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Why we need more transparency in health insurance: Part Two - Eliminating carve-outs

In the first of this series on reforming healthcare through transparency, I talked about a long-term vision for moving to a more direct care model of payment for health services. Today, I want to talk about the need to eliminate an increasingly common and opacifying practice specific to mental health care called behavioral health carve-outs. 

So let's talk about carve outs. Which health insurance company pays for your visits to your primary care physician? Which insurance company pays for your visits to a mental health practitioner? If you answer with two different companies, you have what's called a "carve out." 

Carve outs are essentially your primary insurance company outsourcing utilization management, paneling providers, and payment rules to a secondary insurance company that probably claims to be able to provide mental health care cheaper than your primary company. Those carve out companies are incentivized to keep behavioral health/mental health care spending as low as possible, thus saving your primary health insurance company money. However this practice creates a HUGE philosophical and operational disconnect in the healthcare delivery system.

If mental health conditions are health conditions just like any other medical condition (as is stated by parity laws all over the US), how can they possibly be "carved out" of your medical insurance plan to a company incentivized to keep behavioral health care spending lower? How will anyone see that I, as your counselor, helped reduce your medical care utilization over an entire year by helping you manage your anxiety and reduce your frequent visits to medical specialists, if the "carved out" insurance company is measuring my success only on how little I bill for your mental health care alone? 

Behavioral health carve outs seemed to provide savings when they started, especially when traditional medical insurers that never paid for behavioral healthcare before were faced with managing new panels of mental health practitioners and utilization management. However evidence is mounting that managing medical and mental health conditions in an integrated fashion is more effective.  Integrated care requires integrated payment systems and integrated incentives for quality, not silos. 

Health insurance companies would do well to promote the integration of electronic health record systems (EHRs) and helping individual practitioners access major medical system EHRs so they can collaborate more fluidly with clients' other medical care providers rather than concentrating on micro-level cost reductions. While concentrating on reducing utilization helps this quarter's numbers, it doesn't help the insurance companies or consumers long-term as a cost reduction strategy. 

Do you have a carve out? How has care access been for you? How coordinated are your insurance companies and providers? I'm eager to hear your experiences. 





Katie PlayfairComment