[Senate Hearing 117-823]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 117-823

                      BEHAVIORAL HEALTH CARE WHEN
                      AMERICANS NEED IT: ENSURING
                      PARITY AND CARE INTEGRATION

=======================================================================

                                HEARING

                               BEFORE THE

                          COMMITTEE ON FINANCE
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             SECOND SESSION

                               __________

                             MARCH 30, 2022

                               __________

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]                                     
                                     

            Printed for the use of the Committee on Finance

                               __________

                   U.S. GOVERNMENT PUBLISHING OFFICE                    
54-676 PDF                  WASHINGTON : 2024                    
          
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                          COMMITTEE ON FINANCE

                      RON WYDEN, Oregon, Chairman

DEBBIE STABENOW, Michigan            MIKE CRAPO, Idaho
MARIA CANTWELL, Washington           CHUCK GRASSLEY, Iowa
ROBERT MENENDEZ, New Jersey          JOHN CORNYN, Texas
THOMAS R. CARPER, Delaware           JOHN THUNE, South Dakota
BENJAMIN L. CARDIN, Maryland         RICHARD BURR, North Carolina
SHERROD BROWN, Ohio                  ROB PORTMAN, Ohio
MICHAEL F. BENNET, Colorado          PATRICK J. TOOMEY, Pennsylvania
ROBERT P. CASEY, Jr., Pennsylvania   TIM SCOTT, South Carolina
MARK R. WARNER, Virginia             BILL CASSIDY, Louisiana
SHELDON WHITEHOUSE, Rhode Island     JAMES LANKFORD, Oklahoma
MAGGIE HASSAN, New Hampshire         STEVE DAINES, Montana
CATHERINE CORTEZ MASTO, Nevada       TODD YOUNG, Indiana
ELIZABETH WARREN, Massachusetts      BEN SASSE, Nebraska
                                     JOHN BARRASSO, Wyoming

                    Joshua Sheinkman, Staff Director

                Gregg Richard, Republican Staff Director

                                  (II)
                            
                            C O N T E N T S

                              ----------                              

                           OPENING STATEMENTS

                                                                   Page
Wyden, Hon. Ron, a U.S. Senator from Oregon, chairman, Committee 
  on Finance.....................................................     1
Crapo, Hon. Mike, a U.S. Senator from Idaho......................     3
Cornyn, Hon. John, a U.S. Senator from Texas.....................     5
Cantwell, Hon. Maria, a U.S. Senator from Washington.............     5

                               WITNESSES

Dicken, John E., Director, Health Care, Government Accountability 
  Office, Washington, DC.........................................     6
Keller, Andy, Ph.D., president and CEO, and Linda Perryman Evans 
  presidential chair, Meadows Mental Health Policy Institute, 
  Dallas, TX.....................................................     8
Ratzliff, Anna, M.D., Ph.D., co-director, Advancing Integrated 
  Mental Health Solutions (AIMS) Center; and professor, 
  University of Washington, Seattle, WA..........................    10
Williams, Reginald D., II, vice president, international health 
  policy and practice innovations, Commonwealth Fund, Washington, 
  DC.............................................................    12

               ALPHABETICAL LISTING AND APPENDIX MATERIAL

Cantwell, Hon. Maria:
    Opening statement............................................     5
Cornyn, Hon. John:
    Opening statement............................................     5
Crapo, Hon. Mike:
    Opening statement............................................     3
    Prepared statement...........................................    47
Dicken, John E.:
    Testimony....................................................     6
    Prepared statement...........................................    48
    Responses to questions from committee members................    52
Keller, Andy, Ph.D.:
    Testimony....................................................     8
    Prepared statement...........................................    54
    Responses to questions from committee members................    61
Ratzliff, Anna, M.D., Ph.D.:
    Testimony....................................................    10
    Prepared statement...........................................    81
    Responses to questions from committee members................    85
Williams, Reginald D., II:
    Testimony....................................................    12
    Prepared statement...........................................    91
    Responses to questions from committee members................   102
Wyden, Hon. Ron:
    Opening statement............................................     1
    Prepared statement...........................................   113

                             Communications

AHIP.............................................................   115
American Ambulance Association...................................   119
American Association on Health and Disability....................   121
American Counseling Association..................................   124
Association for Behavioral Health and Wellness...................   127
Bamboo Health....................................................   130
Children's Hospital Association..................................   132
COMPASS Pathways.................................................   136
Curtis, John D...................................................   138
ERISA Industry Committee.........................................   138
Healthcare Leadership Council....................................   143
HR Policy Association and American Health Policy Institute.......   144
Michael J. Fox Foundation for Parkinson's Research...............   149
National Association of Health Underwriters......................   151
National Center on Domestic Violence, Trauma, and Mental Health..   154
Partnership for Employer-Sponsored Coverage......................   157
Smarter Health Care Coalition....................................   159
Society for Human Resource Management............................   160

 
                      BEHAVIORAL HEALTH CARE WHEN
                      AMERICANS NEED IT: ENSURING
                      PARITY AND CARE INTEGRATION

                              ----------                              


                       WEDNESDAY, MARCH 30, 2022

                                       U.S. Senate,
                                      Committee on Finance,
                                                    Washington, DC.
    The hearing was convened, pursuant to notice, at 10 a.m., 
via Webex, in Room SD-215, Dirksen Senate Office Building, Hon. 
Ron Wyden (chairman of the committee) presiding.
    Present: Senators Stabenow, Cantwell, Carper, Cardin, 
Bennet, Casey, Warner, Whitehouse, Hassan, Cortez Masto, 
Warren, Crapo, Grassley, Cornyn, Cassidy, Lankford, and Daines.
    Also present: Democratic staff: Shawn Bishop, Chief Health 
Advisor; Eva DuGoff, Senior Health Advisor; and Michael Evans, 
Deputy Staff Director and Chief Counsel. Republican staff: 
Gable Brady, Senior Health Policy Advisor; Kellie McConnell, 
Health Policy Director; and Gregg Richard, Staff Director.

   OPENING STATEMENT OF HON. RON WYDEN, A U.S. SENATOR FROM 
             OREGON, CHAIRMAN, COMMITTEE ON FINANCE

    The Chairman. The committee will come to order. Today the 
committee meets for our third hearing on mental health care 
this year, and we are going to begin with mental health parity.
    For 13 years now, the parity law has required equal 
treatment by insurance companies of mental health care and 
physical care. That law was a result of extraordinary efforts 
by two late Senators, Senators Wellstone and Domenici. Both 
came from families touched by mental health challenges, and I 
can tell you there are a lot of Senators who have experienced 
the same thing.
    The parity law was supposed to be a game-changer, yet 
instead, mental health patients have spent the last 13 years 
all too often bogged down in insurance company foot-dragging, 
red tape, and piles of excuses.
    This committee--and I appreciate Senator Crapo and Senator 
Cornyn, Senator Stabenow, Senator Cantwell--our colleagues are 
committed to fixing this on a bipartisan basis. I also say--it 
is not on the docket today, but I strongly believe that more 
needs to be done to hold the executives of these mental health 
companies accountable. I am going to give four examples of what 
is wrong.
    First, too many Americans are getting shoved by these 
insurance companies into ghost networks. When you are stuck in 
a ghost network, you cannot get a provider to take your 
insurance. The insurance company directory of providers is 
often wrong, or 10 years out of date, or insurance companies 
pay so little for mental health services that patients get 
stuck with the whole bill. When families pay good money for 
insurance and wind up with a ghost network, you sure do not 
feel like you are getting parity. You feel like you are getting 
ripped off.
    The next example is, mental health patients are getting 
whacked by coverage limits that cut off their stays in a 
hospital. Health treatments ought to be driven by a 
professional diagnosis, not an arbitrary cap set to protect 
insurance company profits.
    Third, insurance companies are relying on loopholes to deny 
coverage, requiring prior authorizations before they pay for 
care. Setting unreasonably high standards for the medical 
subsidy of mental health care is just wrong, particularly for 
somebody experiencing a mental health crisis. These 
bureaucratic roadblocks to insurance coverage can be fatal. If 
you break your arm, you do not have to make a dozen phone calls 
and put together a mountain of paperwork to prove to your 
insurance company that you have to see a doctor. A mental 
health crisis should not be different.
    Fourth, we have heard repeatedly--and I have talked to my 
colleagues about this--of stonewalling on paying claims. I was 
struck during the pandemic that even leading health 
institutions, like our own Oregon Health and Science 
University, could not get mental health claims paid by the 
insurance companies. At first, the insurance companies just 
waltzed them around, but then I wrote a letter calling for a 
GAO inquiry into the stonewalling. And what do you know? The 
floodgates opened up and a gusher of money was sent to Oregon 
Health and Science Center for these claims. It should not take 
a U.S. Senator weighing in to get paid for mental health care 
in America.
    These four barriers make a mockery out of the parity that 
Senators Wellstone and Domenici envisioned. And as we know, 
those two did not agree on everything, but they sure thought 
that we ought to do right by mental health patients. And that 
is what the parity law is about.
    Tools like ParityTrack, which is now run by an organization 
headed by former Surgeon General David Thatcher and former 
Congressman Patrick Kennedy, are out there working to hold 
States and Federal regulators accountable for enforcing parity 
law. It is going to take a lot of work in Congress, and at the 
grassroots level, to address these issues. But I want to say, 
as we touched on here today, we have working groups. Senator 
Crapo has been meeting me more than halfway to try to deal with 
this, and this committee is going to work until we get these 
problems fixed.
    Now I will wrap up with the second challenge and then go to 
my friend, Senator Crapo. What we want to do is bring mental 
health and physical health closer together. Mental health 
should not be fenced off from the rest of the health-care 
system. That lack of integration, which I guess is the 
technical term practitioners use, also can be fatal.
    People typically start with a primary care doctor, but less 
than half the patients who receive a referral to a mental 
health-care provider are able to get the care they need. The 
approach is often too slow to help somebody really get through 
a crisis. As many as one in three people who have died by 
suicide saw their primary care doctor within a month of their 
passing. Let's be clear. We are not talking about any kind of 
blame game on primary care docs who are trying to do their best 
in a difficult time, seeing dozens of patients every day. The 
truth is, patients need more options. What is needed, and what 
we have been talking about on our committee--and again, I 
appreciate Senator Crapo having these conversations with me. 
What we need is a fresh strategy so we can get primary care and 
mental health care for as many people as possible at almost the 
same time. That is really the lodestar within the interminable 
delays that slow down badly needed care.
    Taking care integration beyond the doctor's office is 
another priority. I am very proud that in my home State we have 
come up with something called ``CAHOOTS.'' We got it into law, 
got it placed in Medicaid, where for the first time mental 
health folks and law enforcement are teaming up on some of 
these very difficult situations on the streets. The mental 
health people like it. The law enforcement people like it. I 
think it is the wave of the future.
    There is a lot of work to do. The committee is focused on 
guaranteeing that Americans can get the mental health care they 
need when they need it.
    I thank all of our witnesses. I think it is going to be a 
particularly important hearing. I also want to thank Senator 
Cornyn. I understand you have worked with one of your Texas 
folks to have them come on up, and if you would like to 
introduce them at some point, we can do that.
    Senator Crapo?
    [The prepared statement of Chairman Wyden appears in the 
appendix.]

             OPENING STATEMENT OF HON. MIKE CRAPO, 
                   A U.S. SENATOR FROM IDAHO

    Senator Crapo. Thank you, Mr. Chairman. And I appreciate 
our partnership on this. We have a strong record of bipartisan 
solutions on big deals, and this is another one of those, and I 
appreciate that. Thank you. And thank you to our witnesses, 
some of whom have come across the country to testify before the 
committee today.
    We have heard from providers across the continuum of care, 
government officials, and policy experts who have shared a 
range of thoughtful perspectives and recommendations. This is 
the fourth mental health hearing that this committee has held 
this Congress. Despite diverse viewpoints on some policy 
questions, all have agreed on the profound importance of 
ensuring all Americans have access to high-quality mental 
health-care services.
    Our country has experienced a challenging couple of years. 
Even as hospitalizations and deaths caused by COVID-19 continue 
to decline and stabilize in the United States--hopefully 
permanently--the pandemic will have lasting impacts on the 
Nation's mental health. Lockdowns, school closures, and other 
government restrictions led to social isolation, new and 
worsened cases of depression, and widespread anxiety. For many, 
the pandemic also resulted in tragic personal losses, worsening 
these and other mental health conditions.
    I have also heard from health-care providers across Idaho, 
where the stress and uncertainty of the pandemic have further 
exacerbated professional burnout. Onerous regulatory burdens 
have caused many physicians and allied health professionals to 
retire early, or to reduce their hours. The resulting workforce 
shortage makes it more challenging for patients to access the 
mental health services they need.
    Studies have found that the prevalence of mental health 
illness is similar between rural and urban areas, but 
individuals living in rural and frontier areas often face 
significant barriers in accessing needed mental health services 
closer to home. On average, rural residents have to travel 
further to receive services, and providers are less likely to 
practice in these communities.
    While the pandemic has increased the pervasiveness of 
mental health concerns, it also has led to innovative solutions 
that address these challenges much better than in the past, 
such as the expansion of telehealth services. Telehealth 
expands access in underserved rural areas, improves care 
coordination and integration, and provides more privacy to 
patients to combat stigma.
    While there is no easy solution, I am committed to working 
alongside my colleagues to tackle these challenges in a 
bipartisan and fiscally responsible way. We cannot simply throw 
more money at the problem and expect to solve everything. 
Instead, we must focus on developing data-driven, innovative, 
and creative solutions to address these challenges.
    I look forward to hearing from today's panel on their ideas 
to ensure that Americans in need can access timely, high-
quality mental health-care services. Thank you all for being 
here, again.
    [The prepared statement of Senator Crapo appears in the 
appendix.]
    The Chairman. Thank you, Senator Crapo. And we will go on 
to the member introductions in just a minute. I want to touch 
on what Senator Crapo talked about. He and I have teamed up 
often over the years--whether it is forestry, transportation, 
health-care issues--and I think it would be fair to say the two 
of us think this is one of the most important challenges that 
we have dealt with, because this was a challenge before the 
pandemic, and it will continue to be after the pandemic. So you 
have a group of Senators, Democrats and Republicans, who are 
all in on this.
    One other quick point. And that is, Senator Crapo made 
mention of the telemedicine piece. And one of the best parts of 
the budget that passed--and it was led by this committee--was 
to make sure that we could get audio-only telemedicine. And my 
colleagues remember, we all sat here, and the practitioners 
said, ``Hey, we love broadband. Get it. Get going. Make it 
happen. But until you do it, get audio-only, and audio-only, 
particularly for seniors, folks in rural areas.'' So, Senator 
Crapo and I really dug in for audio-only coming out of our 
hearings, and I want to thank him for that.
    Okay, on to the introductions. John Dicken of the 
Government Accountability Office has done a lot of work for us 
over the years. I believe I am one of the largest partakers of 
GAO work, if you were to add all of the characters up in the 
Congress. He does a good job on the health-care markets, public 
health issues, private markets, and we appreciate that he has 
been at GAO since 1991, with a master's degree in public 
administration from Columbia University.
    Now I would like to let Senator Cornyn introduce Dr. Andy 
Keller, and then we will have Senator Cantwell introduce Dr. 
Anna Ratzliff.

            OPENING STATEMENT OF HON. JOHN CORNYN, 
                   A U.S. SENATOR FROM TEXAS

    Senator Cornyn. Thank you, Mr. Chairman. It is my pleasure 
to introduce our next witness, or one of our witnesses, Dr. 
Andy Keller. Dr. Keller is president and CEO of the Meadows 
Mental Health Policy Initiative, a Texas-based nonprofit 
dedicated to improving mental health delivery, care delivery, 
in Texas and across the Nation. He is a licensed psychologist 
with more than 20 years of experience in behavioral health 
policy financing and best practices. His work is centered on 
helping communities implement evidence-based and innovative 
care, and developing regulatory and financial frameworks to 
support them. Dr. Keller and the Meadows Institute have been 
leaders in the establishment of innovative programs that I hope 
will be emulated across the country.
    In June of last year, the Meadows Institute Lone Star 
Depression Challenge was named the recipient of a $10-million 
Lone Star Prize. This challenge, in partnership with the Center 
for Depression Research and Clinical Care at UT Southwestern, 
will catalyze an unprecedented Statewide and national effort to 
put depression care in Texas on par with care for heart disease 
and cancer.
    The Meadows Institute also helped lead the development of 
Right Care in Dallas, which uses a multidisciplinary response 
team to reshape behavioral health crisis response in the city, 
and divert people who are suffering mental health crises who 
happen to commit crimes or encounter the police so that they 
can get the care and treatment that they need to recover and 
get better.
    I was glad to be joined by Meadows Institute last month to 
discuss the incredible work Dallas is accomplishing because of 
its collaboration with Right Care. Dr. Keller is a wealth of 
knowledge and a steadfast advocate for innovative mental health 
policies.
    I am sure we have a lot to learn from his testimony. So, 
Dr. Keller, welcome here. Thank you for your service to Texas 
and the Nation, and it is a pleasure to have you here today.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Cornyn.
    Senator Cantwell?

           OPENING STATEMENT OF HON. MARIA CANTWELL, 
                 A U.S. SENATOR FROM WASHINGTON

    Senator Cantwell. Thank you, Chairman Wyden, and thank you 
to you and Ranking Member Crapo for holding this important 
hearing. And I really do appreciate the collaboration between 
the two of you.
    I want to take a moment to introduce Dr. Anna Ratzliff, who 
is from the State of Washington, who has been a pioneer in 
improving the mental health-care system. Dr. Ratzliff is a 
psychiatrist and professor at the University of Washington, 
Department of Psychiatric and Behavioral Sciences. She served 
as a psychiatric consultant delivering behavioral health care 
in primary care settings in Washington State. And she is a 
national expert on the Collaborative Care Model that helps 
medical teams improve and coordinate and integrate care. I 
cannot tell you how important this work is.
    She has also served in several national and international 
leadership positions that helped clinics implement the 
Collaborative Care Model. She has additional expertise in 
suicide prevention and training the mental health workforce, 
including serving as the director of UDub's psychiatric 
resident training program and director of the University of 
Washington integrated care training program. She is a member of 
the American Psychiatric Association and has partnered closely 
with APA to disseminate and promote improved access to care 
through integrated care and to advocate for policies that would 
support deployment of the Collaborative Care Model more 
broadly.
    Dr. Ratzliff, thank you so much for being here today. Thank 
you for taking time to talk about this innovative model. I 
think you will find the members here, at least present, 
including Senator Stabenow, to be very up on these issues, and 
just very anxious to understand how we as a Nation really, if 
you ask me--you know, I served 6 years in our State legislature 
on the Health Care Committee, and everything was, did it 
improve the quality of care, did it help us lower costs, and 
did it deliver more transparency in the system? And we usually 
voted for the things that did all three.
    This is exactly what collaborative care does. And that is 
why it is so important. So, thank you, Mr. Chairman. Thank you 
for holding this hearing.
    The Chairman. Thank you, Senator Cantwell. And, Dr. 
Ratzliff, we are going to have the Northwest collaboration 
action between Washington and Oregon, because we so appreciate 
your leadership. And just so the record notes, as Senator 
Cantwell touched on, the American Psychiatric Association, of 
course, has been at the forefront of developing these 
integrated care models. They recommended to us Dr. Ratzliff, so 
we are glad that that is happening.
    And Mr. Reggie Williams is here. He leads the Commonwealth 
Fund's program on international health policy and practice 
innovations. They focus on behavioral health. As you know, 
Senator Stabenow has been our leader on all things relating to 
behavioral health, so we are glad you are here to focus on 
that. Prior to his work with the Commonwealth Fund, Mr. 
Williams worked for 15 years as the managing director at 
Avalere, focused on evidence-based medicine policy, digital 
health policy, and he chaired the board of directors of Mental 
Health America, an important nonprofit. He got his bachelor's 
degree in biomedical ethics from Brown University.
    Okay, let's get on with our witnesses. And let's start with 
you, Mr. Dicken.

STATEMENT OF JOHN E. DICKEN, DIRECTOR, HEALTH CARE, GOVERNMENT 
             ACCOUNTABILITY OFFICE, WASHINGTON, DC

    Mr. Dicken. Thank you, Chairman Wyden, Ranking Member 
Crapo, and members of the committee. I am pleased to be here 
today to discuss the new GAO report released today titled 
``Mental Health Care: Access Challenges for Covered Consumers 
and Relevant Federal Actions.'' This is the most recent in a 
series of GAO reports examining ways that the pandemic has 
affected behavioral health care and examining State and Federal 
oversight of behavioral health-care parity.
    In 2020, 53 million Americans in the United States--which 
is one in five adults--had any mental illness. This includes an 
estimated 14 million people who had serious mental illness. The 
COVID-19 pandemic and related economic crisis have intensified 
concerns that even more people are affected by mental health 
conditions, and that people with underlying mental health 
conditions could be experiencing increased severity of those 
conditions. Further, the pandemic has highlighted longstanding 
concerns about the accessibility of health-care services, even 
for those with health-care coverage.
    The bottom line of today's report is that health-care 
coverage does not guarantee access to mental health-care 
services. Based on interviews with 29 stakeholder 
organizations, and a review of research, GAO found that 
consumers experienced challenges finding mental health-care 
providers in their health plan's network.
    For example, providers who were listed as ``in network'' 
may not be accepting new patients, may have long wait times, or 
do not provide the specific service the patient is seeking. In 
some cases, they actually may not be in the plan's network at 
all. Challenges like these can cause consumers to face high 
health-care costs, delays in receiving care, or difficulties in 
finding a provider close to home.
    GAO found that factors contributing to these challenges 
included low reimbursement rates for mental health services, 
and inaccurate or out-of-date information on provider networks. 
GAO also found that consumers experienced challenges with 
restrictive health plan approval processes and plan coverage 
limitations, both of which can limit their ability to access 
services. Many of the stakeholder organizations interviewed, 
and research reviewed, noted that the process for gaining 
approval for mental health services can be more restrictive 
than it is for other medical services.
    For example, representatives from one health system 
reported that some health plans are less likely to grant prior 
authorizations for mental health hospital stays compared with 
medical and surgical hospital stays. Some stakeholders also 
noted various coverage limitations and restrictions that limit 
consumers' access to certain mental health-care treatments, or 
limit the types of providers eligible for payment. These 
include certain statutory restrictions on the types of mental 
health-care providers eligible for reimbursement under 
Medicare.
    Let me conclude by briefly noting some of the Federal 
efforts that may address some aspects of the challenges that 
consumers experience attempting to access mental health care. 
The Departments of Labor and Health and Human Services are 
taking steps to improve access to mental health providers, 
including steps to enforce requirements for certain health 
plans to update and maintain provider directories. The 
Substance Abuse and Mental Health Services Administration, with 
HHS, is managing several programs aimed at addressing 
structural issues that contribute to a lack of capacity in 
mental health-care systems. This includes grant programs to 
increase access to community-based mental health care. And the 
Health Resources and Services Administration, within HHS, is 
managing several programs that provide funding intended to 
increase the mental health workforce.
    Finally, there are Federal efforts focused on issues with 
health plan administrative approval processes. The Departments 
of Labor and HHS are taking steps to enhance their oversight of 
the use of non-quantitative treatment limits by behavioral 
plans, such as requirements for prior authorization. This is 
part of their broader responsibility to oversee compliance with 
mental health parity laws. These laws generally require that 
coverage of mental health treatment be no more restrictive than 
coverage for medical or surgical treatment.
    This concludes my prepared statement, and I would be 
pleased to respond to any questions the committee may have.
    [The prepared statement of Mr. Dicken appears in the 
appendix.]
    The Chairman. Thank you very much, Mr. Dicken.
    Dr. Keller?

 STATEMENT OF ANDY KELLER, Ph.D., PRESIDENT AND CEO, AND LINDA 
PERRYMAN EVANS PRESIDENTIAL CHAIR, MEADOWS MENTAL HEALTH POLICY 
                     INSTITUTE, DALLAS, TX

    Dr. Keller. Chair Wyden, Ranking Member Crapo, and members 
of the Senate Finance Committee, thank you for your leadership 
on these issues, including the excellent work of the committee 
gathering feedback from across the country and putting 
actionable policy ideas that you summarized in the report that 
was just released by the committee.
    My name is Andy Keller. I lead the Meadows Mental Health 
Policy Institute. We are dedicated to helping Texas and the 
country move forward the availability and the quality of 
evidence-driven mental health and substance use care. I want to 
thank you also for setting aside this hearing to focus 
specifically on the harms caused by the dramatic lack of parity 
today in mental health and substance use disorder benefits 
across the country, and for bringing us together to look at 
solutions.
    As I describe in more detail in my written testimony, we 
all need to come together. It is going to take providers, 
health purchasers, insurers, regulators, and people and 
families affected by mental illness and addiction to address 
these issues. But we also need action by the Federal 
Government. It is essential for creating the infrastructure 
nationally that we need to move out of this decades-long 
quagmire.
    And, Chair Wyden, you described well that our behavioral 
health today is worse than it has ever been, and the pandemic 
made it worse. Suicide is currently the fourth-leading cause of 
loss of life years. Overdose deaths claim even more people and 
increased by almost a third during the pandemic. During last 
year, the Surgeon General offered an unprecedented first-ever 
public health advisory focused on the mental health of the 
Nation's youth, and these consequences fall hardest on Black, 
Indigenous, Hispanic, and other people of color who too often 
receive inequitable and less culturally responsive care.
    There are really two reasons why we are in this mess. 
First, we have dramatically cut spending on behavioral health 
over the last 40 years. The cuts started in the 1990s, and 
today we spend 20 percent less compared to the rest of health 
care on mental health than we did before these cuts and these 
aggressive mechanisms that Mr. Dicken described quite well were 
put into place.
    The other reason is that we have failed, until recently, to 
begin to actually enforce those parity laws that five 
successive presidential administrations put into place, dating 
back to the Clinton administration. And continued enforcement 
is essential. Just to give you a couple of the outcomes of the 
impact of the nonquantitative treatment limitations--which is a 
mouthful, but it is an important thing for us to focus on--Mr. 
Dicken described how commercially insured people are five to 
six times more likely to use out-of-network care because of the 
limitations that were just described. And when we look at 
reimbursements, it is not hard to see why. Reimbursements for 
mental health are consistently 20 percent lower than benchmark 
reimbursements for other specialties and for primary care.
    And these barriers have to be addressed by all of us coming 
together. It is not going to be enough just to have regulatory 
enforcement. We are also going to need to increase the 
infrastructure for primary care-based interventions like 
collaborative care.
    I want to just focus on three solutions. There is more 
detail on these in my written testimony. The first is that 
enforcement does need to continue. Laws are not enough. We can 
have a speed limit, but unless it is being enforced, people are 
not going to obey it. And that has only been going on really in 
earnest since late last year.
    It is also going to require more effort there and 
additional funds to expand the breadth of those efforts. We 
would also like the Department of Labor to be vested with the 
authority to assess civil monetary penalties for parity 
violations, and we would also like to see ERISA amended to 
provide the DOL with authority to directly pursue parity 
violations by entities that provide administrative services to 
ERISA-group health plans. That sort of expanded enforcement 
needs to continue, and it needs to be broadened.
    The second thing is, the parity protections should be 
extended to Medicare beneficiaries. The data suggests that the 
failures of commercial plans apply as much or more so to 
Medicare beneficiaries, especially the lack of available 
providers. And there are also numerous gaps in the Medicare 
mental health and addiction benefits that are not faced by 
people with commercial coverage, or with Medicaid in most 
States.
    And the most important thing that Congress can do would be 
to launch an emergency initiative to bolster the capacity of 
primary care to effectively serve more Americans and relieve 
the pressure on specialty networks. Integration works, and it 
is really our only path forward. While insurers do need to do 
more, they cannot on their own--no matter how much we regulate 
and enforce--fix a misdesigned health system. Today we fail to 
detect and treat needs until 8 to 10 years after they emerge. 
The Collaborative Care Model which was described can leverage 
the availability of psychiatrists 3.5 times over. The Primary 
Care Behavioral Health model can leverage other licensed 
practitioners 2.5 times over. Both are currently covered by 
Medicare or almost all commercial payers and most Medicaid 
plans. But no single payer can do this. It is going to take an 
infrastructure investment. The RAND Corporation has laid it out 
in a study last year that showed how to do this. There is 
existing legislation filed in the House by Representatives 
Fletcher and Herrera Beutler that could form the basis for 
this. It is legislation that every medical association 
supports. It would need to be broadened to include primary care 
behavioral health, and expanded many times over--probably in 
the hundreds of millions of dollars--to have the breadth 
needed.
    We are doing this in Texas now: $20 million put up to get a 
third of the State through those reforms. This will be the 
standard of care in 20 years. But if we wait that long, we are 
going to lose 2 million more Americans to suicide and overdose.
    Thank you for the opportunity to be here today.
    [The prepared statement of Dr. Keller appears in the 
appendix.]
    The Chairman. Dr. Keller, you may not have seen it, but 
when you mentioned expanding coverage for Medicare folks, 
everybody was nodding their Adam's apple off. So thank you for 
that and for your leadership.
    Dr. Ratzliff?

STATEMENT OF ANNA RATZLIFF, M.D., Ph.D., CO-DIRECTOR, ADVANCING 
     INTEGRATED MENTAL HEALTH SOLUTIONS (AIMS) CENTER; AND 
        PROFESSOR, UNIVERSITY OF WASHINGTON, SEATTLE, WA

    Dr. Ratzliff. Thank you, Chairman Wyden, Ranking Member 
Crapo, and thank you to the committee for conducting this 
hearing today. My name is Dr. Anna Ratzliff. I am a 
psychiatrist and professor at the Department of Psychiatry and 
Behavioral Sciences at the University of Washington. I have 
personal experience with the providers delivering integrated 
care, and I am the co-director of the AIMS Center, which has 
implemented a model of integrated care, which has been talked 
about today, the Collaborative Care Model.
    As a member of the American Psychiatric Association, I have 
partnered closely with the APA to promote this model through 
policy and advocacy. Effective integrated care is an important 
solution to our current health-care crisis, as everyone is 
talking about.
    The Collaborative Care Model is a specific model of 
integrated care developed at the University of Washington to 
treat common mental health conditions such as depression and 
anxiety in primary care settings. This model is evidence-based, 
with over 90 validated studies showing its effectiveness, and 
has been recognized by the Centers for Medicare and Medicaid 
Services with specific billing codes that were introduced in 
2017.
    I believe the power of integrated behavioral health care, 
and specifically the Collaborative Care Model, is best 
illustrated through patient voice. Daniel was one of my 
patients who has given me permission to share his story. Daniel 
is a young adult who had been struggling with untreated mental 
health conditions since he was an adolescent, and these 
eventually led to a suicide attempt. He finally sought 
treatment through his primary care provider, and on his first 
visit she recognized that he was struggling with mental health 
symptoms and connected him that day to a behavioral health-care 
manager whose office was just down the hall.
    Daniel was able to walk with his PCP to meet this 
behavioral health provider, and later scheduled an intake 
appointment within the same week. As a psychiatric consultant, 
I was able to review his case within a few days, and during my 
regular meetings with my behavioral health-care manager. My 
consultation was done using telepsychiatry, since my office was 
not located in that primary care setting. And this approach 
allowed me to review multiple patients in the clinic in the 
time that it would normally take me to only see one patient.
    Although I did not see Daniel in person, we were able to 
determine his diagnosis, and I provided recommendations around 
medications to be prescribed by his primary care provider, and 
for behavioral interventions to be delivered by his behavioral 
health-care manager right there in primary care, where he was 
comfortable being able to get care. Within weeks, he was 
feeling better. And he enrolled in a local community college. 
He eventually was able to successfully complete his training 
and become a medical assistant.
    This example is important because Daniel said that he never 
would have sought mental health care if it had not been so 
seamlessly available in his primary care setting. And his 
mother feels that this access saved his life.
    As you can see from this patient's experience, integrated 
care has several important features. Patients can receive care 
without the need for referrals, which frequently can take 
months and often results in patients not being able to receive 
any care. More widespread use of the Collaborative Care Model 
can help alleviate some of the portion of the mental health 
workforce shortage that was mentioned in the preceding 
testimony.
    As a team-based approach, this model leverages expertise 
like mine as a psychiatric consultant to support 60 to 80 
patients in as little as 1 to 2 hours a week. Innovative care 
allows for the early diagnosis and intervention of mental 
health conditions and has proven to reduce suicidal ideation 
and prevents emergency room visits and hospitalizations.
    Additionally, this model has demonstrated effectiveness in 
addressing the behavioral health needs of special populations. 
This model has been able to be delivered in rural settings, 
often using telehealth to bring psychiatric expertise to these 
communities.
    The Collaborative Care Model is also an important strategy 
to improve behavioral health equity. Studies that compare 
depression outcomes in BIPOC and White patients who receive 
treatment with the Collaborative Care Model show either 
equivalent or significantly better outcomes for the BIPOC 
patients.
    Finally, expanding the use of the Collaborative Care Model 
can also help reduce health-care costs. Studies have 
demonstrated that for every $1 spent on the Collaborative Care 
Model, about $6\1/2\ in total health-care costs are saved in 
the subsequent years.
    Although the implementation of the Collaborative Care Model 
makes sense, the requisite startup costs have proven to be a 
barrier to its adoption by primary care practices. I encourage 
the committee to consider the following policy recommendations 
endorsed by the APA to further the adoption of the 
Collaborative Care Model.
    Fund primary care offices to assist with the implementation 
of the Collaborative Care Model. Eliminate the cost-sharing 
requirement under Medicare to remove an additional barrier for 
patients and Medicare beneficiaries. Increase the current 
reimbursement for CPT codes for the Collaborative Care Model to 
more appropriately reflect the value and benefits of services 
and care being provided.
    In closing, I want to reiterate how encouraged I am by the 
bipartisan, bicameral support we have seen from Congress, and 
in particular this committee, regarding addressing our most 
pressing mental health and substance use disorder needs.
    Thank you.
    [The prepared statement of Dr. Ratzliff appears in the 
appendix.]
    The Chairman. Thank you very much. We are going to look 
forward to working with you.
    Mr. Williams?

     STATEMENT OF REGINALD D. WILLIAMS II, VICE PRESIDENT, 
     INTERNATIONAL HEALTH POLICY AND PRACTICE INNOVATIONS, 
               COMMONWEALTH FUND, WASHINGTON, DC

