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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
00;00;00;03 - 00;00;30;29
Alan Weil
Hello and welcome to “A Health Podyssey”. I'm your host Alan Weil. As we record this episode, Gallup just reported that almost one quarter of Americans say they visited a mental health professional in 2022, up from 13% in 2004. They also reported that one quarter of Americans describe their mental health as only fair or poor, the highest level they've ever seen.
00;00;31;02 - 00;00;58;23
Alan Weil
Meanwhile, the American Association of Medical Colleges has a report that says, quote, “A lack of available providers, inadequate insurance coverage, high out-of-pocket costs and fragmented care,” unquote, make access to mental health care difficult even for those with health insurance. So what do we know about access to psychiatric care for people with health insurance? That's the topic of today's episode of “A Health Podyssey”.
00;00;58;25 - 00;01;29;11
Alan Weil
I'm here with Jane Zhu, associate professor of medicine in the Division of General Medicine at Oregon Health and Science University. Dr. Zhu and coauthors published a paper in the July 2023 issue of Health Affairs assessing psychiatrists network breadth across Medicare Advantage, Medicaid Managed Care Plans and Affordable Care Act plans in 2019. They found network breadth for psychiatrists was notably narrower in Medicare Advantage markets than in those other markets.
00;01;29;14 - 00;01;35;10
Alan Weil
We'll discuss these findings in today's episode. Dr. Zhu, welcome to the program.
00;01;35;12 - 00;01;37;04
Jane Zhu
Thanks for having me on.
00;01;37;06 - 00;02;03;19
Alan Weil
This is really important work. We know that we have a large amount of unmet mental health needs in the country. When you focus on Medicare Advantage, I'm thinking seniors, people over 65. So let's start with just a little bit of context setting question. What do we know about the mental health needs of seniors and in particular, the degree to which those needs are or not being met?
00;02;03;21 - 00;02;34;25
Jane Zhu
Yeah, well, I mean, I think if you take a step back, the situation for seniors or older adults looks a lot like for other populations in the U.S. So we know that one in five Medicare beneficiaries has a mental health diagnosis. Many more have symptoms of anxiety and depression that go under or undiagnosed. And in particular, older men, especially in rural areas, have high risk of suicidal ideation that is often underrecognized.
00;02;34;27 - 00;03;02;20
Jane Zhu
As of 2021, there's estimates that fewer than half of all older adults with mental health conditions receive treatment. And for a lot of the reasons that you've already mentioned at the top, these access gaps have probably climbed as a result of the COVID pandemic. There were lots more people reporting symptoms of mental health conditions like anxiety and depression, a lot more treatment gaps.
00;03;02;22 - 00;03;13;27
Jane Zhu
So it is a problem. And I think as the US population ages, there's an increasingly larger need to address this issue amongst older adults.
00;03;13;29 - 00;03;35;04
Alan Weil
So most of our listeners are probably at least generally familiar with concepts like mental health parity. We think, oh, we have an insurance card, it helps us get to the doctor. If we have mental health needs, it should help us there too. Your paper focuses on sort of the narrowness or breadth of networks and that's a fairly technical measure as you define it.
00;03;35;04 - 00;03;46;26
Alan Weil
But maybe in a in a less technical way, you can explain to us what is the concept of network breadth and what do you mean when you say someone is facing a narrow network?
00;03;46;28 - 00;04;10;07
Jane Zhu
Sure. Yeah. So provider networks are really the sets of clinicians and facilities that are contracting with the health plan to deliver care to the plan's enrollees. And so in that way, I like to think of provider networks as a key link between coverage and access to care. It's really only relevant to managed care plans like those in Medicare Advantage.
00;04;10;10 - 00;04;36;06
Jane Zhu
Obviously, the private plans that work with Medicare and under a capitated model, managed care plans often have, you know, a constant tradeoff between access and cost of care. And one way in which managed care plans can exert influence over the costs of care, obviously, at the potential risk of reducing access, is to design what we call narrower or simply more restrictive networks.
00;04;36;08 - 00;04;57;25
Jane Zhu
And I'll say there's there's probably, you know, we really want to think about it from both the insurers perspective and from the provider's perspective. So from the insurers perspective, you can really imagine that by designing a narrower network, you might be able to direct patients to a specific set of providers who you know are going to be lower cost, higher quality.
00;04;57;27 - 00;05;44;01
Jane Zhu
And studies suggest that patients are often willing to tolerate a narrower network in exchange for lower premiums. So the consumers are not don't find this necessarily problematic, you know, when they sign up for plans. But then there are also provider-side reasons for narrower mental health networks. And I think we'd be remiss not to talk about those. You know, we know, for example, that there is a mental health provider crisis in terms of, you know, shortages, especially in rural areas, that we know that there is very historically very low psychiatrist acceptance of insurance, and that is seen across market.
