications Build a diverse and sustainable workforce pipeline and Build diversity, equity, and inclusion among your staff and leaders.

a) Partner with local high schools, colleges, and community organizations to encourage more students to enter the behavioral health care field. Consider funding and partnering with your provider organizations to create shadowing, apprenticeship, and internship opportunities.

b) Address non-clinical barriers that may prevent students from entering the behavioral health workforce. For example, consider launching a loan repayment program to make it more financially feasible for people to pursue clinical training. These programs can be structured to incentivize service in the same geographical area or network after they graduate. For more, see our case study How L.A. Care designed a provider loan repayment program.

What is the problem?

Clinical evidence is critical for health plans to determine coverage and institute quality standards. However, there has historically been less research on behavioral health care than in the physical health space, which has led to a limited understanding of the scientific/biological mechanisms behind behavioral health conditions. Behavioral health care also leverages a range of psychosocial interventions that can be difficult to measure, and improvement in behavioral health conditions can be harder to assess than other health conditions since metrics are often patient-reported. So, while many evidence-based behavioral health therapies exist, stakeholders define success in different ways. This leads to disagreement about what care is worth delivering and paying for.

What can health plans do?

Health plans should invest in building the clinical evidence base for behavioral health care to identify which interventions deliver the most effective and cost-efficient outcomes. Plans also have an opportunity to create consensus and standardization on how to measure recovery and quality care in a patient-centered, evidence-based way.

1. Partner with other health plans to mutually agree on a definition of quality care.

Many health plans use different metrics and standards to define quality behavioral health care. This makes it difficult for providers to deliver on the range of expectations across their plan partners. Plans have a unique opportunity to move the industry forward by aligning on standards for quality and compensating accordingly. Using claims data, health plans should consult providers, academic experts, government guidelines, and patients, and then collaborate with other health plans—including competitors—to do the following.

a) Come to consensus on foundations of high-quality care in areas with fewer defined care standards. While there are still many unknowns in behavioral health treatment, there is also a lot of evidence of what helps patients the most. Work with other plans to identify the most impactful elements of high-quality care, then incentivize providers to deliver on these elements. For example, ATLAS (Addiction Treatment Locator, Assessment, and Standards Platform) represents a collaborative effort between health insurers, providers, academic experts, and a nonprofit organization to clarify standards for high-quality addiction care and align payment practices with proven treatment for substance use disorders.

b) Diversify metrics used to measure progress, setting expectations that healing and recovery in behavioral health is not linear. Use longitudinal patient outcomes data alongside patient and clinician input to help leaders and team members understand realistic timelines and milestones for recovery and healing. Use outcomes metrics and patient-centered functional measures where possible to measure patient progress, rather than process metrics that measure volumes. Any definition of quality care in behavioral health must recognize that recovery is not linear. For example, returning to use is a normal part of the recovery process for patients in substance use treatment.

2. Analyze and share data stratified by REGAL (race, ethnicity, gender and sexual orientation, age, language) with partner organizations to understand the effectiveness of interventions for different populations.

Use this data to identify disparities across your member population, and regularly exchange data with provider partners to plan and measure the success of equity-focused interventions. Ultimately work toward embedding equity measures into value-based contracts with providers to incentivize the delivery of equitable care.

3. Invest in building the evidence base for innovative and nontraditional care models by partnering with providers and local community behavioral health organizations.

Many community and provider organizations offer promising innovative care models, including peer-led and community-based programs. But health plans are often hesitant to pay for these services without robust data on their impact, leaving providers to struggle to maintain funding to deliver these programs, much less evaluate them.

Consider providing funding and technical support to help provider and community partners implement and measure the impact of these programs to build the evidence base. Prioritize investing in models that meet the needs of your current member population, with a focus on models that support individuals who are low-income or have high acuity needs.

What is the problem?

Social inequities create adverse social determinants of health (SDOH), including food insecurity, unsafe physical environments, social isolation, and financial instability. These SDOHs lead to— and exacerbate—behavioral health conditions. Health plans increasingly recognize the need to address SDOH to improve’ health outcomes and reduce overall costs. But health plans that focus on addressing the root causes of the SDOH—including structural racism and intergenerational poverty—will ultimately be better positioned to improve health outcomes and cut costs.

What can health plans do?

Plans can bolster their provider partners’ efforts by helping finance SDOH related services.

1. Increase reimbursement rates and coverage for professionals who address members’ social needs, such as CHWs.

There are several existing types of behavioral health professionals and services that address the SDOH needs of members. See section 1, tactic 1 and section 2, tactic 4 for more details on how to expand reimbursement for these staff.

2. Encourage providers to use V-codes and Z-codes to get a better understanding of member complexity—ultimately working toward tying reimbursement to SDOH screening and services.

