Report: Insurance payment differences for mental vs. physical health is highest in N.H.

Monitor staff
Published: 12/4/2017 12:08:57 AM

Insurance payments for office visits related to mental health procedures are often lower than those related to physical health procedures, and a national study says that in some cases the discrepancy is bigger in New Hampshire than in any other state.

“The number is probably a little fuzzy. If you use a different approach you’d probably get a little different number ... but it agrees with what we’ve found,” said Tyler Brannen, health care policy analyst with the New Hampshire Insurance Department, which has found similar discrepancies regarding Medicare payments. “It’s good to have more evidence: Yeah, somebody else says so, too.”

The analysis released Friday by Milliman, an actuarial and research firm based in Seattle, fits into state efforts to establish parity between insurance coverage for mental health and substance abuse treatment on the one hand and general services on the other.

In New Hampshire, the group said, the difference was particularly stark. Under PPO medical plans within network, for example, primary care reimbursement was 69 percent higher than reimbursement for behavioral health in New Hampshire in 2015.

That was the highest discrepancy of any state, although the difference in payments was large almost everywhere. In Massachusetts, for example, similar reimbursement was 54 percent higher for primary care than for behavioral health; in Maine, it was 55 percent higher; in Vermont, 57 percent.

“This is a really high priority for us to look at,” said Jennifer Patterson, health policy legal counsel for the state Insurance Department. “The law requires they be covered on par with other medical/surgical services – it doesn’t say they have to pay the same, but it says the process by which payments are determined must be the same.”

It’s not easy, however, to determine how to fairly compare disparate procedures, such as treating chronic diabetes versus treating chronic depression.

“How do you make the comparison? That’s the kind of question that we’re asking,” Brannen said.

The Insurance Department has hired consultants to evaluate private insurance carriers’ compliance with parity laws in 2016 and 2017, examining what are known as nonquantitative treatment limits – “nonquantitative” meaning they may not have a straightforward number attached to them, such as a dollar amount.

The Milliman report says that states and insurance departments need to also consider such things as “medical management standards, prescription drug formulary design, step therapy protocols ... and restrictions based on geography, facility type, provider specialty or similar criteria.”

“It is a real challenge,” Patterson said.

The Milliman study looked at 42 million insurance claims over three years in all 50 states for various medical practices. It found that similar procedures in what is known as behavioral health, which includes mental illness, were less than for other medical services.

“I think this reflects long-standing differences,” said Ken Norton, executive director of the New Hampshire chapter of National Alliance on Mental Illness. “Prior to the Affordable Care Act, there really were discriminatory practices – it was okay to treat it differently in terms of payment, lifetime caps, limit number of visits – that really prevented people with mental illness from getting appropriate care.”

NAMI released a report of its own Friday, titled “The Doctor is Out,” detailing what it said are discrepancies in access to mental health care across the country.

While it may be hard to sympathize with people who often have six-figure incomes, the difference in reimbursement can affect mental health care by making physicians less likely to enter the field, thus making it tougher for patients to get help.

“People are not getting timely access to mental health care. It is extremely difficult to get access to a psychiatrist; it’s extremely difficult to recruit psychiatrists,” Norton said. “If providers are being paid less for psychiatry, then they don’t have the resources to pay salaries to recruit and retain psychiatrists.”

“If Doctor A is graduating with hundreds of thousands in student loans and is a surgeon, and Dr. B is graduating with the same amount of loans and is a psychiatrist – and the salary might be, say, $250,000 (for the surgeon) versus $175,000 – then why would they want to go into psychiatry?” Norton said.

(David Brooks can be reached at 369-3313 or or on Twitter @GraniteGeek.)

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