Ghost Networks in Mental Healthcare

Finance: Barriers to Mental Health Care: Improving Provider Directory Accuracy to Reduce the Prevalence of Ghost Networks, May 3, 2023

The problem of ghost networks varies, depending upon one’s health plan. If one enters mental health care through Medicaid, state departments of health generally have up to date listings for programs that provide both psychiatric and social worker services. This was my experience as a patient in the District of Columbia. I did not choose a health plan when I was in the DC system, which made finding a primary care physician interesting. After moving to Maryland, I chose Kaiser for medical care, but could not do so for mental health servcies.

Participants in a Psychiatric Rehabilitation Program include access to a nurse practitioner (which is usually what Medicaid pays for). PRPs have case managers who will do the searching for you when a therapist is needed - although this may take some time, precisely because of the problem of ghost networks. Medicaid patients have access to certified counselors and licensed marriage and family therapists, but not to Licensed Clinical Social Workers. LCSWs were only covered by Medicare, while the other therapists were not. 

Starting in 2024, the counselors available with Medicaid are added to Part B coverage. This makes ghost networks a problem for more people - although wider availability may help individuals find care.

In my case, my relationship with my nurse practitioner in my PRP proved toxic, so I had to find a new provider. In reality, there was not much choice - only one was open - even though more were listed.

Before moving to Medicare after two years of Medicaid after my SSDI began, I could no longer meet the asset test of Medicaid when I received assets from my divorce (although I probably did not have to take this step). At this time, I signed up for the Affordable Care Act Silver Plan. The coverage was too expensive and the copays too high for care when I fell and broke a rib. Luckily, at the two year mark, I moved to  Medicare Parts B/D and a Psychiatrist and LCSW. A year later, I signed up for Part C.  

Shifting from Medicaid to the Affordable Care Act to Medicare was seamless with my Primary Care Physician, unlike my mental health services. Of late, I was offered the ability to go out of the HMO for services due to regulatory changes. None were as convenient as what Kaiser provided.

I had previously been a Kaiser member fifteen years prior to this as a government contract employee. During this time, I noted that the DC Government, where I had been working a few years earlier, had shifted to Kaiser as well for their employees.

The point of my tale of coverage is that, once I chose Kaiser, my relationship with my PCP was unchanged, although details of copayments and prescription coverage did vary, especially regarding the pharmaceuticals.

For those who sign up for managed care, we have achieved fusion in some aspects, but not in others - although this will change in 2024 as far as therapists are concerned. One can work for a company, get an individual policy under the ACA at a later time, get Medicaid when disabled and full Medicare without changing doctors. What is complicated is what is covered and what is not with the same provider network.

The real antidote to ghost networks is the kind of network care that is provided through community healthcare in Medicaid and to managed care participants (regardless of funding). Getting to single payer funding is not an issue as much as is seamless coverage WITHIN THE SAME PROVIDER NETWORK regardless of which government or employer plan one uses.

Professional employees always get good coverage, as do unionized employees. Others need to rely on some sort of governmentally funded care. For those in this situation, the care package should be the same, with providers getting the same level of support in each setting.

If this sounds like an endorsement of Medicare for All, which is essentially Dual Eligibility for all (meaning Medicare reimbursement with Medicaid copays) for all seniors, then you have been listening. 

There are other options, however, like Medicare Part E coverage replacing dual eligibility for seniors in long term care (taking these patients off of state Medicaid rolls) and a public option added to Affordable Care Act coverage (which could replace Medicaid - at least for non-retirees - and be more heavily subsidized than current coverage. The other option is to have employers offer direct care. 

Attachment: Single Payer Video