Mental health inadequacy

Feb. 15--The passage of the Affordable Care Act allowed many previously uninsured Marylanders to obtain coverage in 2014, but that coverage has not always translated into access to care: According to some health officials and advocates, many newly insured people have had difficulty finding physicians who are taking new patients, or even taking their insurance.

The problem is particularly pronounced when it comes to mental health care, including in Carroll County.

According to Adrienne Ellis, director of the Maryland Parity Project within the Mental Health Association of Maryland, not only is there a shortage of psychiatry providers within the insurance plans offered through the Maryland Health Benefit Exchange, but those psychiatrists that are listed are often listed incorrectly, with wrong numbers, deceased practitioners or invalid insurance information being the norm. Nor is it clear who, if anyone, has the authority to ensure psychiatric provider listings are accurate, although state health officials have said it is a currently a topic of top level discussions.

In a study published in January, the Maryland Parity Project surveyed the 1,154 psychiatrists listed as part of the provider networks of insurers offering health plans through the Maryland Health Benefits Exchange. The study found 657 -- more than half -- could not be reached at all due to incorrect or outdated information. Of those who could be reached, 216 were not actually psychiatrists, but some other type of provider and only 457 reported actually accepting the insurance they were listed as accepting.

Of actual psychiatrists who could be reached, accepted the listed insurance plan and were accepting new patients within a 45-day period or less, the study found there were only 156.

"When people don't have access to critical mental health care on an outpatient basis, it's very easy for them to end up in crisis and using more intense levels of care, including inpatient care and hospital stays. It's not good for individuals or the health care system," Ellis said. "We fully support the Affordable Care Act in getting more people insured, but it's only the first step. We need to make sure they can actually use that [insurance] to get the care they need when they need it."

In Carroll County, where there is already a less-dense population of health care providers, access issues are even more pronounced. The Carroll County Health Department has received calls for years from people with private insurance who could not find a physician within their insurer's provider network and were looking for help, according to Dawn Brown, director of quality assurance and prevention. While the Affordable Care Act allowed more people to access insurance, Brown said it hasn't done enough to ensure accuracy or adequacy of health care providers in the county, especially in regards to mental health.

"The same struggles are still there," Brown said. "There is still an access and demand problem; even more people are looking for that care than before and then you still don't have the doctors to cover it. Then when you think you have the listings for a doctor, the information is outdated."

The situation is bad enough in Carroll to qualify as a crisis, especially when it comes to childhood and adolescent psychiatry, according to Karen Koenigsberg. She's a program coordinator with the Get Connected Family Resource Center in Westminster, a nonprofit that helps connect families in crisis with social, medical and mental health resources.

"There are very few child psychiatric providers in Carroll County, let alone that have openings," Koenigsberg said. "We've seen an increase in this since the exchange, since the beginning of the [Affordable Care Act]."

Accuracy and responsibility

The problems caused by a lack of sufficient psychiatric providers is one with no short-term solutions, according to Ellis, and a systemic issue that the entire U.S. health care apparatus must address. The issue of accuracy in insurer listings of psychiatric and other providers is another matter: Ellis said that in November, the Maryland Parity Project looked at the 2015 provider listings for two of the insurers examined in 2014 -- which remain anonymous in the report -- and found no changes made to correct inaccuracies.

"That gives credence to the fact that there is a problem that nobody is recognizing is a problem," she said. "There is no reason these carriers cannot be auditing their plans and taking off the doctors that are not participating."

One possible reason -- it's not clear who has the authority to force insurers to audit their provider network listings.

After an initial inquiry, a spokesman for the Maryland Health Benefit Exchange told the Times that it was the Maryland Insurance Administration, which regulates insurance carriers and approves their rate plans, that had the regulatory authority to ensure the accuracy of insurer provider listings.

A spokeswoman for the MIA, meanwhile, told the Times that while the MIA did have the authority to regulate the listings of providers on insurers' own websites, they did not have the authority to regulate listings on the MHBE website, http://www.marylandhealthconnection.gov.

"The link on Maryland Health Connection's website goes to a centralized health information exchange, known as CRISP [Chesapeake Regional Information System for our Patients], rather than to each of the insurance companies' own directories," Vivian Laxton, MIA spokeswoman, wrote in an email. "State law requires insurance companies to keep their lists up to date, but the ... rule does not apply to CRISP."

