Ghost networks haunt mental health access, study finds

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Dive Brief:

• A secret shopper study conducted by researchers at the Ohio State University found that less than a quarter of calls to mental health providers in commercial insurance networks ended with a scheduled appointment.
• It’s the latest study uncovering ghost networks, or providers listed as in-network by insurers that are unreachable or unavailable to care for patients. About 60% of the over 5,800 calls placed by researchers to providers were left unanswered, raising concerns about mental care access.
• Inaccuracies in the provider directories were the primary barrier to mental healthcare access, affecting over half of calls in which researchers actually talked to a clinician or their staff, according to the study. Other problems included lack of appointment availability and wrong specialty areas listed.

Dive Insight:

The study, published Friday in JAMA Health Forum, analyzed calls to psychiatrists and psychologists listed in the directories of the largest commercial carriers in five states — Delaware, Montana, New Jersey, Rhode Island and Virginia. Calls were made based on the closest listed clinician for a simulated patient in a standard preferred provider organization plan.

These calls uncovered widespread ghost networks in commercial insurers' provider networks, which cover most insured U.S. residents. 

Unanswered calls for ambiguous reasons, like a busy signal or generic voicemail, were the primary contributor to ghost networks in the study. However, 56% of the calls deemed evaluable by the researchers because they were picked up or outright disconnected uncovered inaccuracies in the provider directories.

Errors in mental health clinicians’ contact information was the most common type of inaccuracy, including about 22% of calls revealing specialty errors. In 11% of calls, the numbers were either disconnected or out-of-service, which indicated a direct, verifiable sign that directory information was wrong. In contrast, unanswered calls because of a busy signal or that continued to ring without a pickup left researchers unable to verify if direction information was correct.

The researchers also noted 1.6% of calls with network status errors, such as a clinician no longer being active in the network.

Another 1 in 5 evaluable calls were affected by capacity limitations, including a clinician not accepting new patients or not having appointment availability. While the information was correct, this represented a subtler sign of ghost networks since the clinician was still inaccessible in practice despite the listing being accurate.

Various state and federal laws, including the No Surprises Act, require insurers to publish accurate provider directories, but the laws haven’t translated to more accessible mental healthcare, the study suggested.

The laws can rely too heavily on regulating the wrong metrics, and overlook other barriers to care, researchers said.

Mental healthcare has been notoriously difficult to access. Psychologists, in particular, tend to work alone in small offices that often lack staff to handle phone calls and scheduling. This has contributed to a mental health crisis in the U.S., marked by high rates of mental illness and major care gaps.

Ghost networks have been one barrier. Although ghost networks are common across different insurance types and specialties, the HHS Office of the Inspector General found that 28% of listed behavioral health clinicians in Medicaid directories were completely unreachable or inactive.

The CMS proposed a regulation just this week to clean up provider directories in Medicare Advantage. The federal agency also wants to make a centralized provider directory to serve as a single source of provider and facility information nationwide for patients. The process has been conducted in stages, with hopes that new MA data from the proposed regulation will feed into the directory.