00;05;44;02 - 00;06;05;27
Jane Zhu
So psychiatrists are more likely to take cash pay and to provide care out of network than to to participate in a plan. And so these for these multiple reasons, you know, when we think about narrow networks, we're really thinking about the concept of restriction in terms of who patients are able to see.
00;06;06;00 - 00;06;22;19
Alan Weil
So you made a really important point here is that it's easy to think of a narrow network as a bad thing. I don't have as many choices, but if it leads to directing people to higher quality providers, that could be a good thing. And if you're saving some money in your premium, it might be something you're willing to accept.
00;06;22;19 - 00;06;25;14
Alan Weil
You might not prefer it, but you'd prefer to have the money in your pocket.
00;06;25;21 - 00;06;53;14
Jane Zhu
Exactly. Everything in the health policy world is a matter of tradeoffs, as we know. But the problem is, you know, when the network is too narrow as to be inadequate, then that becomes a big problem. And, you know, enrollees just will not receive the coverage or the services they're promised when they sign up for a plan. And research actually suggests that narrower networks are associated with lower access to specialists, especially in behavioral health care and oncology care.
00;06;53;17 - 00;07;12;00
Jane Zhu
Studies show that narrow networks create these what we call hassle costs for health care. They lead to increase out of network care, increase out-of-pocket spending, treatment delays or forgone care. And that's particularly prevalent in mental health care specifically.
00;07;12;02 - 00;07;34;04
Alan Weil
So you can sort of think of this as a gradient where maybe full open access is very expensive and certain amount of narrowing is something you'd be willing to tolerate. But when you get to a certain point, it actually is a true barrier to access and you're not getting what you thought you were and you're not getting what you paid for just because of the narrowness. You studied
00;07;34;07 - 00;07;46;10
Alan Weil
psychiatrist participation in networks in a number of different markets. Tell us what you found about those network designs in Medicare Advantage and how that compared to the other markets you looked at.
00;07;46;13 - 00;08;17;25
Jane Zhu
Sure. So this was a Herculean effort by my coauthors, but we linked more than ten data sources to create a really comprehensive novel data set that will join sort of plans across markets and then their networks and the providers for the year 2019. So I'd like to highlight probably three main findings. The first is that we found psychiatrist networks to be narrower, much narrower than those for primary care and for other specialists across all markets.
00;08;17;25 - 00;08;46;03
Jane Zhu
So Medicare Advantage, Medicaid managed care, and the ACA Marketplace plans. The second finding is that psychiatrist networks in M.A., in Medicare Advantage specifically were far narrower than those in other markets. About two thirds of Medicare Advantage networks were narrow, which we defined in our study as including less than 25% of available psychiatrists in a given network service area.
00;08;46;06 - 00;09;15;22
Jane Zhu
And that was compared to about 40%, give or take, in Medicaid managed care and the ACA Marketplaces. And then finally, when we looked at the 2000 plus counties for which we had available data, we found that in over half of those counties there wasn't a single Medicare Advantage participating psychiatrist, not a single one. So, so very, very surprising in different dimensions.
00;09;15;24 - 00;09;42;02
Alan Weil
Yeah. So you're describing already in a context of limited access within these markets, you have even greater limitations. Medicare Advantage relative to the others. And just help me understand, you find counties where there's just literally no one. And yet the plan exists and the plan covers mental health benefits, but there's no one to go to, is that right?
00;09;42;05 - 00;10;22;04
Jane Zhu
Yeah. I mean, I think there are, yes. In so many words, there's no psychiatrist. So, I mean, I think one of the limitations, obviously, that we need to acknowledge here is that our study was not able to look at, for example, mental health nurse practitioners who are increasingly delivering mental health services. There are studies that show that, you know, as Medicare participation among psychiatrists continually falls over time, that acceptance amongst and psychiatric mental health nurse practitioners has actually remained fairly stable and that they're delivering an increasing proportion of those services.
00;10;22;04 - 00;10;47;26
Jane Zhu
So that is one potential aspect of care delivery that we're not able to see using our data. The other that I think is worth mentioning is that there are other studies that suggest that Medicare Advantage networks for primary care physicians tend to be quite broad. And so that is another group of providers that are increasingly delivering mental health services.
00;10;48;01 - 00;11;16;15
Jane Zhu
So it is possible that Medicare Advantage is essentially skipping over the psychiatrist population in favor of these other providers. But we're not really gaining any visibility into that question using our data alone. That being said, psychiatrists serve a very important purpose. They are the mental health specialists that sort of deliver services for advanced cases of mental health conditions.
00;11;16;21 - 00;11;46;16
Jane Zhu
They help to manage medication treatment. And yet if access to that group is completely limited, that also presents a problem. And as a primary care physician, I know this you know very well personally, I refer people out who I cannot personally manage as a primary care physician and they cannot, you know, I've personally experienced that they cannot get to those psychiatrists in a timely manner.