    Mr. Williams. Good morning. Thank you, members of the 
Senate Finance Committee, for inviting me to speak. Chairman 
Wyden, Ranking Member Crapo, you have both been leaders on this 
pressing issue. Your bipartisan commitment will advance 
solutions for people in need.
    I am Reggie Williams, and I lead the international program 
at the Commonwealth Fund. I also co-lead our work on behavioral 
health. For over 10 years, I have volunteered my time in the 
mental health community, currently serving on the boards of the 
Youth Mental Health Project and The Fountain House. In the 
past, I have chaired the board of Mental Health America. My 
focus has been on improving systems that people and their 
families must navigate to achieve the lives they want to live.
    I testify today not only as someone who has spent 20 years 
in health policy, but also as a Black man who strives to manage 
his own mental health. We all know there is a behavioral health 
crisis in the United States. The crisis is nationwide, without 
regard for political affiliation, class, or education. It is 
particularly acute for economically disadvantaged and 
historically excluded communities.
    At the core of the crisis is unmet need. There have been 
incredible strides with the Affordable Care Act, but 
yesterday's Senate Finance Committee bipartisan report, the GAO 
report, definitively details the unmet needs and barriers, 
especially for Black and Latino people, youth, and Medicare and 
Medicaid beneficiaries.
    The problem is big and complex. However, I believe we have 
the tools to make meaningful change in people's lives. There 
are three things that we can do.
    First, integrate mental health and substance use care with 
primary care. Two, expand and diversify the behavioral health 
workforce. And three, leverage the potential of health 
technology.
    Integration: Expanding the capacity of primary care 
providers through integration increases access. Studies show 
that patients view primary care providers as trusted sources of 
information. That can combat stigma. Integration offers a 
solution that includes everything from consultation, co-
location, and patient-centered 
decision-making goals. It also helps when we think of this 
integration across a broad continuum. Innovative payment 
approaches can continue to support integration through new fee-
for-service billing codes, care management payments, bundled 
payments, and primary care capitation. As policymakers 
contemplate ways to support CMS in the States, there are many 
promising models to consider. As I stated in my written 
testimony, the Southwest Montana Community Health Center, a 
Federally Qualified Health Center in Butte, MT, links people to 
counseling and community programs, and has demonstrated 
substantial reductions in substance use. Another is addressing 
social isolation through psychosocial rehab by connecting 
people with serious mental illness to primary care, psychiatric 
care, and home and community-based services. This approach has 
reduced hospitalizations and decreased costs for Medicaid.
    Expand and diversify the workforce: The evidence supports 
including a wider array of providers and behavioral health-care 
teams. Trained and accredited peer support specialists leverage 
their lived experience to engage people and reduce substance 
use and the use of hospitals and emergency rooms. Community 
health workers have demonstrated that every dollar invested in 
a community health worker returned nearly $2.50. Further, 
engaging peers and community health workers who are 
representative of the communities in which they live can be an 
important way to address stigma.
    Another example has been seen in the introduction of new 
types of providers like the general practice mental health 
worker. They have been successful in the Netherlands, where 
they have been integrated into primary care and have prevented 
exacerbations of mental health.
    Despite improved outcomes and cost savings, most Americans 
do not have access to the providers I mentioned. To remedy 
that, there is an opportunity to implement financial 
incentives, support efforts to recruit and retain, implement 
learning collaboratives and quality improvement initiatives, 
and ensure insurance coverage for a broader workforce, 
including peers in the Medicare program.
    Leveraging health technology: During the pandemic, the use 
of telephone and online platforms skyrocketed. In additional, 
digital health tools have received unprecedented investment and 
can help solve the provider shortage. On the other hand, we do 
not want to champion the use of tools that are ineffective or 
inaccessible for beneficiaries, especially for people facing 
the greatest barriers, such as rural Americans or people with 
disabilities. It is critical that the expansion of health 
technologies be undertaken with universal and equitable access 
in mind. As Congress and the Biden administration weigh options 
for extending telehealth flexibilities, it will be essential to 
ameliorate rather than exacerbate these disparities. It is also 
noteworthy that the temporary continuous coverage requirement 
that kept Medicaid coverage intact during the public health 
emergency helped to ensure access to these services.
    In conclusion, as I stated, the problem is big and complex, 
but we have the tools to improve lives, especially for youth, 
people with serious mental illness, those in rural communities, 
and historically excluded Black, Latino, and Indigenous 
communities. In the coming months, we can work together to 
implement bipartisan policies to expand access to equitable and 
affordable care. Our communities will be stronger for it, and I 
believe we can be better.
    Thank you.
    [The prepared statement of Mr. Williams appears in the 
appendix.]
    The Chairman. Mr. Williams, thank you. And thank you all 
for very valuable testimony.
    Let me start with you, Mr. Dicken. And I very much 
appreciate your helping our investigators work through this 
bizarre array of ghost network practices that are just flagrant 
rip-offs, in my view. And I wanted to ask you about one 
instance. You basically, working with the various studies, 
found that in 83 percent of the instances within your report, 
families would try to get an appointment for a child with an 
adolescent psychiatrist, and they could not get one.
    So my first question to you is, is that sort of thing 
common?
    Mr. Dicken. Yes; thank you, Chairman Wyden. And you are 
right that we did find in multiple studies and heard from many 
stakeholders concerns about those provider directories not 
being accurate, calling them, in some cases, ghost networks. 
And so we heard across, whether it was Medicaid plans, private 
insurance plans, Medicare plans, in multiple cities, problems 
that many providers listed in a directory would not be 
available for new patients, or not available at all.
    The Chairman. Very good. We will also say for shorthand, it 
is common, because it is clear that is what you said.
    All right; Dr. Ratzliff, ghost networks. Have you seen 
these kinds of practices, Dr. Ratzliff?
    Dr. Ratzliff. Yes, I unfortunately have had patients who 
needed to seek care and would go to their provider directory, 
call sometimes 30 or 40 providers, and be told that there was 
no access, no availability, be put on wait lists, or just never 
hear a response. And this often resulted in people not being 
able to access the care that they needed.
    The Chairman. So you would call, in these kinds of 
instances, something like this nothing resembling parity?
    Dr. Ratzliff. Nothing resembling parity. You could go out 
and get a primary care provider in those practices, in those 
insurance panels, but not access to mental health care.
    The Chairman. All right.
    Dr. Keller, why is this happening? What is the problem? 
Because I personally think this is making a mockery, a mockery 
out of the parity law, based on what we just heard from Mr. 
Dicken and Dr. Ratzliff. Why is it happening?
    Dr. Keller. It is happening for two reasons. One, we are 
not paying on par. The studies clearly show that the insurers 
are paying 20 percent less in reimbursement compared to other 
specialty care and primary care. So they are not paying enough. 
And that is why people who want to pay cash, who will pay more, 
are somehow magically able to get people.
    The second thing is the administrative hassle. The thing 
that the non-quantitative treatment limitations do is, they 
make it a hassle. And that is the other reason why people only 
take cash: they do not want to have to fill out all that 
paperwork. They do not want to have to have people call 
multiple times to get authorizations. They do not want to be 
harassed. So the administrative burden and the lack--I mean, it 
is not rocket science. It is two things that are driving this 
down.
    The Chairman. But isn't part of it that nobody is holding 
these giant insurance companies accountable? Because I think 
you heard me describe the situation at Oregon Health and 
Science University. Now, I go up there regularly, as we all do, 
to talk to our universities, and talk to the practitioners, and 
they basically said they could not get the claims paid. I said, 
``Oh, I bet some of it has to do with the challenge during the 
pandemic; folks were worried about COVID, and you could not get 
workers, and folks would leave for other fields.''
    And we all kind of thought about it, and I said I was going 
to open this GAO inquiry, which Mr. Dicken knows is what has 
led to this effort this morning. And after there was a small 
newspaper story--this was not like a headline everywhere--a 
small newspaper story saying we were going to have an 
investigation here into whether the parity law was really being 
complied with, and OHSU got a gusher of payments within a 
matter of weeks. And you do not know really whether to laugh or 
cry, because we are glad that folks got reimbursed, but we 
cannot say that every single Senator in this body is going to 
suddenly take the place of enforcers.
    We have to get these insurers and these agencies and people 
who are supposed to carry out this law to get off the dime and 
get serious about this. Because as far as I can tell, the big 
insurance companies are just muscling everybody around with 
their excuses and this parade of reasons why they should not 
have to comply with the law that is 13 years old.
    In fact, I heard one statement from one of them saying, but 
we are still working through what the law is about. What a 
bunch of baloney! After 13 years--and Senator Wellstone and 
Senator Domenici had a good law. My brother was a 
schizophrenic, and we saw it for years and years. The Wyden 
family would go to bed at night worrying about whether my 
brother was going to hurt himself or somebody else. And when we 
passed the law of Senator Wellstone and Senator Domenici, I 
said this was going to be a new day for everybody else, every 
other family that was dealing with these issues, but we are in 
the same position today because of these insurance companies 
muscling everybody around and figuring out excuses for not 
complying with parity.
    So, we are going to get to the bottom of it. You all have 
been great.
    My friend, Senator Crapo.
    Senator Crapo. Thank you, Mr. Chairman. And to you and to 
our witnesses, I have to step out for a quick meeting, so I 
only have a chance for one quick question here, and I think I 
will choose you, Dr. Keller. I could ask this to any of you, 
but we have heard a lot of discussion today about the 
Collaborative Care Model. Could you just describe in a little 
more detail, get down in the weeds a little bit? What is the 
Collaborative Care Model and how does it work?
    Dr. Keller. I am happy to. So the Collaborative Care Model 
basically puts a behavioral health-care manager in the primary 
care practice. So it is to help the primary care doctor be able 
to carry out the additional procedures that are necessary to 
assess, diagnose, and treat mental health and addiction 
disorders within primary care. So it is just like the doctor 
now has a nurse, and he can go and take your blood pressure, 
and he can take your temperature, and that helps the doctor out 
so she can do her part.
    The behavioral health-care manager basically extends the 
ability of the primary care provider to do those in-office, and 
it works just as well with virtual presence through telehealth 
as it does through in-person.
    And then there is also a psychiatric consultant to help 
with medication questions. And that psychiatric consultant 
reviews what is going on, is there to help support the primary 
care doctor, so the primary care doctor can treat--upwards of 
70 percent of mental health conditions can be treated 
successfully in primary care with the same or better outcomes 
than specialty care with those two supports.
    And then the other thing is, they have special data systems 
to track people. Because what happens is, if you have 
depression, sometimes you do not take your meds. Sometimes you 
do not come back to your appointment, and somebody needs to 
make sure you do not fall through the cracks. And so the 
registry and the tracking system, the care manager uses to make 
sure the person does not fall through the cracks.
    Senator Crapo. So this obviously involves additional 
providers and additional staff in a traditional doctor's 
office, if you will. Correct?
    Dr. Keller. I would say, Senator, that it is a redeployment 
of staff into them. We do not need more people to do this; we 
need them redeployed in the primary care settings.
    Senator Crapo. All right. And so does this mean, though, 
that there is a need for us to change either the mandates or 
the incentives, or what have you, in the insurance markets? Or 
does it mean--and I think Dr. Ratzliff talked about this--that 
we need to change the reimbursement policies in Medicare and in 
other 
government-run health-care systems? Is that piece of it, the 
finance side of it, something that we need to be able to tool 
up?
    Dr. Keller. There could be some tweaks to that, but 
basically once it is up and running, payment mechanisms in 
commercial care and Medicare and most Medicaid plans currently 
cover it somewhat adequately. But what they do not cover are 
the startup costs, and they do not cover the technical 
assistance needed to convert a practice quickly. So it is 
really getting over that hump of startup where we require 
additional investments.
    Senator Crapo. Well, thank you. I am going to have to run. 
I will be right back soon, Mr. Chairman.
    The Chairman. Thank you, Senator Crapo. We are going to be 
working on all of this together.
    Senator Stabenow is next.
    Senator Stabenow. Well, thank you so much, Chairman Wyden 
and Ranking Member Crapo. It is just a very exciting time for 
those of us who have worked a long time on mental health issues 
to see the focus on this committee--thank you so much--and to, 
frankly, see the focus in President Biden's budget, which is 
the strongest focus on investments in mental health and 
addiction I think ever. So that is exciting as well. And I did 
want to say, as the person who was honored to offer the 
amendment to the Affordable Care Act to implement the 
Wellstone-Domenici mental health parity language, it is 
shocking to me to see that we still do not have this after all 
of this time.
    But I want to thank all the witnesses. You have done a 
great job explaining why integrated behavioral health care is 
so very important. And I think for us, we have to make it clear 
that integrated health care is much more than a buzzword or the 
name of a new payment model. It really is a system-wide 
transformation that we need to make happen. It requires funding 
community behavioral health care the same way we fund physical 
health care in the community. For far too long, behavioral 
health care has been funded through grants and inadequate 
reimbursements where providers were paid for an individual 
service but not for the broader range of services that address 
the patient's full range of needs, like community health 
centers are reimbursed for.
    So the good news is, this is changing. And I want to again 
commend President Biden for including in his budget, for the 
first time, an extension across the country to all States for 
our bipartisan, evidence-based Certified Community Behavioral 
Health Clinics. And these clinics see everyone who walks in the 
door. They are open 24/7, 365 days a year, which is so 
important--mobile crisis stabilization, check-in visits with 
peer support, specialists treating mental health and substance 
abuse, working with hospitals, primary care, veterans groups, 
everybody in the community. So what we need to do is make sure 
we are fully moving forward on this model.
    So, Dr. Keller, I know Texas has nearly 40 Certified 
Community Behavioral Health Clinics. Can you talk about the 
role of these clinics in improving access to behavioral health 
care in Texas? How is the model working in your State? And 
then, what would it mean to Texas to be able to fully 
participate in the fully funded program that Senator Blunt and 
I have been leading, but so many members of our committee, 
including your own Senator from Texas, are co-sponsoring?
    Dr. Keller. Well, thank you, Senator Stabenow. And thank 
you for your leadership on this, and for Congress's leadership, 
because it is a critical model. In fact, it is so effective and 
so important that we have moved it forward with 38 of our 39 
community centers in Texas, despite not being one of the eight 
States that had the sort of easier path to do that. And we put 
it together with sort of--and it is super effective. And I 
mean, just think about it. A lot of times our community 
behavioral health centers are really the only provider in a 
region in our rural areas. So not only are they a bulwark for 
the service to people with severe mental illness, with 
addiction, but to folks with less severe concerns in the 
community. And it is very important that that be undergirded.
    I mean, the real challenge we have is funding. And we have 
been able to do that through a hodgepodge of our 1115 waiver, 
with some interesting negotiations with CMS--and the grant 
programs that were extended under the pandemic were very 
helpful. But that sort of funding is insecure. It is a constant 
battle to figure out how we continue to do this, and the type 
of direct Federal funding that HQFCs currently have is what we 
need.
    And it really is, I believe, Senator, a parity issue; that 
we need to put these behavioral health treatments on par. I 
think we saw during the pandemic how hard it was to get funding 
out. You and Senator Cornyn had to team up to get those funds 
out there and to provide relief funds to behavioral health 
providers, because there are not those direct paths. And that 
patchwork of funding is a barrier at multiple levels, but the 
model itself is extremely effective, including by bringing 
addiction treatment into the integration, which is essential.
    Senator Stabenow. Well, thank you. And it really is. If we 
are to have full parity, we have to have parity in 
reimbursement. We have to have parity in funding. And that is 
what this does. It says the wonderfully successful Federally 
Qualified Health Centers model that everyone supports, strong 
bipartisan support, is now going to be applied on the mental 
health and addiction side.
    And in so many places, I know in Michigan for sure, they 
are located at the same place. They are fully integrated, which 
I think really is the goal for us: to be able to serve our 
people in the community.
    Let me speak just a little bit more. We have heard from all 
of you about the fact that many private health plans are still 
not providing mental health parity, not moving forward on this. 
I strongly support the administration's efforts to crack down 
on this. We need to do more. We need to enforce the laws on the 
books so that Americans can get the care they need.
    But I think we also have to do more. You have talked about 
Medicare, which is very important. I know it is also included 
in the President's budget, to include making sure that Medicare 
beneficiaries have access. They have to have the best type of 
providers as well, which goes to the question of workforce. And 
that is an area that Senator Daines and I are working on in 
this committee.
    So we have a bipartisan bill--I have a bipartisan bill with 
Senator Barrasso to add licensed professional counselors and 
therapists to the Medicare program and increase access to 
licensed clinical social workers, for example. Also, I am very 
supportive of Senator Cortez Masto's and Senator Cornyn's work 
to expand access to peer support specialists.
    So, Mr. Williams, could you talk about the importance of 
counselors, peer support specialists, clinical social workers 
in the mental health workforce area, and why a strong workforce 
can help us achieve real parity?
    The Chairman. This will be the last question on this round. 
It is a very important one. We just have 20 members all waiting 
to ask questions. Mr. Williams, respond, if you would, to 
Senator Stabenow.
    Mr. Williams. Thank you, Senator, for that question. Peer 
support specialists and community health workers are vital 
resources to expand the workforce. As we have discussed, the 
need is quite wide. And these individuals and professionals who 
are peers, are community health workers, can expand the 
availability of resources and supports. We see that in places 
where you cannot have someone necessarily co-located or 
integrated in a full model that can be intensive. But just 
having one or two additional people that a physician can turn 
to, to refer an individual to to get services, can be very 
important.
    Our data show that those individuals who are delivering 
those services actually meet people's needs in a wide variety 
of ways by being individuals who can be concordant with their 
needs. They understand the experience that they have had, and 
they can then refer them to services to get them out of the 
situation that they are in. And so, when we think about the 
expansion of the workforce, adding things like care management 
payments, bundled payments, primary care capitation, are all 
ways in which these expanded workforce individuals can be paid 
and reimbursed in our current system.
    The Chairman. Very important, and I strongly support 
Senator Stabenow's work on this critical issue.
    Our next members--and we will see who is online and who is 
here--would be Senator Grassley, Senator Cantwell, and Senator 
Cornyn.
    Senator Grassley, are you online?
    [No response.]
    The Chairman. Senator Cantwell?
    [No response.]
    The Chairman. Senator Cornyn is here. We welcome him. 
Please.
    Senator Cornyn. Thank you, Mr. Chairman.
    Dr. Keller, I am looking at some of the statistics with 
regard to self-injury and suicide among children, particularly 
given the terrible circumstances of the pandemic, the 
isolation, the anxiety over being able to put food on the 
table, jobs, and the like. It had a particularly heavy toll on 
our children. In the first half of 2021, children's hospitals 
reported cases of self-injury and suicide in children ages 5 to 
17 at a 45-percent higher rate than during the same time in 
2019. I know that in Texas, 12 publicly funded medical schools 
have come together for the Texas Child Mental Health Care 
Consortium to provide telehealth services to children at 
school.
    Can you talk a little bit about the importance of 
leveraging technology like telehealth in order to deliver those 
services, and the challenges we have across the economy in 
terms of trained workforce to be able to provide the access 
that we would all like to see expanded and provided?
    Dr. Keller. Certainly. Thank you, Senator, for that 
question. And that Texas experience, I think, has been 
instructive by the way we brought all 12 medical schools 
together. And really that is where most of our child 
psychiatrists and our child fellows are. So we only have a 
couple of hundred child psychiatrists in Texas, and being able 
to bring more of them together through that network was 
essential. And we did it through telehealth.
    And right now, that telehealth network is available for 
real-time urgent care requests in hundreds of districts across 
Texas, reaching over 2 million of the 5 million school-aged 
children we have in Texas. And we were able to stand that up 
during the pandemic through legislative funding, and we were 
able to have that be Statewide.
    And it is critical that we not just have UT Southwest or 
Baylor College of Medicine and Dell involved, but also UT 
Tyler, and Texas Tech El Paso, and Texas Tech Lubbock being 
able to reach out, because they know their communities, and 
telehealth allows them to get to those schools and do those 
real-time urgent care visits. And we were also able to use ARPA 
funds allocated by the last legislature, the Texas legislature, 
to expand that. So now it is not just urgent care, but we are 
actually able to do more routine care. And it has been 
essential.
    It is essential too, because it provides supports in 
primary care. And I would say that those emergency room 
statistics you talked about, when we talked with--working very 
closely with Children's Health in Dallas, the priority they 
have put in terms of what is the best way to reduce pressure on 
the emergency room is primary care interventions. It is 
basically leveraging those primary care networks, helping them 
do more so that children do not end up having to get in the 
situation where they end up in our emergency rooms.
    Senator Cornyn. And of course, I mentioned the work that 
the Meadows Institute is doing on the Lone Star Depression 
Challenge. Depression, as you point out, can affect people 
periodically at different times. Unfortunately, we have seen, 
particularly among our veterans population, the self-medication 
that makes things actually worse rather than better.
    We know that about 60 percent of the people who die as a 
result of a gunshot are suicides. And it strikes me that 
untreated depression is a real public health emergency and 
challenge. Could you talk a little bit about the Lone Star 
Depression Challenge and what lessons that you have learned so 
far that would be helpful to inform Federal policy?
    Dr. Keller. Yes, Senator. Thanks for asking about that. 
Well, basically what Dr. Ratzliff described, the Collaborative 
Care Model, we borrowed that from our friends in Washington 
State, and a leading philanthropist in Texas whom you know 
well, Deedie Rose, the Meadows Family, and most recently Lyda 
Hill, have basically put in $20 million to allow us to work in 
partnership with Texas medical schools to bring health systems 
across the State into overcoming those startup costs.
    Basically, they are funding the startup costs that Dr. 
Ratzliff described. And by the end of 4 more years--we are 
about a year into it, and within 4 years, we are going to have 
a third of the State able to access Collaborative Care. And 
right now, Baylor Scott and White Health System is furthest 
along in that. And in the first several clinics they have, they 
serve actually several hundred thousand people a year. We have 
seen depression outcomes go from 15 percent remission to over 
60 percent within the first year, because it works.
    And so, it is the startup costs, and that is really what 
Texas philanthropists have come together to do through the Lone 
Star Depression Challenge. And we are very appreciative.
    Senator Cornyn. You and Dr. Ratzliff talked about the 
Collaborative Care Model, but we have found multidisciplinary 
teams very helpful in other areas like law enforcement, and I 
mentioned the Right Care Program, and Dallas has a great model. 
A concern of mine has been, for a long time--and I think we all 
share this concern--is people who are suffering a mental health 
crisis are a danger to themselves and the law enforcement 
officials who encounter them. Because when 911 is called, they 
obviously--the police are not always trained to deescalate the 
confrontation and to make sure that the person who is in crisis 
is actually diverted to appropriate mental health care.
    Could you just briefly--because I know time is limited--
comment on how you think that model is working? And is this 
something that we could continue to share with other parts of 
the country?
    Dr. Keller. Yes, Senator. I think it is similar actually to 
the CAHOOTS model that Chair Wyden talked about. By pairing 
paramedics and mental health professionals together, we can 
reach more people.
    The way we do it in Dallas with the MDRT models is, we have 
them directly partner with law enforcement as well, so they can 
respond to any 911 call. And we now have taken that citywide, 
and we are seeing not only are arrests very low, but less than 
2 percent of folks actually end up in jail. Most of those folks 
actually had outstanding warrants. So people were looking for 
them. So very few people end up in jail. But also, very few 
people end up in the hospital, because the teams use community 
paramedicine to be able to provide follow-up care and make sure 
people get to their appointments and get the care they need.
    So it is basically taking the community paramedicine model 
to mental health folks with mental health needs.
    Senator Cornyn. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Cornyn. And thank you 
again for your help in this whole effort.
    What is important about CAHOOTS--and I will just be very 
brief--is this is a chance to bring mental health folks and law 
enforcement folks together. You know, what we did as we started 
it in Oregon is we said, ``Look, the big challenge here is to 
make sure that the professionals in these fields are able to do 
what they were trained to do.'' That is what I heard 
consistently from mental health folks and law enforcement 
people.
    Obviously, if there is violence taking place, you need to 
make sure the community gets an added measure of safety, and 
that is a law enforcement role. And that is what we know, which 
you all have told us. So many of the instances on the streets 
are mental health issues. And what is striking--and I want to 
commend my colleagues. Senator Booker has been very interested 
in this idea from the very beginning, and Senator Scott has 
been very interested in this idea.
    So I think we have a chance to bring together something of 
a coalition around these issues, and that is what we are going 
to try to do on mental health more broadly in this committee. 
But I appreciate you bringing up CAHOOTS, and for Senator 
Cornyn having you up here.
    Senator Grassley, I think you are next in line based on 
arrival.
    Senator Grassley. I have a long lead-in for a question for 
Dr. Ratzliff and Dr. Keller. Three years ago, Senator Bennet 
and I of this committee passed the ACE Kids Act to establish a 
pediatric home health for kids with complex medical conditions 
so that dozens and dozens of specialists and doctors can 
coordinate their care, and that coordination is very, very 
important. This October, the Centers for Medicare and Medicaid 
Services will fully implement this act. Medicaid programs will 
have the tools to better coordinate, rather than these families 
facing barriers to care and the red tape that goes with it.
    We know that these kids with complex medical needs are also 
more at risk for mental illness. One study suggests that 38 
percent have mental health diagnoses, and many face challenges 
in accessing mental health care. Their parents are five times 
more likely to have poor mental health issues as well.
    So it is important that CMS implement the ACE Kids Act 
timely, but Congress also has to follow this along with another 
Grassley-Bennet bill, Accelerating Kids Access to Care. It will 
streamline the screening and enrollment process for out-of-
State kids or their providers, and I hope that this bipartisan 
bill would be in the committee's mental health package. The 
bill will improve the mental health of the kids with complex 
medical needs.
    So to you folks: what can the ACE Kids effort learn from 
the collaborative care and coordinated care models, especially 
when trying to improve mental health care for kids with complex 
medical needs? I will start with Dr. Ratzliff.
    Dr. Ratzliff. Thank you, Senator, for that question.
    So Collaborative Care has shown to be an effective model 
for addressing adolescent depression, pediatric ADHD, and some 
of the other common mental health disorders. So implementing 
the Collaborative Care Model in practices that serve our kids 
and children is a very important strategy to increase access to 
that effective treatment. I think also, there is the 
opportunity, especially for children with complex needs, to be 
able to address all of their needs in one place, hopefully 
reducing the burden of their families in really trying to 
coordinate that care.
    Many of my patients comment on the fact that they did not 
have to manage that communication between the different 
providers when that service was all offered together in one 
setting. So I think that is a really important opportunity, to 
reduce that burden of the family really having to coordinate 
the care.
    And also, I think it makes it easier for the providers. We 
know that provider burnout is a really big challenge right now. 
And so, anything that we can do to make that easier for the 
whole care team, I think, is very important.
    Senator Grassley. Dr. Keller?
    Dr. Keller. Well, I would just--Dr. Ratzliff explained that 
well. The only thing I guess I would add is that you have--
right now it takes 8 to 10 years before we reach a child with 
mental health needs with effective treatment. And so, being 
able to broaden this to every pediatric practice--both 
specialty ones that deal with children who have special needs, 
but also every child being able to have access to the 
screening--is essential.
    And it is also important around stigma, which is an issue 
across the board, but also for historically underserved and 
excluded communities, people in poverty. If you have to have 
somebody go back to a second appointment, we are going to 
have--studies show 50 percent of people fall through the cracks 
just by saying, ``Okay, we need you to go see the specialist.''
    So by having all of that there, detecting early, those are 
really the things that make it work. And that is part of, I 
believe, the description of the bill you all are looking at, 
and it also is available more broadly in the Collaborative Care 
Model.
    Senator Grassley. A short follow-up to Dr. Ratzliff. Is 
telehealth for mental health any advantage, or just more access 
but not necessarily filling in?
    Dr. Ratzliff. I think telehealth is a very important part 
of really creating those spectrums of health-care access. I 
think it helps with a couple of things. I think the most 
important thing that it helps with is the redistribution of the 
specialty expertise.
    So a lot of our--as I think Dr. Keller said--a lot of the 
people who are child analysts and psychiatrists work for large 
medical centers, or live in larger cities. So, especially for 
our rural populations, our communities where they might not 
have a child and adolescent psychiatrist for example to 
consult, you can get that expertise through telepsychiatry. And 
that makes a huge difference for patients getting the kind of 
expertise that especially patients with complex needs often 
need, those experts being able to weigh in and provide 
recommendations. And sometimes a single visit can be enough to 
really get the recommendations to a primary care provider, or 
other medical provider, who can then implement that plan.
    And so, it is also a way to, I think, leverage a scarce 
resource, right? So sometimes a single visit might be enough, 
and you do not have to actually have ongoing care as long as 
you are having that care coordinated by the local treating 
provider whom that family already feels comfortable with, 
trusts. And again, that is a big important thing for people 
receiving care, because they often can receive that then from a 
trusted provider.
    Senator Grassley. Can I have one more?
    The Chairman. Of course. Sure.
    Senator Grassley. This will be my last one. I might have 
some for answer in writing. And I do not know to what extent 
you are up on things in rural areas, because I missed your 
opening statement, Dr. Ratzliff, but suicide rates among youth 
have risen over the last decade, and are generally higher in 
rural America. In December, the Surgeon General issued an 
Advisory on Youth Mental Health to draw attention to this 
urgent issue. While the advisory indicates rural youth are more 
at risk, the advisory does not speak to the specific resources 
for rural young people.
    So to you, Dr. Ratzliff: given the lack of rural resources 
provided by the Surgeon General's advisory to improve youth 
mental health, what mental health resources are available for 
rural youth? And if you are acquainted with organizations like 
FFA or 4H, are there possibilities for working through those 
organizations?
    Dr. Ratzliff. Thank you for this question. I think there 
are a couple of models that people are using to try to increase 
access for mental health for youth, and I will give an example 
from Washington State. We have something called the Pediatric 
Consultation Line that allows any primary care provider really 
in Washington State, any pediatrician, to actually get 
behavioral health consultation on patients, get support 
provider to provider, so that those providers that are located 
in rural settings can actually get that kind of support.
    I think the idea of community organizations--and I was 
actually in 4H, so I think it is a great one to think about--
actually there are opportunities there to really think about 
how we maybe make those organizations more aware of how to 
recognize youth at risk. And then often those communities know 
their community and can connect people to care.
    So I think there are opportunities to think about how we 
really engage our community organizations and partner with 
either their local primary care providers, or other services, 
to make sure that anybody who is identified can get the help 
they need.
    Senator Grassley. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Grassley.
    And, Dr. Ratzliff, apropos of your further comments on 
telehealth, just so you know a little bit of the history of 
this committee, not only did Senator Crapo and I team up on the 
audio-only portion of the latest iteration of how to expand 
telehealth, but essentially the way this came to be was, before 
he retired, this committee, under the leadership of then-
Chairman Hatch, produced the CHRONIC Care law, which was the 
first law to acknowledge that Medicare is no longer just an 
acute-care program. It is primarily chronic disease: cancer and 
diabetes and heart disease and strokes.
    Anyway, Senator Crapo remembers the centerpiece, and this 
was something Chairman Hatch deserves great credit for, because 
he worked with Senator Crapo and I. It was completely 
bipartisan--Senator Bennet and Senator Warner--the major 
telehealth provisions in that package. And we were just on our 
way to kind of getting them implemented when Seema Verma, then 
Donald Trump's head of CMS, called us up and said, ``Hey, can 
we use your stuff for essentially the model for the initial 
round of telehealth provisions in CARES and the like?'' And we 
were able, Senator Crapo and I and others, to shoehorn that 
part of the CHRONIC Care law, the telehealth provisions, and it 
really became the Medicare jumpstart for finally getting 
serious about telehealth.
    So when you talk to us about these issues, you have our 
attention. And continue to keep your foot on the pedal because, 
at a minimum, when we are concerned about inflation, it costs 
people a ton of money to fill their gas tank and go out and get 
to a provider. So there are ways to save money here. This is an 
inflation-combating tool.
    All right, let's see where we are. Let me call out to 
others in order of arrival. Senator Cassidy?
    Senator Cassidy. Senator Cassidy is here.
    The Chairman. Senator Cassidy, are you there?
    Senator Cassidy. I am here. Do you have me?
    The Chairman. Wonderful. Let us hear from you.
    Senator Cassidy. Sounds great.
    Dr. Keller, you mentioned the importance of access to 
evidence-based services for those with severe mental illness. 
As we both know, the Coordinated Specialty Care is an evidence-
based suite of services for those with first-episode psychosis. 
And it is part of a mental health reform bill that Chris Murphy 
and I put together in 2016 to expand access, and yet I find out 
that this access is actually quite limited, even though NIH 
verifies that it is just what we should be doing.
    So I have learned, in general, Medicaid will cover parts of 
the continuum, but not a coordinated specialty care 
comprehensive approach; that every State receives SAMHSA 
community health block grant dollars, which are a required set-
aside for first-episode psychosis that could be braided into 
the Medicaid dollar to provide the comprehensive access.
    So I guess my question to you, as being on the front line, 
is why has it been so difficult to implement the Coordinated 
Specialty Care for States and providers? I guess I will start 
with that.
    Dr. Keller. Well, thank you, Senator Cassidy, for bringing 
attention to that. I want to commend SAMHSA for the set-aside 
for first-episode psychosis care. In Texas, we have used that 
to dramatically expand our capacity. The problem is that it is 
primarily available to people who are either uninsured, who are 
served through the block grant, or some people with Medicaid. 
And Medicaid makes it difficult to pay for it because of the 
fragmented funding approach that you talked about.
    So, I think the reforms you talk about and the need for 
Medicaid to have value-based purchasing arrangements, and 
bundled payments to be able to pay for that, would make it 
easier to expand that access. But I think it also needs to be 
expanded to commercial insurance. And this is why parity 
enforcement is essential, because the onset of schizophrenia, 
the onset of severe bipolar disorder, is not limited to people 
without insurance or who are in poverty. People with commercial 
insurance deserve the same access. And I will tell you, today 
we have a two-tiered system in the State of Texas for people 
with Coordinated Specialty Care. We have excellent access for 
people who do not have insurance, and we have almost no access 
for people who do have insurance, unless they want to pay out 
of pocket.
    Senator Cassidy. Well, let me ask you. One, that is very 
troubling, but for those who do not have insurance, what I have 
heard and what I think I heard you say, is that Medicaid and 
SAMHSA do not really work well together. By the way, you can 
thank Congress for making SAMHSA do that set-aside.
    But with that said, they do not work well together. And 
yet, then you said that they actually have excellent access. So 
would you square that for me?
    Dr. Keller. Yes, absolutely. So the work has been done on 
the ground in Texas by Texas providers to basically take the 
set-aside, which--thank you to Congress for doing that, because 
that did make it easier for our providers to stand that up. And 
then they have to do the mind-numbing work at the clinic to do 
that, and not every clinic is able to do that.
    So, the access for uninsured people through the block grant 
is excellent. The access through Medicaid is spotty. And 
really, I do believe you are correct, Senator, that better 
coordination--and I believe the current SAMSHA Assistant 
Secretary is working on that. I think for CMS, it needs to be a 
priority. CMS has so many things going on. If they could 
prioritize this for expedited sort of work, and work on these 
bundled payment arrangements, that would be wonderful.
    Senator Cassidy. Okay.
    Mr. Williams--thank you very much for that--you spoke about 
the mental health of people who are dually eligible for 
Medicare and Medicaid, and that nearly one-third of duals have 
a serious mental illness such as schizophrenia, bipolar, or 
severe major depressive disorder, at a rate three times higher 
than that of the non-dual patient.
    But you know, dual-eligibles have worse outcomes than those 
who are not dually eligible. And my office has been looking at 
this, and we have found if you take a State which does not have 
a dual-eligible population compared to one that does, and it is 
the same type of patient in both States, the academic 
literature suggests that where they do not have two forms of 
coverage, they actually do better. If you will, giving them the 
second form of coverage, dividing the care between the 
incentives for the care, actually ends up making things worse.
    So, any thoughts about that, because the duals do terribly? 
And is part of the problem the fact that they are duals as 
opposed to having only one payer?
    Mr. Williams. Senator, thank you for that question. The 
needs of the duals population are complex. Administrative 
barriers disproportionately deter poor and marginalized 
communities and individuals from receiving health-care 
services. Low-income people who have to work long hours, or 
have limited health literacy, or----
    Senator Cassidy. Well, Mr. Williams, I am almost out of 
time. So let me cut to the chase. Is it possible that actually 
making them a dual, giving them both Medicaid and Medicare 
coverage, although you do it because you want to help, may be 
part of the problem?
    Mr. Williams. Our health-care system is complex. We need 
individuals like patient navigators to really help dual-
eligible Medicare beneficiaries access services. And back to my 
three points that I mentioned in my remarks.
    Mental health services can be integrated at the site of 
primary care. So engaging in that primary care office and 
getting people access to the services and navigating those 
administrative requirements is important. Second, having 
qualified providers like peers, community health workers, and 
others that can be resources for individuals to help them 
navigate the complexity. And then finally, the sharing of 
technology and information. Having data at your fingertips as a 
provider and as a patient are ways that you can navigate those 
complexities associated with being a dual-eligible.
    And we see promising things with special needs plans which 
have been customized to meet the behavioral health needs of 
many individuals.
    Senator Cassidy. I thank you, and I yield, Mr. Chairman.
    The Chairman. Thank you, Senator Cassidy. And, Senator 
Cassidy, before you go, let me just note we very much 
appreciate your leadership on this. Your expertise on all these 
health issues is much appreciated.
    Okay, let's see. The next Senators in line of appearance 
would be Senator Cardin, Senator Lankford, Senator Brown, and 
Senator Daines.
    Senator Cardin, are you out there in cyberspace?
    [No response.]
    The Chairman. Senator Lankford?
    [No response.]
    The Chairman. Senator Brown?
    [No response.]
    The Chairman. Senator Daines? And I understand Senator 
Bennet is available online right now.
    Senator Bennet. Thank you, Mr. Chairman. Can you hear me?
    The Chairman. Yes.
    Senator Bennet. Great. And I just want to thank you and 
Ranking Member Crapo for continuing this incredibly important 
work on mental and behavioral health. I want to thank--I 
listened to some of the discussion earlier, and I just want to 
thank Senator Grassley and Senator Cornyn for their partnership 
on these issues. And I really hope, colleagues, that we are 
able to come together on a bipartisan bill here in the Finance 
Committee on this really important set of issues. I think we 
will. I think we can. And I also want to take the opportunity 
to thank my colleague from North Carolina, Richard Burr. I am 
grateful that we are partnering again to address the important 
issue of parity.
    But before I get to parity, I want to make an observation 
about the integration. Colorado has been working to integrate 
mental health and primary care for years. In 2014, Colorado 
received $65 million in State Innovation Model funds to create 
a coordinated, accountable system of care that improves 
integration of physical and behavioral health services in over 
300 primary care practices.
    While the initiative was a great success, most practices 
were not able to keep their integration work going once the 
Federal funding ran out. And I appreciate the witnesses' 
comments and their testimony about a number of successful 
models.
    I am also interested in models that might not be mentioned 
today. Other community-centered evidence-based models like 
those across my State should receive our support as well.
    So, Mr. Williams, could you comment on the importance of 
centering and establishing these integration effort practices 
with the specific communities they serve in mind? And should we 
make sure that increased reimbursement for integration is 
targeted for more than a handful of models?
    Mr. Williams. Thank you for that question, Senator. And 
yes, I believe that there are many opportunities and ways to 
ensure the integrated model. As was articulated in the 
bipartisan report that was released yesterday, there is a broad 
continuum of ways you can achieve integration. And doing so 
ultimately helps get people access to services.
    Telehealth is obviously a way in which you can assure that, 
where you have a low mental health resource, substance abuse 
resource area, you can get access to providers and other 
individuals who can help those people. And that can be done 
through very simple means like phone and texts. But the 
solutions that I also mentioned are around workforce, around 
expanding the use of technology. They are all ways in which you 
can provide a wide variety of services to individuals.
    I think, when you look at the models that have been 
pioneered by groups like the Cherokee Health System in 
Tennessee, that have federally qualified health-care clinics 
but also have a behavioral health component that is strong 
within their programs, they blend those two resources together 
to provide the services and supports for individuals. And they 
do that in a customized way based upon these individuals' 
needs. And so, we have the payment policies in place through 
bundled payments, through capitations, that could support this 
type of care delivery. Making these investments will help 
increase access regardless of location.
    Senator Bennet. Thank you for that comprehensive answer. I 
appreciate it.
    Mr. Dicken, since the final regulations implementing the 
Federal parity law went into effect in 2014, Colorado has 
worked hard to ensure compliance across our Statewide Medicaid 
managed care system. Last year, Colorado's health financing 
department released a report on how Medicaid parity is faring. 
And I am proud that our Medicaid system is compliant across the 
majority of requirements. But they and our department of 
insurance have both highlighted the difficulty in establishing 
parity for non-quantitative treatment limitations, or NQTLs. 
This includes non-numeric benefit limitations like medical 
necessity criteria, network admission standards, 
preauthorizations, and step therapy.
    In my view, NQTLs largely affect a patient's ability to 
obtain the care they need when they need it. And I believe that 
improved technical assistance and clear guidance from Federal 
agencies like CMS would give States and other insurers the 
tools they need to improve compliance.
    With just the few seconds I have left, Mr. Dicken, in your 
work at the GAO have you found areas where better technical 
assistance and guidance would help improve compliance, 
especially when it comes to NQTLs in plan benefits?
    Mr. Dicken. Thank you, Senator Bennet. You are correct that 
we have heard of a number of challenges that stakeholders have 
in terms of those non-quantitative treatment limits. The 
Department of Labor and CMS have, over time, provided more 
guidance, more frequently asked questions, responses on how to 
address those. But it continues to be a challenge that many 
stakeholders identify, and that the Department of Labor and CMS 
have identified in their investigations. But there continue to 
be non-quantitative treatment limitations that are different 
for mental health than for other medical and surgical services.
    Senator Bennet. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Bennet. I appreciate your 
good work on all of this.
    Our next four will be Senator Carper, Senator Casey, 
Senator Warner, and Senator Cortez Masto. And to give our 
guests a little bit of a situational awareness, kind of a 
brief, it is going to get a little hectic around here, because 
we are going to have votes, and both Senator Crapo and I are 
working on the important Russian trade bill, or cutting off 
normal relations with the Russians. So we will be going back 
and forth. But we are just going to keep this going, and the 
two of us can do that.
    Okay, Senator Carper is next.
    Senator Carper. Mr. Chairman, can you hear me?
    The Chairman. Tom, we cannot hear you.
    Senator Carper. I will try again. Testing, testing. Can you 
hear me now?
    The Chairman. Yes.
    Senator Carper. All right; great. All right, I want to say 
``thank you'' to our witnesses today for your testimony. Before 
I begin, I want to say again, thank you, Mr. Chairman, for the 
opportunity to work with Senator Cassidy on this bipartisan 
working group that focuses on addressing the pediatric mental 
health crisis. I think we have made real progress so far, and I 
look forward to continuing our work on this important issue 
with my co-chair, our good friend Senator Cassidy.
    I think it is clear that COVID-19 significantly exacerbated 
mental health stress on children, and on a lot of adults, 
highlighting our Nation's acute shortage of mental health 
services. My State of Delaware had over 9,000 Delawarians who 
suffered from some sort of depression. However, according to 
the State, our State students who have access to mental health 
resources within schools are 10 times more likely to seek care.
    Last year, the Finance Committee heard testimony, you may 
remember, from the U.S. Surgeon General, who stressed that one 
of the most central tenets in creating accessible and equitable 
systems of care is to meet people where they are. For most 
people, that is right there in schools. Just last week, our 
Secretary of Health and Human Services, Xavier Becerra, and 
Secretary of Education, Miguel Cardona, announced a joint 
department effort to expand the school-based health services.
    It is clear that there is a growing momentum to recognize 
the role that schools already play in ensuring that children 
have the health services and support necessary to build 
resilience and thrive. Investing in schools and community-based 
programs has been shown to improve mental health and emotional 
well-being of children at low cost, a high benefit, and a good 
outcome.
    Mr. Williams, a question, please--and any of the other 
panelists who may want to respond too, but we will start off 
with Mr. Williams. How can we further improve coordination 
between primary care and mental health providers to better 
support our children? Working through school-based services, do 
you see a role for the Federal Government beyond providing 
guidance and tactical assistance to State programs? Mr. 
Williams, please.
    Mr. Williams. Thank you for that question, Senator.
    Senator Carper. You're welcome.
    Mr. Williams. Connecting primary care and behavioral health 
is very important to build a strong connection between the 
providers and community organizations, and this is vital for 
our Nation's youth. The current behavioral health crisis is 
particularly notable for its impact on our Nation's youth. Less 
than half of adolescents with depression over the past year 
reported being able to receive care, and this was even more 
acute in Black and Indigenous People of Color.
    Hospitals are reporting emergency room visits among 
adolescents rising at a high rate. Numerous models that I 
shared in my written testimony show the power of bringing 
community-based providers and organizations close to the 
health-care system to improve access to service and build that 
connection.
    Through integration, expanding the workforce, and using 
technology, we can improve collaborations with community 
service providers. They can be just down the hall, like the 
models we mentioned today, but they can also be a phone call or 
a video-chat away. However, there needs to be appropriate 
financial resources in place to ensure that community-based 
organizations are not awash with references from the health-
care system.
    Integrated approaches need to be a two-way street in which 
the community service organizations and others have resources 
at their disposal to provide this care and need. And so, 
through things like global payments, capitation, and other 
approaches, you can ensure that there are enough dollars that 
can flow to the individuals who would provide the bridge to 
services that are so important.
    Thank you.
    Senator Carper. One other quick question, Mr. Williams. In 
your perspective, how can telehealth be used to better 
integrate behavioral health care within the primary care 
setting, particularly for the pediatric population? Go ahead.
    Mr. Williams. Pediatricians are often the first line of 
defense in many ways. They are trusted individuals whom people 
go to when they have care concerns about their children. And so 
there is an opportunity there to empower that primary care 
provider, that pediatrician, to get access to services and do 
it in a trusted manner.
    Some of the models that we have reviewed and looked at have 
provided primary care providers and pediatricians tools and 
resources so that when they see the first inkling of a 
potential issue or problem that a child is facing, they can 
then appropriately identify the right service for them.
    And so you try to use these evidence-based models in an 
effort to connect people to the services that will best meet 
their needs. And you do not necessarily have to have a person 
in the office, but you can also pick up the phone, or use 
health technology to be able to connect people. So there are 
many different ways in which you can achieve that goal.
    Senator Carper. Mr. Chairman, if I could in closing, just 
note that last fall Senator Cornyn and I introduced legislation 
called Telehealth Improvement for Kids Essential Services, 
TIKES, and it can provide guidance and strategies to States on 
how to effectively integrate telehealth into their Medicare and 
CHIP programs. We think we are on to something, and hopefully 
we will have the opportunity to discuss it further at a later 
hearing. Thank you so much. And thanks----
    The Chairman. Thanks for the good work you are doing, 
Senator Carper, with Senator Casey. So I am going to run and 
vote, and--excuse me, Senator Carper and Senator Cassidy are 
working together. And Senator Casey will be next online. Thank 
you.
    Senator Casey. Mr. Chairman, thanks very much for this 
opportunity to have this hearing. And I want to start with Mr. 
Williams.
    We know that so many people in our country need the 
services we are talking about here today, but often they do not 
access them because the systems that they have to navigate are 
so complex. These are seniors, people with disabilities, who 
depend upon both Medicare and Medicaid. We know that over 12 
million Americans are eligible for both programs, both Medicare 
and Medicaid, so-called dual-eligibles. A half-million of those 
12 million are in the State of Pennsylvania.
    Mr. Williams, as you note on page 5 of your written 
testimony, and I am quoting here: ``Nearly one-third of 
individuals dually eligible for Medicare and Medicaid have been 
diagnosed with a serious mental illness.'' And then you go on 
to say that the rate is three times higher than for those who 
are not dually eligible. At the same time, they have to 
navigate two completely separate health-care programs. They 
might have one insurance card for their primary care doctor, 
another insurance card for behavioral health, and then a third 
one for prescription drugs, and the list goes on from there.
    Earlier this year, Senator Tim Scott and I introduced the 
PACE Expanded Act, Senate bill 3626, which is legislation to 
expand the availability of these programs that integrate 
primary care, behavioral health, and other services. So my 
question for you, Mr. Williams, is, how would meaningful 
integration involving Medicare and Medicaid help ensure that 
people who rely upon both programs can access the behavioral 
health services that they need?
    Mr. Williams. Thank you for that question, Senator Casey. 
The administrative barriers that disproportionately deter 
individuals are high for dual-eligible beneficiaries. Having to 
navigate two systems can be difficult. It is a trait that we 
find is common across our health-care system in the United 
States.
    Complexity is something we like here in the United States, 
and it is something that we need to focus on navigating. In 
fact, the United States is the only country that has a 
workforce called ``patient navigators.'' Those individuals are 
charged with helping people manage the benefits which they 
have, and doing it in an effective manner so that they can get 
the services they need.
    To help dually eligible Medicare and Medicaid 
beneficiaries, mental health services can be integrated at the 
site of primary care and can help eliminate gaps in services to 
providers and the community. There, there is an opportunity for 
the coordination, co-
location, or setting of shared goals that can be used to 
ultimately develop a care plan for an individual.
    You also have a host of other qualified providers that can 
be brought into the care system through these coordination 
activities. Peers, community health workers, other 
professionals can be a part of the care team and provide the 
continuity and coordination to help people over time. And then 
finally, I say health information technology provides a wide 
variety of ways to ensure that the data and information that 
are available are in the hands of both the providers and the 
patients, making their traversing of the health-care system 
that they are a part of easier.
    Finally, there are a wide variety of plans, special needs 
plans in particular, that have customized their benefits for 
behavioral health. And they have shown promise in being able to 
meet the needs of beneficiaries, both of Medicare and Medicaid, 
in a good and positive way.
    So there is lots of complexity, but we have the people, 
organizations, data, and systems to navigate this complexity. 
Thank you.
    Senator Casey. Mr. Williams, thanks very much.
    My last question is for Dr. Ratzliff. I wanted to ask you 
about an issue that is particularly important to folks in rural 
areas and communities of color. Community organizations--
whether they are faith communities or different workplaces or 
early childhood programs, schools--are often the first to know 
the signs that a child or a teen is experiencing a mental 
health challenge.
    My question is, how can integrated behavioral health and 
primary care practices partner with these community-based 
organizations to connect people with mental health support?
    Dr. Ratzliff. Thank you so much for that question. I will 
answer with an example that I have seen in a project we 
supported in California, where actually, for example, a senior 
center became closely partnered with a primary care 
organization. And what they actually did is that they could 
have a bidirectional support for the patients whom they served.
    So that senior center might be the first place that, for 
example, depression or anxiety was recognized. They could make 
sure to try to connect those patients to that primary care 
organization so that they could get access to integrated 
behavioral health that was located there. And additionally, 
part of integrated behavioral health is also addressing 
psychosocial needs. And sometimes those patients needed to be 
more engaged, to be activated, to get connected to community, 
to find purpose in their life. And that was where often that 
organization, that community-based service, could be 
coordinated and be part of the treatment plan, really, for that 
patient.
    So that is an example of how that might work together.
    Senator Casey. Thanks very much.
    Thanks, Mr. Chairman.
    Senator Crapo [presiding]. Thank you.
    Senator Lankford?
    Senator Lankford. Thank you very much. You all, thank you 
for the testimony today; it is very helpful.
    I want to drill down on an area we have not talked about 
much, and that is the CCBHC program on this. In Oklahoma, we 
received a grant through the pilot program on there. Our 
Oklahoma State Department of Mental Health and Substance Abuse 
then separated out 1,400 tablets to law enforcement, different 
areas across the State, to be able to get immediate response 
back. What we have seen through that has been pretty 
remarkable, quite frankly. We have saved about $15.5 million in 
jail time, and about 82 percent of the people who would have 
been headed to jail were actually headed to treatment 
facilities instead.
    What I am interested in--that is what we are seeing in 
Oklahoma. What are you seeing in other parts of the country, 
for those of you who are tracking that? And is this a model 
that we can continue to help? When I talk to law enforcement in 
Oklahoma, they will tell me their jails have the greatest 
number of people with mental health needs than any other 
facility in the entire State. And their law enforcement is 
trying to figure out how to be able to help those folks with 
mental health issues initially, and to get treatment to them 
the fastest possible way. But obviously they are generalists 
and trying to deal with all things law enforcement and trying 
to get to a specialist as quickly as they can.
    What have you seen as a response to this in other areas of 
the country? And what can we do to multiply this?
    Dr. Keller?
    Dr. Keller. Well, your neighbors to the south in Texas have 
seen similar results, Senator. And I think the essential thing, 
regardless of what State you are working in is, you need to do 
two things.
    You need to be able to get that mental health provider 
embedded with law enforcement, preferably able to respond 
without having law enforcement as an option, so that the 
behavioral health provider--and we found also that paramedicine 
has helped too, if you can bring community paramedics in there 
as well. But the essential thing is being able to get that 
out--and you are right. Telehealth works fantastically for that 
because it provides that expertise out there. But the second 
thing you need is, you need a place for people to go. You have 
to have treatment in the community. And so CCBHCs are essential 
for that.
    So, in a lot of rural areas, collaborative care can be for 
primary care practices there. And what we have found is most 
important is same-day access to a prescriber. And if you can do 
that, and you put those two things together, you are going to 
see fantastic outcomes.
    Senator Lankford. Okay, that is very helpful.
    I want to drill down a little bit. I am a co-sponsor of the 
NOPAIN Act, which is trying to deal with the issue of opioid 
addiction, and to try to find other treatment options to be 
able to help those folks dealing with pain. And there are a lot 
of folks with chronic pain, but we need to find other options 
for them as early as possible in the process on that.
    What are we dealing with right now in trying to be able to 
help individuals with chronic pain, dealing with other 
alternatives that are non-addictive? What have we seen a rise 
of, or any other treatments that you have seen?
    Dr. Ratzliff. I can start. Thank you for that question.
    I think one of the things that we are seeing is that there 
are alternatives. Some of the medications for OUD treatment can 
be effective for addressing pain as well. I think that takes a 
lot of coordination to actually support patients in making the 
transition into new treatments.
    And so again, I think the focus on being able to do that in 
primary care with those patients who are often showing up is 
really critical. Some of the models of integration that we are 
talking about today are one approach that could be helpful to 
actually provide that support, where patients are often seeking 
that help from their primary care doctor.
    Senator Lankford. I have a follow-up with you as well on 
the issues of rural health care. Dr. Keller just mentioned that 
as well, and the telehealth issues in rural health care. I know 
this is also an area that you have worked on.
    What can you bring to us as we are dealing with rural 
mental health care?
    Dr. Ratzliff. Thank you for that question.
    I talked a little bit in my initial testimony about how the 
Collaborative Care Model and other models of integration have 
shown to be effective in rural settings as well. We get as good 
and sometimes even better outcomes in some of our rural 
practices where we have implemented mostly Collaborative Care, 
since that is the model I work on.
    I can talk about my personal experience with that. At the 
University of Washington, we actually partnered with a rural 
access hospital that was in a county that did not have a single 
prescriber. So occasionally, someone would come in for a day 
and that was it. That was what was available in that community.
    When we implemented Collaborative Care there, that rural 
access practice had a primary care practice. We were able to--
they hired a behavioral health-care manager. Some of us at the 
University of Washington actually provided consultation or 
support to that primary care practice. And what we saw was 
incredible work done by those primary care providers. But they 
felt really supported, having access to people like us who had 
expertise that they did not have, and being able to really 
serve their community. And I think that that was a really 
powerful example of how you really need to get creative in 
partnerships and leveraging the workforce in new ways.
    Senator Lankford. Okay. Thank you.
    Thank you all for the work that you are doing on this and 
bringing to this. This has been an important issue for our 
committee. Obviously, coming out of COVID there has been 
greater attention to juvenile mental health, but quite frankly, 
it has been mental health across the entire country as we 
continue to be able to process through this. So I really 
appreciate your testimony today.
    Senator Crapo. Thank you.
    Next is Senator Daines, and he will be followed by Senators 
Warner and Cortez Masto.
    Senator Daines?
    Senator Daines. Mr. Chairman, thank you. I understand this 
is the fifth hearing the Finance Committee has held this 
Congress to discuss mental health. I think about so many 
Montanans and Americans across our country battling mental 
health, as well as the addiction issues. I do appreciate the 
committee's efforts here to bring better outcomes for patients. 
I think everything we are doing here is a means to better 
outcomes, which is going to be the end.
    The past few months I have been working with Senator 
Stabenow. We have been working to develop policy solutions that 
are going to help strengthen and improve the mental health 
workforce.
    The numbers are pretty staggering. If you look at the 
shortages in mental health professionals, the estimate that we 
have seen is 148 million Americans live in mental health 
professional shortage areas. That is 45 percent of our 
population. And I can tell you in a rural State like Montana, 
these shortages can even be more severe. As they say, it is a 
long way between telephone poles in a place like Montana. I am 
looking forward to discussing how we break down some of these 
barriers and be better at leveraging our workforce to expand 
critical access to care for patients in Montana and around the 
country.
    A few questions. Back in Montana we have had a successful 
peer support network that allows people who have gone through 
recovery to help others who are battling with mental health or 
addiction challenges. Nothing is better than having a success 
story and a role model to help someone else in need. We have 
seen that peer recovery support leads to reduced hospital 
admission rates, increased quality of life, and decreased cost 
to the mental health system. That is why I have cosponsored the 
PEERS Act, which would expand access to peer support services 
for mental health and substance use disorders.
    Dr. Keller, why do you think peer support is successful? 
And what would it mean to patients if Medicare was allowed to 
cover such services?
    Dr. Keller. Well, Senator, thank you for that question, and 
I think you explained it actually quite well. People being able 
to relate to the experience of having gone through something, 
and also having overcome something and--even if your symptoms 
are not fully addressed, or you are still struggling with 
things--to be able to move your life forward.
    And that is really the unique value that peers are able to 
bring. And they should be available in every type of health 
coverage that we have, including Medicare, and apparently, 
they're not. So I think extending that to people with Medicare 
would basically be an important step of parity in terms of 
being able to have the same sort of access that often we have 
in Medicaid programs.
    I would also argue that commercial plans should be looking 
at that more too, because encouraging commercial plans to do 
that--and showing the evidence--is an excellent way to expand 
the workforce. And there is unique effectiveness in peers 
because of their lived experience.
    Senator Daines. Yes, well, I appreciate that insight, and I 
think on the peer side too, it is not only the benefit to the 
person who is being helped, but the person who is doing the 
helping also further strengthens their resolve and commitments. 
I always say, if you want to really learn something, go teach 
something, right? And then you really have a much stronger 
passion for the subject.
    Earlier this month I worked with my colleagues on this 
committee to secure the extension of the CARES Act policy which 
allowed employers to offer first-dollar telehealth. In rural 
States, again like Montana, it is critical to ensure that 
workers and their families have access to affordable care, 
including mental health services. I was also encouraged to see 
that additional telehealth flexibilities were extended by 
Congress so that patients were able to continue accessing 
important telehealth services no matter where they live.
    Dr. Ratzliff, how valuable have these telehealth 
flexibilities been in terms of increasing access to psychiatric 
care? And moving forward, should telehealth be part of the 
solution to help address the workforce shortages?
    Dr. Ratzliff. Thank you for that question. I think they 
have been incredibly important. I have multiple examples from 
my practices of patients who either accessed care for the first 
time using telehealth, or really were able to stay connected to 
really lifesaving medications--for example, some of the 
practices that I am working with that are providing medications 
for opioid use disorder. Being able to actually continue to 
access those services probably saved patients' lives.
    I think that it is very important that we continue to be 
flexible, to allow patients to access the care they want at the 
time they need it, and ideally in the mode that they need it. 
You know, many people, for example, find it very helpful to 
continue working, being able to actually use telehealth as a 
way to continue to access care and not have to take a half day 
off work to be able to go to a single appointment.
    So I think that is very important. I do think that there is 
an important policy piece that we should think about. In some 
of the policy work, especially around Medicare, there is a 
requirement that you have to actually be seen once in person 
every 6 months. And it is the only stipulation like that around 
telehealth care. And I do not know why it is just there for 
mental health. And so I would urge that we think about changing 
that, because I think it is, again, a parity issue. I do not 
know why for mental health there would be that stipulation. 
That decision should really be between the clinician and the 
patient to make, if that needed to be.
    Senator Daines. Thanks for flagging that issue. I am out of 
time, Mr. Chairman.
    The Chairman. Thank you, Senator Daines.
    We are now on to Senator Warner.
    Senator Warner. Thank you, Mr. Chairman. And let me echo 
what so many of my colleagues have said about both the value of 
telehealth and the workforce shortage issues we have. And I 
agree with Senator Daines's earlier comment. This notional idea 
that there ought to be different standards on mental health 
providers in terms of the in-person visits versus other 
providers does not make much sense to me.
    I want to direct my first question to Mr. Williams. Your 
written testimony was really helpful in terms of coordination 
between primary care and mental health. And as we just 
discussed, and other witnesses testified, the fact that 
Medicare is actually doing a reimbursement on these consults 
for telehealth mental health practices makes a lot of sense. 
But I am told from practitioners in Virginia that failure to 
have that Medicaid match is really preventing some of these 
mental health services from being delivered on a telehealth 
basis.
    So, Mr. Williams, would providing a Federal match to State 
Medicaid programs for telehealth consults really help this 
collaboration between primary care and mental health care?
    Mr. Williams. Thank you for that question, Senator. And 
yes, providing additional services, supports, and dollars to 
help ensure that people have access to telehealth is important. 
And I think telehealth, as we have all discussed here today, is 
a really positive way that has much potential to kind of ensure 
that there is access to the provider and services.
    But I think we also must realize that telehealth has not 
been evenly accessed. Black and rural Medicare beneficiaries 
have lower telehealth use compared to others. Telehealth use 
varies dramatically by State, with higher use in the Northeast 
and the West, and lower use in the Midwest and the South. So we 
have a little bit of work to do to understand those 
differences. Yes, the expansion is positive and good and 
provides an avenue for more access. But there is also the 
opportunity to ensure that everyone gets equal access.
    And I just would like to note that the temporary continuous 
coverage requirement that kept Medicaid coverage intact during 
the public health emergency helped to ensure access to a wide 
variety of services, and that should include telehealth. Thank 
you.
    Senator Warner. Thank you. And I do think this notion of 
continuing some level of Federal match on Medicaid for 
telehealth is important.
    I want to go to Dr. Keller. I was pleased to see in the 
2022 parity report to Congress that new authorities were given 
to the Department of Labor, Treasury, HHS, that have led to 
increased and improved enforcement. But as I was looking 
through that, I saw one health insurer and two of their large 
plans actually covered nutritional counseling around diabetes--
I have a type 1 diabetic daughter, so that is very important--
but it did not cover the kind of consultations needed around 
anorexia, bulimia, and other eating disorders. Unfortunately, I 
have a lot of personal family history with a daughter who has 
those type of eating disorders, actually the same daughter with 
type 1 diabetes with maybe TMI. But the number of colleagues 
and others who are experiencing this has become almost endemic 
in itself.
    So, Dr. Keller, what other ways can we look at trying to 
make sure that we--I know that there was enforcement action in 
part of this area--but what other things can we do, at the 
initial stage of plan design, to make sure that this critical 
area around eating disorder plans is not discriminated against 
in terms of coverage?
    Dr. Keller. Well, Senator, I really appreciate you bringing 
attention and sharing your experience on that with your family. 
I would actually like to provide some additional detail, 
because there are some specific things around eating disorder 
diagnosis that we would like to share. But I would say in 
general, one of the biggest problems that enforcement is trying 
to address right now is the fact that we are treating the 
below-the-neck physical health conditions differently than the 
above-the-neck. And unfortunately, our body is connected. And I 
think nothing, no mental health disorder, expresses that more 
than eating disorders. And I think the example you bring up 
shows exactly the thing. And the reason is, you have different 
people in these insurance companies managing those benefits.
    So, on the below-the-neck needs--you know, nutrition--they 
are designing it in a way to try to advance outcomes in a more 
integrated way. On the above-the-neck psychiatry piece, they 
are trying to limit those costs and to try to weed out spending 
more. And they are being very successful. They are spending 20 
percent less than they used to before these things went into 
place, and unfortunately the burden is being felt by families. 
And so, being able to continue enforcement is essential for 
that and to have the exact same parity, and also have them 
working across the divisions within the insurance companies to 
try to end those sorts of things.
    And I think also, being able to do primary care 
interventions, whether it is Collaborative Care, primary care, 
behavioral health, other integrated models, is essential 
because we are also not detecting those needs until 8 to 10 
years after they begin. And so we put the burden on the family 
to have to discover those needs and figure out what to do, 
often in a crisis.
    And so, if we are looking earlier when we are dealing with 
health, nutrition, weight gain, other types of things in those 
well-child checks for the child, and we are addressing their 
mental health at the same time, we are going to find those 
needs sooner and begin to treat them better, just like we do 
now for cancer, like we do now for heart disease. We have to 
get the detection earlier, and the care in primary care.
    Senator Warner. Well, Dr. Keller, I appreciate that. And I 
hope I can get more information from you.
    And, Mr. Chairman, I would love to continue working with 
you and the committee on this very important issue.
    The Chairman. Thank you, Senator Warner. We know this is 
important to you, and we look forward to working closely with 
you.
    Senator Whitehouse? Oh, excuse me; Senator Cortez Masto--I 
apologize to my colleague--is next. Senator, are you out there?
    Senator Cortez Masto. I am here, thank you.
    The Chairman. Wonderful. It is your time.
    Senator Cortez Masto. Thank you so much for holding this 
hearing. It is such an important topic that we need to address. 
I am so pleased that the Senate Finance Committee is working on 
addressing mental health. I am pleased to be able to join my 
colleague, Senator Cornyn, in cochairing the Subcommittee on 
Increasing Integration, Coordination, and Access to Mental 
Health.
    Let me start with Mr. Williams. We have established that 
Medicare coverage issues persist among seniors, just as they do 
among families. And if you believe the old adage that ``as goes 
Medicare, so goes the market,'' then the mental health coverage 
gap in Medicare has consequences for private coverage too.
    So, Mr. Williams, let me ask you this. If there was better 
Medicare coverage of mental health, could we reasonably expect 
better commercial coverage as well?
    Mr. Williams. Thank you for that question, Senator. Yes, I 
believe very much that Medicare sets a benchmark. I started my 
career focused on Medicare policy. In doing so, and working at 
the National Academy of Social Insurance, I learned that 
through Medicare policy, the rest of health-care policy goes.
    We have seen that consistently with the Medicare 
Modernization Act, with several Balanced Budget Acts, through 
the Affordable Care Act, that when we use the leverage of the 
Medicare program, it effects change throughout all of the 
health-care system. And we have that opportunity to do and make 
that same change with behavioral health, which includes both 
mental health and substance use services.
    And a vital way in which that can be done is through the 
expansion of peer support. Certified and trained accredited 
peer support specialists have been able to help individuals 
achieve recovery goals and do it in a cost-effective way. And 
so, if Medicare were to expand coverage of that type of 
provider, that benefit would, one, be available to Medicare 
beneficiaries, but it would also set the precedent that would 
be an area of focus and opportunity for the commercial sector.
    And so, yes, an action in Medicare is great for Medicare 
beneficiaries. It meets their needs. But it also is the 
beginning of a chain of change that ultimately will impact the 
entire health-care system.
    Senator Cortez Masto. Mr. Williams, thank you. And that is 
why this conversation is so important. And I was pleased to be 
able to introduce legislation around peer-to-peer counseling 
programs and was so pleased that Senator Daines joined me, and 
we were able to get it passed because we have seen the benefits 
of really putting in place action around addressing mental 
health and doing something about it, and why the conversations 
we are having are so important.
    But let me ask Dr. Keller this, because a couple of 
witnesses have talked about mental health crisis services in 
the context of parity in Medicare. If you get into a car 
accident, a paramedic trained in emergency medicine takes you 
in an ambulance to an emergency room where you are cared for by 
a physician. You might be admitted for a few days and sent on 
your way with follow-up instructions. But if you are 
experiencing a mental health crisis, the ambulance cannot take 
you to a crisis center. Medicare will not pay for the health 
providers that are best equipped to treat you in that moment--
people like peers or licensed counselors--and they will not pay 
for your nights in a stabilization facility. They will not pay 
community health workers who help to set you up with a 
counselor for ongoing care.
    So, Dr. Keller, if we are to achieve parity in Medicare, do 
we need to expand coverage of the crisis services as well?
    Dr. Keller. Well, Senator, thank you for that question. And 
thank you for your leadership on this in partnership with 
Senator Cornyn on Senate bill 1902, which would extend that to 
Medicare. And it is essential for exactly the reasons you said.
    And that really begins at the moment when the person shows 
up, because not only will Medicare not cover the crisis care, 
it will not pay for the CAHOOTS person that might be coming to 
help you with your mental health care, or the right care 
person.
    We need to have the Medicare coverage kick in just like 
Medicaid does now, just like some commercial insurance does 
now, at the point of crisis all the way through to the 
transport and to get the person to the stabilization unit, and 
to cover the full array of crisis services which do include 
peers as well as essential providers within that network. And I 
think it is important on the Medicare side. It is also 
important on the commercial side.
    So I think parity across Medicaid, Medicare, and commercial 
payers in this area--and your bill, I believe, does that, and 
we strongly support that.
    Senator Cortez Masto. And thank you. And I have to thank 
Senator Cornyn and his staff. They have been great partners on 
this legislation. Clearly, we need the parity, and we need the 
integration for this.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Cortez Masto, and thank 
you for all your help in the CAHOOTS effort, particularly the 
focus on bringing together law enforcement and mental health 
folks. Your leadership on that was especially valuable.
    All right; now we have Senator Hassan, our colleague from 
New Hampshire.
    Senator Hassan. Thank you so much, Mr. Chair, and thanks to 
you and the ranking member for holding this hearing, and thanks 
to all of our witnesses, not only for being here today, but for 
the work that you do.
    Dr. Keller, I want to start with a question for you.
    Too few individuals who have an opioid use disorder are 
receiving medication-assisted treatment, which is the gold 
standard for opioid use disorders. Access to treatment is 
limited by the requirement that providers obtain a special DEA 
waiver known as the X waiver in order to prescribe 
buprenorphine. Few providers have opted into this program, 
leaving even those patients who have insurance unable to access 
a provider in-network.
    So how has the X waiver limited patient access to 
buprenorphine-prescribing providers?
    Dr. Keller. Well, Senator, thank you for this question, and 
thank you for your leadership on this issue.
    Medication-assisted treatment is the single most effective 
thing we can do to not just improve treatment, but to save 
lives. Our modeling has shown that we could save almost every 
life if we were to extend it out. And the X waiver is the 
primary barrier to that because it creates additional hassles, 
that, by the way, those same providers do not have for the 
prescription of the opioids that caused the addiction. I would 
also add, though, that if we do not have primary care-based 
supports like Collaborative Care, primary care-based behavioral 
health, we will not have the workforce to help them, because it 
is hard to do MAT.
    Senator Hassan. I appreciate that. I think we are moving--
the X waiver is one of the critical barriers, and that is why 
Senator Murkowski and I have a bipartisan Mainstreaming 
Addiction Treatment Act which would eliminate the X waiver. So 
I am going to continue to push for that. But to your point, we 
obviously need this to be part of an integrated and 
collaborative care model.
    Mr. Williams, because of the pandemic, the Federal 
Government lifted restrictions on medication-assisted 
treatment, allowing patients to receive remote care and take 
home additional doses of medication. How did these 
flexibilities affect treatment outcomes during the pandemic? 
And what lessons should we take forward as we consider the 
future of tele-mental health?
    Mr. Williams. Thank you for that question. We know MAT 
works. Numerous studies have shown us that. The COVID-19 
pandemic gave us an opportunity to see how expanded 
flexibilities in telemedicine allowed individuals to be 
screened and put on treatment.
    The DEA and SAMHSA also made it easier to initiate and 
maintain MAT, and that was a way that people were able to 
access services. We saw that substance use treatment facilities 
offering telehealth services jumped nearly 30 percent to 60 
percent in 2020. For mental health facilities, the share grew 
from 38 percent to 69 percent.
    So there is a real growth in using these tools to access 
MAT in a more effective way. It is very early to understand the 
impact of these flexibilities. But we have promising data 
actually from Texas that shows that telehealth-initiated 
therapy and the restrictions that were lifted increased the 
prescription fills for individuals.
    So we have good data and evidence that is starting to show 
us that this may be a new way in which we can make MAT 
available to individuals. And I think there is a near-term 
opportunity to build on this progress to ensure that access is 
for as many people as possible in the field.
    Senator Hassan. Well, thank you for that. And I look 
forward to seeing us follow the data more and learn more.
    Dr. Ratzliff, patients are more likely to receive mental 
health care when primary care physicians and behavioral health 
specialists work together under one roof. This care integration 
breaks down barriers to accessing treatment and improves health 
outcomes. And I have certainly heard from both primary care 
docs and patients about the strength of these programs.
    What are the key design factors that make integrated care 
models work? And how can Congress better support those models?
    Dr. Ratzliff. Thank you for this question. I think there 
are a couple of key things.
    The first is that I think we really need a model of how to 
work together. I think the Collaborative Care Model is a good 
example, but I would focus on a couple of the principles, 
because I think there have been questions about broader 
integrated care models.
    I would say one of the foundational pieces that maybe we 
have not talked about as much is really measuring that the 
outcomes are actually achieved, and that that is a really 
important piece that we want to make sure is part of any model 
of integration; that patients are actually getting the kind of 
care that will result in meaningful change in their life. So 
that is a really important piece.
    I think it is also important that there are payment 
mechanisms, and again I applaud Medicare for introducing a 
mechanism to support Collaborative Care. But that really 
acknowledged that there is a lot of work in care coordination, 
in supporting each other as providers, that is really critical 
to actually pay for. It is not the kind of care that we are 
used to paying for, where it was only direct services, but I 
think continuing to think about how to expand mechanisms for 
practices--you know, especially those that have accomplished 
good outcomes--to receive payment for that care that they are 
delivering is important.
    Senator Hassan. Well, thank you. Thank you for your work.
    The Chairman. I thank my colleague for her good work on 
this. Our next two are going to be Senator Whitehouse and 
Senator Warren, and that will close the hearing.
    Senator Whitehouse?
    Senator Whitehouse. Thanks so much, Mr. Chairman, and 
thanks for holding this conversation. I think it is really 
important.
    Mental health parity has been on the books for years, since 
my friend and fellow Rhode Islander then, Patrick Kennedy, got 
the parity bill passed in a father-son team effort with my 
colleague here in the Senate, Ted Kennedy. And yet here we are, 
many years later still seeing continued failures in parity.
    It strikes me that the enforcement mechanism is spread 
across multiple agencies, with the result that there is no 
clear accountability at the end of the day. And I am wondering 
if the witnesses have thoughts about how best to hold folks 
accountable for parity violations, whether that enforcement 
should be located in one place. And I will just note that had 
we been able to pass Build Back Better, and depending on what 
comes ahead, there was actually the prospect of civil monetary 
penalties for these longstanding violations.
    I know that underneath it there is a staffing issue that 
needs to be resolved, but it seems to me that there is also a 
lack of pressure from the payers to get to where they should be 
by law.
    Let me ask Dr. Ratzliff first.
    Dr. Ratzliff. Well, I do agree that we need to enforce 
parity. As a provider, I can see the impacts of not doing that. 
For specific policy recommendations, I think I would defer to 
my colleague, Dr. Keller.
    Senator Whitehouse. That is a hand-off to you, Dr. Keller.
    Dr. Keller. Thank you, Senator. Thank you, Dr. Ratzliff.
    So we have to continue enforcement, but I do think that 
centralizing enforcement responsibility to DOL and both giving 
them the adequate staff resources and also adding civil 
penalties would be essential. And I take the point you raise 
that there has to be a point person on the regulatory side as 
well.
    We found that--you know, we tried to do things in Texas 
back in 2017, and it is too fragmented. And really it does 
take, I think, the Federal effort through the Department of 
Labor to move that forward.
    We would also argue, too, that amending ERISA to allow DOL 
to also directly go after the administrative services 
organizations, the TPAs, because it is not just the purchasers 
that should be responsible, the group health plans, but also 
their administrative entities, because a lot of that advice and 
guidance and lack of parity is coming from their actions.
    Senator Whitehouse. Thank you. If anybody else wants to 
chime in, I invite you to do that in a response--you know, I 
will make this a question for the record, and if anybody wishes 
to follow up in writing, that would be great.
    But with 2 minutes left, I wanted to go to another 
question, which is that in the mental health arena, which is 
obviously a very broad one, there seem to be three areas where 
focus would be particularly useful and valuable right now.
    One is on children's mental health, as we have seen 
children's mental health issues explode through COVID.
    The second is in the area of addiction and recovery. As the 
author with Senator Portman of the CARA bill that first put 
investment into recovery, I think there is more room for 
progress in the addiction and recovery space.
    And the third is in the area of police encounters with 
people who are having a mental health crisis of some kind, and 
how we provide support to police departments so that they can 
better manage those systems and have the resources that they 
know they can call on when they understand that that is part of 
the problem that they are going to address. Very often with 
these people, it is not the first time there was a call. The 
police officers are aware that there is a problem, but they 
just do not have the resources to address it.
    So any thoughts on that, I would appreciate, and I guess I 
will go to Dr. Ratzliff and Dr. Keller first.
    Dr. Ratzliff. Thank you for this question. So I would say I 
think it is really important that we are thinking about all 
three of these populations of patients that are in acute need 
of mental health services. I guess I would go back to focusing 
on--I think we need immediate support, especially when you 
think of police encounters. It is important that that person 
who is meeting a patient out in the community is actually able 
to interact with them in a different way and actually bring 
them to treatment, not to incarceration.
    I think, though, what you need then is a strong service to 
actually continue to provide access to care. And right now, the 
main place that they are going to do that, actually for all 
three of the issues that you raise, is primary care.
    So I guess I will just come back to really that it is so 
important to invest in really building up that system to be 
able to deliver care, to be able to bring in a broad workforce 
to work together in that space, and to be able to provide 
adequate reimbursement for that coordination and support of 
treatment.
    Senator Whitehouse. My time has run out. So, if anybody 
else cares to answer, if you could do it in writing as a 
response to the question for the record, I think the chairman 
would appreciate me not going on.
    [The question appears in the appendix.]
    Senator Whitehouse. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Whitehouse, for your good 
work.
    Senator Warren?
    Senator Warren. Thank you, Mr. Chairman.
    So in 2020, one in every five adults experienced mental 
illness. For substance use disorder, the figure was one in 
seven. And despite the critical need for mental health and 
substance use disorder services, few Americans get the 
treatment that they need. If you ask people experiencing mental 
illness if they got the help they needed, one in three say 
``no.'' And just under 10 percent of adults experiencing 
substance use disorder were able to access treatment.
    Now there are a lot of factors that contribute to the 
degree of unmet behavioral health needs, but one of the most 
egregious is the way that insurance companies flout Federal 
laws requiring them to provide this care. And a big way that 
insurers restrict access to behavioral health care is by more 
aggressively subjecting these services to what are called non-
quantitative treatment limitations, NQTLs. I know you are all 
familiar with these.
    So, Dr. Ratzliff, let me start with you. You have seen this 
play out in your own practice. Can you explain how insurers use 
NQTLs to create barriers to behavioral health care? And what 
effect does this have on your patients?
    Dr. Ratzliff. Yes, I will talk specifically. I have 
mentioned this example, but I think one of the biggest factors 
that we have seen is actually having these ghost networks--I 
mean, really not being able to actually call off the list that 
you are given and find somebody that you can actually get care 
from. And this again, I think some people--you know, people are 
already struggling with depression and anxiety, so it is really 
hard to call multiple people over and over again and never get 
an answer or never get a response for treatment.
    So I think that is one of the most egregious ways that I 
have seen that.
    Senator Warren. So, narrower provider networks, more and 
more phone calls that you have to make in order to get 
approval. And of course, the response, I assume, is that 
patients delay care, or give up altogether.
    So we have known about this problem for a long time. This 
is not the first time this has come to our attention. And in 
2020, Congress passed legislation to give Federal agencies 
enforcing our parity laws more tools to evaluate insurance 
companies' use of these practices.
    Now, the law also required regulators to review at least 20 
plans each year to assess for compliance. In a report released 
earlier this year, the Department of Labor, the Department of 
Health and Human Services, and Treasury stated that the 
specific plans selected for such review were chosen based on 
existing investigative leads or open investigations into 
reported violations.
    So, Mr. Dicken, if I can, I want to ask you. You run the 
health-care team at the Federal Government's watchdog unit, the 
Government Accountability Office, and you have looked into this 
issue.
    If we are trying to understand if insurance companies are 
following Federal parity laws, does it make sense to look only 
at insurers that have received complaints?
    Mr. Dicken. Thank you, Senator Warren. No, we have raised 
concerns that by only focusing on either complaints or other 
targeted reviews of health plans, that that leaves risk that 
there could be other plans that are not known. There are a 
number of reasons why consumers may not be making complaints or 
be aware of the requirements.
    Senator Warren. Well, thank you. You know, I agree with you 
on this. I agree that we need to monitor all plans for 
compliance with our parity laws. You know, it is the same 
reason a teacher might give a pop quiz. Instead of just 
focusing on a handful of students who did not turn in their 
homework, you give it to the whole class to find out who is 
doing great, who is having a little trouble, and who is in big 
trouble. But you only get that if you are able to reach all the 
way across.
    Now, Dr. Keller, we are not going to make insurance 
companies take pop quizzes, but we can do randomized audits. So 
how would requiring Federal enforcers to conduct randomized 
audits of plans strengthen efforts to identify and eliminate 
unequal application of NQTLs?
    Dr. Keller. Well, I think you explained it actually quite 
well, because I think really these are across the board. And 
the sad reality is that every plan that has been reviewed so 
far has dramatic gaps.
    So the only way we are going to be able to enforce across 
all those plans is if all of them know that there is a 
possibility, and also that they know that there is a 
significant possibility, of an audit. So I would argue we need 
to actually do more than 20. We need to also make sure that 
they are in-depth, and we need to expand the penalties aligned 
with them so that in addition to having the test, the test has 
consequences for the final grade.
    Senator Warren. I thank you very much for that answer. Just 
focusing on the parity violations, we know that these are 
dramatically under-reported. We cannot rely on complaints as 
the only signal that an insurer is breaking the law.
    I believe in randomized audits. And that is why I will be 
reintroducing my Behavioral Health Coverage Transparency Act to 
require Federal enforcement agencies to conduct randomized 
audits of plans, and at the same time to simplify the complaint 
process, which makes it easier for patients to report parity 
violations.
    Health care, including behavioral health care, is a human 
right, and we must ensure that Americans do not face additional 
barriers to getting the often lifesaving care that they need.
    So, thank you all for your work. I very much appreciate it. 
I know your patients appreciate it. And thank you for being 
with us today. Thank you.
    The Chairman. Thank you very much, Senator Warren.
    And to our guests, how fitting that we close 2\1/2\ hours 
in, after we have focused on ghost networks, with Senator 
Warren basically offering the second side of the same coin. 
Ghost networks and treatment limits are the same thing, and 
this is going to be a debate now about taking on these big 
insurers and finally getting this fixed.
    And for me--and we will excuse you very shortly--the kind 
of two relevant dates were my brother passing in 2002, and he 
struggled with schizophrenia for years and years, and 
essentially his internal organs gave out as a result of all of 
the medicines, the pounding that so many were taking then. You 
have heard that every night for years on end, we would worry 
that he would hurt himself or somebody else who was on the 
streets.
    And then the next big date was 2008 when Paul Wellstone and 
Pete Domenici, two people who did not see eye to eye on 
everything--we thought this is it, liberation. People are going 
to get a fair shake. Mental health and physical health will get 
treated the same. And I remember my dad and I looking at the 
newspaper that morning, Senator Warren, and I said, ``Good for 
Paul. Good for Pete Domenici.'' I was a member of the Senate 
then, and I said, ``This is for Jeff. This is one that is 
really going to really liberate a lot of people.''
    And here we are 13 years later, fighting the same problems. 
The GAO folks told us 2\1/2\ hours ago that there are these 
ghost networks. Well, we can walk through the ghost network, 
but when you are shoved into a ghost network by an insurance 
company, you are not going to be able to get a provider. You 
are not going to be able to get someone to take your insurance. 
You are often not getting an accurate directory. So you do not 
even know who in the hell to call. And then the reimbursement 
levels are so low that the patient very often gets stuck with 
the bill.
    So we are going to be pushing back on all fronts here. We 
closed it with another good suggestion from Senator Warren. We 
have had colleagues raise additional ideas for enforcement. But 
I want you to know--and, Dr. Ratzliff, your roots in the 
Pacific Northwest are particularly helpful because Senator 
Cantwell is going to be a leader in this.
    This is the time when we are finally going to take on these 
big insurance companies, and we are not going to accept the 
excuses, the stonewalling, and what I saw in Portland, OR, 
where our premiere institution basically could not even get 
claims paid until their Senator raised a ruckus in the 
newspaper, and then all of a sudden, Senator Warren, all the 
claims got paid.
    So we have been fed a lot of baloney about this, and for 
those who missed it, I particularly focused on the insurance 
executive who said, ``Gee, we're just starting to learn more 
about this. It's going to take more time to get comfortable 
with it.''
    Well, my message to them is, time has run out. Time has run 
out. We have heard from Senators on both sides of the aisle. 
There is a commitment to getting it fixed.
    So for 2\1/2\ hours you gave us a roadmap on how to do it. 
We thank you. We are going to be calling on you often in the 
days ahead.
    And with that, the Finance Committee is adjourned.
    [Whereupon, at 12:32 p.m., the hearing was concluded.]

