In the wake of the COVID-19 pandemic, treatment providers, advocates and lawmakers are calling for Rhode Island to confront its problems with access to mental health care.
Despite a federal law called the 2008 Mental Health Parity and Addiction Equity Act that’s meant to prevent such problems, barriers to psychological treatment in Rhode Island make it hard for holders of both commercial insurance and Medicaid to see a provider, receive therapy and get the medication for mental conditions, according to advocates, therapists and patients.
“At the moment, unfortunately, I would have to say that the behavioral health care system in Rhode Island is broken and it’s fragmented, and that’s for a variety of reasons,” said Susan A. Storti, president of The Substance Use and Mental Health Leadership Council of R.I.
Partly, it’s workforce issues that are keeping people from getting mental health care, with the biggest underlying factor being inadequate reimbursement rates offered through both commercial insurance and Medicaid, Storti and others said.
“Right now, the demand for mental health services is outpacing the availability of services within the community,” Storti said. ”You have so many conflicting variables coming into play. It’s become the perfect storm. We can’t compete with the pay scale in the surrounding states.“
Susan E. Enck, a licensed clinical psychologist at Brown Medicine’s Warwick Primary Care, said patients and mental health providers were already “stretched to the breaking point” before the spring of 2020, but the pandemic intensified the crisis, leading to longer waiting lists and patients getting sent by insurers to out-of-network providers.
Enck pointed to the 2019 Milliman Research Report, showing out-of-network utilization rates for commercial “preferred provider organization” plans growing to 540% more likely for behavioral health office visits compared with medical/surgical primary care office visits in 2017, up from 500% more likely two years earlier. In Rhode Island, there was a 428% disparity in 2017, compared with 210% in 2014.
The report found a widening gap in in-network reimbursement rates for mental health visits compared with medical/surgical care. Primary care reimbursements were 23.8% higher than behavioral health reimbursements in 2017, up from 20.8% in 2015, while in Rhode Island primary care reimbursements were 21.6% higher in 2017, compared with 19.4% higher in 2015.
The maximum allowed in allowances through Medicaid in Rhode Island is $92.47 per month for initial psychiatric care visits and $38.18 for subsequent visits.
“Now you toss in a pandemic, where you have people out of work, so they can’t pay for behavioral health services, and sort of the isolation and the stress overall from being in a pandemic, there’s even more of a disparity,” Enck said.
Sen. Louis P. DiPalma, D-Middletown, and Rep. Julie A. Casimiro, D-North Kingstown, recently filed bills in the General Assembly that would create a review process for Medicaid reimbursement rates set by the state for various services, including mental health, some of which have remained stagnant for 20 years. The measures have been referred to each chamber’s finance committee.
DiPalma said Rhode Island also should invest in more certified community mental health centers. It currently has six. “We sorely need to shore up mental health services,” he said.
Gov. Daniel J. McKee’s office said his fiscal 2023 state budget included $42.4 million for the behavioral health care system, including funding to support the community mental health center. A spokesperson also said he has backed efforts to recruit and retain behavioral health workers.
Laurie-Marie Pisciotta, executive director of the Mental Health Association of Rhode Island, said the problem is so bad that sometimes providers have “gone out of business” or take higher-paying jobs at hospitals, rather than working in outpatient, community-based programs. Many psychiatrists and psychologists won’t accept health insurance due to inadequate reimbursement rates. And it’s not uncommon for mental health care providers to move out of state for better pay, she said.
“Providers have problems paying their bills, paying administrative staff who do hours of provider authorization paperwork and claim processing, and answering phones,” Pisciotta said. “Sometimes they’ll close their Rhode Island practice and go to Massachusetts and get reimbursed at much higher rates.”
Pisciotta said some health insurers in Rhode Island are committing parity violations by offering directories of mental health care providers that are not accurate or up to date, which she called “ghost networks.”
When members try to select a provider, they find out many no longer accept insurance or went out of business, Pisciotta said.
Pisciotta also said insurers routinely under-reimburse mental health care providers in Rhode Island, another violation of the federal law that says insurers must provide coverage no more restrictively for behavioral health benefits than medical benefits.
In response, an America’s Health Insurance Plans spokesperson said mental health parity “does not include requiring plans to pay identical amounts for [behavioral health] and other clinicians.
“Rather, federal parity law recognizes that a variety of factors like level of training, licensure, experience and geographic market dynamics go into determining provider reimbursement rates, as long as these factors are considered for both medical and behavioral providers,” said David L. Allen.
Enck said overwhelmed providers such as her don’t know where to turn.
“I know when I need to refer people out, a lot of practices aren’t taking new patients,” Enck said.
At the federal level, President Joe Biden recently proposed an investment of $700 million into programs that train and assist people to become behavioral health care providers, $225 million in training for paraprofessionals needed to support them, and a revamp to the federal law so that health plans cover three behavioral health visits each year without a copay from the patient.
Beth Lamarre, executive director of the National Alliance on Mental Illness Rhode Island, said the copay proposal could reduce barriers.
“It might encourage people to seek out services who never did before,” Lamarre said.
Marc Larocque is a PBN staff writer. Contact him at Larocque@PBN.com.