00;11;46;19 - 00;12;27;23
Alan Weil
Well, I want to talk to you about what we do about all of this and what the implications of these findings are. We’ll cover those topics after we take a short break. And we're back. I'm speaking with Dr. Jane Zhu about the narrowness of psychiatrist networks in Medicare Advantage plans relative to the other market study. Before the break, we got a sense of of some real limitations in these markets.
00;12;27;25 - 00;12;55;25
Alan Weil
Now, as you might imagine, not everyone was happy seeing the results of your paper. And I saw a comment from an organization working with the health plan saying that it's not really fair to compare access in Medicare Advantage to these other programs. You should compare it to traditional Medicare. How do you how do you respond to that criticism or comment?
00;12;55;28 - 00;13;25;04
Jane Zhu
I sort of you know, I appreciate the comment. I think that, you know, the key issue here that makes the comparison between Medicare Advantage and traditional Medicare not exactly apples to apples, is the fact that MA plans are managed care plans that use provider networks, whether intentionally or unintentionally, to direct access. In Medicare, in traditional Medicare, anybody can go to a provider who accepts Medicare.
00;13;25;04 - 00;14;07;05
Jane Zhu
So there's not the same sort of structure of of these provider networks. So it's not exactly a comparison that we can use well. That being said, even if you were to sort of take a step back and look at the situation for mental health service delivery in Medicare and traditional Medicare, we have reasons to be concerned. And that includes for reasons I already discussed, really low rates of Medicare acceptance among psychiatrists, known treatment gaps and service delays in the Medicare population, self-reported challenges and access to care.
00;14;07;07 - 00;14;39;14
Jane Zhu
In fact, the Commonwealth Foundation in 2021, I believe, put out a survey where they compared, or they they surveyed Medicare enrollees in the US around their mental health service concerns, and they compare that to another ten high income countries. And they found that in the US in particular, Medicare enrollees were more likely to report delays in treatment, cost barriers and the like for mental health services in particular.
00;14;39;14 - 00;14;51;22
Jane Zhu
So I don't think that necessarily comparing to traditional Medicare paints a rosier picture. It just paints the picture that this is a problem across the board.
00;14;51;24 - 00;15;10;16
Alan Weil
Right. It seems like sort of both of these could be true. It could be true that everyone has difficulty obtaining access to mental health services. It could also be true that MA plans compare to other managed care plans have narrower networks, and that's something we ought to wonder about in a world where there's supposed to be parity.
00;15;10;19 - 00;15;43;29
Jane Zhu
Exactly. And that's I think that's the biggest concern for me is that this has been yet not yet reported that MA networks are that much narrower than in Medicaid managed care and in the ACA plans that also use provider networks. So there's something else going on. Our our our findings suggest in Medicare Advantage in particular, and what exactly that is, whether it's purposeful design by insurers or, you know, provider acceptance of of insurance or a combination of those factors is yet unclear.
00;15;43;29 - 00;15;51;08
Jane Zhu
But we've definitely carved out that this is a big and previously unrecognized issue.
00;15;51;15 - 00;16;11;10
Alan Weil
Well, I love that that's how you pivoted the conversation, because I feel like that's one of the roles we often play at Health Affairs is you find something that you don't know the first time you find it, why, but you know that it's important. And so this is important. And what I'm struck by is we have network adequacy standards in all of these programs.
00;16;11;11 - 00;16;31;03
Alan Weil
You can't have a managed care plan out there that's regulated by the federal government or the states that doesn't meet certain kinds of network adequacy standards. So how do we think about the legal and regulatory framework that's applied to these programs relative to the findings that you report?
00;16;31;05 - 00;17;05;23
Jane Zhu
You know, just take a step back and we really talk about network adequacy standards a lot, but they're really underdeveloped. So the you know, as we talk about network adequacy, adequate provider networks is something that's very easy to conceptualize, but it's very, very challenging to implement and operationalize. And we've seen that in in policy. And it's it's underdeveloped, but it is one way in which regulators can curb the most undesirable consequences and really safeguard access to care when narrow networks are too narrow.
00;17;05;24 - 00;17;35;03
Jane Zhu
So there's a few different reasons I think that their efficacy has been really limited. There's imprecise definitions and they've been inconsistently operationalized. Traditionally they've been sort of defined very broadly. But interestingly enough, in Medicare Advantage, network adequacy standards actually have have historically been amongst the most robust. There's actually 26 different categories of provider types, including mental health practitioners.