                            A P P E N D I X

              Additional Material Submitted for the Record

                              ----------                              


                Prepared Statement of Hon. Mike Crapo, 
                       a U.S. Senator From Idaho
    Thank you, Mr. Chairman, and thank you to our witnesses, some of 
whom have come from across the country to testify before the committee 
today.

    We have heard from providers across the continuum of care, 
government officials, and policy experts who have shared a range of 
thoughtful perspectives and recommendations. This is the fourth mental 
health hearing that the committee has held this Congress. Despite 
diverse viewpoints on some policy questions, all have agreed on the 
profound importance of ensuring all Americans have access to high-
quality mental health-care services.

    Our country has experienced a challenging couple of years. Even as 
hospitalizations and deaths caused by COVID-19 continue to decline and 
stabilize in the United States, the pandemic will have lasting impacts 
on the Nation's mental health. Lockdowns, school closures, and other 
government restrictions led to social isolation, new and worsened cases 
of depression, and widespread anxiety. For many, the pandemic also 
resulted in tragic personal losses, worsening these and other mental 
health conditions.

    I have also heard from health-care providers across Idaho, where 
the stress and uncertainty of the pandemic have further exacerbated 
professional burnout. Onerous regulatory burdens have caused many 
physicians and allied health professionals to retire early or reduce 
their hours. The resulting workforce shortage makes it more challenging 
for patients to access the mental health services they need.

    Studies have found that the prevalence of mental health illness is 
similar between rural and urban areas. Individuals living in rural and 
frontier areas often face significant barriers in accessing needed 
mental health services closer to home. On average, rural residents have 
to travel farther to receive services, and providers are less likely to 
practice in these communities.

    While the pandemic has increased the pervasiveness of mental health 
concerns, it has also led to innovative solutions that address these 
challenges, such as the expansion of telehealth services. Telehealth 
expands access in underserved rural areas, improves care coordination 
and integration, and provides more privacy to patients to combat 
stigma.

    While there is no easy solution, I am committed to working 
alongside my colleagues to tackle these challenges in a bipartisan and 
fiscally responsible way. We cannot simply throw more money at the 
problem and expect it to solve everything. Instead, we must focus on 
developing data-driven, innovative, and creative solutions to address 
these challenges.

    I look forward to hearing from today's panel on their ideas to 
ensure that Americans in need can access timely, high-quality mental 
health-care services.

                                 ______
                                 
            Prepared Statement of John E. Dicken, Director, 
             Health Care, Government Accountability Office
   mental health care: consumers with coverage face access challenges
    Chairman Wyden, Ranking Member Crapo, and members of the committee, 
I am pleased to be here today as you examine issues related to consumer 
access to behavioral health services. Behavioral health conditions--
which include mental health and substance use disorders--affect 
millions of people in the United States.\1\ Additionally, the effects 
of the COVID-19 pandemic and related economic crisis--such as increased 
social isolation, stress, and unemployment--have intensified concerns 
that behavioral health conditions have affected even more people.
---------------------------------------------------------------------------
    \1\ For example, in 2020, the Substance Abuse and Mental Health 
Services Administration (SAMHSA) estimated that nearly 74 million 
adults in the U.S. (29 percent) were reported to have either a mental 
illness or a substance use disorder. See Substance Abuse and Mental 
Health Services Administration, Key Substance Use and Mental Health 
Indicators in the United States: Results From the 2020 National Survey 
on Drug Use and Health (Rockville, MD: October 2021).

    We have issued several recent reports addressing various aspects of 
behavioral health care in the United States. They include three reports 
issued since the onset of the COVID-19 pandemic that examined, among 
other things, ways that the pandemic affected behavioral health 
care.\2\ Prior to the pandemic, we issued a report focused on State and 
Federal oversight of behavioral health parity requirements defined in 
law.\3\ In general, Federal law requires that when certain health plans 
offer coverage for medical and surgical treatment as well as mental 
health or substance use disorder treatment, the coverage for mental 
health and substance use disorder treatment may be no more restrictive 
than coverage for medical or surgical treatment.\4\
---------------------------------------------------------------------------
    \2\ See GAO, Behavioral Health and COVID-19: Higher-Risk 
Populations and Related Federal Relief Funding, GAO-22-104437 
(Washington, DC: December 10, 2021); Behavioral Health: Patient Access, 
Provider Claims Payment, and Effect of COVID-19 Pandemic, GAO-21-437R 
(Washington, DC: March 31, 2021); and COVID-19: Urgent Actions Needed 
to Better Ensure an Effective Federal Response, GAO-21-191 (Washington, 
DC: November 30, 2020).
    \3\ See GAO, Mental Health and Substance Use: State and Federal 
Oversight of Compliance With Parity Requirements Varies, GAO-20-150 
(Washington, DC: December 13, 2019).
    \4\ See the Paul Wellstone and Pete Domenici Mental Health Parity 
and Addiction Equity Act of 2008 (MHPAEA), Pub. L. No. 110-343, div. C, 
tit. V, sub. B, Sec. Sec. 511-12, 122 Stat. 3765, 3881-93 (October 3, 
2008). MHPAEA was enacted in 2008 to help address discrepancies in 
health-care coverage between mental illnesses and physical illnesses. 
MHPAEA both strengthened and broadened Federal parity requirements 
established by the Mental Health Parity Act of 1996, including 
extending parity to cover the treatment of substance use disorders.

