Cost-Sharing Disparities for Out-of-Network Care for Adults with Behavioral Health Conditions

Abstract

Importance: Individuals in the United States with mental illnesses and substance use disorders can face major access barriers from limited provider (eg, clinicians and facilities) networks in health insurance plans. Objective: To evaluate the cost-sharing payments for out-of-network (OON) care for private insurance plan enrollees with mental health conditions, alcohol use disorders, or drug use disorders compared with those with congestive heart failure (CHF) or diabetes. Design, Setting, and Participants: This cross-sectional study used data from a large commercial claims database from 2012 to 2017. The study included adults with mental health conditions, with alcohol use disorders, with drug use disorders, with CHF, and with diabetes who were aged 18 to 64 years and enrolled in employer-sponsored insurance plans. Main Outcomes and Measures: Main outcomes included OON care during hospitalization, OON care during outpatient care, cost-sharing payments with OON care, OON cost sharing as a proportion of total health care spending, and OON cost sharing as a proportion of total cost sharing. Results: The study sample included 3209929 enrollees with mental health conditions (mean [SD] age, 45.9 [12.6] years; 64.8% women), 294550 with alcohol use disorders (mean [SD] age, 42.8 [13.4] years; 60.9% men), 321535 with drug use disorders (mean [SD] age, 41.1 [13.9] years; 59.1% men), 178701 with CHF (mean [SD] age, 53.8 [8.9] years; 62.6% men), and 1383398 with diabetes (mean [SD] age, 52.5 [9.0] years; 58.9% men). Enrollees with behavioral conditions were more likely to encounter OON clinicians in inpatient and outpatient settings. For instance, those with drug use disorders were 12.9 percentage points (95% CI, 12.5-13.2 percentage points; P