Out-of-Network Care More Common in Substance Use, Mental Disorder Treatment

Patients with private insurance who saw behavioral health professionals went out-of-network for their care more often than their peers who received care from medical or surgical health professionals, according to a study published today in Psychiatric Services.

Tami L. Mark, Ph.D., of RTI International, and colleagues analyzed deidentified health insurance claims data from 22.8 million individuals in the Merative MarketScan Commercial Database who had private insurance in 2021. They compared the percentage of out-of-network claims for behavioral health providers with the percentage of out-of-network claims for medical and surgical providers across four settings: inpatient facilities, subacute inpatient facilities, outpatient facilities, and office visits to independent practitioners.

Across all settings, patients with substance use disorder (SUD) were most likely to go out-of-network for care, followed by those with a mental disorder and those who received medical or surgical care. For example, the percentages of out-of-network encounters in acute inpatient facilities such as hospitals were 18.1% for SUD, 4.3% for mental disorders, and 1.5% for medical or surgical treatments. The percentages of out-of-network encounters in subacute inpatient facilities such as residential settings were 35.9% for SUD, 31.7% for mental disorders, and 1.7% for medical or surgical treatments.

“Our finding of greater use of out-of-network behavioral health providers versus medical or surgical providers is consistent with findings from other studies in which researchers used different methodologies (e.g., secret shopper calls, employer surveys, consumer surveys, and provider network analyses) that showed that consumers have limited access to in-network behavioral health providers,” the researchers wrote. “Health plans have strategies to increase providers’ network participation, such as increasing reimbursement rates, reducing the administrative inconveniences of joining a health plan, and reducing the administrative burden of being paid by a health plan.”

For related information, see the Psychiatric News article “Access to In-Network Mental Health Care Still Lags Far Behind Other Medical Care.”

(Image: Getty Images/iStock/megaflopp)

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Youth Later Diagnosed With Psychotic Disorders May Show Up in Acute Care Settings First

Most people receiving a first diagnosis of a psychotic disorder have had some indication of mental health problem in the previous year. A study published today in AJP in Advance suggests that as many as two-thirds of adolescents and young adults who are diagnosed with psychotic disorder may have sought mental health care during the year prior to diagnosis.

While similar patterns of health care use were seen in patients who were later diagnosed with unipolar depression, the authors did find that people who would go on to develop a psychotic disorder received specialty mental health services in inpatient and emergency department settings more frequently. 

Gregory Simon, M.D., M.P.H., of Kaiser Permanente Washington Research Institute and colleagues reviewed the medical records of all diagnoses made in youth/young adults (aged 15 to 29) between Jan. 1, 2007, and Dec. 31, 2013, among participants in the Colorado, Northern California, Northwest, Southern California, and Washington regions of Kaiser Permanente. During this period, they identified 624 confirmed cases of a first diagnosis of a psychotic disorder, which included 105 diagnoses of a schizophrenia spectrum disorder, 78 diagnoses of a mood disorder with psychosis, and 441 diagnoses of other psychotic disorders. For comparison, they also examined data from 1,862 patients who had received a diagnosis of first unipolar depression and 1,851 control patients selected from all health plan members who had at least one outpatient visit during the study period.

Of the patients with a first diagnosis of a psychotic disorder, 29% had received mental health outpatient care in the previous year, 8% had received mental health inpatient care, 24% had received emergency department mental health care, and 29% made a primary care visit that involved a mental health diagnosis. 

Patients who received a first diagnosis of unipolar depression had similar rates of previous mental health outpatient or primary care visits, but the patients who later developed a psychotic disorder were far more likely to have received inpatient and emergency mental health services. Specifically, compared with patients receiving a first diagnosis of unipolar depression, those with a first diagnosis of psychosis were 2.96 times more likely to have received mental health inpatient care in the previous year, and 3.74 times more likely to have received mental health emergency department care. 

“The strong and specific association between use of acute care mental health services and subsequent presentation with psychotic symptoms suggests the potential value of assessment for prodromal or early psychotic symptoms in people receiving inpatient or emergency care for mental health concerns,” Simon and colleagues wrote. “Systematic assessment following emergency department or inpatient mental health care may hasten identification and engagement in appropriate specialty care.”

For more information, see the Psychiatric News article “Early Identification of People With Psychosis Linked to Educating Outpatient Providers” and the Psychiatric Services article “Is the Clinical High-Risk State a Valid Concept? Retrospective Examination in a First-Episode Psychosis Sample.”

(Image: iStock/gradyreese)

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