    Today we are releasing a report entitled Mental Health Care: Access 
Challenges for Covered Consumers and Relevant Federal Efforts.\5\ As 
the title indicates, this report focuses on consumers who have coverage 
for mental health care and the challenges they encounter despite having 
that coverage. There have been longstanding concerns in the U.S. about 
the accessibility of mental health services for these consumers. 
Although approximately 91 percent of the U.S. population is covered by 
public or private health plans, having such coverage does not guarantee 
access to mental health services. For example, a 2021 report by Mental 
Health America (a nonprofit advocacy and research group) estimated that 
54 percent of consumers covered by a health plan did not receive the 
mental health treatment they needed--indicating that ensuring coverage 
is not the same as ensuring access to mental health care.\6\
---------------------------------------------------------------------------
    \5\ See GAO, Mental Health Care: Access Challenges for Covered 
Consumers and Relevant Federal Efforts, GAO-22-104597 (Washington, DC: 
March 29, 2022).
    \6\ M. Reinert, D. Fritze, and T. Nguyen, The State of Mental 
Health in America 2022 (Alexandria, VA: Mental Health America, 2021).

    My testimony today summarizes the findings from the report released 
---------------------------------------------------------------------------
today. Accordingly, my testimony discusses:

    1.  Challenges that consumers with coverage for mental health 
services may experience accessing these services; and

    2.  Ongoing and planned Federal efforts to address these 
challenges.

    For this report we interviewed Federal officials from the 
Departments of Health and Human Services (HHS) and the Department of 
Labor (DOL), which share responsibilities for overseeing compliance 
with mental health parity laws. We also interviewed representatives 
from 29 stakeholder organizations representing consumers, health plans, 
providers, insurance regulators, and mental health and Medicaid 
agencies.\7\ These included national organizations and organizations 
from four states--Connecticut, Oregon, South Carolina, and Wisconsin--
selected based on mental health metrics and geographic variation, among 
other factors. GAO also reviewed relevant reports obtained from these 
agencies and organizations and reviewed academic and industry research 
focused on consumer access to mental health care. More detailed 
information on our objectives, scope, and methodology can be found in 
the issued report. Our work was performed in accordance with generally 
accepted government auditing standards.
---------------------------------------------------------------------------
    \7\ In reporting our findings based on the testimonial evidence 
collected from the 29 stakeholder organizations, we generally indicate 
the numbers of organizations that identified specific challenges using 
indefinite quantifiers as defined in the issued report.
---------------------------------------------------------------------------
  challenges finding in-network providers and navigating plan details
    In our March 2022 report, we found that consumers experience a 
variety of challenges accessing mental health benefits provided under 
their health plans. Some of the challenges occur because of limited 
access to in-network providers or broader structural issues in the 
mental health system that make it difficult to access affordable mental 
health care or certain types of mental health care in a timely manner. 
Other challenges occur because of processes used by health plans to 
approve mental health treatment or limitations in services and 
treatments covered by some health plans--these can delay or limit the 
course of treatments or make treatments unavailable for certain 
consumers.
Limited Access to In-Network Providers and Broader Structural Issues
    Stakeholders we interviewed told us that limited access to in-
network providers can result in consumers seeking care from out-of-
network providers, typically resulting in higher costs for the 
consumer, possible delays in receiving care, or difficulties in finding 
a provider close to home. Most of the stakeholders we interviewed told 
us that one factor contributing to this challenge is low reimbursement 
rates for mental health service providers, which many said can reduce 
providers' willingness to join plan networks. This point was also 
supported by reports and research we reviewed.\8\ The ability to 
develop a provider network is also exacerbated by an overall shortage 
in the mental health workforce. This shortage limits the pool of 
providers who could join a network and may give existing providers 
leverage to opt out of networks and receive higher rates for their 
services than those offered by the plans.
---------------------------------------------------------------------------
    \8\ For example, one study that examined provider participation in 
networks for plans sold on State marketplaces created by the Patient 
Protection and Affordable Care Act found that only 21.4 percent of 
mental health-care providers participated in the networks compared to 
45.6 percent of primary care providers. The researchers noted that 
relatively low reimbursement rates for mental health care could be one 
factor contributing to these differences. See J.M. Zhu, Y. Zhang, and 
D. Polsky, ``Networks in ACA Marketplaces Are Narrower for Mental 
Health Care Than for Primary Care,'' Health Affairs, vol. 36, no. 9 
(2017).

    Another challenge for consumers' ability to find in-network 
providers is inaccurate information in health plans' provider 
directories. Many stakeholder organizations said that inaccurate 
directories could create what they referred to as a ``ghost network''--
in other words, providers who are listed in a directory as 
participating in the network, but who are either not taking new 
patients or are not actually in a patient's network. For example, 
recent studies that evaluated consumers' use of provider directories to 
schedule outpatient appointments with psychiatrists found that 
inaccurate or out-of-date information complicated consumers' ability to 
obtain care.\9\
---------------------------------------------------------------------------
    \9\ See M. Malowney, S. Keltz, D. Fischer, and J. Boyd, 
``Availability of Outpatient Care From Psychiatrists: A Simulated-
Patient Study in Three U.S. Cities,'' Psychiatric Services, vol. 66, 
no.1 (2015): 94-96; S. Cama et al., ``Availability of Outpatient Mental 
Health Care by Pediatricians and Child Psychiatrists in Five U.S. 
Cities,'' International Journal of Health Services, vol. 47, no. 4 
(2017): 621-635; and M. Scheeringa, A. Singer, T. Mai, and D. Miron, 
``Access to Medicaid Providers: Availability of Mental Health Services 
for Children and Adolescents in Child Welfare in Louisiana,'' Journal 
of Public Child Welfare, vol. 14, no. 2 (2020): 161-173.

    Representatives from most of the stakeholder organizations we 
interviewed also identified structural challenges that limit the 
overall capacity of the mental health system as affecting covered 
consumers' access to care, and literature we reviewed examined some of 
these issues.\10\ For example, some of the stakeholders noted that the 
mental health workforce shortage makes it difficult to keep up with the 
demand for mental health services. Similarly, a shortage of available 
inpatient treatment beds limits consumers' access to the treatment they 
need. Some attributed this shortage to increased demand for services, 
budget cuts, or staffing issues--in some cases related to the COVID-19 
pandemic. In addition, representatives from many of the stakeholder 
organizations told us that a shortage of intermediate care options, 
such as residential treatment facilities or intensive outpatient 
programs, has created challenges for consumers in getting intermediate 
levels of care.\11\
---------------------------------------------------------------------------
    \10\ For example, see, Interdepartmental Serious Mental Illness 
Coordinating Committee, The Way Forward: Federal Action for a System 
That Works for All People Living With SMI and SED and Their Families 
and Caregivers (2017), and University of Wisconsin, Population Health 
Institute, 2019 Wisconsin Behavioral Health Systems GAPs Report 
(Madison, WI: Prepared for the Wisconsin Department of Health Services, 
2020).
    \11\ Intermediate levels of care are less intensive than inpatient 
care but more intensive than routine outpatient care, and may consist 
of acute residential treatment, partial hospitalization programs, 
intensive outpatient programs, and family stabilization services. 
Residential treatment programs may offer long-term mental health care 
in a structured, homelike setting, where the patient stays for the 
duration of the treatment. Intensive outpatient programs provide 
weekday treatments under which patients can return home each evening.

    Representatives from several stakeholder organizations also told us 
that the lack of access to broadband Internet services, particularly in 
rural areas, can limit consumers' ability to use telehealth for mental 
health services. This may make it more difficult to access mental 
health services, particularly when in-person treatment is unavailable, 
such as during periods of social distancing during the COVID-19 
pandemic or when consumers have to travel long distances to see a 
provider. Despite broadband Internet limitations in some areas, 
representatives from most stakeholder organizations we interviewed 
indicated that enhanced use of telehealth during the pandemic generally 
helped improve access to mental health care.
Plans' Administrative Approval Processes and Coverage Limitations
    Stakeholders we interviewed reported that the need to obtain health 
plans' approval for certain mental health services, as well as other 
coverage limitations, can adversely affect access to mental health 
care. Taken together, these challenges can delay or limit the course of 
treatments or, in some cases, make treatments unavailable for certain 
consumers.

    Representatives from many stakeholder organizations we interviewed 
specifically cited non-quantitative treatment limitations (NQTL) used 
by health plans--such as the need for obtaining prior authorizations--
as creating delays in accessing needed treatments or limiting time 
spent in treatment. For example, representatives from one health system 
reported that some health plans are less likely to grant prior 
authorization for mental health hospital stays compared with medical 
and surgical hospital stays. Some also said plans' processes for 
determining whether continuing a treatment is medically necessary can 
limit the duration of a consumer's treatment, even if the provider does 
not agree that the patient is ready for discharge. In some cases, 
stakeholders said that health plans are applying these limits to 
consumers' mental health benefits in more restrictive ways than to 
medical and surgical benefits, which highlights ongoing mental health 
parity issues. Some of the reports we reviewed also identified the use 
of NQTLs by health plans that did not comply with mental health parity 
standards as presenting a potential challenge to consumers in accessing 
mental health care.\12\
---------------------------------------------------------------------------
    \12\ For example, see, J. Volk et al., Equal Treatment: A Review of 
Mental Health Parity Enforcement in California (California Health Care 
Foundation, 2020). The California Health Care Foundation is dedicated 
to advancing meaningful, measurable improvements in the way the health-
care delivery system provides care to the people of California.

    Representatives from several of the stakeholder organizations also 
told us that variation in the use of treatment standards can affect 
covered consumers' access to mental health care. Currently, there is no 
agreed-upon set of standards used in the U.S. to make mental health 
treatment decisions. The stakeholder representatives indicated that, 
absent such standards, it can be difficult for providers and health 
plans to agree on the treatment a patient may need, and some said 
health plans may limit a consumer's treatment options. For example, 
representatives from one provider told us they often feel pressured by 
health plans to move patients out of hospital-based services to less 
intensive outpatient treatment. Representatives from another provider 
said health plans will stop coverage of a suicidal patient's treatments 
once the patient is stable, even though a provider believes the patient 
needs continuing care.\13\
---------------------------------------------------------------------------
    \13\ The issues surrounding a lack of uniform standards of care, 
and how that can affect treatment decisions for mental health care, 
have been litigated in Federal court. See Wit v. United Behavioral 
Health, No. 14-cv-02346-JCS, 2019 WL 1033730 (N.D. Cal. 2019).

    Regarding coverage limitations and restrictions, representatives 
from several stakeholder organizations and reports and research we 
reviewed identified challenges accessing mental health care faced by 
consumers with certain forms of coverage. For example, representatives 
from many of the stakeholder organizations contended that the scope of 
mental health services covered by Medicare and commercial plans is 
generally more limited than Medicaid. As a result, consumers with 
Medicare or commercial coverage may not have access to the range of 
mental health services available to consumers with Medicaid. Many 
stakeholder organizations cited Medicaid's coverage of crisis care and 
peer support as examples where the services were more comprehensive 
than Medicare and commercial coverage.\14\
---------------------------------------------------------------------------
    \14\ According to SAMHSA, crisis services may include crisis 
telephone lines dispatching support based on the caller's assessed 
need, mobile crisis teams dispatched to the community where there is a 
need (i.e., not in a hospital emergency department), and crisis 
receiving and stabilization facilities that serve patients from all 
referral services. SAMHSA also defines peer support services as a range 
of recovery activities and interactions outside of the clinical setting 
between people who have shared lived experiences with a mental illness. 
For more information, see Substance Abuse and Mental Health Services 
Administration, Crisis Service Meeting Needs, Saving Lives: National 
Guidelines for Behavioral Health Crisis Care--A Best Practice Toolkit 
(Rockville, MD: August 2020) and Who Are Peer Workers? (Rockville, MD, 
September 2021).

    Stakeholder representatives also cited challenges consumers face 
related to statutory coverage restrictions on federally funded 
programs, such as Medicare. For example, some told us that Medicare 
restrictions on the types of providers eligible for reimbursement, 
including Licensed Professional Counselors and Licensed Marriage and 
Family Therapists, affect access to mental health services for Medicare 
enrollees by limiting the pool of accessible providers. In addition, 
some stakeholders we spoke with highlighted the fact that Medicare has 
a lifetime limit for enrollees of 190 days of inpatient care in 
psychiatric hospitals. These stakeholders said that this limit creates 
barriers and disruptions to care for people with serious mental 
illnesses who may need more inpatient care.
            related federal efforts may address aspects of 
                    mental health access challenges
    Based on our interviews with agency officials and reviews of agency 
documentation, we identified various ongoing or planned Federal efforts 
to address some of the challenges consumers with coverage may 
experience accessing mental health care. These efforts aim to address 
challenges related to finding in-network providers, broader structural 
issues, and health plan administrative approval processes.

    Addressing Limited Access to In-Network Providers. DOL and HHS are 
taking steps to ensure access to in-network mental health providers. 
For example:

        HHS's Center for Medicare and Medicaid Services requires 
Medicare Advantage plans to meet a number of network adequacy criteria, 
such as requirements for plans to demonstrate that their networks do 
not unduly burden beneficiaries in terms of travel time and distance to 
network providers or facilities, including inpatient psychiatric 
facility services and psychiatric services.

        DOL and HHS are implementing requirements for certain health 
plans to update and maintain provider directories.

        The Health Resources and Services Administration within HHS 
manages several programs that provide funding intended to increase the 
mental health workforce.

    Addressing Broader Structural Issues. The Substance Abuse and 
Mental Health Services Administration (SAMHSA) within HHS manages 
several programs aimed at addressing structural issues that contribute 
to a lack of capacity in the mental health system. For example:

        Funding 12 grants designed to establish or expand Assertive 
Community Treatment programs to deliver a mix of individualized, 
recovery-oriented services to persons living with serious mental 
illness to help them successfully integrate into the community.

        Overseeing the Certified Community Behavioral Health Clinics 
expansion grant program. These clinics provide comprehensive, 
integrated mental health services, such as crisis mental health 
services and primary care screening and monitoring.

    Addressing Issues with Health Plan Administrative Approval 
Processes. DOL and HHS are taking steps to enhance their oversight of 
the use of NQTLs by health plans--such as requirements for prior 
authorization--as part of their broader responsibilities to oversee 
compliance with mental health parity laws. These steps are being taken, 
in part, to meet requirements specified in the Consolidated 
Appropriations Act, 2021, which requires group health plans that cover 
both medical and surgical and mental health and substance use disorder 
benefits to perform and document comparative analyses of the design and 
application of NQTLs.\15\
---------------------------------------------------------------------------
    \15\ Pub. L. 116-260, Sec. 203, 134 Stat. at 2900 (2020).

    Mr. Chairman and members of the committee, this concludes my 
prepared statement. I would be pleased to respond to any questions that 
---------------------------------------------------------------------------
you or other members of the committee may have at this time.

    For future contacts regarding this statement, please contact John 
E. Dicken at (202) 512-7114 or at [email protected].

                                 ______
                                 
          Questions Submitted for the Record to John E. Dicken
              Questions Submitted by Hon. Thomas R. Carper
                       health services in schools
    Question. It is clear that COVID-19 has significantly exacerbated 
mental health stress on children and youth, highlighting the Nation's 
acute shortage of mental health services. In my State of Delaware, over 
9,000 Delawareans ages 12 through 17 suffer from some sort of 
depression. However, according to the State, students who have access 
to mental health resources within schools are 10 times more likely to 
seek care.

    Earlier this year, the Finance Committee heard testimony from the 
U.S. Surgeon General who stressed that one of the most central tenets 
in creating accessible and equitable systems of care is to meet people 
where they are. For most young people, that's right there in schools. 
And just last week, Secretary of Health and Human Services Xavier 
Becerra and Secretary of Education Miguel Cardona announced a joint-
department effort to expand school-based health services.

    It is clear there is growing momentum to recognize the role schools 
already play in ensuring children have the health services and supports 
necessary to build resilience and thrive. We know that investing in 
school and community-based programs has been shown to improve mental 
health and emotional well-being of children at low cost and high 
benefit.

    How can we improve coordination between primary care and mental 
health providers to better support our children, including through 
school-based services?

    Do you see a role for the Federal Government beyond providing 
guidance and technical assistance to State programs?

    Answer. While our work did not specifically address issues 
regarding coordination between primary care and mental health care for 
children, our work did identify challenges children have in accessing 
mental health services. For example, in our recent report, we cited 
research that examined children's access to specialists that found that 
the percentage of psychiatrists that did not accept public or private 
insurance was greater than that of other specialties, such as 
dermatology or neurology. We also reported on mental health workforce 
shortages, including shortages of available child psychiatrists. For 
example, a representative from one hospital system we contacted noted 
they are having trouble finding child psychiatrists and are trying to 
find contracted care to meet the mental health needs of children.

    Regarding coordination between primary care and mental health 
providers more broadly, and the role of the Federal Government in that 
regard, in our report, we noted one Federal program that helps 
community providers deliver integrated care, and thus goes beyond 
providing guidance and technical assistance. Specifically, we noted 
that the Substance Abuse and Mental Health Services Administration 
currently oversees the Certified Community Behavioral Health Clinics 
(CCBHC) expansion grant program. CCBHCs provide comprehensive, 
integrated mental health services to individuals in need and receive an 
enhanced Medicaid reimbursement rate in order to cover the cost of 
expanding resources to serve clients with complex needs. CCBHCs provide 
or contract nine types of services, including 24 hours a day, 7 days a 
week crisis care, evidence-based practices in the treatment of mental 
and substance abuse disorders, and coordinated care between primary 
care, hospital facilities, and physical health integration. Under this 
program, services are also provided to children and adolescents with 
serious emotional disturbance, thus this program has the potential to 
better support integration of mental health services for children.

               Questions Submitted by Hon. John Barrasso
        increasing access to mental health providers in medicare
    Question. As a doctor, I know the importance of improving access to 
mental health care for all Americans. This is especially important in 
rural parts of the country, which face some of the largest shortages in 
the country.

    For seniors, finding a mental health provider can be particularly 
challenging. This is because Medicare restricts certain types of mental 
health providers from billing the program.

    As you noted on page 7 of your testimony, you were told by 
stakeholders that ``Medicare restrictions on the types of providers 
eligible for reimbursement, including licensed professional counselors 
and marriage and family therapists, affect access to mental health 
services for Medicare enrollees by limiting the pool of accessible 
providers.''

    Senator Stabenow and I introduced bipartisan legislation to address 
this issue. S. 828, the Mental Health Access Improvement Act would 
allow licensed professional counselors and marriage and family 
therapists to bill Medicare.

    This is especially important in Wyoming, where many of our 
community mental health centers rely on professional counselors and 
marriage and family therapists to provide care.

    Can you please discuss the impact of allowing licensed professional 
counselors and marriage and family therapists to provide care for 
Medicare patients?

    Answer. Allowing Licensed Professional Counselors and Licensed 
Marriage and Family Therapists to be eligible for Medicare coverage and 
payment may expand the pool of accessible providers. According to the 
Centers for Medicare and Medicaid Services, there is no separately 
enumerated benefit category under Medicare that provides coverage and 
payment for the services of licensed professional counselors. As stated 
in the testimony, some stakeholders told us that Medicare restrictions 
on the types of providers eligible for reimbursement, including 
Licensed Professional Counselors and Licensed Marriage and Family 
Therapists, affects access to mental health services by limiting the 
pool of accessible providers. For example, representatives from one 
health system told us that, of the 22 licensed therapists on staff, 
only three were the types of licensed providers that are eligible for 
Medicare reimbursement. The representatives said this limitation 
exacerbated their current capacity issues, as they had over 1,700 
patients on a waiting list to see an outpatient provider. As we 
reported earlier this year, another governmental program--the Veterans 
Health Administration--has expanded the types of mental health 
professionals available to veterans, and since 2010, has made an effort 
to increase its hiring of licensed professional counselors and marriage 
and family therapists.\1\
---------------------------------------------------------------------------
    \1\ See GAO, Veterans Health Care: Efforts to Hire Licensed 
Professional Mental Health Counselors and Marriage and Family 
Therapists, GAO-22-104696 (Washington, DC: March 28, 2022).
---------------------------------------------------------------------------
                               telehealth
    Question. Patients in Wyoming are using telehealth to help meet 
their health-care needs during the pandemic. Members of this committee 
support making sure telehealth becomes a permanent part of health-care 
delivery for those patients who want to utilize this service.

    Congress, with bipartisan support, has already taken steps to 
extend telehealth flexibilities for five months following the 
expiration of the public health emergency.

    Can you discuss the importance of telehealth in terms of the 
delivery of mental health services?

    Answer. Reports we reviewed indicated that access to telehealth may 
improve patient outcomes, and representatives from most stakeholder 
organizations we interviewed highlighted positive examples of the use 
of this care during the COVID-19 pandemic. For example, some 
representatives said that, while demand for mental health services 
greatly increased during the pandemic, their ability to provide 
outpatient mental health services through telehealth was a key tool in 
meeting this increased demand. In addition, some representatives 
described benefits from telehealth such as patients not having to 
travel to an in-person appointment during the pandemic and a reduction 
in appointment no-shows. However, stakeholders from several 
organizations we interviewed told us the lack of access to broadband, 
particularly in rural areas, can limit consumers' ability to use 
telehealth for mental health services.

                                 ______
                                 
Prepared Statement of Andy Keller, Ph.D., President and CEO, and Linda 
    Perryman Evans Presidential Chair, Meadows Mental Health Policy 
                               Institute
    Chair Wyden, Ranking Member Crapo, and members of the Senate 
Finance Committee, thank you for the opportunity to testify today 
regarding two issues that are integral to the effective treatment of 
behavioral health disorders: enforcement of behavioral health parity 
and the integration of behavioral and physical health treatment.

    My name is Andy Keller, and I lead the Meadows Mental Health Policy 
Institute (Meadows Institute), a Texas-based non-profit and policy 
research institute committed to helping Texas and the Nation improve 
the availability and quality of 
evidence-driven mental health and substance use care. The Meadows 
Institute provides independent, nonpartisan, data-driven, and trusted 
policy and program guidance that creates systemic and equitable 
changes, so all people can obtain effective, efficient behavioral 
health care when and where they need it. We are committed to helping 
Texas become a national leader in treatment for all people suffering 
from mental illness and addiction. More on our work and history can be 
found on our website.\1\
---------------------------------------------------------------------------
    \1\ The Meadows Institute website can be viewed here: https://
mmhpi.org; our latest policy work here: https://mmhpi.org/work/policy-
updates/; and our history here: https://mmhpi.org/about/story-mission/.
---------------------------------------------------------------------------
  america's behavioral health is worse than ever, despite decades of 
              bipartisan consensus on the need for parity
    America has long faced a behavioral health crisis, one that has 
been greatly exacerbated by the COVID-19 pandemic:

        While overall rates of death from suicide dropped slightly in 
the last 2 years after nearly 2 decades of increase,\2\ deaths from 
suicide continued to increase for Black, indigenous, and Hispanic 
subgroups.\3\ Suicide is now the fourth leading cause of life-years 
lost,\4\ resulting in nearly $70 billion per year in medical costs and 
lost productivity.\5\
---------------------------------------------------------------------------
    \2\ Garnett, M.F., Curtin, S.C., and Stone, D.M. Suicide mortality 
in the United States, 2000-2020. National Center for Health Statistics 
Data Brief, 433. Hyattsville, MD: National Center for Health 
Statistics, 2022. https://www.cdc.gov/nchs/data/databriefs/db433.pdf.
    \3\ Curtin, S.C., Hedegaard, H., and Ahmad, F.B. Provisional 
numbers and rates of suicide by month and demographic characteristics: 
United States, 2020. Vital Statistics Rapid Release, 16. Hyattsville, 
MD: National Center for Health Statistics, 2021. https://www.cdc.gov/
nchs/data/vsrr/VSRR016.pdf.
    \4\ Centers for Disease Control and Prevention, National Center for 
Injury Prevention and Control. Web-based Injury Statistics Query and 
Reporting System (WISQARS) Years of Potential Life Lost (YPLL) [online] 
(2020). https://www.cdc.gov/injury/wisqars/fatal_help/ypll.html.
    \5\ Centers for Disease Control and Prevention. (2021, April). 
Preventing suicide [fact sheet]. https://www.cdc.gov/suicide/pdf/
preventing-suicide-factsheet-2021-508.pdf.
---------------------------------------------------------------------------
        Overdose deaths continue to rise, reaching an all-time high in 
2020 of nearly 92,000 deaths, with rates of overdose deaths climbing a 
staggering 31 percent from 2019 to 2020.\6\
---------------------------------------------------------------------------
    \6\ Hedegaard, H., Minino, A.M., Spencer, M.R., Warner, M. Drug 
overdose deaths in the United States, 1999-2020. National Center for 
Health Statistics Data Brief, 428. Hyattsville, MD: National Center for 
Health Statistics, 2021. https://www.cdc.gov/nchs/data/databriefs/
db428.pdf.
---------------------------------------------------------------------------
        Underlying indicators of depression increased fourfold during 
the pandemic, affecting nearly one-third of Americans.\7\ Rates are 
currently three times higher than baseline.\8\
---------------------------------------------------------------------------
    \7\ Santomauro, D.F. et al. (2021). Global prevalence and burden of 
depressive and anxiety disorders in 204 countries and territories in 
2020 due to the COVID-19 pandemic. The Lancet, 398(10312), 1700-1712. 
https://doi.org/10.1016/S0140-6736(21)02143-7.
    \8\ National Center for Health Statistics. (2022, March 14). 
Anxiety and Depression (Household Pulse Survey). Centers for Disease 
Control and Prevention. https://www.cdc.gov/nchs/covid19/pulse/mental-
health.htm.
---------------------------------------------------------------------------
        In late 2021, the U.S. Surgeon General issued America's first 
ever public health advisory focused on mental health for the Nation's 
youth.\9\ The proportion of youth emergency department visits for 
mental health needs increased by almost one-third during the COVID-19 
pandemic,\10\ and by summer 2021 the rate of pediatric emergency room 
visits for suicide was double pre-pandemic levels.\11\
---------------------------------------------------------------------------
    \9\ The U.S. Surgeon General's Advisory. (2021). Protecting youth 
mental health, https://www.hhs.gov/sites/default/files/surgeon-general-
youth-mental-health-advisory.pdf.
    \10\ Leeb, R.T., Bitsko, R.H., Radhakrishnan, L., Martinez, P., 
Njai, R., and Holland, K.M. (2020). Mental Health-Related Emergency 
Department Visits Among Children Aged 18 Years During the COVID-19 
Pandemic--United States, January 1-October 17, 2020. MMWR. Morbidity 
and Mortality Weekly Report, 69. https://doi.org/10.15585/
mmwr.mm6945a3.
    \11\ Yard et al. (2021, June 18). Emergency Department Visits for 
Suspected Suicide Attempts Among Persons Aged 12-25 Years Before and 
During the COVID-19 Pandemic--United States, January 2019-May 2021. 
Morbidity and Mortality Weekly Report, U.S. Department of Health and 
Human Services/Centers for Disease Control and Prevention, 70(24), 888-
894. https://www.cdc.gov/mmwr/volumes/70/wr/pdfs/mm7024e1-H.pdf.

    These consequences fall hardest on Black, Indigenous, Hispanic, and 
other people of color, who generally receive inequitable and less 
culturally responsive care, with access to care often frustrated by 
language and cultural barriers, treatment inaccessibility, and 
premature care termination.\12\ The burden of racism adds yet another 
insidious and toxic stress that increases risks of poor health for a 
range of health outcomes, including mental illness and addiction.\13\ 
The COVID-19 pandemic exacerbated these effects, with Black and 
Hispanic adults more likely to report symptoms of anxiety and 
depression.\14\ People of color have also disproportionately shouldered 
the burden of negative financial impacts \15\, 
\16\, \17\ and of grief--a primary driver of mental illness 
and addiction.\18\, \19\, \20\ The pandemic 
resulted in the loss of at least 140,000 primary caregivers,\21\ with 
disproportionate losses among American Indian, Black, and Hispanic 
children.
---------------------------------------------------------------------------
    \12\ Substance Abuse and Mental Health Services Administration. 
(2020). Double Jeopardy: COVID-19 and Behavioral Health Disparities for 
Black and Latino Communities in the U.S. (Submitted by OBHE) (p. 5). 
https://www.samhsa.gov/sites/default/files/covid19-behavioral-health-
disparities-black-latino-communities.pdf.
    \13\ Paradies, Y., Ben, J., Denson, N., Elias, A., Priest, N., 
Pieterse, A., Gupta, A., Kelaher, M., and Gee, G. (2015). Racism as a 
Determinant of Health: A Systematic Review and Meta-
Analysis. PLOS ONE, 10(9), e0138511. https://doi.org/10.1371/
journal.pone.0138511.
    \14\ Vahratian, A., Blumberg, S.J., Terlizzi, E.P., and Schiller, 
J.S. (2021). Symptoms of anxiety or depressive disorder and use of 
mental health care among adults during the COVID-19 pandemic--United 
States, August 2020-February 2021. MMWR. Morbidity and Mortality Weekly 
Report, 70(13), 490-494. https://doi.org/10.15585/mmwr.mm7013e2.
    \15\ Centers for Disease Control and Prevention. (2021). Health 
equity considerations and racial and ethnic minority groups, CDC. 
https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-
ethnicity.html.
    \16\ Parker, K., Menasce Horowitz, J., and Brown, A. (2020). About 
Half of Lower-Income Americans Report Household Job or Wage Loss Due to 
COVID-19, Pew Research Center. https://www.pewresearch.org/social-
trends/2020/04/21/about-half-of-lower-income-americans-report-
household-job-or-wage-loss-due-to-covid-19/.
    \17\ Fairlie, R. (2020). COVID-19, Small Business Owners, and 
Racial Inequality. National Bureau of Economic Research. https://
www.nber.org/reporter/2020number4/covid-19-small-business-owners-and-
racial-inequality.
    \18\ Kaplow, J.B., Saunders, J., Angold, A., and Costello, E.J. 
(2010). Psychiatric symptoms in bereaved versus non-bereaved youth and 
young adults: A longitudinal, epidemiological study, Journal of the 
American Academy of Child and Adolescent Psychiatry, 49, 1145-1154. 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2965565/.
    \19\ Keyes, K.M., Pratt, C., Galea, S., McLaughlin, K.A., Koenen, 
K.C., and Shear, M.K. (2014). The Burden of Loss: Unexpected Death of a 
Loved One and Psychiatric Disorders Across the Life Course in a 
National Study, American Journal of Psychiatry, 171(8), 864-871. 
https://doi.org/10.1176/appi.ajp.2014.13081132.
    \20\ Verdery, A.M., Smith-Greenaway, E., Margolis, R., and Daw, J. 
(2020). Tracking the reach of COVID-19 kin loss with a bereavement 
multiplier applied to the United States. Proceedings of the National 
Academy of Sciences of the United States of America, 117(30), 17695-
17701. https://doi.org/10.1073/pnas.2007476117.
    \21\ Hillis, S.D., Blenkinsop, A., Villaveces, A., Annor, F.B., 
Liburd, L., Massetti, G.M., Demissie, Z., Mercy, J.A., Nelson III, 
C.A., Cluver, L., Flaxman, S., Sherr, L., Donnelly, C.A., Ratmann, O., 
and Unwin, H.J.T. (2021). COVID-19--Associated Orphanhood and Caregiver 
Death in the United States. Pediatrics, 148(6), e2021053760. https://
doi.org/10.1542/peds.2021-053760.
---------------------------------------------------------------------------
  behavioral health spending has consistently failed to keep up with 
                                 needs
    The simplest explanation for these consistently worsening 
behavioral health indicators is that we have dramatically cut spending 
on behavioral health over the last 40 years.\22\ In 1986, behavioral 
health represented 9.3 percent of all medical spending. But a host of 
policy decisions, including the shift among insurers to manage 
behavioral health as a cost-center separate from other health 
conditions, led to extensive spending reductions. By 1998, behavioral 
health spending had been reduced by at least 20 percent more than other 
health-care spending, to just 7.4 percent of all medical spending, and 
these decreased spending levels held constant going forward.
---------------------------------------------------------------------------
    \22\ Mark, T.L., Yee, T., Levit, K.R., Camacho-Cook, J., Cutler, 
E., and Carroll, C.D. (2016). Insurance financing increased for mental 
health conditions but not for substance use disorders, 1986-2014. 
Health Affairs, 35(6), 958-965. https://doi.org/10.1377/
hlthaff.2016.0002.

    The budget of the Substance Abuse and Mental Health Services 
Administration (SAMHSA) is also illustrative. Between FY 2007 and FY 
2017, SAMHSA's budget hovered between $3.2 billion and $3.6 billion a 
year. Since then, recognition of the unprecedented surge in substance 
use disorders and mental health needs has driven Federal and State 
spending upwards. The FY 2022 SAMHSA budget is nearly $6 billion 
---------------------------------------------------------------------------
higher--an exponential increase in funding in 5 years.

    However, nearly 4 decades of services erosion cannot be fixed 
overnight, and to offset the trajectory we are on, we will need both 
the public and private sectors as part of the solution.
     behavioral health parity is a longstanding and ongoing concern
    It has been more than 25 years since President Bill Clinton signed 
the Mental Health Parity Act, providing the first parity protections 
for people with mental health conditions. And it was almost exactly 20 
years ago that President George W. Bush's New Freedom Commission on 
Mental Health called out ``the unfair treatment limitations and 
financial requirements placed on mental health benefits in private 
health insurance.''\23\ Those efforts culminated with the passage of 
the groundbreaking Paul Wellstone and Pete Domenici Mental Health and 
Addiction Equity Act (MHPAEA) in 2008. President Barack Obama expanded 
these protections across all private payers in 2010 with the Affordable 
Care Act.
---------------------------------------------------------------------------
    \23\ President's New Freedom Commission on Mental Health. (n.d.). 
Achieving the Promise: Transforming Mental Health Care in America. 
Retrieved March 28, 2022, from https://govinfo.library.unt.edu/
mentalhealthcommission/reports/FinalReport/FullReport.htm.

    Unfortunately, despite attention from Congress and presidential 
administrations for decades, parity implementation gaps persist, with 
millions of Americans unable to access needed behavioral health 
services. A 2019 Milliman research report detailed widespread network 
adequacy and reimbursement parity concerns for commercially insured 
consumers:\24\
---------------------------------------------------------------------------
    \24\ Melek, S., Davenport, S., and Gray, T.J. (2019). Addiction and 
mental health vs. physical health: Widening disparities in network use 
and provider reimbursement (Milliman Research Report, p. 140). https://
www.milliman.com/-/media/milliman/importedfiles/ektron/addictionand
mentalhealthvsphysicalhealthwideningdisparitiesinnetworkuseandproviderre
imbursement.ashx.

        Commercially insured individuals were between five and six 
times more likely to use out-of-network providers for their behavioral 
health needs than for other health care.
        Primary care reimbursements were 19.8 to 28.3 percent higher 
than behavioral health reimbursements, and medical/surgical specialty 
visits were 17.0 to 18.9 percent higher.

    And in January of this year, the Department of Labor (DOL), 
Department of Health and Human Services (HHS), and the Treasury 
released The Report to Congress on Implementation of the Paul Wellstone 
and Pete Domenici Mental Health Parity and Addiction Equity Act of 
2008.\25\ In what the three departments termed ``a failure to deliver 
parity,'' the report found broad non-compliance with MHPAEA's 
requirements among health insurance plans, with all 58 plans reviewed 
failing to meet requirements. Specific alarms were raised regarding the 
use of non-
quantitative treatment limitations (NQTLs),\26\ which are non-numerical 
limits on the scope or duration of benefits for treatment (such as pre-
authorization requirements, differences in provider availability, and 
application of medical necessity standards).
---------------------------------------------------------------------------
    \25\ MHPAEA. (2022). Realizing Parity, Reducing Stigma, and Raising 
Awareness: Increasing Access to Mental Health and Substance Use 
Disorder Coverage (2022 MHPAEA Report to Congress, p. 54). https://
www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/mental-
health-parity/report-to-congress-2022-realizing-parity-reducing-stigma-
and-raising-awareness.
pdf.
    \26\ Employee Benefits Security Administration. (2022). U.S. 
Departments of Labor, Health and Human Services, Treasury Issue 2022 
Mental Health Parity and Addiction Equity Act Report to Congress. U.S. 
Department of Labor. https://www.dol.gov/newsroom/releases/ebsa/
ebsa20220125.

    The report emphasized many specific examples of the inappropriate 
use of NQTLs, including the exclusion of certain medicines as treatment 
for substance use disorder conditions and requiring pre-certification 
for all mental health and substance use disorder outpatient services as 
opposed to only for a limited range of medical/surgical outpatient 
---------------------------------------------------------------------------
care.

    While it is important to acknowledge that insurers face systemic 
challenges in meeting network adequacy requirements for behavioral 
health care, the data clearly show that they are able to do so for all 
other medical/surgical specialties. While there is work to be done to 
improve consensus on standards and further clarity both reporting and 
parity requirements themselves, the simple fact that every single plan 
failed to meet expectations underscores the wide gulf between the 
promise of parity and the realities facing Americans in need of mental 
health and substance use disorder care today.

    The Meadows Institute supports the departments' call for enhanced 
MHPAEA enforcement and recognizes the need for regulators, effected 
consumers, and the insurance industry to continue to improve reporting 
processes and agreed-upon practices. Additionally, the Meadows 
Institute encourages Congress to vest DOL with the authority to assess 
civil monetary penalties for parity violations and to amend The 
Employee Retirement Income Security Act of 1974 (ERISA) to expressly 
provide DOL with the authority to directly pursue parity violations by 
entities that provide administrative services to ERISA group health 
plans.
                   medicare-specific parity concerns
    These failures also affect Medicare beneficiaries. In 2020, 
Medicare spending reached $829.5 billion, accounting for 20 percent of 
total national health-care expenditures.\27\ Despite this, Medicare 
beneficiaries served through both fee-for-service and stand-alone 
Medicare Advantage plans do not enjoy the protections of MHPAEA. 
Consequently, the approximately one in four Medicare beneficiaries 
estimated to have a mental illness are subject to a range of behavioral 
health treatment limitations that do not apply to Medicare-covered 
medical/surgical services.\28\ These limitations also have broader 
systematic consequences beyond their direct impact on Medicare 
beneficiaries, because Medicare also plays an important role in setting 
rates, benchmarks, and codes for other health coverages.
---------------------------------------------------------------------------
    \27\ Health Affairs Forefront. (2021). National Health Spending in 
2020. Health Affairs. Retrieved March 28, 2022, from https://
www.healthaffairs.org/do/10.1377/forefront.20211214.
144442/full/.
    \28\ Beth McGinty. (2020). Medicare's Mental Health Coverage: How 
COVID-19 Highlights Gaps and Opportunities for Improvement, https://
doi.org/10.26099/sp60-3p16.

    Medicare imposes both quantitative and non-quantitative treatment 
limitations. Arguably, the most glaring example of a discriminatory 
quantitative Medicare limitation is the 190-day lifetime limit on 
inpatient psychiatric care. This discriminatory limitation restricts a 
Medicare beneficiary to just 190 days of inpatient care in their 
lifetime--without consideration of treatment necessity. A Medicare 
beneficiary disabled because of a chronic serious mental illness may 
easily exceed the 190-day lifetime limit, especially if they gain 
Medicare coverage at a younger age. We support the Medicare Mental 
Health Inpatient Equity Act (H.R. 5674/S. 3061), which would remove the 
---------------------------------------------------------------------------
artificial 190-day limitation.

    Network Adequacy: The data show that Medicare Advantage (MA) 
beneficiaries often lack access to in-network mental health providers, 
and metrics are often insufficient to ensure an adequate network of 
providers. This forces participants to turn to higher-cost, out-of-
network care or to forego care entirely. A Kaiser Family Foundation 
analysis found that, on average, MA plans included less than one-
quarter of psychiatrists in a county, and more than a third included 
less than 10 percent of psychiatrists in their county.\29\ Medicare 
also imposes numerous NQTLs that would otherwise violate MHPAEA, 
including prior authorization requirements and limitations on providers 
and behavioral health services. As seen with the commercial plans, 
administrative burdens posed by NQTLs are often just as significant a 
barrier as low reimbursement rates.
---------------------------------------------------------------------------
    \29\ Jacobson, G., Rae, M., Neuman, T., Orgera, K., and Boccuti, C. 
(2017). Medicare Advantage: How robust are plans' physician networks? 
Kaiser Family Foundation. https://www.kff.org/report-section/medicare-
advantage-how-robust-are-plans-physician-networks-report/.

    Prior Authorizations: MA plans are often subject to burdensome, 
unnecessary prior authorization requirements. According to the Kaiser 
Family Foundation, four in five MA enrollees are in plans that require 
prior authorization for some services, and more than half of enrollees 
are in plans that require prior authorization for mental health 
services.\30\ The prior authorization process has been shown to be 
wasteful and to potentially contribute to clinician burnout.\31\ A 2017 
American Medical Association survey of 1,000 physicians further noted 
that 92 percent of those surveyed reported that prior authorizations 
have a negative impact on patient clinical outcomes.\32\
---------------------------------------------------------------------------
    \30\ Jacobson, G., and Neuman, T. (2018). Prior authorization in 
Medicare Advantage plans: How often is it used? Kaiser Family 
Foundation. https://www.kff.org/medicare/issue-brief/prior-
authorization-in-medicare-advantage-plans-how-often-is-it-used/.
    \31\ Colligan, L., Sinsky, C., Goeders, L., Schmidt-Bowman, M., and 
Tutty, M. (2016). Sources of physician satisfaction and dissatisfaction 
and review of administrative tasks in ambulatory practice: A 
qualitative analysis of physician and staff interviews. American 
Medical Association. https://www.ama-assn.org/sites/ama-assn.org/files/
corp/media-browser/public/ps2/ps2-dartmouth-study-111016.pdf.
    \32\ American Medical Association. (2018). 2017 AMA prior 
authorization physician survey. https://www.ama-assn.org/sites/ama-
assn.org/files/corp/media-browser/public/arc/prior-auth-2017.pdf.

