Behavioral health — counseling, mental health care, and care for substance use issues — is one of the basic benefits associated with health insurance and healthcare delivery. The COVID-19 pandemic has reminded us of the gross inadequacy of current behavioral health to deliver high quality care to most Americans. The past 30 years of health care delivery have seen few innovations and changes in delivery for behavioral health. We need rapid investment if we are to mitigate the negative impact of COVID-19 on our collective and individual mental health needs. Innovations in delivery and access developed during the pandemic won’t last if we don’t consider how these services are provided and paid for.
Behavioral health and actuarial value
Health insurance plan benefit design may appear to be a mystical science, but it follows a precisely defined actuarial process. Health benefits include inpatient and outpatient hospital services, emergency department services, and pharmaceuticals, as well as principle services of primary care. How each service is “valued” in this process directly influences the time and effort spent to develop those portions of the final plan benefits chosen by health insurance companies.
Health insurance companies price their plans based on the accumulated and expected average costs for all the various benefits in the plan: ambulatory care, hospital, pharmacy, etc. The actuarial value (AV) is defined as the average percent of an individual’s health care costs that are paid for by insurance.
The Affordable Care Act introduced tiers [PDF] that represent roughly 60, 70, 80, and 90% AV. That is, 60% AV means the insurance pays, on average, 60% of an individual’s healthcare costs, while 90% AV is more expensive, but covers 90% of healthcare costs. High-cost items like hospitalization, expensive pharmaceuticals, and devices drive much of the cost of health insurance.
Benefits like annual physicals, screening, and outpatient therapy, while common, are orders of magnitude less costly. They do not add much to the overall cost of an insurance plan. For example, changing a primary care co-pay from $25 per visit to $0 will only change the AV of an insurance plan by less than 1%. The AV matters a lot as we consider ways to expand access, integration, and innovation in mental health and addiction services.
COVID-19 highlights inadequate access
The COVID-19 pandemic has shed a bright light on the inadequacy of health services in America. More people are suffering pandemic related mental, emotional, and other health problems. And care may be more difficult to access. Telehealth delivery of mental health care may improve access, but will payment for telehealth continue past COVID-19 emergency declarations? The AV assigned to such services may shed some light on this question.
Actuarial value and innovation
Mental health and substance use treatment are considered essential health benefits in ACA-compliant plans. And many non-ACA plans also include these services in their benefits. However, the AV of behavioral health is so low that no one really focuses much energy on this part of plan design. Since behavioral health does not appear to have much impact on the AV of a health plan, there is not much incentive to develop innovative models for behavioral health within the insurance industry. Why innovate on a benefit with no apparent financial upside? (This is true with primary care as well.)
Very little variation exists in behavioral health coverage, integration, and delivery between the numerous plans offered by an insurance company. Not much has changed over the past 25 years. Even self-insured plans (plans for large businesses that provide their own health insurance) don’t have much innovation in how they deliver behavioral health services. It is particularly disappointing that these self-funded plans lack innovation, as they have the potential to provide innovative care to their employees to maximize access to and benefit from behavioral health services. Alas, there is not much variation. Employers, large and small, often just package their behavioral health from the “off the rack” offerings of the third party or plan administrator. These cookie-cutter benefit designs can unintentionally lead to unbalanced healthcare access for patients.
While there has not been much innovation in insurance plan benefit design, a number of attempts at improving access to and quality of behavioral health services have emerged over the past half-century. Payment reform, employee assistance programs, integrated care, and new web-based applications have begun to offer alternatives to standard managed or private psychology and psychiatric practice.
Parity is not always equal
Parity between behavioral health and medical care has been a goal for many healthcare providers and advocacy groups to increase access to valuable services. But parity [PDF] has not always promoted an equitable and positive outcome. For example, the move to co-insurance payments for BH visits is in parity with medical care visits, but likely has a disproportionate negative impact on access. A 40% co-payment for a broken bone may seem like no big deal, but a 40% co-payment for 6 outpatient visits to a therapist may be a deterrent. When calculating the actuarial value of behavioral health, parity in a spreadsheet is not parity in practice.
Employee Assistance and online programs
Employers sometimes offer services through Employee Assistance Programs (EAPs). EAPs offer a range of programs for a low per-employee-per-month fee: grief counseling, professional coaching, wellness/nutrition, stress counseling, etc. Offered in concert with an EAP or as standalone benefits, there are a growing number of niche behavioral health services that offer in-home, online programs for depression, anxiety, and substance misuse.
These behavioral health “apps” are totally outside the usual care models and health services evaluation methods. They will not be in claims data nor electronic health records. There is little regulation or external evaluation. And there are dozens, if not hundreds, of third party, for-profit, vendors pitching their services to employers and consumers. Rigorous studies of EAPs and online behavioral health apps would help us assess their quality, cost, access, and value. Validated analyses of these services will naturally generate further exploration, evaluation, and innovation in behavioral health interventions.
Integrated primary care and behavioral health
Integrating behavioral health into primary care makes sense [PDF]. Primary care is where most of the people get most of their care most of the time. And many primary care clinicians already provide basic mental, emotional, and behavioral health services, including prescriptions, brief counseling, and referral. Co-locating a behavioral health clinician in a primary care practice could increase access, decrease stigma, and create a culture where medical and behavioral health are really part of the same health care model and delivery system.
However, integrated primary care and behavioral health is just a delivery model, not yet fully supported by payers. While a successful clinical innovation, integrated models have not resulted in adequate insurance payment. The AV of integrated primary care and behavioral health has yet to drive innovative plan redesigns.
Time for behavioral health innovation
It is time to consider how to build innovation into our behavioral health delivery and payment models:
- How do we increase access to behavioral health?
- What are the best models for delivering care?
- Is integrated primary care and behavioral health the best model?
- How do EAPs deliver high quality behavioral health care?
- Are online behavioral health apps adequate for patients suffering common mental health problems?
- How do we use payment to drive innovation?
- What creative ways can we invent to increase access to behavioral health care in a host of venues, multiple delivery models, and paid for by numerous funders?
While creativity is absolutely necessary to stimulate innovation and foster improved outcomes, we also need concurrent efforts focused on access to care.
Time to expand access to behavioral health
As a start, ACA-compliant plans should expand coverage for mental health, direct contracting with more providers, and integrated primary care and behavioral health. Consider how to engage innovators in delivering behavioral health. Despite a low AV, the overall financial benefit of these services is clear. The return on investment [PDF] for behavioral health is estimated at around $3-$7 per dollar spent.
More than that, the benefit to human life is immense. If we spend more on mental, emotional, and behavioral health care during COVID-19, we may be able to reverse the troubling increase in deaths of despair. Increased behavioral health spending will decrease suffering. The moment is now to expand behavioral health innovation, spending, and access.
Jack Westfall