Mental-health care suffers shortages

The Affordable Care Act should make it easier for people to get the mental-health services they need, but a lack of providers willing to accept commercial insurance and a shortage of mental-health professionals is making it hard to achieve parity when it comes to mental-health benefits.

The Affordable Care Act requires that large group health plans offer both physical and behavioral health options to employees, said Michael Lott-Manier, assistant director of public policy and strategic initiatives for Mental Health America of Colorado, based in Denver. The ACA also requires that mental-health services be offered at the same level as what physical health benefits are offered. There must be parity.

“For mental health, parity is primarily around provision of services,” said Tom Base, chief business development officer for Mental Health Partners in Boulder. “Back in the old days, they would say you would be limited to six therapy sessions. They can no longer do that. It has to be on par with how they pay for physical health services, and they are not going to cut you off from seeing your cardiologist.”

Base is happy that mental-health and substance-abuse issues finally are being recognized as part of what makes up a whole-person health-care plan, but he is upset that there is no parity around payment.

Reimbursement is terrible for people in the exchanges and people who have commercial insurance for the first time, he said. “It is much worse than even Medicare.”

Providers have to ask commercial insurance plans for one and a half to two times what Medicare is paying to make back 75 percent of what Medicare pays out for mental-health benefits, he said. That is scaring medical professionals out of the mental-health field, he said.

“They call it parity. Commercial insurance pays for therapy and medication management. We provide other services they won’t cover, so this is why you will see Mental Health Partners — which is a very large organization with a very diverse revenue stream and huge economies of scale — accept commercial insurance. We think it is the right thing to do. We may break even on it if we are very lucky and do everything right,” he said. “For some small clinics or individual providers, there is no way they can take on the administrative burden for this cost.”

Colorado began requiring large group health plans to offer coverage for six mental-health issues, including depression, anxiety, post-traumatic stress disorder and alcoholism, in 2007, Lott-Manier said.

Colorado was the leader in the United States in determining what commercial plans should have to cover to qualify as a real health plan.

The ACA requires that all new plans include 10 essential health benefits, including behavioral health and substance-abuse treatment.

“In terms of policy, that is tremendous progress,” he said. “It is the implementation where it starts to break down.”

Colorado would like to see 80 percent of primary-care practices in the private sector integrating behavioral-health, mental-health and substance-abuse treatment by 2019.

Larry Pottorff, executive director of North Range Behavioral Health in Greeley, said his organization has had some hiccups around dealing with commercial insurance and payments but for the most part, he believes the Affordable Care Act has been good for people who need behavioral-health services.

“The Affordable Care Act strengthened behavioral-health providers’ ability to bill for those services,” he said. The biggest challenge facing North Range Behavioral Health has been finding licensed staff members.

One of the requirements of accepting commercial insurance for these types of services is that they have to be offered by licensed providers.

“The challenge for us and other medical health centers is there are not enough to go around right now,” Pottorff said. “Some of that is attributable to the fact there is probably more funding available in some areas. It made us really need to recruit more folks in that category. All-in-all, things are going fairly well.”

Base agreed, saying that it is nearly impossible to make an appointment with a psychiatrist or psychologist these days. If you are lucky enough to find a provider, you will be even luckier if they accept your insurance.

North Range traditionally has been publicly funded, focusing on Medicaid patients, because Colorado has such a robust mental-health program for lower-income people. Pottorff believes that in the next five to 10 years, the “funding mechanisms of being publicly funded are going to be changed.”

Included with that will be different payment models, including a movement toward integrated care, in which people can visit their primary-care providers and get mental-health or substance-abuse treatment in the same location. Weld County already is doing some of this.

North Range has behavioral-health staff embedded in primary-care health clinics to meet that need.

On an up note, Colorado is one of the states that expanded Medicaid, so “we are very fortunate in Colorado; our mental-health benefit is very rich,” Base said. “They provide comprehensive services, and they pay fairly. It is a win for the provider, patient and state. That’s great, but the only issue is that there is a huge increase in demand without having providers and not being able to pay them enough makes it challenging to be responsive and accessible.”

The patients who are getting short shrift are the middle class — people who make between $25,000 and $75,000 a year. Low-income patients have great benefits, and the rich can pay out of pocket for any expenses they incur, but the middle class is stuck relying on subpar benefits.

Colorado health insurers are attempting to fix that with Accountable Care Organizations, which help physicians provide coordinated health care. Centura Health is working with UnitedHealthcare along the Front Range to cut health-care costs and improve patient health at the same time. The idea is to shift the state’s health-care system from one based on volume of care to one that rewards quality and value.

Stigma is another problem in Colorado. People feel shame about having to seek out mental-health care or speak about their mental-health experiences in public, Lott-Manier said.

“We wait until there is a problem or crisis to take action,” he said. “If we treated mental health the same way we treat cancer, we wouldn’t wait until stage four to do anything about it. Our national push is before stage four.”

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