    Evidence-Based Care for Severe Needs: Medicare, along with most 
commercial plans and many Medicaid plans, also fail to cover a number 
of evidence-based, multidisciplinary team interventions for people with 
the most severe mental health and substance use disorders. This 
includes Coordinated Specialty Care for early psychosis and Assertive 
Community Treatment (ACT) teams for people with persistently severe 
needs. The value and cost savings associated with the use of ACT teams 
has been established over decades of research.\33\, \34\ 
Coordinated Specialty Care (CSC) has been shown to produce greater 
improvement in clinical and functional outcomes as compared with 
standard care for those experiencing first-episode 
psychosis.\35\, \36\
---------------------------------------------------------------------------
    \33\ The Lewin Group. (2000). Assertive community treatment 
literature review. From SAMHSA Implementation Toolkits website: http://
media.shs.net/ken/pdf/toolkits/community/13.ACT_
Tips_PMHA_Pt2.pdf.
    \34\ Bond, G.R., Drake, R.E., Mueser, K.T., and Latimer, E. (2001). 
Assertive community treatment for people with severe mental illness: 
Critical ingredients and impact on patients. Disease Management and 
Health Outcomes, 9, 141-159. https://link.springer.com/article/10.2165/
00115677-200109030-00003.
    \35\ Rosenheck, R. et al. (2016). Cost-effectiveness of 
comprehensive, integrated care for first episode psychosis in the NIMH 
RAISE early treatment program. Schizophrenia Bulletin, 42(4), 896-906. 
https://academic.oup.com/schizophreniabulletin/article/42/4/896/
2413925.
    \36\ Kane, J.M. et al. (2016). Comprehensive Versus Usual Community 
Care for First-Episode Psychosis: 2-Year Outcomes From the NIMH RAISE 
Early Treatment Program. The American Journal of Psychiatry, 173(4), 
362-372. https://doi.org/10.1176/appi.ajp.2015.15050632.

    Crisis Care: Medicare also fails to cover mental health crisis 
services, a failure mirrored in commercial coverage. As we roll out the 
988 crisis number nationally and as communities across the Nation work 
to establish a full continuum of crisis services, that failure is 
unacceptable. Earlier this year, we joined RI International and the 
National Association of State Mental Health Program Directors to 
publish Sustainable Funding for Mental Health Crisis Services, which 
identifies standardized existing health-care codes that every insurer 
should reimburse, including Medicare.\37\ The Meadows Institute is very 
appreciative to Senator Wyden for his continued leadership on the need 
to adequately fund and support crisis care and to Senators Cornyn and 
Cortez Masto for focusing on the important role that insurance coverage 
must play in supporting crisis care. We strongly support Senators 
Cornyn and Cortez Masto's Behavioral Health Crisis Services Expansion 
Act (S. 1902), which would expand reimbursement for the full spectrum 
of crisis services under Medicare and other payers.
---------------------------------------------------------------------------
    \37\ Crisis Now. (2022). Sustainable Funding for Mental Health 
Crisis Services. https://crisisnow.com/wp-content/uploads/2022/01/
Sustainable-Funding-Crisis-Coding-Billing-2022.pdf.

    Peer Support: Similarly, peer support services are not covered 
within Medicare. Peer support services are provided by people with 
lived experience of a mental illness or substance use disorder who have 
completed specialized training and are certified to deliver support 
services under appropriate State or national certification standards. A 
2018 analysis showed that providers with peer services had 2.9 fewer 
hospitalizations per year and saved an average of $2,138 per Medicaid 
enrolled month in Medicaid expenditures.\38\ We support Senators Cortez 
Masto and Cassidy's PEERS Act of 2021 (H.R.2767/ S. 2144), which would 
specify that peer support specialists may participate in the provision 
of behavioral health integration services with the supervision of a 
physician or other entity under Medicare.
---------------------------------------------------------------------------
    \38\ Bouchery, E., Barna, M., Babalola, E., Friend, D., Brown, J., 
Blyler, C., Ireys, H., The Effectiveness of a Peer-Staffed Crisis 
Respite Program as an Alternative to Hospitalization, Psychiatric 
Services, August 2018.

    Substance Use Disorder Care: There are also major gaps in access to 
substance use disorder (SUD) care in Medicare, Medicaid, and commercial 
plans. Broadly speaking, we support the positions set forth by the 
Medicare Addiction Parity Project. Despite a significant number of 
Medicare beneficiaries requiring SUD treatment, Medicare simply does 
not adequately cover most essential SUD benefits and services. SUD 
services within MA, especially services and medications for opioid use 
disorders (OUD), are disproportionately subject to burdensome and 
unnecessary prior authorization requirements and other limitations that 
---------------------------------------------------------------------------
hinder timely access to appropriate medications and services.

    There is also a significant issue with SUD network adequacy and a 
lack of SUD providers covered by Medicare. Providers that are not 
covered by Medicare include Licensed Professional Counselors, Licensed 
Addiction Counselors, Certified Alcohol and Drug Counselors, and Peer 
Support Specialists. As a result, many patients who seek treatment are 
unable to access it.

    For Medicare and commercial health plans alike, we are particularly 
concerned about barriers to access for Medication-Assisted Treatment 
(MAT). An analysis we conducted in August 2020 showed that universal 
access to MAT could have saved almost at least 24,000 lives annually 
from overdose.\39\ There are also coverage, prior authorization, and 
network adequacy barriers to MAT in essentially all health plans.
---------------------------------------------------------------------------
    \39\ https://mmhpi.org/wp-content/uploads/2020/09/COVID-
MHSUDPrevention.pdf.
---------------------------------------------------------------------------
      the most important reform: integration of behavioral health 
                           into primary care
    The primary impediment to parity is the lack of providers to 
deliver care cost-
effectively, and integration of behavioral health providers and care 
deliver into primary care offers the only path to removing this 
barrier. To adequately address the magnitude of behavioral health need 
in America, we must combine enhanced parity enforcement with an 
aggressive effort to integrate behavioral health into primary care. 
Broad scale adoption of evidence-based primary care interventions for 
mental health and substance use disorders are essential to realizing 
the promise of parity for two reasons. First, decades of research and 
over 90 randomized control trials have clearly shown that the two-
thirds of needs which fall into the mild to moderate range can be 
better treated in primary care than in specialty care.\40\ Second, 
serving most people in primary care would allow America's limited 
specialty care workforce to focus on people with more severe and 
complex needs.
---------------------------------------------------------------------------
    \40\ Carlo, A.D., Barnett, B.S., and Unutzer, J. (2021). Harnessing 
collaborative care to meet mental health demands in the era of COVID-
19. JAMA Psychiatry, 78(4), 355. https://doi.org/10.1001/
jamapsychiatry.2020.3216.

    Currently, our behavioral health workforce is not well-deployed 
upstream in U.S. primary care settings as compared to other 
industrialized nations.\41\ This is a major reason why we fail to 
detect and treat mental health needs until 8 to 10 years after symptoms 
emerge.\42\ But America faced this same challenge with heart disease 
and cancer and successfully turned the tide on both by leveraging 
primary care over the last 4 decades. Until the 1980s, we identified 
heart disease primarily when a person had a heart attack, and we began 
treatment then, after the heart was damaged, to resuscitate the person 
and prevent a recurrence. We would also wait to detect cancer until it 
resulted in functional impairment--a broken bone, coughing up blood--
with devastating consequences and higher mortality rates. Today, we 
have systems in place in primary care to detect and treat most heart 
disease and many cancers much earlier, when they are easier to address 
successfully, much less likely to be disabling and burdensome to the 
person receiving care, and less costly to society.
---------------------------------------------------------------------------
    \41\ Tikkanen, R., Fields, K., Williams III, R.D., and Abrams, M.K. 
(2020). Mental health conditions and substance use: Comparing U.S. 
needs and treatment capacity with those in other high-income countries. 
The Commonwealth Fund. https://www.commonwealthfund.org/publications/
issue-briefs/2020/may/mental-health-conditions-substance-use-comparing-
us-other-countries.
    \42\ American Academy of Child and Adolescent Psychiatry. (2012). 
Best principles for integration of child psychiatry into the pediatric 
health home. https://www.aacap.org/App_Themes/AACAP/docs/
clinical_practice_center/systems_of_care/
best_principles_for_integration_of_child_
psychiatry_into_the_pediatric_health_home_2012.pdf.

    Two models best represent the promise of reaching people in primary 
care rather than referring them to overwhelmed and understaffed 
specialty care systems: (1) the Collaborative Care Model (CoCM) and (2) 
Primary Care Behavioral Health (PCBH). CoCM and PCBH each have the 
potential to magnify the reach of our limited workforce many times 
over, and analysis carried out by the Meadows Institute shows that CoCM 
can leverage psychiatrist time 3.5 times over and PCBH can leverage 
other licensed practitioner time 2.65 times over.\43\ In early 2021, 
comprehensive studies through both RAND and the Bipartisan Policy 
Center endorsed these strategies,\44\ and RAND offered specific 
recommendations for scaling them nationwide.
---------------------------------------------------------------------------
    \43\ Meadows Mental Health Policy Institute. (2022). Integration 
and the pediatric behavioral health workforce. https://mmhpi.org/wp-
content/uploads/2022/03/Briefing-Summary_BHI_
Workforce_Pediatrics_March2022.pdf.
    \44\ McBain, R.K., Eberhart, N.K., Breslau, J., Frank, L., Burnam, 
M.A., Kareddy, V., and Simmons, M.M. (2021). How to transform the U.S. 
mental health system: Evidence-based recommendations. RAND Corporation. 
https://www.rand.org/pubs/research_reports/RRA889-1.html; BPC 
Behavioral Health Integration Task Force. (2021). Tackling America's 
mental health and addiction crisis through primary care integration: 
Task force recommendations. Bipartisan Policy Center. https://
bipartisanpolicy.org/download/?file=/wp-content/uploads/2021/03/
BPC_Behavioral-Health-Integration-report_R03.pdf.

    CoCM is the most extensively researched and evidence-based 
integration strategy to detect and treat mental health and substance 
use disorders before they become crises,\45\ and it is now being 
implemented at scale in health systems serving millions of Texans.\46\ 
The potential cost-savings of widespread implementation are 
considerable: a pivotal 2013 study found Medicare and Medicaid savings 
of up to six-to-one in total medical costs and estimated $15 billion in 
Medicaid savings if only 20 percent of beneficiaries with depression 
received it,\47\ and the RAND report cited a 13:1 return on investment. 
Importantly, CoCM is proven to work just as well for Black, Hispanic, 
and other communities of color,\48\ and PCBH has shown growing promise 
with pediatric populations.\49\
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    \45\ Carlo, A.D., Barnett, B.S., and Unutzer, J. (2021). Previously 
cited.
    \46\ Meadows Mental Health Policy Institute. (2021). Lone star 
depression challenge. https://mmhpi.org/the-lone-star-depression-
challenge/.
    \47\ Unutzer, J., Harbin, H., Schoenbaum, M., and Druss, B. (2013, 
May). The collaborative care model: An approach for integrating 
physical and mental health care in Medicaid health homes. Health Home 
Information Resource Center. http://www.chcs.org/media/
HH_IRC_Collaborative
_Care_Model__052113_2.pdf.
    \48\ Wells, K., Sherbourne, C., Schoenbaum, M., Ettner, S., Duan, 
N., Miranda, J., Unutzer, J., and Rubenstein, L. (2004, April). Five-
year impact of quality improvement for depression: Results of a group-
level randomized controlled trial. Archives of General Psychiatry, 
61(4), 378-386. https://pubmed.ncbi.nlm.nih.gov/15066896/. Ell, K., 
Aranda, M.P., Xie, B., Lee, P-J., and Chou, C-P. (2010, June). 
Collaborative depression treatment in older and younger adults with 
physical illness: Pooled comparative analysis of three randomized 
clinical trials. American Journal of Geriatric Psychiatry, 18(6), 520-
530. https://pubmed.ncbi.nlm.nih.gov/20220588/.
    \49\ Remoue Gonzales, S., and Higgs, J. (2020). Perspectives on 
integrated behavioral health in pediatric care with immigrant children 
and adolescents in a Federally Qualified Health Center in Texas. 
Clinical Child Psychology and Psychiatry, 25(3), 625-635. https://
journals.
sagepub.com/doi/10.1177/1359104520914724.

    Though certain distinctions exist between the two approaches, both 
effectively address pediatric workforce shortages by: (a) sharing an 
interdisciplinary team-based structure, (b) treating a wide array of 
behavioral health presentations, (c) leading to stigma-reduction, (d) 
utilizing evidence-based measures to guide treatment planning and 
monitoring, (e) having dedicated insurance billing codes for long-term 
financial sustainability for practices, (f) allowing for real-time 
availability of behavioral health care, and (g) employing brief, 
evidence-based interventions in a short-term care format to help 
patients access care sooner. Both CoCM and PCBH rely on approved 
existing billing codes that are reimbursed by Medicare, most major 
commercial insurance plans, and most States' Medicaid plans. Texas, of 
note, is expected to activate Medicaid reimbursement for CoCM in CY 
2022, which is helping to drive implementation of CoCM and integration 
---------------------------------------------------------------------------
broadly.

    However, coverage alone is not enough. As the RAND report 
previously noted, CoCM and PCBH are not available in most primary care 
settings today, with ``implementation of models like CoCM . . . 
underwhelming and largely confined to academic medical centers.'' Given 
this, the RAND report recommends a nationwide effort to provide 
technical assistance and financial incentives scaled in the hundreds of 
millions of dollars to help the hundreds of thousands of primary care 
practitioners across the Nation rapidly adopt these models.

    Only a national effort of this magnitude can turn the tide on 
rising deaths from suicide and overdose. America faced this same 
challenge 15 years ago regarding the adoption and meaningful use of 
electronic health records, and we employed technical assistance and 
financial incentives to scale their availability nationally in just a 
few years. If we wait 20 years, this will be the standard of care 
nationwide, but in the meantime we will lose over two million more 
Americans to suicide and overdose and relegate tens of millions more to 
poor access, delayed care, and a range of tragic outcomes.

    Today in Texas we are showing that such a rapid transition is 
possible. Over the next 5 years, the Meadows Institute and our partners 
are using the $10 million Lone Star Prize awarded by Lyda Hill 
Philanthropies to bring this care to over 10 million Texans.\50\ In 
addition, Texas is deploying $7 million in American Rescue Plan Act 
(ARPA) funds to accelerate implementation of integration in pediatric 
settings to increase access across 18 Texas health systems.
---------------------------------------------------------------------------
    \50\ Meadows Mental Health Policy Institute. (2021). Lone star 
depression challenge. https://mmhpi.org/the-lone-star-depression-
challenge/.

    Congressional efforts such as the Collaborate in an Orderly and 
Cohesive Manner Act (H.R. 5218) by Rep. Fletcher (D-TX) and Rep. 
Herrera Beutler (R-WA) could form the basis for such action, and this 
effort is supported by every major medical association.\51\ To address 
the magnitude of the national crisis facing us today, this legislation 
should be broadened to include PCBH and scaled up to funding levels 
sufficient for national scaling such as those recommended by RAND.
---------------------------------------------------------------------------
    \51\ American Psychiatric Association. (2021). Eighteen 
organizations express support for the Collaborate in an Orderly and 
Cohesive Manner (COCM) Act which would bolster innovative model of 
provision of mental health care. https://www.psychiatry.org/newsroom/
news-releases/eighteen-organizations-express-support-for-the-
collaborate-in-an-orderly-and-cohesive-manner-cocm-act-which-would-
bolster-innovative-model-of-provision-of-mental-health-care.

    The Meadows Institute encourages the committee to support large-
scale efforts to build integrated care infrastructure and widescale 
adoption of models such as CoCM. We also encourage the committee to 
support the Collaborate in an Orderly and Cohesive Manner Act (H.R. 
5218) to help primary care providers implement integrated behavioral 
health and primary care models, but broaden it to cover models such as 
PCBH and expand its reach by funding it at levels suggested by the RAND 
---------------------------------------------------------------------------
report as necessary for widescale adoption.

                                 ______
                                 
        Questions Submitted for the Record to Andy Keller, Ph.D.
                 Questions Submitted by Hon. Ron Wyden
                integrated care at independent practices
    Question. Testimony at the Finance Committee's March 30th hearing 
on mental health parity and integration of care made clear that there 
is potential for integrated care teams to help patients get the 
behavioral health care that they need, when they need it. As the 
Finance Committee examines opportunities to improve the take-up rate of 
integrated care models in physician practices, it will be vital to 
ensure that behavioral health integration models can work for physician 
practices of all shapes and sizes--and not just large physician 
practices that are affiliated with major health systems.

    Are there approaches to care integration that you have seen that 
show the most promise for being implemented in smaller and independent 
primary care practices?

    Answer. We strongly agree that this Senate should prioritize an 
urgent national effort to rapidly expand access to behavioral health 
integration models that engages physician (and other primary care 
provider) practices of all shapes and sizes, just as we have done in 
Texas. As a base for this effort, we strongly support H.R. 5218, the 
Collaborate in an Orderly and Cohesive Manner Act, which would provide 
grant-funded support and technical assistance to exactly the kinds of 
smaller, independent practices you are asking about in order to 
facilitate their use of the Collaborative Care Model (CoCM). However, 
the ambition of that legislation is too small given the scope of our 
national mental health and addiction crisis (we are spending $30 
million in Texas alone with our philanthropic efforts to expand access 
to about half the State), and if the scope can be expanded, the bill 
should also support implementation of the Primary Care Behavioral 
Health (PCBH) model (in addition to CoCM).

    Expanding access to CoCM is the best practice for integrating 
behavioral health with primary care and one of the most important 
things we can do to improve care and save countless lives for people 
struggling with mental health conditions or substance use disorder 
(SUD). CoCM is a proven tool to detect and treat mental health and 
substance use concerns in primary care settings before they become 
crises. The model is a team-based \1\ approach to care that routinely 
measures both clinical outcomes and a patient's goals over time to 
increase the effectiveness of mental health and SUD treatment in 
primary care settings.\2\, \3\ CoCM is also the only evidence-based 
medical procedure currently reimbursable in primary care. It has been 
covered by Medicare since 2017 \4\ and by nearly all commercial payers 
since 2019 \5\--and has strong evidence of cost savings.\6\, \7\, \8\ 
The potential for cost savings with widespread implementation is 
considerable; a 2013 study found a six-to-one cost savings in total 
medical costs in Medicare and Medicaid settings and estimated $15 
billion in Medicaid savings if just 20 percent of beneficiaries with 
depression receive CoCM services.\9\
---------------------------------------------------------------------------
    \1\ Unutzer, J., Harbin, H., Schoenbaum, M., and Druss, B. (2013, 
May). The collaborative care model: An approach for integrating 
physical and mental health care in Medicaid health homes. Health Home 
Information Resource Center. http://www.chcs.org/media/HH_IRC_
Collaborative_Care_Model__052113_2.pdf.
    \2\ Nafziger, M., and Miller, M. (2013). Collaborative primary 
care: Preliminary findings for depression and anxiety, Washington State 
Institute for Public Policy. http://www.wsipp.wa.gov/ReportFile/1546/
Wsipp_Collaborative-Primary-Care-Preliminary-Findings-forDepression-
and-Anxiety_Preliminary-Report.pdf.
    \3\ Alford, D.P., LaBelle, C.T., Kretsch, N., Bergeron, A., Winter, 
M., Botticelli, M., and Samet, J.H. (2011). Collaborative care of 
opioid-addicted patients in primary care using buprenorphine: Five-year 
experience. Archives of Internal Medicine, 171(5), 425-431. https://
jamanetwork.com/journals/jamainternalmedicine/fullarticle/226781.
    \4\ Centers for Medicare and Medicaid Services. (2022). Behavioral 
health integration services. https://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-MLN/MLNProd
ucts/Downloads/BehavioralHealthIntegration.pdf.
    \5\ Alter, C., Carlo, A., Harbin, H., and Schoenbaum, M. (2019). 
Wider implementation of collaborative care is inevitable. Psychiatric 
News, 54(13), 6-7. https://doi.org/10.1176/appi.pn.2019.6b7.
    \6\ Unutzer, J., Schoenbaum, M., and Druss, B. (2013, May). The 
collaborative care model: An approach for integrating physical and 
mental health care in Medicaid health homes. Health Home Information 
Resource Center. http://www.chcs.org/media/HH_IRC_Collaborative_Care_
Model__052113_2.pdf.
    \7\ Press, M.J., Howe, R., Schoenbaum, M., Cavanaugh, S., Marshall, 
A., Baldwin, L., and Conway, P.H. (2017). Medicare payment for 
behavioral health integration. The New England Journal of Medicine, 
376, 405-407. https://www.nejm.org/doi/10.1056/NEJMp1614134.
    \8\ Melek, S.P., Norris, D.T., Paulus, J., Matthews, K., Weaver, 
A., and Davenport, S. (2018, January). Potential economic impact of 
integrated medical-behavioral health care. Updated projections for 
2017. https://www.milliman.com/-/media/milliman/importedfiles/
uploadedfiles/insight/2018/potential-economic-impact-integrated-
healthcare.ashx.
    \9\ Unutzer, J., Schoenbaum, M., and Druss, B. (2013, May). The 
collaborative care model: An approach for integrating physical and 
mental health care in Medicaid health homes. Health Home Information 
Resource Center. http://www.chcs.org/media/HH_IRC_Collaborative_Care
_Model__052113_2.pdf.

    Most importantly, CoCM is effective across a variety of settings 
and clinic practices. In smaller practices, contracting with offsite 
telemedicine-based collaborative care teams can relieve some of the 
complexity of implementing CoCM and, in rural settings in particular, 
can ameliorate challenges of finding staff based locally.\10\ Numerous 
studies demonstrate the effectiveness of the Collaborative Care Model 
in Federally Qualified Health Centers (FQHCs) and community-based 
clinics for adults with depression,\11\ anxiety,\12\ opioid and alcohol 
use disorders,\13\ and also for specific populations, including Black 
and Hispanic communities \14\ and pregnant women.\15\ Additionally, 
early evidence suggests that CoCM implemented in FQHCs also improves 
outcomes for child and youth patients.\16\
---------------------------------------------------------------------------
    \10\ Fortney, J.C., Pyne, J.M., Mouden, S.B., Mittal, D., Hudson, 
T.J., Schroeder, G.W., Williams, D.K., Bynum, C.A., Mattox, R., and 
Rost, K.M. (2013). Practice-Based Versus Telemedicine-Based 
Collaborative Care for Depression in Rural Federally Qualified Health 
Centers: A Pragmatic Randomized Comparative Effectiveness Trial. 
American Journal of Psychiatry, 170(4), 414-425. https://doi.org/
10.1176/appi.ajp.2012.12050696.
    \11\ Carlo, A.D., Jeng, P.J., Bao, Y., and Unutzer, J. (2019). The 
Learning Curve After Implementation of Collaborative Care in a State 
Mental Health Integration Program. Psychiatric Services, 70(2), 139-
142. https://doi.org/10.1176/appi.ps.201800249.
    \12\ Bauer, A.M., Azzone, V., Goldman, H.H., Alexander, L., 
Unutzer, J., Coleman-Beattie, B., and Frank, R.G. (2011). 
Implementation of Collaborative Depression Management at Community-
Based Primary Care Clinics: An Evaluation. Psychiatric Services, 62(9), 
1047-1053. https://doi.org/10.1176/ps.62.9.pss6209_1047.
    \13\ Watkins, K.E., Ober, A.J., Lamp, K., Lind, M., Setodji, C., 
Osilla, K.C., Hunter, S.B., McCullough, C.M., Becker, K., Iyiewuare, 
P.O., Diamant, A., Heinzerling, K., and Pincus, H.A. (2017). 
Collaborative Care for Opioid and Alcohol Use Disorders in Primary 
Care: The SUMMIT Randomized Clinical Trial. JAMA Internal Medicine, 
177(10), 1480. https://doi.org/10.1001/jamainternmed.2017.3947.
    \14\ Lagomasino, I.T., Dwight-Johnson, M., Green, J.M., Tang, L., 
Zhang, L., Duan, N., and Miranda, J. (2017). Effectiveness of 
Collaborative Care for Depression in Public-Sector Primary Care Clinics 
Serving Latinos. Psychiatric Services, 68(4), 353-359. https://doi.org/
10.1176/appi.ps.201600187.
    \15\ Grote, N.K., Katon, W.J., Russo, J.E., Lohr, M.J., Curran, M., 
Galvin, E., and Carson, K. (2015). Collaborative Care for Perinatal 
Depression in Socioeconmically Disadvantaged Women: A randomized trial; 
Research Article: Collaborative Care for Perinatal Depression. 
Depression and Anxiety, 32(11), 821-834. https://doi.org/10.1002/
da.22405.
    \16\ Sheldrick, R.C., Bair-Merritt, M.H., Durham, M.P., Rosenberg, 
J., Tamene, M., Bonacci, C., Daftary, G., Tang, M.H., Sengupta, N., 
Morris, A., and Feinberg, E. (2022). Integrating Pediatric Universal 
Behavioral Health Care at Federally Qualified Health Centers. 
Pediatrics, 149(4), e2021051822. https://doi.org/10.1542/peds.2021-
051822.

    However, implementing this model beyond the research setting in 
real-world practices continues to be an ongoing challenge, largely due 
to start-up costs and the need for technical assistance. The Meadows 
Mental Health Policy Institute (the Meadows Institute) is currently the 
lead on a 5 year, $10 million effort called the Lone Star Depression 
Challenge. This effort has acquired additional philanthropic support 
totaling nearly $15 million more to expand and accelerate its reach, 
and the State of Texas recently added $7 million in American Rescue 
Plan Act (ARPA) funds to include more pediatric practices. One key part 
of this expansion involves work with the Amarillo Area Foundation to 
provide technical assistance and remove obstacles associated with 
implementation of integrated behavioral health care for the rural and 
frontier practices in the 26 northern-most counties of the Texas 
Panhandle that it serves. So, Texans are showing how even the most 
remote practices can benefit from CoCM and overcome their 
---------------------------------------------------------------------------
implementation barriers with start-up grants and technical assistance.

    Additionally, gaps in integrated care implementation have caught 
the attention of the private sector where technology companies' 
investments have been focused on the need to provide technical 
assistance in implementing CoCM. Specifically, companies such as 
Neuroflow and Concert Health have partnered with small independent 
practices with success. Neuroflow's health technology platform and 
management services work well for small and solo primary care practices 
by facilitating and automating workflows that would otherwise by 
prohibitively time consuming and expensive for practices with limited 
administrative support. In addition, Concert Health has seen smaller 
practices implement CoCM more rapidly with their support because of 
their ability to engage staff at all levels, from the practice owner to 
frontline professionals. And they have seen smaller practices 
successfully reach more than 100 patients at any given time through 
CoCM.
              coverage and payment for mobile crisis teams
    Question. Too often, children and adults in crisis are unable to 
get access to the behavioral health care they urgently need, leading 
individuals to seek care in emergency departments, face encounters with 
law enforcement, or become incarcerated in jails. To help these 
individuals receive the timely care they need, some communities and 
programs, including the CAHOOTS program in Oregon, have explored 
strategies using health professionals as first responders when 
individuals experience a mental health or substance use related crisis. 
The American Rescue Plan Act (ARPA) provided Medicaid programs with 
enhanced Federal funding to support these innovative approaches. 
However, challenges remain in fostering broader coverage for these 
crisis programs across payers over the long term.

    Can you provide details on how the Centers for Medicare and 
Medicaid Services (CMS) could structure coverage and payment for mobile 
crisis teams within the Medicare program?

    Answer. Medicare fails to cover any of the most important mental 
health crisis services, a failure mirrored in most commercial coverage 
as well. As the 988 dialing code is rolled out nationally, and as 
communities across the Nation work to establish a full continuum of 
crisis services, that failure is no longer tolerable. Earlier this 
year, we joined RI International and the National Association of State 
Mental Health Program Directors to publish Sustainable Funding for 
Mental Health Crisis Services, which identifies standardized existing 
health-care codes that every insurer should reimburse, including 
Medicare.

    The Meadows Institute is also very appreciative of Senator Wyden 
for his continued leadership on the need to adequately fund and support 
crisis care and of Senators Cornyn and Cortez Masto for focusing on the 
important role that insurance coverage must play in supporting crisis 
care. We strongly support Senators Cornyn and Cortez Masto's Behavioral 
Health Crisis Services Expansion Act (S. 1902), which would expand 
reimbursement for the full spectrum of crisis services under Medicare 
and other payers.

    The Meadows Institute also supports the recommendations of the 2021 
NASMHPD Technical Assistance Collaborative Paper, Funding Opportunities 
for Expanding Crisis Stabilization Systems and Services. Specifically, 
CMS and State officials should encourage crisis stabilization providers 
to bill Medicare for covered services provided to Medicare 
beneficiaries. Medicare covers crisis psychotherapy (CPT codes 90839 
and 90840) and CPT code 90839 is one of the most commonly used codes 
for billing Medicare for mental health services.\17\ Although only 
certain provider types are eligible to bill these codes, CMS and State 
officials should encourage providers to utilize telehealth, including 
audio-only, psychotherapy and ``incident to'' billing policies for 
higher credentialed providers whenever possible. The ``incident to'' 
policy allows Medicare-enrolled providers to bill for services 
technically provided by an employee whom they supervise, allowing 
Medicare to reimburse for services provided by a broader array of 
practitioners.
---------------------------------------------------------------------------
    \17\ Beronio, K.K. (2021, September). Funding opportunities for 
expanding crisis stabilization systems and services. National 
Association of State Mental Health Program Directors. https://
www.nasmhpd.org/sites/default/files/8_FundingCrisisServices_508.pdf.

    Question. Can you describe which elements of mobile crisis care are 
most critical, and the types of professionals involved in effective 
---------------------------------------------------------------------------
mobile crisis team models?

    Answer. Historically (and still in most communities across the 
United States), mental health emergency calls for service often result 
in a public safety or police-driven response, rather than in an 
emergency medical services response like other health-care emergencies. 
In addition to the potential for injury and death that this poses to 
the individual (especially people of color), even in the best 
circumstances these encounters routinely result in an array of bad 
outcome for the individual in crisis, as law enforcement officers are 
often forced to choose between three largely ineffective and 
inappropriate options: (1) arrest the individual; (2) transport the 
individual to a hospital emergency department where there is likely to 
be an extended wait; or (3) inaction, which leaves the vulnerable 
individual with no connection to care.\18\
---------------------------------------------------------------------------
    \18\ Munetz, M.R., Griffin, P.A. (2006). Use of the Sequential 
Intercept Model as an approach to decriminalization of people with 
serious mental illness. Psychiatric Services, 57(4), 544-549. https://
pubmed.ncbi.nlm.nih.gov/16603751/.

    The Meadows Institute strongly supports this committee's work to 
create and strengthen alternative options for individuals in crisis. 
Evidence is emerging on the utility of alternative models of crisis 
response to reduce police involvement in subsets of 911 calls. For 
example, the noted CAHOOTS (Crisis Assistance Helping Out On The 
Streets) program in Eugene, OR has a proven track record of delivering 
much-needed care to people in crisis situations. Civilian-only response 
teams, such as the CAHOOTS team, provide a valuable service by 
replacing law enforcement responses for crisis calls that do not pose a 
public safety risk. Such teams can also help to address many calls of 
lower acuity originating from the soon-to-be-
---------------------------------------------------------------------------
established 988 alternative crisis line.

    However, by design, these teams are unable to address the wider 
range of 911 calls that involve a mental health emergency and do pose a 
public safety risk, expressly reference a risk of violence, or pose a 
level of actual or perceived risk that cannot be determined with 
certainty until the response to the emergency occurs. In many 
communities, civilian-only response teams also do not have the ability 
to initiate involuntary psychiatric commitments, again relegating these 
needs to an unreformed response option.

    To meet the needs of individuals in crisis regardless of their 
perceived risk of violence or level of acuity, we strongly support 
supplementing civilian-only teams such as CAHOOTS with the 
multidisciplinary response team (MDRT) model that incorporates public 
safety.\19\ An MDRT is a community-based paramedicine approach with an 
integrated team comprised of a community paramedic, a specially trained 
law enforcement officer, and a licensed mental health professional able 
to make definitive diagnoses and treatment decisions in the field. The 
team can respond to all calls, including high-acuity mental health 
emergency calls for service.\20\
---------------------------------------------------------------------------
    \19\ Meadows Mental Health Policy Institute (2021). Multi-
Disciplinary Response Teams: Transforming Emergency Mental Health 
Response in Texas. Dallas, TX: Meadows Mental Health Policy Institute. 
mmhpi.org.
    \20\ U.S. Department of Health and Human Services, Health Resources 
and Services Administration, and Office of Rural Health Policy. (2012). 
Community paramedicine: Evaluation tool. https://www.hrsa.gov/sites/
default/files/ruralhealth/pdf/paramedicevaltool.pdf.

    The components of the MDRT model include: (1) data linkage to 
facilitate rapid identification of mental health calls and real-time 
data on past mental health services to inform team decision-making; (2) 
a paramedic-led multidisciplinary co-
response team that deploys a paramedic, a behavioral health clinician, 
and a police officer to respond as one integrated, co-trained unit to 
mental health calls; and (3) a clinically informed dispatch system in 
which a clinician is embedded in the dispatch call center either in 
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person or virtually to triage mental health calls.

    As we have explained more fully in a recent paper we released as 
part of a project funded by the Pew Charitable Trusts, MDRTs are 
expressly designed to be able to respond to mental health calls 
involving higher levels of acuity, including calls that may require 
medical treatment, reference a weapon or threat of violence, involve 
unknown or perceived risks, involve overdose or the need for substance 
use disorder care, and/or potentially necessitate involuntary 
commitment.

    Implementing an MDRT as an alternative first response also allows 
traditional police resources to remain in service while leveraging the 
unique skill sets of the MDRT to resolve a mental health emergency. The 
MDRT approach integrates both law enforcement and civilian response in 
ways that address the multiple issues often raised in a single 911 
call, including calls involving a mental health crisis that presents a 
public safety risk. The City of Dallas has been able to use its full 
scale MDRT program to redeploy officers to more focused public safety 
work, and we believe that this has been one contributor to the City's 
success in both reducing use of police to respond to mental health 
emergencies and reduce violent crime at the same time.

    Leveraging the MDRT model can also help begin to address concerns 
around introducing bias in our crisis response system, particularly 
around inequitable treatment responses that can come from segregating 
responses as ``violent'' versus ``nonviolent.'' As Kevin Martone of the 
Technical Assistance Collaborative recently explained, calls for 
service are typically made by third parties, which means call takers 
and operators depend on information shaped by a caller's perceptions 
and biases of the person they're calling about.\21\ He asked a salient 
question, ``[W]ill a 911 call about a Black man experiencing the same 
stay with 911 and result in police dispatch because the caller 
perceives the man to be dangerous?'' Researchers note that these 
concerns may be valid; for example, a study published in 2017 revealed 
that people often misperceive Black men to be larger and more 
threatening than White men of the same size.\22\ Utilizing an MDRT 
model with the ability to respond to all calls regardless of perceived 
risk of danger could help ameliorate potential issues that may arise 
from dispatching different service types based on an artificial 
distinction of a ``violent'' versus ``nonviolent'' crisis call. Our 
overarching goal should always be to avoid situations in which 
communities of color are more likely to receive a police response than 
other communities simply because their crises are more likely to be 
coded as ``violent.''
---------------------------------------------------------------------------
    \21\ Hepburn, S. (2022). Homelessness and crisis: Who will answer 
the call? #CrisisTalk. https://talk.crisisnow.com/homelessness-and-
crisis-who-will-answer-the-call/.
    \22\ American Psychological Association. (2017). People see Black 
men as larger, more threatening than same-sized White men [Press 
release]. American Psychological Association. https://www.apa.org/news/
press/releases/2017/03/black-men-threatening.

    Question. How can emergency medical technicians (EMTs) be 
---------------------------------------------------------------------------
incorporated into mobile crisis response teams?

    Answer. As detailed in our response to the question just above, we 
strongly support both civilian-only models that do so (like B-HEARD in 
New York City) and models that incorporate a public safety component, 
like the MDRT model, which fully integrates community paramedics into a 
team response to crises.

    Support for civilian-only models incorporating paramedics like B-
HEARD is well established, and the Meadows Institute fully supports 
their use. But there has been less attention on models that deploy 
community paramedics on a team that can address public safety concerns. 
To meet the needs of individuals in crisis regardless of their 
perceived risk of violence or level of acuity, we strongly support the 
MDRT model. An MDRT is a community-based paramedicine approach with an 
integrated team comprised of a community paramedic, a specially trained 
law enforcement officer, and a licensed mental health professional able 
to make definitive diagnoses and treatment decisions in the field. The 
team can respond to all calls, including high-acuity mental health 
emergency calls for service.\23\
---------------------------------------------------------------------------
    \23\ U.S. Department of Health and Human Services, Health Resources 
and Services Administration, and Office of Rural Health Policy. (2012). 
Community paramedicine: Evaluation tool. Community paramedicine: 
Evaluation tool. https://www.hrsa.gov/sites/default/files/ruralhealth/
pdf/paramedicevaltool.pdf.

    MDRTs operate on the principles of community paramedicine, which 
entails functioning as a single integrated unit, relying on shared 
knowledge and experience, and responding as a team.\24\ The lead 
paramedic is a community health paramedic (CHP) who has special 
training to provide individualized care to patients who are at risk of 
preventable hospital admission or readmission based on chronic care 
needs. A CHP receives training on patient navigation, referral to 
resources, and identification of health-related risk factors for 
hospital or emergency care recidivism. This level of training and focus 
on individualized patient care is a departure from the typical acute 
stabilization and transport training a medic receives, and is vital to 
successful triage, treatment, care linkage, and preventative care 
services. In Dallas, the RIGHT Care team paramedic continues to monitor 
care of the individual and assess significant changes to the person's 
physical condition on the scene and after a transfer of care.
---------------------------------------------------------------------------
    \24\ Meadows Mental Health Policy Institute. (2021, May). Multi-
Disciplinary Response Teams: Transforming Emergency Mental Health 
Response in Dallas. Meadows Mental Health Policy Institute. https://
mmhpi.org/wp-content/uploads/2021/06/MDRT-Transforming-Crisis-Response-
in-Texas.pdf.

    Question. Rural and underserved areas may face particular barriers 
related to workforce capacity and the ability to quickly connect people 
in crisis to care. Can you describe how these models can be best 
---------------------------------------------------------------------------
implemented in these settings?

    Answer. It is important to remember that telehealth services in a 
mental health context were initially designed to reach clients in 
underserved areas, whether that was due to geographic constraints or a 
lack of resources for health care.\25\ Telehealth services, especially 
those made available to first responders, drastically reduce the ``time 
to treatment'' for high acuity patients.\26\ Effectively utilizing 
telehealth can alleviate the burden on first responders, allowing for 
rapid response during a mental health emergency.
---------------------------------------------------------------------------
    \25\ Bashshur, R.L., Shannon, G.W., Bashshur, N., and Yellowlees, 
P.M. (2016). The Empirical Evidence for Telemedicine Interventions in 
Mental Disorders. Telemedicine journal and e-health: The official 
journal of the American Telemedicine Association, 22(2), 87-113. 
https://doi.org/10.1089/tmj.2015.0206.
    \26\ Simon, L.E., Shan, J., Rauchwerger S.A., Reed, M.E., Warton, 
M.E., Vinson, D.R., Konik, Z.I., Vlahos, J., Groves, K. and Ballard, 
D.W. (2020). Paramedic's perspectives on telemedicine in the ambulance: 
A survey study. https://www.jems.com/patient-care/perspectives-on-
telemedicine/.

    Telehealth in mental health emergency response rapidly brings 
services to patients, relieving the burden on overtaxed systems. 
Telehealth also ensures equity in mental health response, allowing for 
higher-acuity patients to be triaged by qualified mental health 
professionals if the situation demands it. Incorporating telehealth 
services into an MDRT furthers the goal of rapid-response mental health 
care in order to divert vulnerable individuals from the criminal 
---------------------------------------------------------------------------
justice system while also easing the burden on under-resourced systems.

    Communities in Texas are incorporating telehealth services when 
responding to mental health calls for service, whether as part of an 
MDRT approach or as a standalone tool for law enforcement officers. For 
example, the City of Abilene is using telemedicine to facilitate pre-
hospital care, with a repurposed military MRAP vehicle functioning as a 
mobile hospital equipped with secure video conferencing software to 
triage critical patients more effectively and direct them to the 
appropriate resource for care.\27\
---------------------------------------------------------------------------
    \27\ Philips, B.U. ``Current Programs and Innovations in 
Telemedicine.'' Texas Tech University Health Sciences Center. https://
capitol.texas.gov/tlodocs/84R/handouts/C4102016021009001/3c5178d7-355d-
4418-a50c-58b2b296f2fd.PDF.

                                 ______
                                 
              Questions Submitted by Hon. Thomas R. Carper
                       health services in schools
    Question. It is clear that COVID-19 has significantly exacerbated 
mental health stress on children and youth, highlighting the Nation's 
acute shortage of mental health services. In my State of Delaware, over 
9,000 Delawareans ages 12 through 17 suffer from some sort of 
depression. However, according to the State, students who have access 
to mental health resources within schools are 10 times more likely to 
seek care.

    Earlier this year, the Finance Committee heard testimony from the 
U.S. Surgeon General who stressed that one of the most central tenets 
in creating accessible and equitable systems of care is to meet people 
where they are. For most young people, that's right there in schools. 
And just last week, Secretary of Health and Human Services Xavier 
Becerra and Secretary of Education Miguel Cardona announced a joint-
department effort to expand school-based health services.

    It is clear there is growing momentum to recognize the role schools 
already play in ensuring children have the health services and supports 
necessary to build resilience and thrive. We know that investing in 
school and community-based programs have been shown to improve mental 
health and emotional well-being of children at low cost and high 
benefit.

    How can we improve coordination between primary care and mental 
health providers to better support our children, including through 
school-based services?

