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Invited Commentary
Health Policy
October 8, 2020

Going Beyond Cost-Sharing Parity to Improve Behavioral Health Access

Author Affiliations
  • 1Department of Medicine, The University of Pennsylvania Perelman School of Medicine, Philadelphia
  • 2Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
  • 3Department of Psychiatry, The University of Pennsylvania Perelman School of Medicine, Philadelphia
  • 4Department of Medicine, University of Washington School of Medicine, Seattle
  • 5Value and Systems Science Lab, Seattle, Washington
JAMA Netw Open. 2020;3(10):e2020232. doi:10.1001/jamanetworkopen.2020.20232

Concerted steps are needed to meet the needs of US individuals with serious mental illness (SMI), such as schizophrenia, bipolar disorder, and major depressive disorder. These conditions challenge people’s ability to work and care for themselves, but nearly one-half of the 11.4 million adults in the US with SMI in 2018 perceived that their behavioral health needs were unmet and more than one-third did not receive any care.1

Through the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008, the Centers for Medicare & Medicaid Services sought to increase the use of behavioral health services among fee-for-service Medicare beneficiaries by creating out-of-pocket cost-sharing parity between those services and other medical and surgical services. Under MIPPA, cost-sharing for behavioral health services was gradually reduced from 50% in 2009 down to 20% in 2014.2

The study by Fung and colleagues2 evaluated the association between these reductions with behavioral health use and total spending. They analyzed these outcomes among fee-for-service Medicare beneficiaries with SMI who were low-income and experienced MIPPA-driven reductions in cost-sharing (study group), comparing them with low-income beneficiaries eligible for full cost-sharing subsidies and therefore not exposed to MIPPA cost-sharing reductions (free care group). Out-of-pocket costs decreased among the study group, but there were no differential changes in use or total spending between the study and free care groups. In both groups, the percentage of beneficiaries with an annual psychiatrist visit decreased while annual visits to other practitioner types (eg, psychologists, primary care practitioners, or social workers) for behavioral health care increased.

Fung and colleagues2 should be commended for generating findings that highlight the challenges facing policy makers, practitioners, payers, and patients in improving behavioral health access. The study also highlights several important questions that should be addressed to inform future policies.

First, future work should consider additional cost-sharing reductions. Although cost-sharing could be an effective instrument for improving access, specific reductions from 50% to 20%—which corresponded to an observed average reduction in adjusted annual out-of-pocket costs from $133 to $65—may be insufficient for that purpose. The remaining absolute dollar amount matters and may still be prohibitive for low-income patients with SMI who must balance health care with food, housing, and other essential needs. Greater cost-sharing reductions may be needed for low-income patients who are not already receiving free care before access is improved..

Second, future work should quantify specific needs among individuals with different types of SMI and evaluate nonfinancial barriers to care. Even with meaningful cost-sharing reductions, patients with SMI may face other barriers to behavioral health services. Practioner supply may pose a challenge, as the number and distribution of available behavioral health practitioners fall short of need.1 Nearly one-half of psychiatrists do not accept Medicare or network commercial insurance payment, and more than one-half of them do not accept Medicaid.3 More broadly, behavioral health practitioners, both psychiatrists and nonpsychiatrists, are disproportionately concentrated in urban areas compared with rural areas.4 Policy makers must undertake efforts to train, place, resource, and incentivize more behavioral health practitioners to care for patients in areas of need.

On the demand side, we should identify opportunities to proactively engage and identify needs among individuals with SMI. By affecting insight, motivation, and decision-making, SMI conditions can complicate patients’ understanding of their own health needs and efforts by health care practitioners to identify them. These debilitating effects can then create pent-up demand for behavioral health care. Quantifying specific health needs among individuals with different SMI conditions can complement efforts to reduce stigma, discrimination, and neglect that represent potential barriers to care.

Although many of these changes require our society to recognize and accept the importance of behavioral health care and the multiple barriers preventing those with SMI from accessing care, policy makers can speed progress by using new care delivery approaches. For example, telemedicine can overcome nonfinancial barriers by helping to deliver care to patients at home. Peer support and affinity group strategies have been successful in substance use treatment and could be used among patients with SMI to improve their motivation to access care. Leaders could also leverage behavioral incentives. For instance, employers commonly fund wellness programs for medical care, incentivizing employees to check their blood pressure, cholesterol levels, and blood glucose levels annually via so-called “know your numbers” campaigns. Similar programs could be created for behavioral health care and implemented widely to undercut stigma.

Third, future work should elucidate use patterns among low-income patients with SMI and how use is associated with quality and cost outcomes. The findings by Fung and colleagues2 suggest that across both study and free care groups, visits to mental health practitioners decreased while visits to other practitioners increased—a pattern that does not necessarily align with the notion that cost barriers are creating pent-up behavioral health demand. Part of the reason may be associated with evaluating claims data and methods: Fung and colleagues2 used diagnosis codes rather than visit types or practitioner specialties to determine behavioral health vs other visits. More granular data are needed to evaluate use patterns and assess how they are associated with not only cost outcomes, but also important measures of quality and experience. More work is also needed to understand how individuals with different SMI use care at different stages of disease and treatment, and what observed patterns mean for their health.

Such insights could guide policy efforts to promote better care delivery approaches. For instance, integrated care models—ones that incorporate behavioral and physical health services in the same setting and coordinate patient care across a range of physician and nonphysician team members (eg, care managers, social workers, therapists)—can improve behavioral and physical health outcomes while lowering total cost of care.5 If the use of integrated care is associated with better outcomes among individuals with SMI, policy makers could prioritize testing and expansion of these care delivery models and complementary measures, such as refining billing codes,6 to support implementation.

Ultimately, the study by Fung and colleagues2 underscores how no single effort—in this case, relative cost-sharing reductions under MIPPA—may be sufficient to truly improve behavioral health access. However, work in the aforementioned 3 areas can build on lessons from cost-sharing parity efforts by identifying the next and best steps for improving behavioral health access.

Today’s crises—coronavirus disease 2019, rising unemployment, widening income inequality, and persistent structural racism—only serve to highlight the urgent need for progress. Reducing out-of-pocket costs has been a step in the right direction, but to address the ongoing significant mental health crisis facing our country, we need to test and implement effective policies and strategies that go beyond cost-sharing parity.

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Article Information

Published: October 8, 2020. doi:10.1001/jamanetworkopen.2020.20232

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Chaiyachati KH et al. JAMA Network Open.

Corresponding Author: Krisda H. Chaiyachati, MD, MPH, MSHP, Department of Medicine, The University of Pennsylvania Perelman School of Medicine, 423 Guardian Dr, Blockley Hall, Rm 1313, Philadelphia, PA 19104 (krisda.chaiyachati@pennmedicine.upenn.edu).

Conflict of Interest Disclosures: Dr Chaiyachati reported being supported in part by grant K12-HS026372-01 from the Agency for Healthcare Research and Quality. Dr Livesey reported receiving consultancy fees from UnitedHealth Group outside of the submitted work. Dr Liao reported receiving personal fees from Kaiser Permanente Washington Health Research Institute outside of the submitted work.

Substance Abuse and Mental Health Services Administration (SAMHSA). Key substance use and mental health indicators in the United States: results from the 2018 National Survey on Drug Use and Health. Published 2019. Accessed August 1, 2020. https://www.samhsa.gov/data/report/2018-nsduh-annual-national-report
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