Meanwhile, CRISP, according to spokesman Robert Horst, presents the information on the Maryland Health Connection as is supplied to them by the insurance carriers. Care First, one of the largest insurers on the Maryland Health Benefit Exchange, sent a corporate statement by email about the information it provides CRISP in response to a inquiry by the Times:

"Care First updates provider directory data on our local website weekly. That data is transmitted to CRISP and the Maryland health exchange every two weeks."

According to Ellis, the Care First statement confirms the Maryland Parity Project's suspicions concerning listing accuracy.

"While we understand that MIA doesn't regulate CRISP, we believe that this is likely a problem with the internal directories of the carriers also as those are likely the same directories being sent to CRISP every two weeks," she said.

Care First declined to comment on the question of the inaccuracies in the provider data it appears to have been providing CRISP based on the Maryland Parity Project study.

Adequacy and Solutions

The inaccuracies in provider listings has not gone unnoticed by state officials. In an interview, Maryland Health Benefit Exchange Executive Director Carolyn Quattrocki said that she has been discussing the issue with MIA Commissioner Al Redmer Jr. and there are meetings planned between MHBE, MIA and CRISP set for the coming weeks. One solution is already in the works.

"A few months ago, we asked CRISP if it could create a functionality in its system whereby the [health care] providers themselves could go in and correct incorrect information. If the address is wrong, the phone number is wrong if they have retired; the provider could go in and do that themselves," Quattrocki said. "CRISP has developed that functionality and it is now in testing phase. What we want to do now is to work with the insurance commissioner and the [insurance] carriers to find best way to implement that solution."

There is also discussion taking place in the Maryland legislature, according to Del. Susan Krebs, R-District 5, who said the questions raised by the Maryland Parity Project study are a concern in the Health and Government Operations Committee on which she serves.

"Everyone agrees it needs to be addressed," she said.

Not everyone agrees on just where the search for a solution should focus, however.

Krebs said that in her mind, the problem might lie with health care providers who are not reporting information to insurance carriers, which seems to be the opposite conclusion of that reached by Quattrocki.

Quattrocki said the problem is too large to attribute to any one group of actors.

"With something this complicated, with this many players involved, it's not a single source of the problem," Quattrocki said. "Some of these problems arise from the providers themselves. ... In other cases it may be that the [insurance] carriers could play a greater role with that accuracy."

An important point to keep in mind, according to Quattrocki, is that the CRISP listings of providers on the Maryland Health Connection website are much more transparent than anything available in the past, when insurers' provider networks were not available publicly to consumers before they chose to purchase a plan with a particular carrier. This transparency was a step in the right direction, she said, but it has also revealed new problems that must be, and are being, tackled.

But according to Ellis, part of the problem highlighted by the new listings in CRISP is actually an old one.

The Mental Health Association of Maryland has been aware of anecdotal evidence of insufficient numbers of psychiatric providers on insurers networks since the '80s, the new CRISP listings have simply allowed the association to prove that insufficiency, according to Ellis. Both Maryland and federal law require that insurers work with enough providers within their networks to provide care to policy holders, she said, and federal law requires parity of access between mental health and other forms of care, that access to mental health care be no more difficult than access to primary medical care.

The Maryland Parity Project recommended in the conclusion of its study that insurance carriers publish the process by which policy holders can seek out-of-network psychiatric care at in-network costs in the event they cannot find a provider with their insurance carriers network, an exception allowed by state law. Ellis said there is also work being done in the Maryland legislature to pass a law that would require insurance carriers to prove they provide parity in access between mental health and primary health care providers.

Maryland state Senator Thomas Middleton, D-District 28, is spearheading that legislative effort. On Tuesday, Feb. 10, he introduced SB 586, which he said would require insurers provide evidence that they maintain adequate health care provider panels to the MIA.

"If you are selling insurance and you are selling to someone and they expect a network of providers that will take care of whatever their needs are that are covered under the policy, they should have an adequate panel [of providers]," Middleton said. "These companies already report that there is this parity [between mental and primary health care] to the federal government. In this legislation, SB 586, we are saying that they should report the same information to MIA."

Middleton said that he is focused on the goal of ensuring accurate and adequate provider listings and that he is open to working with MIA and insurance carriers to find the best way to accomplish that end.

According to Quattrocki, with the discussions that are already taking place, finding a solution should be possible, if not easy, and new laws may not even be necessary.

"I am hopeful that we can come together and find ways to make improvement without legislative direction," Quattrocki said. "The carriers have been very good partners with us and they have every interest in making their networks adequate and having the information on those networks be accurate. I don't think there is any lack of will here."

Reach staff writer Jon Kelvey at 410-857-3317 or jon.kelvey@carrollcountytimes.com.

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