    Answer. As Surgeon General, Dr. Vivek Murthy warned late last year 
in America's first-ever public health advisory focused on mental 
health, even before COVID-19, mental illness among America's youth was 
already at a crisis point, and the pandemic has made it much worse.\28\ 
While that historic advisory emphasized the need to address the 
workforce, it perhaps understated the degree of the United States' 
overstretched and misdeployed workforce. Recent estimates predict 
provider shortages across six behavioral health subspecialties 
surpassing a quarter of a million full-time employees (FTEs) by 
2025.\29\ More alarmingly, the pediatric mental health workforce 
shortage will lead to long-term negative outcomes across countless 
dimensions, particularly in underserved communities and with pronounced 
inequities across communities of color.\30\, 
\31\, \32\, \33\
---------------------------------------------------------------------------
    \28\ The U.S. Surgeon General's Advisory. (2021). Protecting youth 
mental health. https://www.hhs.gov/sites/default/files/surgeon-general-
youth-mental-health-advisory.pdf.
    \29\ U.S. Department of Health and Human Services, Health Resources 
and Services Administration, Bureau of Health Workforce, and National 
Center for Health Workforce Analysis. (2020). Using HRSA's health 
workforce simulation model to estimate the rural and non-rural health 
workforce. https://bhw.hrsa.gov/sites/default/files/bureau-health-
workforce/data-research/hwsm-rural-urban-methodology.pdf.
    \30\ Ramchand, R., Gordon, J.A., and Pearson, J.L. (2021). Trends 
in suicide rates by race and ethnicity in the United States. JAMA 
Network Open, 4(5), e2111563. https://doi.org/10.1001/
jamanetworkopen.2021.11563.
    \31\ Panchal, N., Kamal, R., Cox, C., and Garfield, R. (2021). The 
implications of COVID-19 for mental health and substance use. Kaiser 
Family Foundation. https://www.kff.org/coronavirus-covid-19/issue-
brief/the-implications-of-covid-19-for-mental-health-and-substance-
use/.
    \32\ Kuchment, A., Hacker, H.K., Solis, D. (2020). COVID's ``untold 
story'': Texas Blacks and Latinos are dying in the prime of their 
lives. The Dallas Morning News. https://www.
dallasnews.com/news/2020/12/19/covids-untold-story-texas-blacks-and-
latinos-are-dying-in-the-prime-of-their-lives/.
    \33\ Hillis, S.D., Blenkinsop, A., Villaveces, A., Annor, F.B., 
Liburd, L., Massetti, G.M., Demissie, Z., Mercy, J.A., Nelson III, 
C.A., Cluver, L., Flaxman, S., Sherr, L., Donnelly, C.A., Ratmann, O., 
and Unwin, H.J.T. (2021). COVID-19--associated orphanhood and caregiver 
death in the United States. Pediatrics, 148(6), e2021053760. https://
doi.org/10.1542/peds.2021-053760.

    In addition to shortages, our pediatric mental health workforce is 
not well deployed upstream in U.S. primary care settings when compared 
to other industrialized nations.\34\ This is a major reason why we do 
not detect and treat mental health needs until 8-10 years after 
symptoms emerge.\35\ In addition, pediatric health-care expenses are 
higher in the U.S. than in almost all other industrialized 
countries,\36\ while research consistently suggests that U.S. pediatric 
health outcomes fall far below those of average citizens living in 
other developed nations.\37\
---------------------------------------------------------------------------
    \34\ Tikkanen, R., Fields, K., Williams III, R.D., and Abrams, M.K. 
(2020). Mental health conditions and substance use: Comparing U.S. 
needs and treatment capacity with those in other high-income countries. 
The Commonwealth Fund. https://www.commonwealthfund.org/publications/
issue-briefs/2020/may/mental-health-conditions-substance-use-comparing-
us-other-countries.
    \35\ American Academy of Child and Adolescent Psychiatry. (2012). 
Best principles for integration of child psychiatry into the pediatric 
health home. https://www.aacap.org/App_Themes/AACAP/docs/
clinical_practice_center/systems_of_care/
best_principles_for_integration_of_child_
psychiatry_into_the_pediatric_health_home_2012.pdf.
    \36\ Squires, D., and Anderson, C. (2015). U.S. health care from a 
global perspective: Spending, use of services, prices, and health in 13 
countries. Commonwealth Fund, 15, 1-15. https://
www.commonwealthfund.org/sites/default/files/documents/
___media_files_publications_issue_
brief_2015_oct_1819_squires_us_hlt_care_global_perspective_oecd_intl_bri
ef_v3.pdf.
    \37\ Emanuel, E.J., Gudbranson, E., Van Parys, J., G, \79\, \80\
---------------------------------------------------------------------------
    \77\ Read more about Cloudbreak here: https://mmhpi.org/the-
cloudbreak-initiative/.
    \78\ Wells, K., Sherbourne, C., Schoenbaum, M., Ettner, S., Duan, 
N., Miranda, J., Unutzer, J., and Rubenstein, L. (2004). Five-year 
impact of quality improvement for depression: Results of a group-level 
randomized controlled trial. Archives of General Psychiatry, 61(4), 
378-386. https://pubmed.ncbi.nlm.nih.gov/15066896/.
    \79\  Arean, P.A., Ayalon, L., Hunkeler, E., Lin, E.H.B., Tang, L., 
Harpole, L., Williams, J.W., Unutzer, J., and IMPACT Investigators. 
(2005). Improving depression care for older, minority patients in 
primary care. Medical Care, 43(4), 381-390. https://
pubmed.ncbi.nlm.nih.gov/15778641/.
    \80\ Ell, K., Aranda, M.P., Xie, B., Lee, P-J., and Chou, C-P. 
(2010). Collaborative depression treatment in older and younger adults 
with physical illness: Pooled comparative analysis of three randomized 
clinical trials. American Journal of Geriatric Psychiatry, 18(6), 520-
530. https://pubmed.ncbi.nlm.nih.gov/20220588/.

    CoCM is also the only evidence-based medical procedure currently 
reimbursable in primary care, including by Medicare, nearly all 
commercial payers,\81\ and an increasing number of Medicaid programs. 
Leading employer and private-sector purchasing groups are also calling 
for its expansion. The potential cost savings of widespread 
implementation are considerable: a pivotal 2013 study found Medicare 
and Medicaid savings of up to six-to-one in total medical costs and an 
estimated $15 billion in Medicaid savings if only 20 percent of 
beneficiaries with depression received CoCM services.\82\ The primary 
barriers to adoption are start-up costs and the need for technical 
assistance.
---------------------------------------------------------------------------
    \81\ Alter, C., Carlo, A., Henry Harbin, and Schoenbaum, M. (2019). 
Wider Implementation of Collaborative Care Is Inevitable. Psychiatrics 
News. https://doi.org/10.1176/appi.pn.2019.6b7.
    \82\ Unutzer, J., Harbin, H., Schoenbaum, M., and Druss, B. (2013, 
May). The collaborative care model: An approach for integrating 
physical and mental health care in Medicaid health homes. Health Home 
Information Resource Center. http://www.chcs.org/media/
HH_IRC_Collaborative
_Care_Model__052113_2.pdf.

    As detailed in our testimony, the Meadows Institute encourages the 
committee to support large-scale efforts to build integrated care 
infrastructure and widescale adoption of models such as CoCM. We also 
encourage the committee to support the Collaborate in an Orderly and 
Cohesive Manner Act (H.R. 5218) as a base for a rapid, emergency re-
tooling of the Nation's primary care practices to address the out-of-
control mental health and addiction crisis facing America today, 
especially among the Nation's youth and young adults. We believe that 
the ambition of that legislation is too small given the scope of this 
crisis (we are spending $30 million in Texas alone with our 
philanthropic efforts to expand access to about half the State), and if 
the scope can be expanded, the bill should also support implementation 
of the Primary Care Behavioral Health (PCBH) model (in addition to 
CoCM). A comprehensive 2021 RAND study \83\ offered specific 
recommendations similar to those in H.R. 5218 likely to cost under $1 
billion total for rapidly scaling CoCM (and related practices) 
nationwide through: (1) incentive grants to overcome start-up costs, 
and (2) and technical assistance to access existing billing codes that 
can cover ongoing costs.
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    \83\ McBain, R.K., Eberhart, N.K., Breslau, J., Frank, L., Burnam, 
M.A., Kareddy, V., and Simmons, M.M. (2021). How to transform the U.S. 
mental health system: Evidence-based recommendations. RAND Corporation. 
https://www.rand.org/pubs/research_reports/RRA889-1.html.

                                 ______
                                 
    Prepared Statement of Anna Ratzliff, M.D., Ph.D., Co-Director, 
    Advancing Integrated Mental Health Solutions (AIMS) Center; and 
                  Professor, University of Washington
    Chairman Wyden and Ranking Member Crapo, thank you for conducting 
the hearing today entitled, ``Behavioral Health Care When Americans 
Need It: Ensuring Parity and Care Integration.''

    My name is Dr. Anna D. Ratzliff. I am a psychiatrist and Professor 
in the Department of Psychiatry and Behavioral Sciences at the 
University of Washington where I am a national expert on the 
Collaborative Care Model and specifically, on training teams to 
implement and deliver mental health treatment in primary care settings. 
I have developed additional expertise in suicide prevention training, 
mental health workforce development, adult learning best practices, and 
mentorship. I am the director of the UW Psychiatry Resident Training 
Program at UW Medicine, co-director of the AIMS Center (Advancing 
Integrated Mental Health Solutions) and director of the UW Integrated 
Care Training Program for residents and fellows. As a member of the 
American Psychiatric Association (APA), I have partnered closely with 
the APA to disseminate and promote improved access to care through 
behavioral health delivery in primary care settings or integrated care 
and to advocate for policies that would support deployment of this 
model more broadly.

    I thank you for having me here today to address the myriad issues 
surrounding the state of our Nation's mental health.

    I sit here before you today because the COVID-19 pandemic continues 
to exacerbate mental health conditions, including substance use 
disorders (MH/SUD). Data show that COVID-19 has impacted almost every 
single aspect of our lives, from job security to health equity, health 
outcomes and beyond. Though, as we near the particularly grim number of 
losing a million Americans to the pandemic, being a part of this panel 
here today makes me hopeful that Congress and our Nation will do the 
difficult work of addressing the MH/SUD pandemic that we are facing.

    Before I get into the policy recommendations of my testimony, it is 
important to stress that as psychiatrists, we often see patients who 
cannot advocate for themselves. As such, it is our professional 
responsibility to speak for our patients by promoting policies that 
help them get access to lifesaving care. I will reference a handful of 
my patients in my testimony here today along with the many ways that 
Congress can help promote policies to improve access to help patients 
like mine.

    These policies include incentivizing the integration of behavioral 
health care into primary care, addressing health equity, and increasing 
access to telehealth. Championing evidence-based policies that ensure 
that our patients receive the mental health and substance use disorder 
care that they need will save lives and reduce overall health costs. I 
will detail these policy proposals throughout my testimony below.
           integration of behavioral health and primary care
    As we continue to build our workforce pipeline and as our health-
care system moves toward value-based integrated care, the most 
promising near-term and immediate strategy for providing prevention, 
early intervention and timely treatment of mental illness and substance 
use disorders is the implementation of evidence-based integrated care 
models using a population-based approach. The Collaborative Care Model 
(CoCM) is a specific model of integrated care developed at the 
University of Washington to treat common and persistent mental health 
conditions such as depression and anxiety. The CoCM is an evidence-
based integrated care model with over 90 validated studies to show its 
effectiveness and has been recognized by the Centers for Medicare and 
Medicaid Services (CMS) with specific billing codes introduced in 2017. 
This approach provides MH/SUD treatment in a primary care office 
through consultation between a primary care clinician (PCP) working 
collaboratively with a psychiatric consultant and a behavioral health-
care manager to manage the clinical care of behavioral health patient 
caseloads.

    One of my patients, Daniel, who has given me permission to share 
his story, represents the advantages of integrated behavioral health 
care, specifically the CoCM, as an access point to care. Daniel 
struggled with untreated mental health symptoms in young adulthood, 
eventually leading to a suicide attempt. He sought treatment in primary 
care and at his first visit with his new PCP, she recognized that he 
was struggling with mental health symptoms and referred him to a 
behavioral health-care manger whose office was just down the hall. 
Daniel's PCP was able to walk with him to meet the behavioral health 
provider that day and to schedule an intake appointment the same week. 
As the psychiatric consultant, I was able to review his case within a 
few days during my regular meeting with the behavioral health-care 
manager. This consultation was conducted using telepsychiatry since my 
office was not located in the primary care setting and allowed me to 
review multiple patients at that clinic in the time I would normally 
only be able to see one patient. We were able to determine his 
diagnosis, and I provided recommendations for medications for the 
primary care provider to prescribe and behavioral treatments, like 
behavioral activation, for the behavioral health-care manager to 
deliver when she met with Daniel about every other week. Within weeks, 
he was feeling better, and he enrolled in local community college. He 
eventually was able to successfully complete his training to become a 
medical assistant. This example is important because Daniel said that 
he never would have sought mental health care if it had not been so 
seamless, especially when it was early in his treatment. His mother 
feels that this access saved his life.

    Though Daniel's is just one story, the CoCM is population-based, 
facilitating treatment for many more patients, and dramatically 
improving patient access in comparison to integrated models that use 
one-to-one care. This innovative model allows patients to receive 
behavioral health care through their PCPs, often alleviating the need 
for referrals, which frequently take months and too often result in 
patients receiving no care. This is especially important as studies 
slow only 50 percent of patients who receive a referral for specialty 
mental health care ever follow through with the referral. Among those 
who do, many do not have more than one visit.

    Implementation of the CoCM is a critical strategy to quickly 
improve access for patients by extending the current workforce, 
especially given the shortage of all mental health clinicians. This 
evidence-based model of integrated care allows for the early diagnosis 
and intervention of mental health conditions in the primary care 
setting and is proven to prevent emergency room visits and/or 
hospitalizations. More widespread use of the model can help to 
alleviate a portion of the current psychiatric workforce shortage by 
leveraging the expertise of the psychiatric consultant to be able to 
provide treatment recommendations to the PCP on a panel of patients, 
generally 60-80 patients, in as little as 1-2 hours a week. This is 
possible because the CoCM is a team-based approach in which the 
psychiatric consultant prioritizes their attention only to the patients 
that need their expertise. Given the ability for the psychiatric 
consultant to provide treatment recommendations to the PCP on multiple 
patients versus seeing these patients 1:1, the CoCM is a superior model 
for improving access to MH/SUD care quickly and more effectively to a 
broader population versus colocation models of integrated care.

    Further, the CoCM uses measurement-based care, which means that the 
patient's progress is tracked regularly, and treatment is adjusted if 
clinically indicated. This means that practices can easily identify 
patients that are getting better and patients who may need to access 
more intensive services, strategically allocating resources so that 
each patient is able to receive just the right amount of care.
Serving Rural Communities
    In my work supporting clinics to implement integrated care, I have 
had the opportunity to work to adapt this model to serve rural 
communities. I partnered with one of our Washington rural access 
hospitals that had an active primary care clinic. In this setting, the 
clinic employed a behavioral health-care manager who could work closely 
with a psychiatric consultant located at UW Medicine on the other side 
of the State. This approach allowed patients to receive care without 
fear of stigma and to avoid spending potentially hours in the car to 
travel to a behavioral health prescriber. With our partnership, the 
primary care providers also felt better supported to deliver 
appropriate MH/SUD care to their communities. This example demonstrates 
the power of integrated care to leverage scarce psychiatric expertise 
to serve all our communities.

    These stories from my practice show that the CoCM can work in 
discrete exemplar settings. However, the data on the model's 
effectiveness show more broadly that implementing the CoCM can more 
than double the chance that a patient will have a meaningful response 
to MH/SUD treatment. In addition, studies show that the CoCM can 
improve access to care for patients in rural or underserved areas. 
Because consultations between the team members can be provided 
remotely, the model addresses the uneven distribution of the mental 
health workforce and leverages the scarce psychiatric workforce.
Addressing Health Equity
    In my role as a psychiatric consultant, I have had the opportunity 
to work with a primary care clinic that provided culturally and 
linguistically appropriate health care to a population in which six out 
of seven patients were Black, Indigenous, People of Color (BIPOC). In 
this clinic, I worked with a woman who had recently had her second 
child and developed postpartum depression. She was able to meet with 
her behavioral health-care manager, was diagnosed with major depressive 
disorder and was able to work with the CoCM team members to choose the 
best treatment for her from a range of evidence-based options from 
medications prescribed by the primary care provider to brief behavioral 
interventions delivered by the behavioral health-care manager. All of 
these treatments were immediately available without any need for a 
referral. For this patient, evidence-based therapy was her preferred 
treatment and an approach that was more culturally acceptable to her. 
The team was able to monitor her symptoms in response to treatment to 
make sure that she got better.

    This example is consistent with studies that compared depression 
outcomes in BIPOC and white patients who received treatment with the 
Collaborative Care Model, with results showing either equivalent or 
significantly better outcomes for BIPOC patients. This makes the CoCM 
an important strategy to improve behavioral health equity.
Financial Considerations
    Expanding the use of the CoCM can also help reduce health-care 
costs. The CoCM is currently being implemented in many large health-
care systems and practices, and is also reimbursed by Medicare, most 
private insurers, and numerous State Medicaid programs. According to 
the University of Washington AIMS Center, long term analyses of the 
CoCM have demonstrated that every $1 spent on CoCM saves $6.50 in 
health-care costs--a return on investment of over six to one. In this 
research, the health-care savings came from across all categories, 
including inpatient/outpatient medical, inpatient/outpatient 
psychiatry, and pharmacy. Though implementing the CoCM makes sense from 
the perspective of expanded access, improved outcomes, and long-term 
financial savings, unfortunately, the requisite start-up costs have 
proven to be a barrier to its adoption by many primary care practices. 
Implementing the CoCM requires up-front investments by primary care 
offices to upgrade their electronic medical records, hire behavioral 
health-care managers, etc.
Policy Considerations
    In my role as the AIMS Center co-director, I have worked to 
implement the Collaborative Care Model at hundreds of clinics 
nationally and internationally. I have also partnered closely with the 
APA to deliver training and technical assistance as part of a large 4-
year project in which we trained approximately 10 percent of U.S. 
psychiatrists in the skills needed to deliver Collaborative Care. This 
work in settings across the U.S. has informed the specific 
recommendations outlined below. I encourage the committee to consider 
the following policy recommendations that the APA has outlined to 
further the adoption of the CoCM:

        Fund primary care offices to assist with the implementation of 
the Collaborative Care Model.
        Eliminate the patient cost-sharing requirement under Medicare 
to remove an additional barrier to care for Medicare beneficiaries. 
Practices that have implemented the CoCM have seen patient attrition 
because of the cost-sharing requirements despite patients reporting 
benefits of the CoCM model.
        Increase the current reimbursement for CPT codes for the CoCM 
to more appropriately reflect the value and benefits of services and 
care being provided to patients with MH/SUD needs and to incentivize 
primary care to invest in the model that has proven health-care 
savings.
                               telehealth
    I have learned in my clinical experiences, telehealth is an 
important strategy to increase access to general psychiatric care and 
also supports and complements integrated care. I want to acknowledge 
and express my appreciation of how the rapid expansion of 
telepsychiatry authorized by Congress and the last two administrations 
has significantly enhanced patient access to care. In the practices 
that I currently support, I have seen numerous examples of patients 
with mental health disorders continuing to access much-needed therapy 
and medications and patients with 
opiate-use disorder being able to continue to receive medications that 
have been demonstrated to save lives. As the pandemic evolves, many 
patients continue to receive care via telehealth who otherwise may not 
have initially received or continued care if telehealth were not 
available. The progress we have made in reaching more patients through 
telehealth and coordinating care with other systems of support has been 
a literal lifeline for our patients.

    Prior to COVID-19, substance use disorders and co-occurring mental 
health services were exempt from geographic and site of service 
restrictions under Medicare, but mental health treatment services alone 
were not. At the end of 2020, Congress took the important step of 
permanently waiving these restrictions for mental health. However, 
Congress also passed requirements for patients receiving care via 
telehealth to have an in-person evaluation with their mental health 
provider within the 6-month period prior to their first telehealth 
visit and at subsequent periods as required by the Secretary. This 
arbitrary requirement, which does not apply to those with SUDs or co-
occurring MH/SUDs who see their clinicians via telehealth, creates an 
unnecessary and difficult barrier to needed care for Medicare patients 
with a mental health diagnosis. Whether a patient needs to be seen in 
person is a clinical decision that should be made together by a patient 
and their clinician at the appropriate time.
Policy Considerations
    I encourage the committee to consider the following policy 
recommendations, endorsed by the APA, that would address the current 
challenges with access to telehealth services for behavioral health-
care needs:

        Remove the 6-month in-person requirement for mental health 
treatment to ensure that mental health and substance use disorder 
services furnished via telehealth are treated equally.
        Expand telehealth flexibilities afforded to providers under 
the COVID-19 Public Health Emergency, including lifting of site of 
service and geographic restrictions as well as allowing for the use of 
audio-only telehealth services when clinically appropriate or when no 
other alternative exists.
                                closing
    In closing, I want to reiterate how encouraged I am by the 
bipartisan, bicameral support we're seeing from Congress and in 
particular this committee regarding addressing our most pressing mental 
health and substance use disorder needs. I thank you for extending to 
me the opportunity to testify before you here today and look forward to 
both hearing my colleagues on the panel testify and to answering each 
of your questions.

                                 ______
                                 
    Questions Submitted for the Record to Anna Ratzliff, M.D., Ph.D.
                 Questions Submitted by Hon. Ron Wyden
                     rural behavioral health access
    Question. For many years, the Finance Committee has been focused on 
ensuring that patients in rural areas have access to the care they 
need. This question is especially important for mental health services 
because mental health practitioners tend to be located in urban and 
suburban areas. As the Finance Committee considers options for 
improving integration of behavioral health care and primary care, it 
will be important to better understand whether innovative care models, 
such as the Collaborative Care Model, can improve access to mental 
health care and substance use disorder services in rural areas.

    How have you approached implementing the Collaborative Care Model 
in rural areas?

    Answer. The UW Medicine AIMS Center, which I co-direct, has had 
extensive experience implementing Collaborative Care at over 30 rural 
practices. I also have had the opportunity to directly work with 
several rural practices as the psychiatric consultant. My experience is 
that rural practices can be successful in implementing the 
Collaborative Care Model, especially when supported by practice 
coaching and technical assistance. Some practices may need to innovate 
in the workforce that is hired to serve in the behavioral health-care 
manager role, for example sometimes teaming a care navigator with a 
provider who can deliver therapy. Another important adaptation is to 
have one Collaborative Care team serve several smaller practices. These 
practices also benefit from being able to access psychiatric expertise 
through both direct telehealth services and the use of telehealth to 
support the indirect case consultation which is a core function of the 
Collaborative Care Model. For example, I partnered with one of our 
Washington rural access hospitals that had an active primary care 
clinic. In this setting, the clinic integrated a behavioral health-care 
manager who could work closely with a psychiatric consultant located at 
the University of Washington on the other side of the State.

    Published studies about implementation of Collaborative Care 
demonstrate that patients in rural practices can achieve depression 
outcomes that are equal to or better those practices in non-rural 
settings. In my personal experience, I heard from patients and 
providers that this approach allowed patients to receive care without 
fear of stigma and to avoid spending potentially hours in the car to 
travel to a behavioral health prescriber. The primary care providers 
also feel better supported to deliver care to their communities.

    Several of the policy recommendations discussed in the hearing are 
especially important to support rural practices. Specifically:

        Expand the types of professionals that can be reimbursed by 
Medicare for the delivery of psychotherapy services, for example the 
work that members of this committee have already championed in the S. 
828, the Mental Health Access Improvement Act which would allow 
licensed professional counselors and marriage and family therapists to 
bill Medicare.
        Provide Federal support to help practices implement 
Collaborative Care with funding the implementation of Collaborative 
Care and a focus to make sure rural practices are supported to access 
this funding.
        Support funding of training and technical assistance, 
especially ensuring these resources are familiar with the unique needs 
of rural practices.
        Increase reimbursement rates for the Medicare Collaborative 
Care Codes to fully support the costs of a team to deliver this 
important care.
          disparities in behavioral health access and outcomes
    Question. In the Finance Committee's hearing on youth behavioral 
health with the U.S. Surgeon General, Dr. Vivek Murthy sounded the 
alarm about the deep and pervasive racial and ethnic disparities that 
exist during the mental health crisis. A number of studies have found 
that more than half of people who need behavioral health care do not 
receive it, with higher rates of unmet need for racial and ethnic 
minority populations: 63 percent of African Americans, 65 percent of 
Hispanics, 80 percent of Asian and Pacific Islanders do not receive 
care when needed. Better integrating primary care with behavioral 
health may provide a critical access point for underserved populations 
and reduce racial and ethnic disparities.

    In your experience, how has the integration of behavioral health 
and primary care helped to improve access to care and health outcomes 
for racial and ethnic minorities and underserved populations?

    Answer. The UW Medicine AIMS Center has contributed to several 
important studies demonstrating that Black, Latinx, Asian, and American 
Indian or Alaska Native persons who received Collaborative Care 
achieved equivalent clinical outcomes as compared to white persons, and 
these data were also described in a recent systematic review of 
Collaborative Care Model for racial and ethnic minority populations. In 
my own practice, I have seen the benefit of implementing Collaborative 
Care in practices where Black, Indigenous, People of Color (BIPOC) 
patients can work with a trusted provider and receive culturally 
sensitive care. For example, I have had the opportunity to work with a 
primary care clinic that provided culturally and linguistically 
appropriate health care to a population in which six out of seven 
patients identified as BIPOC. In this clinic, I worked with a woman who 
had recently had her second child and developed postpartum depression. 
This patient was able to receive treatments that were culturally 
acceptable to her. The team was able to monitor her symptoms in 
response to treatment to make sure that she got better.
                integrated care at independent practices
    Question. Testimony at the Finance Committee's March 30th hearing 
on mental health parity and integration of care made clear that there 
is potential for integrated care teams to help patients get the 
behavioral health care that they need, when they need it. As the 
Finance Committee examines opportunities to improve the take-up rate of 
integrated care models in physician practices, it will be vital to 
ensure that behavioral health integration models can work for physician 
practices of all shapes and sizes--and not just large physician 
practices that are affiliated with major health systems.

    How can Congress make sure that the Collaborative Care Model and 
others like it can work in small physician practices that are not part 
of major health systems?

    Answer. There is clear evidence that a Collaborative Care team can 
provide effective care using a centralized behavioral health-care 
manager and psychiatric consultant. This approach could be helpful to 
small practices which could pool resources to create a hub to serve 
several small practices. Additionally, in my experience smaller 
practices can implement Collaborative Care. Even in a population of 
approximately 5,000 patients there are enough mental health needs to 
support a team of a behavioral health-care manager and limited 
psychiatric consultant time.

                                 ______
                                 
              Questions Submitted by Hon. Thomas R. Carper
                       health services in schools
    Question. It is clear that COVID-19 has significantly exacerbated 
mental health stress on children and youth, highlighting the Nation's 
acute shortage of mental health services. In my State of Delaware, over 
9,000 Delawareans ages 12 through 17 suffer from some sort of 
depression. However, according to the State, students who have access 
to mental health resources within schools are 10 times more likely to 
seek care.

    Earlier this year, the Finance Committee heard testimony from the 
U.S. Surgeon General who stressed that one of the most central tenets 
in creating accessible and equitable systems of care is to meet people 
where they are. For most young people, that's right there in schools. 
And just last week, Secretary of Health and Human Services Xavier 
Becerra and Secretary of Education Miguel Cardona announced a joint-
department effort to expand school-based health services.

    It is clear there is growing momentum to recognize the role schools 
already play in ensuring children have the health services and supports 
necessary to build resilience and thrive. We know that investing in 
school and community-based programs have been shown to improve mental 
health and emotional well-being of children at low cost and high 
benefit.

    How can we improve coordination between primary care and mental 
health providers to better support our children, including through 
school-based services?

    Answer. I think there several potential strategies to increase the 
coordination of primary care and mental health. One model is for 
schools that offer school-based health clinics, there is an easy 
opportunity to also implement the Collaborative Care Model, which is 
effective in treating adolescent depression and pediatric ADHD. I 
personally supported the implementation of the Collaborative Care Model 
in a school-based clinic in Mississippi. The providers there were able 
to provide holistic care to meet social needs as well as both physical 
and mental health services of the students they served.

    Another model is to create a close partnership between the schools 
and a local primary care practice that offers youth mental health 
services, utilizing a facilitated referral process to support the 
connection of youth that to primary care. There are also promising 
practices which use a peer youth workforce to help engage at risk youth 
in mental health services. Finally, continuing to create access to 
telehealth services, which can be delivered to school-based settings, 
could increase access for youth.

    One important consideration is that the workforce involved in the 
delivery of youth services need specialized training in evidence-based 
psychotherapies for common mental health disorders in children and 
adolescents and to have skill in engaging youth and families.

    Question. Do you see a role for the Federal Government beyond 
providing guidance and technical assistance to State programs?

    Answer. There are several other areas that may support improved 
access to quality mental health for youth. Specifically, this is an 
area that may benefit from funding to evaluate the promising approaches 
outlined above. Policy can promote workforce development in the 
specialized training in evidence-based treatments shown to be effective 
to improve patient outcomes in youth.

    Many children and adolescents that need access to mental health 
services are utilizing Medicaid benefits. Congress should consider 
policy which would incentivize states to expand their Medicaid coverage 
of MH/SUD services by providing a corresponding raise in the Federal 
Medical Assistance Percentage (FMAP) matching rate for behavioral 
health services.

    Several of the policy changes already proposed to generally support 
the Collaborative Care Model would also benefit access to care for 
youth, including funding the implementation of the Collaborative Care 
Model in pediatric practices and primary care offices that serve 
children. Finally, it is important to continue to support availability 
of access to mental health services through telehealth.

                                 ______
                                 
               Question Submitted by Hon. Chuck Grassley
    Question. During the hearing, I mentioned that 3 years ago, Senator 
Bennet and I passed the Advancing Care for Exceptional Kids Act, or ACE 
Kids. ACE Kids establishes a pediatric health home for kids with 
complex medical conditions. This better aligns Medicaid rules and 
payment to incentivize care coordination, including mental health care. 
These kids often see five to six specialists and 20 to 30 health 
professionals--care coordination is critical. This October, the Centers 
for Medicare and Medicaid Services (CMS) will fully implement ACE Kids. 
State Medicaid programs will have the tools to better coordinate care 
for these kids, rather than facing barriers to care and red tape. We 
know that kids with complex medical needs are more at-risk for mental 
illness. One study suggests 38 percent have a mental health diagnosis 
and many face challenges in accessing mental health care. Their parents 
are five times more likely to have poor mental health. It's important 
CMS implements ACE Kids timely, but Congress must also build upon this 
law by passing the Accelerating Kids' Access to Care. This bill will 
streamline the screening and enrollment process for out-of-State 
pediatric care providers. I hope this bipartisan bill will be in the 
committee's mental health package. The bill will improve the mental 
health of kids with complex medical needs. Given my longstanding work 
on both laws and pending legislation to improve a kid's ability to 
access care out-of-State when needed, I know it is not uncommon for 
children with complex medical conditions to have associated mental or 
behavioral health needs. I would welcome your thoughts as to how best 
to meet mental health needs in complex cases like these, including in 
particular situations when a child needs to receive treatment out-of-
State, such as a complex surgery or organ transplant, and ways to 
ensure coordination between a child's primary providers and out-of-
State specialists.

    Are there policy actions we should be considering that haven't 
already been taken?

    Answer. I applaud the work that has already been done in this area 
to improve access to care for youth, especially making sure children 
can use their medical benefits for out-of-State care. Additionally, the 
policy recommendations outlined to support the Collaborative Care Model 
could improve mental health access for medically complex kids, since 
this is one model by which access to mental health care is improved, 
including for kids such as those targeted by his ACE program.

                                 ______
                                 
                 Question Submitted by Hon. John Thune
    Question. In your testimony, you discussed your work on integrating 
behavioral health into the primary care setting in rural communities. I 
know everyone faces workforce challenges now, but it's especially 
difficult in rural areas.

    Sanford Health serving in South Dakota, North Dakota, and Minnesota 
implemented a program to bring behavioral health into primary care that 
involved some initial seed money from a CMMI demonstration. While that 
funding has lapsed they have prioritized keeping this running, and use 
providers via telehealth to serve multiple facilities. Sanford reports 
improved outcomes in both behavioral health and chronic disease 
management.

    From your perspective, what policies do Congress and CMS need to 
consider to help create the right environment for more rural providers 
to adopt an integrated model?

    Answer. Several of the policy recommendations discussed in the 
hearing are especially important to support rural practices. 
Specifically:

        Expand the types of professionals that can be reimbursed by 
Medicare for the delivery of psychotherapy services, for example the 
work that members of this committee have already championed in the S. 
828, the Mental Health Access Improvement Act which would allow 
licensed professional counselors and marriage and family therapists to 
bill Medicare.
        Provide Federal support to help practices implement 
Collaborative Care with a focus to make sure rural practices are 
supported to access this funding.
        Support funding of training and technical assistance, 
especially ensuring these resources are familiar with the unique needs 
of rural practices.
        Increase reimbursement rates for the Medicare Collaborative 
Care codes to fully support the costs of a team to deliver this 
important care.

                                 ______
                                 
                 Questions Submitted by Hon. Tim Scott
                      telehealth modernization act
    Question. Thanks to the waiver authority initiated under the 
previous administration, telehealth has provided a critical way for 
Medicare patients to continue to access needed care, including mental 
health counseling, throughout the pandemic. However, without 
congressional action, telehealth flexibilities provided by the waiver 
will expire following the end of the public health emergency. My 
bipartisan Telehealth Modernization Act will maintain these 
flexibilities to ensure Medicare patients, especially those in rural 
areas of my State of South Carolina, are able to continue to access 
their lifeline.

    How important has telehealth been to helping to address health-care 
workforce gaps, especially mental and behavioral health counselors 
serving Medicare patients, during COVID-19?

    Answer. The most important benefit of telehealth to address 
workforce needs is the ability to redistribute a limited workforce to 
serve all our communities. This is especially important for Medicare as 
the behavioral health workforce that accepts Medicare is more limited.

    Question. Has the telehealth genie left the bottle--in other words, 
while there was a shift to virtual during the pandemic, has this shift 
fundamentally changed patients' expectations and preferences regarding 
how these services can be accessed?

    Answer. I believe both patients and providers have appreciated the 
flexibilities that mental health treatment accessed through telehealth 
affords. This flexibility allows the patient and their mental health 
provider to share the decision of what type of access would support 
their treatment. For example, a patient who worked in a large factory 
could previously have had to take off almost a half a day to access 
mental health services (time to get out of the factory, travel time to 
the appointment, the appointment time, travel time back from the 
appointment and time to make it into their workstation). Now with 
access to telehealth, all this person would need is a private space 
with video access and they would be able to get the help they need in 
under an hour. This example illustrates not only the benefit of this 
access to the patient but also the functional benefit of the 
flexibility to our communities. In this example, the provider and 
patient still have the option to utilize a face-to-face visit but can 
do this more strategically based on clinical need. Recent survey data 
would support the idea that there is a strong preference of both 
providers and patients to maintain the flexibility of access with 
telehealth availability.

    In order to maximize this flexibility, the committee should 
consider the following policy changes:

        Remove the 6-month in-person requirement for mental health 
treatment to ensure that mental health and substance use disorder 
services furnished via telehealth are treated equally.
        Continue the expanded telehealth flexibilities afforded to 
providers under the COVID-19 Public Health Emergency, including lifting 
of site of service and geographic restrictions and allowing for the use 
of audio-only telehealth services when clinically appropriate or when 
no other alternative exists.

                                 ______
                                 
               Questions Submitted by Hon. John Barrasso
        increasing access to mental health providers in medicare
    Question. As a doctor, I know the importance of improving access to 
mental health care for all Americans. This is especially important in 
rural parts of the country, which face some of the largest shortages in 
the country.

    For seniors, finding a mental health provider can be particularly 
challenging. This is because Medicare restricts certain types of mental 
health providers from billing the program.

    Senator Stabenow and I introduced bipartisan legislation to address 
this issue. S. 828, the Mental Health Access Improvement Act would 
allow licensed professional counselors and marriage and family 
therapists to bill Medicare.

    This is especially important in Wyoming, where many of our 
community mental health centers rely on professional counselors and 
marriage and family therapists to provide care.

    I'm sure the committee would like to hear from anyone else who 
wants to discuss the importance of increasing access to these 
professionals.

    Answer. I fully support the inclusion of a broader behavioral 
health workforce to allow licensed professional counselors and marriage 
and family therapists to bill Medicare. Many of the practices I have 
worked with have successfully used a range of licensed mental health 
professionals, including licensed professional counselors and marriage 
and family therapists, to serve in integrated settings as well as offer 
specialty mental health services.

    An additional consideration to support workforce and increase 
access to effective mental health care for Medicare recipients is to 
increase the value of reimbursement for mental health services for this 
critical workforce.
                               telehealth
    Question. Patients in Wyoming are using telehealth to help meet 
their health-care needs during the pandemic. Members of this committee 
support making sure telehealth becomes a permanent part of health-care 
delivery for those patients who want to utilize this service. Congress, 
with bipartisan support, has already taken steps to extend telehealth 
flexibilities for five months following the expiration of the public 
health emergency.

    Can you discuss the importance of telehealth in terms of the 
delivery of mental health services?

    Answer. I have learned in my clinical experience that telehealth is 
an important strategy to increase access to general psychiatric care 
and supports and complements integrated care. The progress we have made 
in reaching more patients through telehealth and coordinating care with 
other systems of support has been a literal lifeline for our patients.

    Prior to COVID-19, substance use disorders and co-occurring mental 
health services were exempt from geographic and site of service 
restrictions under Medicare, but mental health treatment services alone 
were not. At the end of 2020, Congress took the important step of 
permanently waiving these restrictions for mental health. However, 
Congress also passed requirements for patients receiving care via 
telehealth to have an in-person evaluation with their mental health 
provider within the 6-month period prior to their first telehealth 
visit and at subsequent periods as required by the Secretary. This 
arbitrary requirement, which does not apply to those with substance use 
disorders or co-occurring mental health and substance use disorders who 
see their clinicians via telehealth, creates an unnecessary and 
difficult barrier to needed care for Medicare patients with a mental 
health diagnosis. Whether a patient needs to be seen in person is a 
clinical decision that should be made together by a patient and their 
clinician at the appropriate time.

    I encourage the committee to consider the following policy 
recommendations that would address the current challenges with access 
to telehealth services for behavioral healthcare needs:

        Remove the 6-month in-person requirement for mental health 
treatment to ensure that mental health and substance use disorder 
services furnished via telehealth are treated equally.
        Expand telehealth flexibilities afforded to providers under 
the COVID-19 Public Health Emergency, including lifting of site of 
service and geographic restrictions and allowing the use of audio-only 
telehealth services when clinically appropriate or when no other 
alternative exists.
                      expanding physician training
    Question. The University of Washington has a special relationship 
with Wyoming through the WWAMI program. For those of you who do not 
know, WWAMI is a one-of-a-kind, multi-State medical education program. 
The acronym stands for the States served by UWs medical school--
Washington, Wyoming, Alaska, Montana, and Idaho.

    I try to speak with Wyoming's WWAMI students every year. It is 
always a pleasure to hear about their experience at the University of 
Washington and the rotations they are completing in the WWAMI region.

    As director of the University of Washington's Psychiatry Resident 
Training Program, I know you share my passion for expanding the number 
of psychiatrists, especially those serving in rural communities.

    Can you please discuss how your program exposes residents to rural 
communities?

    Answer. UW Medicine currently supports two innovative rural tracks 
as part of our program. In this model, residents spend 2 years at our 
University of Washington Seattle-based residency then complete 2 years 
of training in either Boise, ID or Billings, MT. Local programs offer 
the opportunity for training to serve a broader range of communities, 
including rural communities.

    This is an important model for academic programs to support the 
development of local community-based programs. In fact, our Boise, 
Idaho program is now a 4-year independent program with their first 
class that started in this academic year. These efforts also help 
recruit and retain a psychiatric workforce with over 80 percent of our 
residents taking their first job after residency in the Pacific 
Northwest.

    Question. Can you discuss ways psychiatric residency programs can 
expand their training sites outside of traditional academic medical 
centers?

    Answer. There are several other training strategies that can be 
helpful to support the training of residents to work in diverse 
communities. One approach is to partner with community settings to 
offer elective training experiences in a different community. For 
example, our UW Medicine Seattle Residency offers elective 
opportunities both to travel to and provide clinical care in a one-
month onsite program in Alaska.

    We also have begun to leverage telehealth training as another 
approach to serve community settings and populations outside the 
Seattle area. We have partnered with the Lummi Tribal Clinic to offer 
elective training to serve this community about 3 hours outside the 
Seattle area. This is a hybrid care delivery and training approach. Our 
trainees travel to spend time in the clinic at the start of the 
rotation and then continue to deliver care through telehealth over the 
following 6 months.

    Both of these approaches have required additional funding 
resources, which can be a significant barrier to broader expansion of 
these models.

                                 ______
                                 
     Prepared Statement of Reginald D. Williams II, Vice President,
International Health Policy and Practice Innovations, Commonwealth Fund
                            formal greeting
    Good morning. Thank you, members of the Senate Finance Committee, 
for inviting me to speak today on the critical topic of ensuring that 
behavioral health services are accessible to people residing in the 
United States. Chairman Wyden and Ranking Member Crapo, you have both 
been leaders on this pressing issue, and I am hopeful that your 
bipartisan commitment to advancing solutions will lead to progress.
                     personal story and background
    I am Reggie Williams, and I lead the International Health Policy 
and Practice Innovations Program at the Commonwealth Fund. I also co-
lead our work on behavioral health, which includes a focus on mental 
health and substance use.

    For over 10 years, I have also volunteered my time in the mental 
health community--currently serving on the boards of the Youth Mental 
Health Project and Fountain House and, in the past, chairing the board 
of directors of Mental Health America. My focus has been on improving 
the systems--or lack thereof--that people and families are forced to 
navigate to achieve the lives they want to live.

    I testify today not only as someone who has spent more than 20 
years in health policy but also as a Black man who strives to manage 
his own mental health--and as someone who has personally witnessed the 
impacts of mental health and substance use on my family, friends, 
coworkers, and my greater community.
                        magnitude of the crisis
    There is a behavioral health crisis in the United States. When I 
say behavioral health, I mean the promotion of mental health, 
resilience, and well-being; the prevention, early identification, and 
treatment of mental illness and substance use; and the support of those 
who experience and/or are in recovery from these conditions, along with 
their families and communities.

