Consumers who are enrolled in commercial insurance plans and who have mental health conditions pay more for out-of-network (OON) care than their counterparts with physical illnesses, according to a study on cost-sharing published in JAMA Network Open.

Despite the passage of legislation that addresses parity of benefits for mental health in 2008, many enrollees in private insurance plans have little option besides receiving care from OON providers. High deductibles and copays, as well as exclusion of OON care from annual caps, make care particularly costly to patients.

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Wendy Yi Xu, PhD, a researcher at the College of Public Health, of The Ohio State University in Columbus, and colleagues performed a cross-sectional study of insurance claims from 2012 to 2017 using a nationwide database. They examined data from adults aged 18 to 64 years who had depression, personality disorders, anxiety, bipolar disorder, schizophrenia, posttraumatic stress disorder, or substance use disorders and were enrolled in employer-sponsored insurance plans. The investigators compared this group with individuals with chronic physical conditions including diabetes and congestive heart failure.

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Outcome measures included receiving OON inpatient or outpatient care, cost-sharing (copays, coinsurance, or deductibles), proportion of OON cost-sharing for total healthcare spending, and proportion of OON cost-sharing for total cost-sharing. The study also explored the use of specific facilities and clinicians for those with mental health conditions.

Statistical analyses included logistic and linear regression models, adjusted for demographic and insurance plan factors. Additionally, analyses focused on the individuals who accounted for the majority of total spending within each group.

The study found that individuals with mental illnesses were more likely to receive inpatient and outpatient care from OON clinicians compared with the group with physical conditions. Furthermore, those with mental health conditions had greater OON cost-sharing expenses alone and as a proportion of all out-of-pocket OON care spending. In general, OON care rates and cost-sharing were greater for care received from behavioral clinicians or facilities.

Limitations of the study included the inability to account for entirely out-of-pocket costs or payments collected by providers beyond allowable reimbursements. In addition, the database could not detect individuals who did not access care because of cost barriers, making cost-sharing burden estimates overly conservative.

“In recent years, health care spending has shifted from employers to employees,” the researchers concluded, “As a result, OON care can pose particularly difficult financial burdens for those with behavioral health conditions.” Given the known socioeconomic impact of mental illness and substance use disorders, access-to-care barriers represent a further challenge for patients.

The study authors also noted, “Cost sharing…may be an important sign of network inadequacy that requires more scrutiny from policymakers.”


Xu WY, Song C, Li Y, Retchin SM. Cost-sharing disparities for out-of-network care for adults with behavioral health conditions. JAMA Netw Open. 2019;2(11):e1914554.