00;17;35;06 - 00;18;07;13
Jane Zhu
And there's there's minimum travel and distance standards that are set, for example. And yet our findings show that clearly these these network adequacy standards have not really done very much to improve the size of these networks. And so, you know, I think for these reasons, there needs to be just a lot more attention paid to what is a meaningful standard for network adequacy.
00;18;07;15 - 00;18;35;00
Jane Zhu
I think that there is more attention now being paid to rather than time and distance standards, thinking about what the patient is actually facing in the end. So having more patient facing measures, how much time are patients waiting? What are their reported barriers to care? Is there, you know, provider churn that's causing them to lose access? Those are measures that CMS has started, you know, starting to look at.
00;18;35;02 - 00;18;58;18
Jane Zhu
And so, you know, there's there's a number of policy directions that we're we're moving towards and I think redefining what network adequacy means in the context of knowing that current regulations are not having any correlation with actual patient access is one of the motivations for doing so.
00;18;58;21 - 00;19;23;21
Alan Weil
Yeah, I'm really looking forward to digging deeper into this. You know, when I think of Medicaid, the common complaint is that you have a card, but you can't find a provider, and yet your findings suggest that the networks are much less narrow in Medicaid managed care than in Medicare, and in Medicare Advantage there's often a sense that, you know, the plans are making a lot of money on this product.
00;19;23;21 - 00;19;37;02
Alan Weil
And so if they needed to increase access, there's the money to do so. So the the the difference between those two markets seems particularly striking to me. Did that come out to you as well?
00;19;37;04 - 00;20;12;17
Jane Zhu
Yes. Yeah, definitely. I mean, the in Medicaid managed care, you know, Medicaid is one of the single largest payers for mental health services in the country. And so for that reason alone, it's received a lot of policy and academic research attention. On the policy standpoint, there's new managed care proposed rules that CMS has has proposed that actually improves the concept and operationalization of network adequacy standards.
00;20;12;17 - 00;20;48;15
Jane Zhu
So, you know, cleaning up provider directories and implementing timely access standards, having secret shopper audits, for example. So there's been a lot of attention directed to networks in Medicaid managed care across the board. But definitely I was surprised, you know, about our findings comparing these markets because less attention has been paid to mental health services and Medicare Advantage, despite obviously these these differences in network size.
00;20;48;17 - 00;21;10;09
Alan Weil
And, you know, I can't help but wonder if there is this a role that stigma plays here. When you think about how MA plans and Part D plans are marketed, we talk a lot about the prescription drugs people take. We we ask people to think about what specialists they see and what care they need. But there really isn't a lot of attention paid to the mental health needs of elders.
00;21;10;12 - 00;21;34;28
Alan Weil
As we ask people to evaluate what plan is the best choice for them. And so the notion that we've sort of segregated out in the decision making process how to pick a plan, mental health needs might mean that that plans just don't feel like they have to pay as much attention to this because they're not getting as much questioning or probing from their potential enrollees.
00;21;35;01 - 00;22;09;17
Jane Zhu
Yeah, I think that's right. That's right. I mean, I think, you know what we, at least this is not my focus of study, but what we don't fully understand is the degree to which stigma and underreporting of mental health systems affects the care seeking behaviors of older adults. So it may be that, you know, when you look at population health management from the plan perspective, you're not seeing that mental health services is what's driving the enrollment or what's driving the decision making, the health care decision making for older adults.
00;22;09;23 - 00;22;37;25
Jane Zhu
And so less attention is paid to designing these networks. That being said, it is totally possible that health plans are seeing that older adults are really favoring their primary care physicians for all of these needs. And therefore, there's not as much interest in going to a psychiatrist or mental health specialist on the part of this population. Whether or not that's true, it's not clear, but there's certainly need for study.
00;22;37;27 - 00;23;01;21
Jane Zhu
The other thing that I would say is, you know, when we think about provider networks and where we're going with mental health delivery, it's also important to think about these new modalities of care, which we haven't yet discussed. Telehealth, for example, has been, you know, in other studies that we our team has produced as well. Telehealth has been basically very prevalent for the delivery of mental health services.
00;23;01;29 - 00;23;33;07
Jane Zhu
And yet we don't know, for example, whether seniors and older adults are as accepting of telehealth as a modality, whether it's supplementary or complementary to the types of services they're already receiving. And whether this is necessarily a a lever that can be used to increase the size of these mental health networks, for example, in Medicare Advantage, given that there are other issues like provider shortages going on.
00;23;33;14 - 00;23;44;17
Alan Weil
Well, Dr. Zhu, thank you so much for sharing this work with us, for setting the stage for future analysis and for being my guest today on “A Health Podyssey”.
00;23;44;20 - 00;23;48;11
Jane Zhu
Thanks so much for having me.
00;23;48;13 - 00;23;52;05
Alan Weil
Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend
00;23;52;06 - 00;23;53;15
Alan Weil
about “A Health Podyssey”.