    The crisis is being felt nationwide, without regard for political 
affiliation, economic prosperity, or education level--but, like so many 
other areas of our health-care system, it is particularly acute for 
economically disadvantaged and underserved communities. The crisis 
predates COVID-19 but was exacerbated by the social isolation, economic 
disruption, and upheaval of the U.S. health system that accompanied the 
pandemic. At the core of the crisis is unmet need.

    There have been incredible strides made toward closing the coverage 
gap and achieving mental health parity with the passage of the 
Affordable Care Act in 2010. Access to behavioral care and treatment, 
however, remains a major issue in the U.S., especially for Black and 
Hispanic populations, for youth, and for Medicare and Medicaid 
beneficiaries.\1\
---------------------------------------------------------------------------
    \1\ Jesse C. Baumgartner, Gabriella N. Aboulafia, and Audrey 
McIntosh, ``The ACA at 10: How Has It Impacted Mental Health Care?'' To 
the Point (blog), Commonwealth Fund, April 3, 2020, https://
www.commonwealthfund.org/blog/2020/aca-10-how-has-it-impacted-mental-
health-care.

    Data from U.S. Department of Substance Abuse and Mental Health 
Services Administration (SAMSHA) show that among adults age 18 or older 
in 2020, 21 percent (or 52.9 million people) had any mental illness 
(AMI) and 5.6 percent (or 14.2 million people) had serious mental 
illness (SMI) in the past year. In 2020, 40.3 million people age 12 or 
older (or 14.5 percent) had a substance use disorder (SUD) in the past 
year, including 28.3 million who had alcohol use disorder.\2\
---------------------------------------------------------------------------
    \2\ SAMHSA, ``Key Substance Use and Mental Health Indicators in the 
United States: Results from the 2020 National Survey on Drug Use and 
Health,'' U.S. Department of Health and Human Services, October 2021, 
https://www.samhsa.gov/data/sites/default/files/reports/rpt35325/
NSDUHFFRPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf.

    There is a mismatch between the demand among people seeking 
behavioral care and the supply of behavioral health providers. Some 142 
million people in the U.S. live in one of the 6,127 mental health 
professional shortage areas, with an estimated 7,400 behavioral health 
providers needed.\3\
---------------------------------------------------------------------------
    \3\ HRSA, ``Shortage Areas,'' U.S. Department of Health and Human 
Services, March 2022, https://data.hrsa.gov/topics/health-workforce/
shortage-areas.

    When compared to other high-income countries, the U.S. is an 
outlier in access to behavioral health services. The 2020 Commonwealth 
Fund International Health Policy Survey revealed that U.S. respondents 
with mental health needs were more likely than respondents in other 
countries to face access barriers. Analysis of the responses further 
revealed that Black and Hispanic Americans faced even greater access 
problems. In totality, these data draw attention to the need for 
continued investment in our Nation's behavioral health system.\4\
---------------------------------------------------------------------------
    \4\ Reginald D. Williams II and Arnav Shah, Mental Health Care 
Needs in the U.S. and 10 Other High-Income Countries: Findings from the 
2020 Commonwealth Fund International Health Policy Survey (Commonwealth 
Fund, October 2021), https://www.commonwealthfund.
org/publications/surveys/2021/oct/mental-health-care-needs-us-10-other-
high-income-countries-survey.

[GRAPHIC] [TIFF OMITTED] T3022.001


    .epsThe current behavioral health crisis is particularly notable 
for its impact on our Nation's youth. Late last year, the U.S. Surgeon 
General issued a crisis advisory for children's mental health.\5\ In 
2020, less than half of adolescents (42 percent) with depression in the 
past year reported receiving any treatment, with Black and Indigenous 
people and youth of color having even worse access to care (only 37 
percent of Hispanic youth reported accessing care) than White young 
people, teenagers, or adolescents. Among young adults with mental 
illness, 47 percent reported unmet needs for mental health care.\6\ 
Hospitals are reporting more emergency department (ED) visits among 
adolescents due to mental health and substance use issues as well as 
waits in the ED of days, sometimes even weeks, before treatment options 
become available.\7\
---------------------------------------------------------------------------
    \5\ Office of the Surgeon General, ``Youth Mental Health Reports 
and Publications,'' U.S. Department of Health and Human Services, 
December 2021, https://www.hhs.gov/surgeon
general/priorities/youth-mental-health/index.html.
    \6\ Highlights for the 2020 National Survey on Drug Use and Health 
(SAMHSA, 2021), https://www.samhsa.gov/data/sites/default/files/2021-
10/2020_NSDUH_Highlights.pd.
    \7\ Rebecca T. Leeb et al., Mental Health-Related Emergency 
Department Visits Among Children Aged <18 Years During the COVID-19 
Pandemic--United States, January 1-October 17, 2020 (CDC, November 
2020), https://www.cdc.gov/mmwr/volumes/69/wr/mm6945a3.htm.

    The Medicaid program serves as the single largest provider of 
behavioral health services in the U.S., and yet half of all Medicaid 
members (50 percent) with serious mental illness, and nearly 70 percent 
of Medicaid members with an opioid use disorder, have reported not 
receiving treatment.\8\
---------------------------------------------------------------------------
    \8\ NAMD, ``Federal Policy Briefs: Behavioral Health Integration,'' 
National Association of Medical Directors, 2022, https://
medicaiddirectors.org/wp-content/uploads/2022/02/Federal-Policy-Brief-
Integration_updated-link-1.pdf.

    One-quarter of all Medicare beneficiaries have mental illness. 
Analysis from the Commonwealth Fund shows that, compared to adults over 
age 65 in other high-
income countries, Medicare beneficiaries are the most likely to see a 
health-care professional to manage their depression or anxiety--and the 
most likely to report having cost-related access problems or stress 
about paying for food, rent, or utilities.\9\ The prevalence of mental 
illness is greatest among beneficiaries under 65 who qualify for 
Medicare because of disability, as well as among low-income 
beneficiaries who are dually eligible for Medicare and Medicaid.\10\
---------------------------------------------------------------------------
    \9\ Munira Z. Gunja, Arnav Shah, and Reginald D. Williams II, 
Comparing Older Adults' Mental Health Needs and Access to Treatment in 
the U.S. and Other High-Income Countries (Commonwealth Fund, January 
2022), https://www.commonwealthfund.org/publications/issue-briefs/2022/
jan/comparing-older-adults-mental-health-needs-and-access-treatment.
    \10\ Beth McGinty, Medicare's Mental Health Coverage: How COVID-19 
Highlights Gaps and Opportunities for Improvement (Commonwealth Fund, 
July 2020), https://www.
commonwealthfund.org/publications/issue-briefs/2020/jul/medicare-
mental-health-coverage-covid-19-gaps-opportunities.

    Nearly one-third of individuals dually eligible for Medicare and 
Medicaid have been diagnosed with a serious mental illness such as 
schizophrenia, bipolar disorder, or major depressive disorder, a rate 
nearly three times higher than for non-dually eligible Medicare 
beneficiaries.\11\
---------------------------------------------------------------------------
    \11\ Logan Kelly, Coordinating Physical and Behavioral Health 
Services for Dually Eligible Members with Serious Mental Illness 
(Center for Health Care Strategies, December 2019), https://
www.chcs.org/resource/coordinating-physical-and-behavioral-health-
services-for-dually-eligible-members-with-serious-mental-illness/.

    Prior to the pandemic, 22 percent of U.S. adults were experiencing 
social isolation or loneliness. Organizations across the globe have 
been implementing programs to curtail the effect of growing 
isolation.\12\ The COVID-19 pandemic only intensified the unmet need 
for services and gaps in access to care for behavioral health services, 
with a higher percentage of adults in the U.S. reporting mental health 
concerns, as well as difficulty accessing services, than adults in 
other high-income countries.\13\
---------------------------------------------------------------------------
    \12\ Laura Shields-Zeeman et al., ``Addressing Social Isolation and 
Loneliness: Lessons from Around the World,'' To the Point (blog), 
Commonwealth Fund, January 27, 2021, https://www.commonwealthfund.org/
blog/2021/addressing-social-isolation-and-loneliness-lessons-around-
world; Melinda K. Abrams et al., ``Solutions from Around the World: 
Tackling Loneliness and Social Isolation During COVID-19,'' To the 
Point (blog), Commonwealth Fund, April 30, 2020, https://
www.commonwealthfund.org/blog/2020/solutions-around-world-tackling-
loneliness-and-social-isolation-during-covid-19.
    \13\ Reginald D. Williams II et al., Do Americans Face Greater 
Mental Health and Economic Consequences from COVID-19? Comparing the 
U.S. with Other High-Income Countries (Commonwealth Fund, August 2020), 
https://www.commonwealthfund.org/publications/issue-briefs/2020/aug/
americans-mental-health-and-economic-consequences-COVID19.

    The problem is big and complex. However, there are tools that can 
be leveraged to make meaningful change in people's lives. Here's what 
---------------------------------------------------------------------------
we can do:

        1.  Increase access to behavioral health services by 
        integrating mental health and substance use treatment and 
        services with primary care. This includes supporting 
        integration and care coordination with innovative payment 
        approaches.
        2.  Expand and diversify the behavioral health workforce, by 
        engaging a wide variety of providers to meet people's unique 
        needs.
        3.  Leverage the potential of health technology to fill gaps 
        and meet unfulfilled needs with telemedicine and digital health 
        solutions.
          integrate mental health and substance use treatment 
                     and services into primary care
    Expanding the capacity of primary care providers to meet the 
behavioral health needs of their patients provides an opportunity to 
increase access to early intervention and treatment as well as to 
promote social connectedness and suicide prevention. Compared to other 
countries, the U.S. has a smaller workforce dedicated to meeting mental 
health needs. Countries like the Netherlands, Sweden, and Australia 
more frequently include mental health providers on primary care 
teams.\14\ This compounds the comparative underinvestment in primary 
care teams in the U.S., which spends 5 percent to 7 percent on primary 
care as a share of total health-care spending, compared to 14 percent 
in other countries belonging to the Organisation for Economic Co-
operation and Development (OECD).\15\
---------------------------------------------------------------------------
    \14\ Eric C. Schneider et al., Mirror, Mirror 2021--Reflecting 
Poorly: Health Care in the U.S. Compared to Other High-Income Countries 
(Commonwealth Fund, August 2021), https://www.commonwealthfund.org/
publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-
poorly; and Molly FitzGerald, Munira Z. Gunja, and Roosa Tikkanen, 
Primary Care in High-Income Countries: How the United States Compares 
(Commonwealth Fund, March 2022), https://www.commonwealthfund.org/
publications/issue-briefs/2022/mar/primary-care-high-income-countries-
how-united-states-compares.
    \15\ Yalda Jabbarpour et al., Investing in Primary Care: A State-
Level Analysis (Patient-
Centered Primary Care Collaborative, July 2019), https://www.pcpcc.org/
sites/default/files/resources/pcmh_evidence_report_2019.pdf.

    Studies repeatedly show that patients view primary care providers 
as trusted sources of information. For example, in recent history, 
primary care providers ranked as the preferred source of information 
around COVID-19 vaccination for all age groups, races, and geographical 
location--regardless of political party.\16\ This trusted environment 
also offers an opportunity to combat stigma associated with discussing 
mental health and substance use and seeking treatment.
---------------------------------------------------------------------------
    \16\ ``American COVID-19 Vaccine Poll'' (African American Research 
Collaborative, 2021), https://africanamericanresearch.us/covid-poll-
methodology/.

    U.S. primary care providers are making strides in treating the 
behavioral health needs of their patients, but they are often working 
without necessary resources and supports. And they are working within a 
health-care system that does not yet fully support providing integrated 
care. As many as 80 percent of people with behavioral health needs 
present in emergency departments and primary care settings; between 60 
percent and 70 percent of these individuals leave without treatment for 
their conditions.\17\ Primary care providers see 45 percent of people 
within 30 days of a suicide attempt, and data show the primary care 
providers have an opportunity to intervene with routine depression 
screening and treatment to prevent suicides.\18\
---------------------------------------------------------------------------
    \17\ Sarah Klein and Martha Hostetter, ``In Focus: Integrating 
Behavioral Health and Primary Care,`` Newsletter Article, Commonwealth 
Fund, August 28, 2014, https://www.
commonwealthfund.org/publications/newsletter-article/2014/aug/focus-
integrating-behavioral-health-and-primary-care.
    \18\ Tackling America's Mental Health and Addiction Crisis Through 
Primary Care Integration (Bipartisan Policy Center, March 2021), 
https://bipartisanpolicy.org/download/?file=/wp-content/uploads/2021/
03/BPC_Behavioral-Health-Integration-report_R03.pdf.
---------------------------------------------------------------------------
The Case for Primary Care and Behavioral Health Integration
    The term ``integration'' describes the bringing together of various 
providers and services. Integration has been used to reference 
everything from consultation to collocation to a setting of shared 
health goals around treating the whole person without clear 
boundaries.\19\ It is helpful to view models of care delivery as 
spanning a continuum of ways to integrate physical and behavioral 
health care (both mental health and substance use).\20\
---------------------------------------------------------------------------
    \19\ A Standard Framework for Levels of Integrated Healthcare 
(SAMHSA-HRSA Center for Integrated Health Solutions, April 2013), 
https://www.pcpcc.org/sites/default/files/resources/SAMHSA-
HRSA%202013%20Framework%20for%20Levels%20of%20Integrated%20Healthcare.
pdf.
    \20\ Integrating Behavioral Health Care into Primary Care: 
Advancing Primary Care Innovation in Medicaid Managed Care (Center for 
Health Care Strategies, Inc., August 2019), https://www.chcs.org/media/
PCI-Toolkit-BHI-Tool_090319.pdf.

[GRAPHIC] [TIFF OMITTED] T3022.002


.eps[GRAPHIC] [TIFF OMITTED] T3022.003


    .epsIt has been projected that effective medical and behavioral 
health service integration that includes a focus on primary care could 
generate nearly $70 billion in U.S. health-care costs savings 
annually.\21\
---------------------------------------------------------------------------
    \21\ ``Potential economic impact of integrated medical-behavioral 
health care,'' Milliman Research Report, January 2018, https://
www.milliman.com/en/insight/potential-economic-impact-of-integrated-
medical-behavioral-healthcare-updated-projections.
---------------------------------------------------------------------------
Support Innovative Payment Approaches
    New approaches to payment policies, including models that hold 
providers accountable for improving quality and controlling overall 
costs, and programs led by Medicaid and Medicare, offer promising 
approaches to encouraging integration.

    Approaches that can be used to pay for integrated care include: (1) 
new fee-for-services billing codes (e.g., Washington State's 
Collaborative Care Model codes); (2) care management payments (e.g., 
New York's case rates for qualified Collaborative Care Model 
providers); (3) bundled payments (e.g., Minnesota's Diamond model); and 
(4) primary care capitation (e.g., Rhode Island's primary care 
capitation framework).\22\ Each of these payment approaches can also be 
tied to value-based incentives around progress toward evidence-based 
behavioral health-care integration or quality performance, depending on 
which program is being implemented.
---------------------------------------------------------------------------
    \22\ Integrating Behavioral Health Care into Primary Care: 
Advancing Primary Care Innovation in Medicaid Managed Care (Center for 
Health Care Strategies, Inc., August 2019), https://www.chcs.org/media/
PCI-Toolkit-BHI-Tool_090319.pdf.

    Implementation can be further supported by financing evidence-based 
learning collaboratives for providers, in addition to financing 
---------------------------------------------------------------------------
integrated care directly.

    Collaboratives help build practices' capacity to adapt to new work 
streams, team-based care, and digital technologies and improve 
integration with community resources.

    As policymakers are contemplating ways to support the Centers for 
Medicare and Medicaid Services (CMS) and the States, there are many 
promising models to consider in support of the integration of 
behavioral health with primary care.

    Illustrative models include:

        Providing incentives for providers to achieve quality 
performance milestones related to behavioral health-care integration 
and participate in quality improvement collaboratives, as Arizona did 
with its Targeted Investments Program, part of a Medicaid waiver 
program. Evaluation reports found a general increase in integration 
levels across all participating providers.\23\
---------------------------------------------------------------------------
    \23\ ``Tackling America's Mental Health and Addiction Crisis 
Through Primary Care Integration,'' Bipartisan Policy Center, March 
2021, https://bipartisanpolicy.org/event/tackling-americas-mental-
health-and-addiction-crisis-through-primary-care-integration/.

        Integrating substance use disorder services within an existing 
primary care setting, as the Southwest Montana Community Health Center, 
a Federally Qualified Health Center (FQHC) in Butte, MT does. This 
health center links people to counseling and other community programs 
by deploying evidence-based models like screening, brief intervention, 
and referral to treatment (SBIRT). In a large study of SBIRT outcomes, 
at 6-month follow-up, illicit drug use was 68-percent lower and heavy 
alcohol consumption was 39-percent lower among individuals who had 
screened positive for hazardous drug and alcohol use.\24\
---------------------------------------------------------------------------
    \24\ ``Integration of Mental Health Services in Primary Care 
Settings,'' Rural Health Information Hub, 2022; Suneel M. Agerwala and 
Elinore F. McCance-Katz, M.D., ``Integrating Screening, Brief 
Intervention, and Referral to Treatment (SBIRT) into Clinical Practice 
Settings: A Brief Review,'' Journal of Psychoactive Drugs, 44:4, 307-
317 (September 2012), https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC3801194/.

        Addressing isolation through psychosocial rehabilitation, as 
Fountain House does. Health and wellness programming ensures people 
with SMI can access primary and psychiatric care, care management, and 
home and community-based services, which have been shown to reduce 
hospitalizations and decrease costs for Medicaid.\25\
---------------------------------------------------------------------------
    \25\ Joshua Seidman and Kevin Rice, Brief Summary of Evidence 
Supporting Clubhouses (Fountain House, January 2022), https://
www.fountainhouse.org/assets/Brief-Summary-of-Evidence-for-
Clubhouses_2022.pdf.

        Embedding mental health teams with primary care practices to 
build stronger local service provider relationships that are responsive 
to community Australia's GP Clinic does. To improve access to primary 
health care, a multidisciplinary team consisting of mental health 
nurses, a social worker and psychologist seek to help manage complex 
needs of people in rural settings.\26\
---------------------------------------------------------------------------
    \26\ Scott J. Fitzpatrick et al., ``Coordinating Mental and 
Physical Health Care in Rural Australia: An Integrated Model for 
Primary Care Settings,'' International Journal of Integrated Care vol. 
18, no. 2 (2018), https://www.ijic.org/articles/10.5334/ijic.3943/.
---------------------------------------------------------------------------
   expand and diversify the workforce by engaging a wide variety of 
                               providers
    The evidence supports engaging a wider array of providers in the 
behavioral health-care team, a broader set of providers than most 
people have access to today. Medicare covers only a set of traditional 
providers, such as psychiatrists, psychologists, and social workers, 
but not other types of licensed providers, such as marriage and family 
therapists or counselors. Through their flexibility, State Medicaid 
managed care plans often cover a range of providers that also 
increasingly include paraprofessionals. Paraprofessionals encompass a 
range of workers, from certified peer support specialists to community 
health workers, that play important roles across the care continuum.

    Trained and accredited peer support specialists leverage their 
lived experience of mental health or substance use conditions to 
support others in recovery. There is evidence that peer support 
specialists can be effective in engaging people with treatment, 
reducing the use of emergency rooms and hospitals and reducing 
substance use among people with co-occurring substance use 
disorders.\27\ Peer support, which was developed in response to the 
lack of access to effective care in many communities, is now 
increasingly part of the continuum of care. Approximately 25 percent of 
mental health treatment facilities and 56 percent of facilities 
treating substance use disorders self-reported offering peer support 
services in 2018.\28\ As of 2018, 39 States allowed for Medicaid 
billing of peer support specialists.\29\
---------------------------------------------------------------------------
    \27\ ``Peers Supporting Recovery from Mental Health Conditions,'' 
SAMHSA, 2017, https://www.samhsa.gov/sites/default/files/
programs_campaigns/brss_tacs/peers-supporting-recovery-mental-health-
conditions-2017.pdf.
    \28\ C. Page et al., ``The Effects of State Regulations and 
Medicaid Plans on the Peer Support Specialist Workforce,'' Health 
Services Research vol. 55, issue S1 (August 2020), https://
onlinelibrary.wiley.com/doi/abs/10.1111/1475-6773.13430.
    \29\ Lynn Videka et al., National Analysis of Peer Support 
Providers: Practice Settings, Requirements, Roles, and Reimbursement 
(University of Michigan School of Public Health Behavioral Health 
Workforce Research Center, August 2019), https://
behavioralhealthworkforce.org/wp-content/uploads/2019/10/BHWRC-Peer-
Workforce-Full-Report.pdf.

    Often, peer support specialists assist with the transition from 
hospital to community or participate in intensive programs, providing 
necessary additional support as part of a care team. Increasingly 
though, peer support specialists are being engaged earlier and can be a 
critical partner and extender for integrated care models, including in 
collaborative care, where they help with navigating treatment and other 
services while building key self-management skills.\30\ Clinicians 
appreciate peer support specialists for the additional support they 
lend and for keeping care grounded in the needs of the individual, 
ensuring that the services ultimately advance recovery.\31\
---------------------------------------------------------------------------
    \30\ Matthew Menear et al., ``Strategies for engaging patients and 
families in collaborative care programs for depression and anxiety 
disorders: A systematic review,'' Journal of Affective Disorders vol. 
263 (February 15, 2020), https://www.sciencedirect.com/science/article/
pii/S0165032719323110#bib0038.
    \31\ Marianne Storm et al., ``Peer Support in Coordination of 
Physical Health and Mental Health Services for People With Lived 
Experience of a Serious Mental Illness,'' Frontiers in Psychiatry vol. 
11 (May 8, 2020), https://www.frontiersin.org/articles/10.3389/
fpsyt.2020.00365/full.

    Community health workers, on the other hand, work closely with the 
community in more of a public health role. Research has demonstrated 
that for every dollar invested in a community health worker 
intervention, it returned $2.47.\32\ In behavioral health, community 
health workers can educate the community about mental health and 
substance use issues, help people identify needs and get connected to 
care, and even offer some frontline interventions to reduce stress. For 
example, community health workers in Louisiana effectively worked with 
pregnant women to facilitate virtual interventions and provide social 
support to prevent the onset of postpartum depression.\33\
---------------------------------------------------------------------------
    \32\ Shreya Kangovi et al., ``Evidence-Based Community Health 
Worker Program Addresses Unmet Social Needs and Generates Positive 
Return on Investment,'' Health Affairs 39(2): 207-213 (February 2020), 
https://pubmed.ncbi.nlm.nih.gov/32011942/.
    \33\ Christopher Mundorf et al., ``Reducing the Risk of Postpartum 
Depression in a Low-Income Community Through a Community Health Worker 
Intervention,'' Maternal and Child Health Journal vol. 22, 520-528 
(December 29, 2017), https://link.springer.com/article/10.1007/s10995-
017-2419-4.

    Furthermore, engaging community health workers who are 
representative of the populations they are seeking to reach can be an 
important way to reduce disparities in communities where people might 
not feel comfortable reaching out for help. Integrated behavioral 
health models that include paraprofessionals illustrate the potential 
---------------------------------------------------------------------------
for improving access to care and treatment. These include:

        Primary care providers who assess patients based on intensity 
of symptoms and then refer them to different types of providers based 
on level of need. Such providers could include a therapist for moderate 
to high needs or, for those with milder needs, lower-intensity 
therapies from providers of evidence-based mindfulness, self-help 
strategies, and well-being workshops. This model is akin to a stepped-
care approach like the United Kingdom's Improving Access to 
Psychological Therapies, which seeks to address patients' needs 
upstream by providing first-line approaches for people normally 
untreated or undiagnosed with a behavioral health condition.\34\
---------------------------------------------------------------------------
    \34\ ``Adult Improving Access to Psychological Therapies 
Programme,'' NHS, https://www.england.nhs.uk/mental-health/adults/
iapt/.

        The engagement of peer specialists as a part of clinical 
teams, as both the Institute for Community Living in New York City and 
the Lowell Community Health Center in Lowell, MA have done. These 
initiatives demonstrated improvements in patient engagement, supported 
the delivery of interventions in smoking cessation and exercise, and 
provided chronic disease management support.\35\
---------------------------------------------------------------------------
    \35\ Mary Docherty et al., How Practices Can Advance the 
Implementation of Integrated Care in the COVID-19 Era (Commonwealth 
Fund, November 2020), https://www.commonwealth
fund.org/publications/issue-briefs/2020/nov/practices-advance-
implementation-integrated-care-covid.

        The introduction of a new type of provider to fill workforce 
gaps, like general practice mental health workers, who are health 
professionals with a background in social support, basic psychology 
training, or nursing and work under supervision of a primary care 
provider. In the Netherlands, the integration of general practice 
mental health workers into primary care settings has improved patients' 
quality of life as well as prevented mental health conditions from 
developing or further intensifying.\36\
---------------------------------------------------------------------------
    \36\ Joost Wammes et al., ``Netherlands,'' in Roosa Tikkanen et 
al., International Health Care System Profiles (Commonwealth Fund, June 
2020), https://www.commonwealthfund.org/international-health-policy-
center/countries/netherlands.

    Despite the evidence on improved outcomes and cost savings, most 
Americans do not currently have access to the providers described here. 
---------------------------------------------------------------------------
To remedy that, policymakers could:

        Ensure that incentives, financing, and support for integrated 
care are inclusive of the paraprofessional workforce.

        Provide specific incentives for systems to recruit, integrate, 
and retain paraprofessionals, and other workforce extenders.

        Implement learning collaboratives and quality improvement 
initiatives around integrating a broader workforce into the continuum 
of care, including issues around effective supervision and delineation 
of roles to maximize impact.

        Consider how to improve coverage of a broader workforce, 
including reimbursement for peer support specialists in Medicare.
           leverage telemedicine and digital health solutions
    Now is the time to be optimistic about the potential of technology 
to address behavioral health needs. The pandemic caused a sudden shift: 
at a time when the need for support was greater than ever, people 
sought mental health care over the telephone and via online platforms. 
In addition, technology-enabled solutions have resulted in 
unprecedented investment in digital health tools that can help solve 
the provider shortage through on-demand therapy, guided mediation, 
chatbots and more.

    Telemedicine can be an effective way to improve mental health, 
especially through cognitive behavioral therapy. Evidence shows that 
telemedicine is at least as effective as face-to-face interventions in 
tackling depression and anxiety, symptoms of obsessive-compulsive 
disorder, insomnia, and excessive alcohol consumption.\37\ Telemedicine 
has also been shown to alleviate maternal depression symptoms.\38\
---------------------------------------------------------------------------
    \37\ Tiago C.O. Hashiguchi, OECD Health Working Paper No. 116: 
Bringing Health Care to the Patient: An Overview of the Use of 
Telemedicine in OECD Countries (OECD, January 2020), https://
www.oecd.org/officialdocuments/publicdisplaydocumentpdf/?cote=DELSA/
HEA/WD/HWP(2020)1&docLanguage=En.
    \38\ Uthara Nair et al., ``The effectiveness of telemedicine 
interventions to address maternal depression: A systematic review and 
meta-analysis,'' Journal of Telemedicine and Telecare vol. 24, issue 10 
(October 22, 2018), https://journals.sagepub.com/doi/10.1177/
1357633X18794332.

    The COVID-19 pandemic, and the expanded flexibilities that were 
authorized around the provision of telehealth services, brought about 
sharp increases in the number of facilities providing telehealth 
treatment for both mental health and substance use services. The 
proportion of substance use treatment facilities offering telehealth 
services jumped from 28 percent in 2019 to 59 percent in 2020. For 
mental health facilities, the share grew from 38 percent to 69 percent 
over the same period.\39\
---------------------------------------------------------------------------
    \39\ Herman A. Alvarado, Telemedicine Services in Substance Use and 
Mental Health Treatment Facilities (SAMHSA, December 2021), https://
www.samhsa.gov/data/report/telemedicine-services.

    Among Medicare beneficiaries, visits to behavioral health 
specialists accounted for the largest increase in telehealth in 2020. 
Telehealth comprised a third of total visits to behavioral health 
specialists. Yet despite the increase in available services, Black and 
rural Medicare beneficiaries had lower telehealth use compared with 
White and urban beneficiaries, respectively. Telehealth use varied by 
State, with higher use in the Northeast and the West and lower use in 
the Midwest and the South. Urban beneficiaries had about 50-percent 
higher telehealth use than rural beneficiaries--1,659 visits per 1,000 
urban beneficiaries versus 1,112 visits per 1,000 among rural 
beneficiaries. Compared with pre-pandemic levels, this represents a 
140- and 20-fold increase in telehealth use for urban and rural 
beneficiaries, respectively.\40\
---------------------------------------------------------------------------
    \40\ Lok W. Samson et al., Medicare Beneficiaries' Use of 
Telehealth in 2020: Trends by Beneficiary Characteristics and Location 
(ASPE Office of Health Policy, December 2021), https://
www.aspe.hhs.gov/sites/default/files/documents/
a1d5d810fe3433e18b192be42dbf2351/medicare-telehealth-report.pdf.

    As Congress and the Biden administration weigh options for 
extending the telehealth flexibilities beyond the public health 
emergency,\41\ it will be essential to understand the barriers faced by 
Black and rural beneficiaries in accessing telehealth and tele-mental 
health services, so that policies serve to ameliorate disparities 
rather than exacerbate them.
---------------------------------------------------------------------------
    \41\ Josh LaRosa, ``Avoiding the Cliff: Medicare Coverage of 
Telemental Health and the End of the PHE,'' To the Point (blog), 
Commonwealth Fund, March 23, 2022, https://www.
commonwealthfund.org/blog/2022/avoiding-cliff-medicare-coverage-
telemental-health-and-end-phe.

    It is also noteworthy that the temporary continuous coverage 
requirement that kept Medicaid coverage intact during the health 
emergency helped to ensure access to medical and behavioral health 
services.\42\ Multiple studies have found that living in a Medicaid 
expansion State was associated with relative reductions in poor mental 
health by improving access, including access to services delivered 
through telehealth.\43\ It is critical that expansion of telehealth and 
other digital innovations in medicine be undertaken with universal and 
equitable access to care in mind.
---------------------------------------------------------------------------
    \42\ Cindy Mann, ``Stable and Continuous Coverage Provisions in 
Medicaid Gain Momentum Through Build Back Better Act,'' To the Point 
(blog), Commonwealth Fund, February 9, 2022, https://
www.commonwealthfund.org/blog/2022/stable-and-continuous-coverage-
provisions-medicaid-gain-momentum-through-build-back.
    \43\ John Cawley et al., ``Third year of survey data shows 
continuing benefits of Medicaid expansions for low-income childless 
adults in the U.S.,'' Journal of General Internal Medicine vol. 33, 
1495-1497 (June 5, 2018), https://pubmed.ncbi.nlm.nih.gov/29943107/.

    CMS has already begun to pilot some innovative models, such as 
Community Health Access and Rural Transformation (CHART), that 
specifically provide technical assistance to rural providers to help 
them fully benefit from technological innovations with both financial 
and regulatory flexibilities. The committee could consider 
opportunities to provide additional support for these types of models, 
with a specific focus on building capacity for providers to offer 
telehealth for behavioral health as well as meeting the various access 
needs of beneficiaries so they can benefit from these innovations. This 
could include helping to identify spaces available to primary care 
providers that can be set aside for telehealth visits when patients do 
---------------------------------------------------------------------------
not have access at home or the knowledge to use the technology.

    Digital mental health is expanding, with a host of startups 
offering solutions that promise to fill gaps in access to care. Digital 
health startups offering mental health services raised $5.1 billion--
$3.3 billion more than any other clinical service, including diabetes 
and cancer care, in 2021.\44\ The vast majority of these tools target 
employers, health plans, or consumers directly as app-based 
subscription services. A few health insurers and provider systems have 
created ``digital formularies'' that seek to make digital tools more a 
part of the system of care. Evidence regarding these tools is highly 
variable; some demonstrate effectiveness in randomized, controlled 
trials reflecting real-world conditions, while some have never been 
tested.
---------------------------------------------------------------------------
    \44\ Adriana Krasniansky, Bill Evans, and Megan Zweig, 2021 year-
end digital health funding: Seismic shifts beneath the surface 
(Rockhealth.org, January 2022), https://rockhealth.com/insights/2021-
year-end-digital-health-funding-seismic-shifts-beneath-the-surface/.

    Technology brings a clear promise for extending the existing 
behavioral health system. The potential benefits include on-demand 
access, tailored to individual needs, and well-tested interventions. 
Technology also increases the potential for reducing disparities for 
people facing the greatest barriers to obtaining access to traditional 
systems of care, such as rural Americans, people who lack access to 
transportation, or persons with disabilities. On the other hand, 
digital tools raise concerns: we need our behavioral health dollars 
spent wisely, and we don't want to champion the use of tools that are 
---------------------------------------------------------------------------
ineffective or inaccessible for beneficiaries.

    There is an opportunity to build capacity at CMS to work with 
National Institutes of Health and the Food and Drug Administration to 
consider payment and coverage implications for innovative new tools as 
they're being developed, ensuring that our public behavioral health 
system stays modern and effective. CMS has already taken steps to 
create codes for certain technologies that are gaining more widespread 
use (such as remote patient monitoring codes); CMS can build on those 
actions with additional support to create a permanent pipeline for 
supporting beneficiaries' access to innovation.

    Policymakers can also help CMS work with States to host a learning 
collaborative and to provide technical assistance on appropriate 
coverage of digital tools in Medicaid, as well as strategies for 
ensuring access for the beneficiaries most likely to benefit.\45\ 
Currently, States often make these decisions in isolation, left to 
identify, evaluate, and implement digital tools without the benefit of 
information on models or technologies that have demonstrated success in 
other health systems or States.
---------------------------------------------------------------------------
    \45\ Andrey Ostrovsky and Morgan Simko, ``Accelerating Science-
Driven Reimbursement for Digital Therapeutics in State Medicaid 
Programs,'' Health Affairs Blog, October 30, 2020, https://
www.healthaffairs.org/do/10.1377/forefront.20201029.537211.

    Among the many examples of the potential to harness technological 
---------------------------------------------------------------------------
innovations to improve behavioral health, illustrative ones include:

        Utilizing telepsychiatry and sharing electronic medical 
records to promote and encourage provider communication and co-
management of patients, like Cherokee Health Systems, a community 
mental health center and Federally Qualified Health Center in Tennessee 
does. Cherokee has embedded licensed behavioral health consultants in 
its primary care provider teams.\46\
---------------------------------------------------------------------------
    \46\ Chapter 4: Integration of Behavioral and Physical Health 
Services in Medicaid (MACPAC, March 2016), https://www.macpac.gov/wp-
content/uploads/2016/03/Integration-of-Behavioral-and-Physical-Health-
Services-in-Medicaid.pdf.

        Introducing a portfolio of digital patient engagement and 
self-management tools, as Montefiore Medical Center in the Bronx has 
done. Montefiore uses a secure online application and messaging system 
that has allowed for long-term clinical monitoring, engagement, and 
follow-up with patients. Interactions with patients were conducted via 
HIPAA-compliant text messages, and patients were offered support, 
screening, condition monitoring, and prompts/recommendations around 
behavior modification, mindfulness exercises, and physical 
exercise.\47\
---------------------------------------------------------------------------
    \47\ Mary Docherty et al., How Practices Can Advance the 
Implementation of Integrated Care in the COVID-19 Era (Commonwealth 
Fund, November 2020), https://www.commonwealth
fund.org/publications/issue-briefs/2020/nov/practices-advance-
implementation-integrated-care-covid.
---------------------------------------------------------------------------
                      conclusion: we can be better
    As I stated earlier, the problem is big and complex. However, we 
have tools to improve people's lives. It is certainly within our power 
to ensure that people's mental health and substance use needs are 
better met, especially youth, people with severe mental illness, 
residents of rural communities, and historically excluded Black, 
Latino, and Indigenous communities. There are myriad approaches to 
expanding access to services and prioritizing mental health, making 
care more convenient, and scaling treatment approaches to help more 
people.

[GRAPHIC] [TIFF OMITTED] T3022.004


    .epsThis can all be done, and our communities will be the stronger 
for it. There is inspiration from abroad that we can draw upon.

    For example, we can take inspiration from Italy's Trieste, which 
gives people grappling with mental health issues help with all aspects 
of their lives, ensuring their physical needs for food, clothing, and 
shelter are met; helping them forge connections with other community 
members; and supporting them in their pursuit of meaningful activities, 
including employment.\48\
---------------------------------------------------------------------------
    \48\ Rob Waters, ``A New Approach to Mental Health Care, Imported 
from Abroad,'' Health Affairs 39, no. 3 (March 2020): 362-66, https://
www.healthaffairs.org/doi/full/10.1377/hlthaff.2020.00047.

    We can be inspired by Belgium's Geel, a community that has accepted 
people with severe mental health needs for hundreds of years, 
supporting them and helping them find their own paths to better 
health.\49\
---------------------------------------------------------------------------
    \49\ Angus Chen, ``For Centuries, a Small Town Has Embraced 
Strangers with Mental Illness,'' July 1, 2016 in NPR, https://
www.npr.org/sections/health-shots/2016/07/01/484083305/for-centuries-a-
small-town-has-embraced-strangers-with-mental-illness.

    In the coming months, we can work to implement policy approaches 
that reflect our own values and commit the investments necessary to 
guarantee a better future for individuals, families, and communities in 
America. You can lead the way by advancing bipartisan policies for 
---------------------------------------------------------------------------
meeting these goals.

    I believe that, as a Nation, we can do better. And by providing new 
opportunities to expand access to equitable, affordable care and 
treatment and address our behavioral health crisis, ultimately, we can 
be better.

                                 ______
                                 
     Questions Submitted for the Record to Reginald D. Williams II
                 Questions Submitted by Hon. Ron Wyden
                     rural behavioral health access
    Question. For many years, the Finance Committee has been focused on 
ensuring that patients in rural areas have access to the care they 
need. This question is especially important for mental health services 
because mental health practitioners tend to be located in urban and 
suburban areas. As the Finance Committee considers options for 
improving integration of behavioral health care and primary care, it 
will be important to better understand whether innovative care models, 
such as the Collaborative Care Model, can improve access to mental 
health care and substance use disorder services in rural areas.

    Can integrated care models work in rural areas? Do psychiatrists 
and behavioral health-care managers need to be located in the same 
physical space as the primary care doctor?

    How can practices leverage telehealth to make the care teams work 
in rural areas?

    Answer. Integrated care models can be equally effective in rural 
areas, and psychiatrists and behavioral health-care managers do not 
need to be located in the same physical space as the primary care 
doctor. Practices can instead leverage telehealth to make care teams 
effective in rural areas.

    In general, the term ``integration'' describes the bringing 
together of various providers and services. Integration has been used 
to reference everything from consultation to collocation to a setting 
of shared health goals around treating the whole person without clear 
boundaries.\1\ It is helpful to view models of care delivery as 
spanning a continuum of ways to integrate physical and behavioral 
health care (both mental health and substance use).\2\ It has been 
projected that effective medical and behavioral health service 
integration that includes a focus on primary care could generate nearly 
$70 billion in U.S. health-care costs savings annually.\3\
---------------------------------------------------------------------------
    \1\ A Standard Framework for Levels of Integrated Healthcare 
(SAMHSA-HRSA Center for Integrated Health Solutions, April 2013), 
https://www.pcpcc.org/sites/default/files/resources/SAMHSA-
HRSA%202013%20Framework%20for%20Levels%20of%20Integrated%20Healthcare.
pdf.
    \2\ Integrating Behavioral Health Care into Primary Care: Advancing 
Primary Care Innovation in Medicaid Managed Care (Center for Health 
Care Strategies, Inc., August 2019), https://www.chcs.org/media/PCI-
Toolkit-BHI-Tool_090319.pdf.
    \3\ ``Potential economic impact of integrated medical-behavioral 
health care,'' Milliman Research Report, January 2018, https://
www.milliman.com/en/insight/potential-economic-impact-of-integrated-
medical-behavioral-healthcare-updated-projections.

    For rural areas, there is strong evidence that both in-person and 
virtually integrated care can support rural practices across the 
spectrum of integration to achieve meaningful improvements in 
behavioral health outcomes. One study found that collaborative care 
with all virtual support outperformed collaborative care with in-
person support for managing depression in rural a federally qualified 
health centers (FQHCs).\4\ Thus, telemedicine can be leveraged to allow 
all members of the care team to be remote and make behavioral health-
care accessible in rural America.
---------------------------------------------------------------------------
    \4\ Fortney JC, Pyne JM, Mouden SB, Mittal D, Hudson TJ, Schroeder 
GW, Williams DK, Bynum CA, Mattox R, Rost KM. ``Practice-based versus 
telemedicine-based collaborative care for depression in rural federally 
qualified health centers: A pragmatic randomized comparative 
effectiveness trial.'' American Journal of Psychiatry. 2013 
Apr;170(4):414-25.

[GRAPHIC] [TIFF OMITTED] T3022.005


    .epsRural FQHCs across the U.S. are already leading important 
integration efforts. Southwest Montana Community Health Center in 
Butte, Montana links people to counseling and other community programs 
by deploying evidence-based models like screening, brief intervention, 
and referral to treatment (SBIRT). By leveraging the available 
resources in the community more effectively, they were able to achieve 
68 percent lower illicit drug use and 39 percent lower heavy alcohol 
consumption six months later among individuals who had screened 
positive for hazardous drug and alcohol use.\5\ Cherokee Health Systems 
in Tennessee, on the other hand, uses telepsychiatry and shared 
electronic medical records to enable provider communication and co-
management of patients, making integration work even when behavioral 
health specialists are not physically on site.
---------------------------------------------------------------------------
    \5\ ``Integration of Mental Health Services in Primary Care 
Settings,'' Rural Health Information Hub, 2022; Suneel M. Agerwala and 
Elinore F. McCance-Katz, M.D., https://www.ruralhealth
info.org/toolkits/substance-abuse/2/treatment/care-delivery/mental-
health-integration; ``Integrating Screening, Brief Intervention, and 
Referral to Treatment (SBIRT) into Clinical Practice Settings: A Brief 
Review,'' Journal of Psychoactive Drugs, 44:4, 307-317 (September 
2012), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3801194/.

