Narrow Networks For Mental Health Providers: Trading Cost For Access

In 2016, 45 percent of health insurance plans purchased on Affordable Care Act (ACA) Marketplaces were considered narrow network plans. Narrow network plans are defined as those that cover less than 25 percent of physicians in a specific geographic area. Amid rising health care costs, this is one of several strategies insurers use to offer competitive premiums in ACA Marketplaces. By limiting the number and type of providers covered, narrow networks allow insurers to leverage their buying power in the market. These plans pay providers at lower rates and use those savings to offer lower premiums to consumers. However, if networks are too narrow, consumers may find it difficult to see a provider and be pushed to seek out-of-network care, resulting in significant out-of-pocket costs. For mental health services where there is already provider shortage, narrow networks could worsen existing issues with patients’ access to care.

In a 2017 paper, Zhu, Zhang, and Polsky tried to determine whether ACA Marketplace plans had adequate networks for mental health care. The authors asked, “Are networks for mental health providers narrower than those for other specialties, specifically primary care?” The authors combined national databases of health plans and in-network providers to determine the basic characteristics of each health plan, provider specialties, and providers covered by each health plan in 2016. They estimated network size by comparing the number of providers included in each network with the total number of providers in each state.

The data showed that mental health providers were significantly less likely than primary care providers to be covered by any Marketplace plan (21.4 percent vs 45.6 percent). Stratifying by provider type (physician vs. non-physician), the researchers found that non-physician providers had lower participation in Marketplace plans compared to physicians across both specialties. This is important because non-physician mental health providers such as counselors, therapists, and behavioral health specialists often work in tandem with psychiatrists to provide services.

These differences in network participation between groups of providers may have led to differences in the size of networks offered by health plans. The authors found that networks for mental health providers were more likely to be narrow compared to networks for primary care providers (57.4 percent vs 38.7 percent) with the difference primarily driven by low provider participation. However, did health plans with narrow networks for mental health providers also have narrow networks for primary care providers? The data showed that this was not the case. There was a low correlation rate in the size of networks between these groups of providers.

Zhu et al. offered two explanations for these findings. First, high demand for mental health services and a relatively low number of providers resulted in a shortage of mental health providers. Second, low reimbursement for time-intensive mental health services like counseling and psychotherapy incentivized providers to opt out of participating in health plans entirely, relying on patients to pay upfront for services.

Thus, the authors argued that interventions aimed at improving access to mental health care must address provider participation in health plans. On the provider side, they argued that by increasing reimbursement rates and reducing the administrative burden of billing, insurers can incentivize providers to enter networks. Addressing workforce shortages by recruiting new providers and shifting services typically provided by psychiatrists to non-physician providers could also allow the system to care for more patients. On the consumer side, it can be difficult to assess the adequacy of the network when selecting health plans. There have been documented issues around appointment availability for new patients and the reliability of provider lists. Because of this, individuals may unknowingly trade provider choice for lower premiums. The authors endorsed state and federal regulations that encourage network transparency to help individuals make more informed decisions. With more Americans enrolled in narrow network plans, policymakers must develop effective strategies that ensure networks appropriately balance cost and access to care.

Article source: Zhu, J. M., Zhang, Y., & Polsky, D. “Networks In ACA Marketplaces Are Narrower For Mental Health Care Than For Primary Care.” Health Affairs 36(9), (2017): 1624–1631.

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