V-codes and Z-codes allow clinicians to document non-clinical issues affecting a member’s health, including homelessness, food insecurity, unemployment, relationship challenges, and social isolation. These codes can serve as valuable tools to help plans prioritize investment in non-clinical services and structure reimbursement arrangements to account for patient complexity. But these codes are currently underutilized because they’re not often tied to payment, meaning there’s no clear incentive for clinicians to use them. Educate providers on the value of documenting these codes and establish incentives when possible. Utilize data collected to shape your behavioral health strategy and population-specific care management programming.

3. Partner with community-based organizations focused on populations experiencing the SDOHs that most impact behavioral health outcomes.

a) Invest in school programs that enable early identification of and intervention for behavioral health conditions in children. Pay special attention to surfacing and preventing adverse childhood experiences (ACEs), which are linked to developing behavioral health conditions later in life. Read our case study on how BCBSND partnered local school district and health systems to provide school-based behavioral health care.

b) Partner with criminal justice-related organizations, jails, and police departments to improve behavioral health care for individuals involved with the criminal justice system and decrease unnecessary arrests related to behavioral health. Involvement with the justice system is increasingly recognized as a social determinant of health, and there is a strong link between incarceration and poor mental health status.

c) Connect in-need members with a range of housing services. Consider funding programs that connect at-risk members with housing and wraparound clinical and social support. Many programs do so by tapping into resources across housing agencies or nonprofits. For strategies for developing housing partnerships, see our research report How to close the housing gap through strategic partnerships.

What is the problem?

Societal discrimination against people with behavioral health conditions prevents many individuals from seeking care. And individuals from marginalized groups often face even greater stigma around accessing behavioral health care, exacerbating inequities in access and outcomes.

Because bias against people with behavioral health conditions is so ingrained in our society, it often influences the way health care organizations (including plans) interact with members. On a structural level, the organization may not be set up to effectively meet the needs of individuals with behavioral health conditions. On an individual level, some team members may not have sufficient knowledge about behavioral health conditions or may hold unconscious bias against people with behavioral health conditions. These structural and individual biases can lead to negative experiences, exacerbating members’ feelings of shame, isolation, and trauma, thus preventing them from interacting with the plan or seeking care in the future.

What can health plans do?

Though cultural and implicit stigma are complex problems, health plans can meaningfully address and prevent stigma by centering member perspectives, improving employees’ and community members’ understanding of behavioral health, and normalizing care.

1. Regularly collect and respond to input from individuals who have lived experience with behavioral health conditions.

Cultural stigma causes many individuals to (often unconsciously) view people with behavioral health conditions as less qualified to make decisions. But neglecting members’ input can leave negative consumer experiences unaddressed, harming trust and engagement. Health plans should intentionally prioritize member input to improve internal processes and inform service coverage decisions.

a) Embed mechanisms to gather input on members’ care experiences and interactions with the health plan. Use different channels, including email, text, phone, and in-person contact, to proactively reach a wide range of members. Ensure that feedback forums are accessible to individuals from different backgrounds (e.g., education level, language). In addition, proactively seek input from community members your organization is not currently serving to understand barriers to care and build trust.

b) Establish a protocol for implementing feedback and closing the feedback loop. After asking for feedback from individuals, make sure that it is recorded in a central location. Review feedback regularly and create time-bound plans to act on it. Follow up with individuals to let them know how their feedback is being used.

2. Provide training to all leaders and employees to reduce bias against people with behavioral health conditions.

Training should help staff unlearn any harmful beliefs they may hold against people with mental health conditions or substance use disorders and promote a culture of acceptance within the organization. Training should promote an accurate understanding of behavioral health conditions, including their causes and prevalence. This information can normalize behavioral health conditions and help people understand them as health conditions rather than personal weaknesses, as they are often portrayed in cultural narratives. Prioritize team members who work directly with members, like care managers and call center employees. Executive leadership should also participate in training to reduce biases that may manifest in strategic decisions about the behavioral health business.

3. Partner with schools and community organizations to increase community members’ understanding of behavioral health conditions and care.

Through widespread and accessible education, health plans can increase people’s understanding of behavioral health conditions and contextualize this information so it’s culturally relevant. There are two common models. The first is to deliver education directly to target consumer groups. For example, staff may go into schools to offer health education, or the organization may fund nonprofits that deliver community education. Prioritize partners that serve the population(s) currently experiencing the worst stigma—though all community members can experience stigma, research has shown that racial discrimination exacerbates it, meaning that communities of color are generally more at risk than their white counterparts.

The second common approach is the “train the trainer” model, which equips community members to raise awareness and promote better understanding of behavioral health needs. Consider trusted community members within your partner organizations, such as faith leaders, teachers, and barbers. For example, with The Confess Project, 1,000 barbers around the United States were trained to talk to Black male clients about mental health and help connect them to resources, like therapy.