    CMS has already begun to pilot some innovative models, such as 
Community Health Access and Rural Transformation (CHART), that 
specifically provide technical assistance to rural providers to help 
them fully benefit from technological innovations with both financial 
and regulatory flexibilities. The committee could consider 
opportunities to provide additional support for these types of models, 
with a specific focus on building capacity for rural providers to offer 
virtually integrated behavioral health care. This could include helping 
to identify spaces available to primary care providers that can be set 
aside for telehealth visits when patients do not have access at home or 
the knowledge to use the technology.
          disparities in behavioral health access and outcomes
    Question. In the Finance Committee's hearing on youth behavioral 
health with the U.S. Surgeon General, Dr. Vivek Murthy sounded the 
alarm about the deep and pervasive racial and ethnic disparities that 
exist during the mental health crisis. A number of studies have found 
that more than half of people who need behavioral health care do not 
receive it, with higher rates of unmet need for racial and ethnic 
minority populations: 63 percent of African Americans, 65 percent of 
Hispanics, 80 percent of Asian and Pacific Islanders do not receive 
care when needed. Better integrating primary care with behavioral 
health may provide a critical access point for underserved populations 
and reduce racial and ethnic disparities.

    Your testimony discusses stigma. Can you explain how the 
integration of mental health services into the primary care model could 
help with the stigma and access barriers associated with accessing 
mental health services?

    Answer. The integration of mental health services into the primary 
care model could help with the stigma and access barriers associated 
with accessing mental health services. Studies repeatedly show that 
patients view primary care providers as trusted sources of information. 
For example, in recent history, primary care providers ranked as the 
preferred source of information around COVID-19 vaccination for all age 
groups, races, and geographical location--regardless of political 
party.\6\ This trusted environment also offers an opportunity to combat 
stigma associated with discussing mental health and substance use and 
seeking treatment. Access in primary care also reinforces that 
behavioral health is part of overall health, not a separate issue that 
requires going to a different setting to begin a conversation around 
getting help. Although research is ongoing in this space, existing 
evidence suggests that it is likely that integrated behavioral health 
care does in fact reduce stigma.\7\
---------------------------------------------------------------------------
    \6\ ``American COVID-19 Vaccine Poll'' (African American Research 
Collaborative, 2021), https://africanamericanresearch.us/covid-poll-
methodology/.
    \7\ Rowan AB, Grove J, Solfelt L, Magnante A. Reducing the impacts 
of mental health stigma through integrated primary care: an examination 
of the evidence. Journal of Clinical Psychology in Medical Settings. 
2021 Dec;28(4):679-93.

    Reducing stigma also requires bridging the gap between providers 
and cultural and linguistic communities that providers may not be fully 
equipped to engage. In these cases, community health workers, 
paraprofessionals who are representative of the populations they are 
seeking to reach, can be an important way to reduce disparities in 
communities where people might not feel comfortable reaching out for 
help. Integrated behavioral health models that include community health 
workers and other paraprofessionals will be an important part of 
equitably reducing stigma and other barriers to care.
     supporting primary care through behavioral health integration
    Question. Primary care practices are often stretched thin with 
daily patient caseloads. These practices could likely benefit from 
support to help deliver behavioral health care in the primary care 
setting. Research suggests that the inclusion of mental health 
providers on primary care teams is less common in the United States, as 
compared to other countries--two-thirds of primary care practices in 
the U.S. did not include mental health providers on the team, according 
to survey data from The Commonwealth Fund. The same survey data 
suggests only about half of primary care practices report feeling 
``well prepared'' to coordinate the care of patients with mental 
illness and only about 20 percent of practices feel well prepared to 
coordinate substance use disorder services.

    Why is the integration of behavioral health services into primary 
care practices falling short in the United States and how can we close 
the gap?

    Answer. The integration of behavioral health services into primary 
care practices falling short in the United States. Compared to other 
countries, the U.S. has a smaller workforce dedicated to meeting mental 
health needs. Countries like the Netherlands, Sweden, and Australia 
more frequently include mental health providers on primary care 
teams.\8\ This compounds the comparative underinvestment in primary 
care teams in the U.S., which spends 5 percent to 7 percent on primary 
care as a share of total health-care spending, compared to 14 percent 
in other countries belonging to the Organisation for Economic Co-
operation and Development (OECD).\9\
---------------------------------------------------------------------------
    \8\ Eric C. Schneider et al., Mirror, Mirror 2021--Reflecting 
Poorly: Health Care in the U.S. Compared to Other High-Income Countries 
(Commonwealth Fund, August 2021), https://www.commonwealthfund.org/
publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-
poorly; and Molly FitzGerald, Munira Z. Gunja, and Roosa Tikkanen, 
Primary Care in High-Income Countries: How the United States Compares 
(Commonwealth Fund, March 2022), https://www.commonwealthfund.org/
publications/issue-briefs/2022/mar/primary-care-high-income-countries-
how-united-states-compares.
    \9\ Yalda Jabbarpour et al., Investing in Primary Care: A State-
Level Analysis (Patient-
Centered Primary Care Collaborative, July 2019), https://www.pcpcc.org/
sites/default/files/resources/pcmh_evidence_report_2019.pdf.

    U.S. primary care providers are making strides in treating the 
behavioral health needs of their patients, but they are often working 
without necessary resources and supports. And they are working within a 
health-care system that does not yet fully support providing integrated 
care. As many as 80 percent of people with behavioral health needs 
present in emergency departments and primary care settings; between 60 
percent and 70 percent of these individuals leave without treatment for 
their conditions. Primary care providers see 45 percent of people 
within 30 days of a suicide attempt, and data show the primary care 
providers have an opportunity to intervene with routine depression 
screening and treatment to prevent suicides. Expanding the capacity of 
primary care providers to meet the behavioral health needs of their 
patients provides an opportunity to increase access to early 
intervention and treatment as well as to promote social connectedness 
---------------------------------------------------------------------------
and suicide prevention.

    The U.S. can start to close the gap by investing in infrastructure 
and incentives for primary care providers to integrate behavioral 
health services. Without additional support, care will remain 
fragmented and siloed in the U.S. This process of integration should 
also leverage telehealth and other modalities of virtual care to ensure 
more equitable access. The U.S. can also engage a wider array of 
providers in the behavioral health-care team. In particular, 
paraprofessionals can play an important role in extending the capacity 
and effectiveness of the care systems. Paraprofessionals encompass a 
range of workers, from certified peer support specialists to community 
health workers, that play important roles across the care continuum.

    Trained and accredited peer support specialists leverage their 
lived experience of mental health or substance use conditions to 
support others in recovery. There is evidence that peer support 
specialists can be effective in engaging people with treatment, 
reducing the use of emergency rooms and hospitals and reducing 
substance use among people with co-occurring substance use 
disorders.\10\ Peer support, which was developed in response to the 
lack of access to effective care in many communities, is now 
increasingly part of the continuum of care. Approximately 25 percent of 
mental health treatment facilities and 56 percent of facilities 
treating substance use disorders self-reported offering peer support 
services in 2018.\11\ As of 2018, 39 states allowed for Medicaid 
billing of peer support specialists.\12\
---------------------------------------------------------------------------
    \10\ ``Peers Supporting Recovery From Mental Health Conditions,'' 
SAMHSA, 2017, https://www.samhsa.gov/sites/default/files/
programs_campaigns/brss_tacs/peers-supporting-recovery-mental-health-
conditions-2017.pdf.
    \11\ C. Page et al., ``The Effects of State Regulations and 
Medicaid Plans on the Peer Support Specialist Workforce,'' Health 
Services Research vol. 55 issue S1 (August 2020), https://
onlinelibrary.wiley.com/doi/abs/10.1111/1475-6773.13430.
    \12\ Lynn Videka et al., National Analysis of Peer Support 
Providers: Practice Settings, Requirements, Roles, and Reimbursement 
(University of Michigan School of Public Health Behavioral Health 
Workforce Research Center, August 2019), https://
behavioralhealthworkforce.org/wp-content/uploads/2019/10/BHWRC-Peer-
Workforce-Full-Report.pdf.

    Community health workers, on the other hand, work closely with the 
community in more of a public health role. Research has demonstrated 
that for every dollar invested in a community health worker 
intervention, it returned $2.47.\13\ In behavioral health, community 
health workers can educate the community about mental health and 
substance use issues, help people identify needs and get connected to 
care, and even offer some frontline interventions to reduce stress. For 
example, community health workers in Louisiana effectively worked with 
pregnant women to facilitate virtual interventions and provide social 
support to prevent the onset of postpartum depression.\14\
---------------------------------------------------------------------------
    \13\ Shreya Kangovi et al., ``Evidence-Based Community Health 
Worker Program Addresses Unmet Social Needs and Generates Positive 
Return on Investment,'' Health Affairs 39(2): 207-213 (February 2020), 
https://pubmed.ncbi.nlm.nih.gov/32011942/.
    \14\ Christopher Mundorf et al., ``Reducing the Risk of Postpartum 
Depression in a Low-Income Community Through a Community Health Worker 
Intervention,'' Maternal and Child Health Journal vol. 22, 520-528 
(December 29, 2017), https://link.springer.com/article/10.1007/s10995-
017-2419-4.

                                 ______
                                 
              Questions Submitted by Hon. Thomas R. Carper
                       health services in schools
    Question. It is clear that COVID-19 has significantly exacerbated 
mental health stress on children and youth, highlighting the Nation's 
acute shortage of mental health services. In my State of Delaware, over 
9,000 Delawareans ages 12 through 17 suffer from some sort of 
depression. However, according to the State, students who have access 
to mental health resources within schools are 10 times more likely to 
seek care.

    Earlier this year, the Finance Committee heard testimony from the 
U.S. Surgeon General who stressed that one of the most central tenets 
in creating accessible and equitable systems of care is to meet people 
where they are. For most young people, that's right there in schools. 
And just last week, Secretary of Health and Human Services Xavier 
Becerra and Secretary of Education Miguel Cardona announced a joint-
department effort to expand school-based health services.

    It is clear there is growing momentum to recognize the role schools 
already play in ensuring children have the health services and supports 
necessary to build resilience and thrive. We know that investing in 
school and community-based programs have been shown to improve mental 
health and emotional well-being of children at low cost and high 
benefit.

    How can we improve coordination between primary care and mental 
health providers to better support our children, including through 
school-based services?

    Answer. The Federal Government can support State Medicaid programs 
to improve coordination between primary care and mental health 
providers to better support our children, including through school-
based services. State Medicaid programs have an important role both as 
a payer and as a leader among payers to improve access to behavioral 
health care for children. State Medicaid programs can ensure sufficient 
coverage for critical behavioral health services delivered in 
coordination with primary care and schools, including making sure that 
well-visit reimbursement allows providers to devote time to behavioral 
health as part of regular checkups. Medicaid can fund the information 
technology needed for coordination across settings, which can be a 
major barrier for implementing school-based care. Medicaid can also 
streamline billing to make integrated care feasible for small and rural 
schools and pediatric practices, as well as provide guidance on how to 
ensure compliance with State and Federal privacy laws in both health 
care and education as these stakeholders collaborate. As Medicaid 
programs take these actions, they set key conventions that allow other 
health insurance payers to follow suit and expand access to care for 
children.

    Question. Do you see a role for the Federal Government beyond 
providing guidance and technical assistance to State programs?

    Answer. The Federal Government can also support states by offering 
planning and/or demonstration grants that can allow Medicaid programs 
to take these critical actions, including convening commercial payers 
to promote alignment in the ways that behavioral health care is 
reimbursed, documented, and supported. Grants could also allow states 
to participate in more intensive technical assistance opportunities, 
such as State-to-State learning collaboratives that can allow states to 
share best practices. The Federal Government can also support better 
oversight of key Medicaid provisions, such as Early and Periodic 
Screening, Diagnostic and Treatment (EPSDT) as it relates to behavioral 
health. Several states have been sued over their failure to guarantee 
children access to behavioral health care under EPDST. The Federal 
Government can assess children's access to behavioral health care in 
the states, identify gaps and potential litigation risks, and support 
states to develop improvement plans to ensure that all children get 
access to the behavioral health care they are promised by law. The 
Federal Government could even make EPSDT compliance mandatory for 
getting Medicaid waivers and other types of flexibility approved.
          primary care and mental health care integration in 
                      combination with telehealth
    Question. The pandemic has hit children's well-being hard, 
intensifying what was already a growing national emergency. While 
longer-term investments in children's health and well-being are 
necessary, immediate steps must be taken to better leverage existing 
provider capacity and telehealth to more effectively address the 
crisis.

    Last year, I introduced the Telehealth Improvement for Kids' 
Essential Services, or TIKES, Act along with my colleague, Senator John 
Cornyn, to provide guidance and strategies to states on how to 
effectively integrate telehealth into their Medicaid and CHIP programs.

    To that end, specific attention must be paid towards how telehealth 
can be used to increase access to services and lead to better 
behavioral health outcomes.

    In your view, how can telehealth be used to better integrate 
behavioral health care within the primary care setting, particularly 
for the pediatric population?

    Answer. Telehealth be used to better integrate behavioral health 
care within the primary care setting, particularly for the pediatric 
population. Evidence shows that telemedicine is at least as effective 
as face-to-face interventions in tackling depression and anxiety, 
symptoms of obsessive-compulsive disorder, insomnia, and excessive 
alcohol consumption.\15\ Telemedicine has also been shown to alleviate 
maternal depression symptoms.\16\ For children, models like the Child 
Psychiatry Access Program have demonstrated effectiveness in increasing 
access to mental health services in a number of states across the U.S. 
through virtual consultation to primary care providers.\17\
---------------------------------------------------------------------------
    \15\ Tiago C.O. Hashiguchi, OECD Health Working Paper No. 116: 
Bringing Health Care to the Patient: An Overview of the Use of 
Telemedicine in OECD Countries (OECD, January 2020), https://
www.oecd.org/officialdocuments/publicdisplaydocumentpdf/?cote=DELSA/
HEA/WD/HWP(2020)1&docLanguage=En.
    \16\ Uthara Nair et al., ``The effectiveness of telemedicine 
interventions to address maternal depression: A systematic review and 
meta-analysis,'' Journal of Telemedicine and Telecare vol. 24, issue 10 
(October 22, 2018), https://journals.sagepub.com/doi/10.1177/
1357633X18794332.
    \17\ Stein BD, Kofner A, Vogt WB, Yu H., ``A national examination 
of child psychiatric telephone consultation programs' impact on 
children's mental health-care utilization.'' Journal of the American 
Academy of Child and Adolescent Psychiatry. 2019 Oct;58(10):1016.

    Increased use of telehealth during the pandemic increased the 
promise of these approaches. The proportion of substance use treatment 
facilities offering telehealth services jumped from 28 percent in 2019 
to 59 percent in 2020. For mental health facilities, the share grew 
from 38 percent to 69 percent over the same period.\18\ In addition, 
technology-enabled solutions have resulted in unprecedented investment 
in digital health tools that can help solve the provider shortage 
through on-demand therapy, guided mediation, chat-bots and more.
---------------------------------------------------------------------------
    \18\ Herman A. Alvarado, Telemedicine Services in Substance Use and 
Mental Health Treatment Facilities (SAMHSA, December 2021), https://
www.samhsa.gov/data/report/telemedicine-services.

    Congress has the opportunity to increase flexibilities around 
telehealth, invest in infrastructure for its effective deployment, and 
incentivize ongoing innovation to better integrate behavioral health 
care within the primary care setting, particularly for the pediatric 
population. Across all of these strategies, attention must be paid to 
the particular access challenges of rural and Black individuals in the 
U.S., who did not benefit from telehealth use at the same rates as 
other populations. Urban beneficiaries had about 50 percent higher 
telehealth use than rural beneficiaries--1,659 visits per 1,000 urban 
beneficiaries versus 1,112 visits per 1,000 among rural beneficiaries. 
Compared with pre-pandemic levels, this represents a 140- and 20-fold 
increase in telehealth use for urban and rural beneficiaries, 
respectively.\19\ Ensuring that resources go toward small, rural, and 
underresourced providers to reach individuals with culturally and 
linguistically effective telehealth can expand equitable access in the 
U.S.
---------------------------------------------------------------------------
    \19\ Lok W. Samson et al., Medicare Beneficiaries' Use of 
Telehealth in 2020: Trends by Beneficiary Characteristics and Location 
(ASPE Office of Health Policy, December 2021), https://
www.aspe.hhs.gov/sites/default/files/documents/
a1d5d810fe3433e18b192be42dbf2351/medicare-telehealth-report.pdf.

                                 ______
                                 
               Questions Submitted by Hon. Sherrod Brown
                mental health in the foster care system
    Question. In your testimony, you noted that in 2020, nearly 47 
percent of young adults reported having unmet needs for mental health 
care, ``with Black and Indigenous people and youth of color having even 
worse access to care . . . than White young people, teenagers, or 
adolescents.'' We also know that while youth in foster care participate 
in mental health services at higher rates than their peers, many still 
have poor mental health outcomes and that Black and Brown youth are 
overrepresented in the system when compared to their general 
population.\20\
---------------------------------------------------------------------------
    \20\ https://www.childwelfare.gov/pubpdfs/
racial_disproportionality.pdf.

    How do we improve the quality of mental health services for youth 
of color in foster care to ensure they receive the services that will 
---------------------------------------------------------------------------
benefit their needs the most?

    How can racial and ethnic data regarding access to mental health 
services for foster youth be better collected and analyzed?

    What best practices, strategies, and resources exist within our 
current foster care system that can serve as a model for expanding 
access to high-quality mental health-care services for youth at large?

    Answer. To advance behavioral health equity in the foster care 
system, policy and program design should account for disparities in 
race and ethnicity in resource distribution and outcomes, with a focus 
on achieving equity. This can be supplemented with other strategies, 
such as expanding the use of youth and family peer support specialists 
and other paraprofessionals that come from the same communities as the 
youth served. Paraprofessionals can provide critical additional social 
supports to both youth and families in ways that are culturally and 
linguistically effective, even when trained licensed providers are in 
short supply. Another strategy is to continue to build the title IV-E 
Prevention Services Clearinghouse to ensure that it supports culturally 
and linguistically effective programs for youth of color from all 
backgrounds served.

    Continuing to improve alignment between the title IV-E Prevention 
Services program and Medicaid will also be critical for ensuring spread 
and scale of effective practices, so that youth and families of color 
can access effective behavioral health care.

                                 ______
                                 
             Questions Submitted by Hon. Sheldon Whitehouse
    Question. The promise of mental health parity has not been 
realized. Mental health parity laws vary between Medicare, Medicaid, 
and private insurance but more importantly, enforcement is 
inconsistent. With jurisdiction spread over multiple agencies, I 
believe there needs to be a coordinated, concerted effort to enforce 
mental health parity laws.

    How can Congress improve enforcement of mental health parity laws?

    What can the agencies responsible for implementation of mental 
health parity law--the Department of the Treasury and Department of 
Labor--do to improve enforcement without the need for congressional 
action?

    What are your recommendations for Congress to address the following 
mental health issues: children's mental health crises; addiction and 
recovery; and crisis intervention, including support for law 
enforcement responding to mental health incidents?

    Answer. Across all of these domains, critical opportunities exist 
in promoting flexibilities for telehealth, advancing integrating care, 
expanding the workforce to include paraprofessionals, and enhancing 
oversight of existing Medicaid benefits, with equity at the center of 
all of these strategies.

    Recent policy changes that promoted flexible and sustainable 
telehealth enabled effective and accessible virtual behavioral health 
care for millions of Medicaid and Medicare beneficiaries, including 
access to high-quality cognitive behavioral therapy and even support 
for medication assisted treatment (MAT) for substance use. Evidence 
shows that telemedicine is at least as effective as face-to-face 
interventions in tackling depression and anxiety, symptoms of 
obsessive-compulsive disorder, insomnia, and excessive alcohol 
consumption.\21\ Telemedicine has also been shown to alleviate maternal 
depression symptoms.\22\ For children, models like the Child Psychiatry 
Access Program have demonstrated effectiveness in increasing access to 
mental health services in a number of States across the U.S. through 
virtual consultation to primary care providers.\23\ Congress has the 
opportunity to increase flexibilities around telehealth, invest in 
infrastructure for its effective deployment, and incentivize ongoing 
innovation to better integrate behavioral health care within the 
primary care setting, particularly for the pediatric population. Across 
all of these strategies, attention must be paid to the particular 
access challenges of rural and Black individuals in the U.S., who did 
not benefit from telehealth use at the same rates as other populations. 
Ensuring that resources go toward small, rural, and under resourced 
providers to reach individuals with culturally and linguistically 
effective telehealth can expand equitable access in the U.S.
---------------------------------------------------------------------------
    \21\ Tiago C.O. Hashiguchi, OECD Health Working Paper No. 116: 
Bringing Health Care to the Patient: An Overview of the Use of 
Telemedicine in OECD Countries (OECD, January 2020), https://
www.oecd.org/officialdocuments/publicdisplaydocumentpdf/?cote=DELSA/
HEA/WD/HWP(2020)1&docLanguage=En.
    \22\ Uthara Nair et al., ``The effectiveness of telemedicine 
interventions to address maternal depression: A systematic review and 
meta-analysis,'' Journal of Telemedicine and Telecare vol. 24, issue 10 
(October 22, 2018), https://journals.sagepub.com/doi/10.1177/
1357633X18794332.
    \23\ Stein BD, Kofner A, Vogt WB, Yu H., ``A national examination 
of child psychiatric telephone consultation programs' impact on 
children's mental health-care utilization.'' Journal of the American 
Academy of Child and Adolescent Psychiatry. 2019 Oct;58(10):1016.

    Behavioral health integration has been used to reference everything 
from consultation to colocation to a setting of shared health goals 
around treating the whole person without clear boundaries.\24\ It is 
helpful to view models of care delivery as spanning a continuum of ways 
to integrate physical and behavioral health care (both mental health 
and substance use).\25\ It has been projected that effective medical 
and behavioral health service integration that includes a focus on 
primary care could generate nearly $70 billion in U.S. health-care 
costs savings annually.\26\ The committee could consider opportunities 
to provide additional support for these types of models, including 
financing and incentives for infrastructure, practice transformation, 
and sustainability, with a specific focus on building capacity for 
child-serving providers.
---------------------------------------------------------------------------
    \24\ A Standard Framework for Levels of Integrated Healthcare 
(SAMHSA-HRSA Center for Integrated Health Solutions, April 2013), 
https://www.pcpcc.org/sites/default/files/resources/SAMHSA-
HRSA%202013%20Framework%20for%20Levels%20of%20Integrated%20Healthcare.
pdf.
    \25\ Integrating Behavioral Health Care into Primary Care: 
Advancing Primary Care Innovation in Medicaid Managed Care (Center for 
Health Care Strategies, Inc., August 2019), https://www.chcs.org/media/
PCI-Toolkit-BHI-Tool_090319.pdf.
    \26\ ``Potential economic impact of integrated medical-behavioral 
health care,'' Milliman Research Report, January 2018, https://
www.milliman.com/en/insight/potential-economic-impact-of-integrated-
medical-behavioral-healthcare-updated-projections.

    Paraprofessionals provide an additional opportunity to further 
expand the workforce and address the needs of children, those in 
recovery, and those in crisis. Paraprofessionals encompass a range of 
workers, from certified peer support specialists to community health 
workers, for adults, families of children with behavioral health 
conditions, and for children and youth themselves, that play important 
roles across the care continuum. Trained and accredited peer support 
specialists leverage their lived experience of mental health or 
substance use conditions to support others in recovery. There is 
evidence that peer support specialists can be effective in engaging 
people with treatment, reducing the use of emergency rooms and 
hospitals and reducing substance use among people with co-occurring 
substance use disorders.\27\ Community health workers, on the other 
hand, work closely with the community in more of a public health role. 
Research has demonstrated that for every dollar invested in a community 
health worker intervention, it returned $2.47.\28\ In behavioral 
health, community health workers can educate the community about mental 
health and substance use issues, help people identify needs and get 
connected to care, and even offer some frontline interventions to 
reduce stress. For example, community health workers in Louisiana 
effectively worked with pregnant women to facilitate virtual 
interventions and provide social support to prevent the onset of 
postpartum depression.\29\ Furthermore, engaging community health 
workers who are representative of the populations they are seeking to 
reach can be an important way to reduce disparities in communities 
where people might not feel comfortable reaching out for help. 
Integrated behavioral health models that include paraprofessionals 
illustrate the potential for improving access to care and treatment.
---------------------------------------------------------------------------
    \27\ ``Peers Supporting Recovery From Mental Health Conditions,'' 
SAMHSA, 2017, https://www.samhsa.gov/sites/default/files/
programs_campaigns/brss_tacs/peers-supporting-recovery-mental-health-
conditions-2017.pdf.
    \28\ Shreya Kangovi et al., ``Evidence-Based Community Health 
Worker Program Addresses Unmet Social Needs and Generates Positive 
Return on Investment,'' Health Affairs 39(2): 207-213 (February 2020), 
https://pubmed.ncbi.nlm.nih.gov/32011942/.
    \29\ Christopher Mundorf et al., ``Reducing the Risk of Postpartum 
Depression in a Low-Income Community Through a Community Health Worker 
Intervention,'' Maternal and Child Health Journal vol. 22, 520-528 
(December 29, 2017), https://link.springer.com/article/10.1007/s10995-
017-2419-4.

    Despite the evidence on improved outcomes and cost savings, most 
Americans do not currently have access to the providers described here. 
---------------------------------------------------------------------------
To remedy that, policymakers could:

        Ensure that incentives, financing, and support for integrated 
care are inclusive of the paraprofessional workforce.
        Provide specific incentives for systems to recruit, integrate, 
and retain paraprofessionals, and other workforce extenders.
        Implement learning collaboratives and quality improvement 
initiatives around integrating a broader workforce into the continuum 
of care, including issues around effective supervision and delineation 
of roles to maximize impact.
        Consider how to improve coverage of a broader workforce, 
including reimbursement for peer support specialists in Medicare.

    Finally, Congress can also support better oversight of key Medicaid 
provisions, such as Early and Periodic Screening, Diagnostic and 
Treatment (EPSDT) for children as it relates to behavioral health. 
Several states have been sued over their failure to guarantee children 
access to behavioral health care under EPDST. The Federal Government 
can assess children's access to behavioral health care in the States, 
identify gaps and potential litigation risks, and support States to 
develop improvement plans to ensure that all children get access to the 
behavioral health care they are promised by law. The Federal Government 
could even make EPSDT compliance mandatory for getting Medicaid waivers 
and other types of flexibility approved. This could help build out a 
stronger continuum of care that addresses integration, recovery, and 
crisis systems.

                                 ______
                                 
               Questions Submitted by Hon. John Barrasso
        increasing access to mental health providers in medicare
    Question. As a doctor, I know the importance of improving access to 
mental health care for all Americans. This is especially important in 
rural parts of the country, which face some of the largest shortages in 
the country.

    For seniors, finding a mental health provider can be particularly 
challenging. This is because Medicare restricts certain types of mental 
health providers from billing the program.

    Senator Stabenow and I introduced bipartisan legislation to address 
this issue. S. 828, the Mental Health Access Improvement Act would 
allow licensed professional counselors and marriage and family 
therapists to bill Medicare.

    This is especially important in Wyoming, where many of our 
community mental health centers rely on professional counselors and 
marriage and family therapists to provide care.

    I'm sure the committee would like to hear from anyone else who 
wants to discuss the importance of increasing access to these 
professionals.

    Answer. The evidence supports engaging a wider array of providers 
in the behavioral health-care team, a broader set of providers than 
most people have access to today. Medicare covers only a set of 
traditional providers, such as psychiatrists, psychologists, and social 
workers, but not other types of licensed providers, such as marriage 
and family therapists or counselors. Through their flexibility, State 
Medicaid managed care plans often cover a range of providers that also 
increasingly include paraprofessionals. Congress has the opportunity to 
support the development of a more expansive behavioral health workforce 
by including them within the existing financing systems. Licensed 
professional counselors and marriage and family therapists are one 
important provider to include in the Nation's behavioral health-care 
systems. Paraprofessionals provide an additional opportunity to further 
expand the workforce. Paraprofessionals encompass a range of workers, 
from certified peer support specialists to community health workers, 
that play important roles across the care continuum.

    Trained and accredited peer support specialists leverage their 
lived experience of mental health or substance use conditions to 
support others in recovery. There is evidence that peer support 
specialists can be effective in engaging people with treatment, 
reducing the use of emergency rooms and hospitals and reducing 
substance use among people with co-occurring substance use 
disorders.\30\ Approximately 25 percent of mental health treatment 
facilities and 56 percent of facilities treating substance use 
disorders self-reported offering peer support services in 2018.\31\ As 
of 2018, 39 states allowed for Medicaid billing of peer support 
specialists.\32\
---------------------------------------------------------------------------
    \30\ ``Peers Supporting Recovery From Mental Health Conditions,'' 
SAMHSA, 2017, https://www.samhsa.gov/sites/default/files/
programs_campaigns/brss_tacs/peers-supporting-recovery-mental-health-
conditions-2017.pdf.
    \31\ C. Page et al., ``The Effects of State Regulations and 
Medicaid Plans on the Peer Support Specialist Workforce,'' Health 
Services Research vol. 55 issue S1 (August 2020), https://
onlinelibrary.wiley.com/doi/abs/10.1111/1475-6773.13430.
    \32\ Lynn Videka et al., National Analysis of Peer Support 
Providers: Practice Settings, Requirements, Roles, and Reimbursement 
(University of Michigan School of Public Health Behavioral Health 
Workforce Research Center, August 2019), https://
behavioralhealthworkforce.org/wp-content/uploads/2019/10/BHWRC-Peer-
Workforce-Full-Report.pdf.

    Often, peer support specialists assist with the transition from 
hospital to community or participate in intensive programs, providing 
necessary additional support as part of a care team. Increasingly 
though, peer support specialists are being engaged earlier and can be a 
critical partner and extender for integrated care models, including in 
collaborative care, where they help with navigating treatment and other 
services while building key self-management skills.\33\ Clinicians 
appreciate peer support specialists for the additional support they 
lend and for keeping care grounded in the needs of the individual, 
ensuring that the services ultimately advance recovery.\34\
---------------------------------------------------------------------------
    \33\ Matthew Menear et al., ``Strategies for engaging patients and 
families in collaborative care programs for depression and anxiety 
disorders: A systematic review,'' Journal of Affective Disorders vol. 
263 (February 15, 2020), https://www.sciencedirect.com/science/article/
pii/S0165032719323110#bib0038.
    \34\ Marianne Storm et al., ``Peer Support in Coordination of 
Physical Health and Mental Health Services for People With Lived 
Experience of a Serious Mental Illness,'' Frontiers in Psychiatry vol. 
11 (May 8, 2020), https://www.frontiersin.org/articles/10.3389/
fpsyt.2020.00365/full.

    Community health workers, on the other hand, work closely with the 
community in more of a public health role. Research has demonstrated 
that for every dollar invested in a community health worker 
intervention, it returned $2.47.\35\ In behavioral health, community 
health workers can educate the community about mental health and 
substance use issues, help people identify needs and get connected to 
care, and even offer some front-line interventions to reduce stress. 
For example, community health workers in Louisiana effectively worked 
with pregnant women to facilitate virtual interventions and provide 
social support to prevent the onset of postpartum depression.\36\
---------------------------------------------------------------------------
    \35\ Shreya Kangovi et al., ``Evidence-Based Community Health 
Worker Program Addresses Unmet Social Needs and Generates Positive 
Return on Investment,'' Health Affairs 39(2): 207-213 (February 2020), 
https://pubmed.ncbi.nlm.nih.gov/32011942/.
    \36\ Christopher Mundorf et al., ``Reducing the Risk of Postpartum 
Depression in a Low-Income Community Through a Community Health Worker 
Intervention,'' Maternal and Child Health Journal vol. 22, 520-528 
(December 29, 2017), https://link.springer.com/article/10.1007/s10995-
017-2419-4.

    Furthermore, engaging community health workers who are 
representative of the populations they are seeking to reach can be an 
important way to reduce disparities in communities where people might 
not feel comfortable reaching out for help. Integrated behavioral 
health models that include paraprofessionals illustrate the potential 
---------------------------------------------------------------------------
for improving access to care and treatment.

    Despite the evidence on improved outcomes and cost savings, most 
Americans do not currently have access to the providers described here. 
To remedy that, policymakers could:

        Ensure that incentives, financing, and support for integrated 
care are inclusive of the paraprofessional workforce.
        Provide specific incentives for systems to recruit, integrate, 
and retain paraprofessionals, and other workforce extenders.
        Implement learning collaboratives and quality improvement 
initiatives around integrating a broader workforce into the continuum 
of care, including issues around effective supervision and delineation 
of roles to maximize impact.
        Consider how to improve coverage of a broader workforce, 
including reimbursement for peer support specialists in Medicare.
                               telehealth
    Question. Patients in Wyoming are using telehealth to help meet 
their health-care needs during the pandemic. Members of this committee 
support making sure telehealth becomes a permanent part of health-care 
delivery for those patients who want to utilize this service.

    Congress, with bipartisan support, has already taken steps to 
extend telehealth flexibilities for five months following the 
expiration of the public health emergency.

    Can you discuss the importance of telehealth in terms of the 
delivery of mental health services?

    Answer. Now is the time to be optimistic about the potential of 
technology to address behavioral health needs. The literature shows 
that telemedicine is effective for improving access to behavioral 
health care, especially through cognitive behavioral therapy. Evidence 
shows that telemedicine is at least as effective as face-to-face 
interventions in tackling depression and anxiety, symptoms of 
obsessive-compulsive disorder, insomnia, and excessive alcohol 
consumption.\37\ Telemedicine has also been shown to alleviate maternal 
depression symptoms.\38\
---------------------------------------------------------------------------
    \37\ Tiago C.O. Hashiguchi, OECD Health Working Paper No. 116: 
Bringing Health Care to the Patient: An Overview of the Use of 
Telemedicine in OECD Countries (OECD, January 2020), https://
www.oecd.org/officialdocuments/publicdisplaydocumentpdf/?cote=DELSA/
HEA/WD/HWP(2020)1&docLanguage=En.
    \38\ Uthara Nair et al., ``The effectiveness of telemedicine 
interventions to address maternal depression: A systematic review and 
meta-analysis,'' Journal of Telemedicine and Telecare vol. 24, issue 10 
(October 22, 2018), https://journals.sagepub.com/doi/10.1177/
1357633X18794332.

    The COVID-19 pandemic, and the expanded flexibilities that were 
authorized around the provision of telehealth services, brought about 
sharp increases in the number of facilities providing telehealth 
treatment for both mental health and substance use services. The 
proportion of substance use treatment facilities offering telehealth 
services jumped from 28 percent in 2019 to 59 percent in 2020. For 
mental health facilities, the share grew from 38 percent to 69 percent 
over the same period.\39\ In addition, technology-enabled solutions 
have resulted in unprecedented investment in digital health tools that 
can help solve the provider shortage through on-demand therapy, guided 
mediation, chatbots and more.
---------------------------------------------------------------------------
    \39\ Herman A. Alvarado, Telemedicine Services in Substance Use and 
Mental Health Treatment Facilities (SAMHSA, December 2021), https://
www.samhsa.gov/data/report/telemedicine-services.

    Yet despite the increase in available services, Black and rural 
Medicare beneficiaries had lower telehealth use compared with White and 
urban beneficiaries, respectively. Telehealth use varied by State, with 
higher use in the Northeast and the West and lower use in the Midwest 
and the South. Urban beneficiaries had about 50-percent higher 
telehealth use than rural beneficiaries--1,659 visits per 1,000 urban 
beneficiaries versus 1,112 visits per 1,000 among rural beneficiaries. 
Compared with pre-pandemic levels, this represents a 140- and 20-fold 
increase in telehealth use for urban and rural beneficiaries, 
respectively.\40\ As Congress and the Biden administration weigh 
options for extending the telehealth flexibilities beyond the public 
health emergency,\41\ it will be essential to understand the barriers 
faced by Black and rural beneficiaries in accessing telehealth and 
tele-mental health services, so that policies serve to ameliorate 
disparities rather than exacerbate them.
---------------------------------------------------------------------------
    \40\ Lok W. Samson et al., Medicare Beneficiaries' Use of 
Telehealth in 2020: Trends by Beneficiary Characteristics and Location 
(ASPE Office of Health Policy, December 2021), https://
www.aspe.hhs.gov/sites/default/files/documents/
a1d5d810fe3433e18b192be42dbf2351/medicare-telehealth-report.pdf.
    \41\ Josh LaRosa, ``Avoiding the Cliff: Medicare Coverage of 
Telemental Health and the End of the PHE,'' To the Point (blog), 
Commonwealth Fund, March 23, 2022, https://www.common
wealthfund.org/blog/2022/avoiding-cliff-medicare-coverage-telemental-
health-and-end-phe.

    It is also noteworthy that the temporary continuous coverage 
requirement that kept Medicaid coverage intact during the health 
emergency helped to ensure access to medical and behavioral health 
services.\42\ Multiple studies have found that living in a Medicaid 
expansion State was associated with relative reductions in poor mental 
health by improving access, including access to services delivered 
through telehealth.\43\ It is critical that expansion of telehealth and 
other digital innovations in medicine be undertaken with universal and 
equitable access to care in mind.
---------------------------------------------------------------------------
    \42\ Cindy Mann, ``Stable and Continuous Coverage Provisions in 
Medicaid Gain Momentum Through Build Back Better Act,'' To the Point 
(blog), Commonwealth Fund, February 9, 2022, https://
www.commonwealthfund.org/blog/2022/stable-and-continuous-coverage-
provisions-medicaid-gain-momentum-through-build-back.
    \43\ John Cawley et al., ``Third year of survey data shows 
continuing benefits of Medicaid expansions for low-income childless 
adults in the U.S.,'' Journal of General Internal Medicine vol. 33, 
1495-1497 (June 5, 2018), https://pubmed.ncbi.nlm.nih.gov/29943107/.

    CMS has already begun to pilot some innovative models, such as 
Community Health Access and Rural Transformation (CHART), that 
specifically provide technical assistance to rural providers to help 
them fully benefit from technological innovations with both financial 
and regulatory flexibilities. The committee could consider 
opportunities to provide additional support for these types of models, 
including financing and incentives for infrastructure, practice 
transformation, and sustainability, with a specific focus on building 
capacity for rural providers to offer virtually integrated behavioral 
health care. This could include helping to identify spaces available to 
primary care providers that can be set aside for telehealth visits when 
patients do not have access at home or the knowledge to use the 
---------------------------------------------------------------------------
technology.

                                 ______
                                 
                 Prepared Statement of Hon. Ron Wyden, 
                       a U.S. Senator From Oregon
    The Finance Committee meets for our third hearing on mental health 
care this year, and we'll begin with mental health parity. For 13 
years, the parity law has required equal treatment by insurance 
companies of mental health care and physical health care. That law was 
the result of the efforts of the late Senators Wellstone and Domenici, 
who came from families touched by mental health challenges.

    The parity law was supposed to be a game-changer, but mental health 
patients have still spent the last 13 years all too often bogged down 
in insurance company foot-dragging, red tape, and piles of excuses. 
This committee is coming together to finally fix this on a bipartisan 
basis. It's not on today's docket, but I'll just say that more finally 
needs to be done to hold the executives of these companies accountable.

    Here are four examples of what's going wrong. First, too many 
Americans are getting shoved by insurers into ``ghost networks.'' When 
you're stuck in a ghost network, you can't get a provider to take your 
insurance. The insurance company's directory of providers is often 
wrong, even years out of date. Or insurance companies often pay so 
little for mental health services that patients get stuck with the 
entire bill. When families pay good money for insurance and wind up 
with a ghost network, you don't feel like you're getting parity, you 
feel like you're getting ripped off.

    Next example: mental health patients are getting whacked by 
coverage limits that cut off their stays in a hospital. Health 
treatments ought to be driven by a professional diagnosis, not an 
arbitrary cap set to protect insurance company profits.

    Third, insurance companies are relying on loopholes to deny 
coverage, requiring prior authorizations before they'll pay for care, 
and setting unreasonably high standards for the ``medical necessity'' 
of mental health care. Particularly for somebody experiencing a mental 
health crisis, these bureaucratic roadblocks to insurance coverage can 
be fatal. If you break your arm, you don't have to make a dozen phone 
calls and gather a mountain of paperwork to prove to your insurance 
company that you really do need to see a doctor. A mental health crisis 
shouldn't be any different.

    Fourth, stonewalling on paying claims. I was struck during the 
pandemic that even leading health institutions like Oregon Health and 
Science University couldn't get mental health services claims paid by 
insurance companies. At first, they claimed it was because they 
couldn't hire enough staff. But after I wrote a letter calling for the 
GAO inquiry into this stonewalling, the floodgates reopened, and the 
claims got paid. It shouldn't take a United States Senator weighing in 
to get paid for needed mental health care.

    These four barriers make a mockery of the parity that Senators 
Wellstone and Domenici envisioned. Tools like ParityTrack, which is run 
by an organization headed by former Surgeon General Dr. David Satcher 
and former Congressman Patrick Kennedy, are out there to hold States 
and Federal regulators accountable for enforcing parity law. It's going 
to take a lot of hard work to address these issues, but members on both 
sides of this committee are working to bring their best ideas forward.

    The second challenge that's up for discussion is bringing mental 
health care and physical health care closer together. Mental health 
should not be fenced off from the rest of the health-care system. This 
lack of integration can be fatal.

    People typically start with their primary care doctor, but less 
than half of patients who receive a referral to a mental health 
provider are able to get the care they need. This approach is often 
slow to help somebody through a crisis. As many as one in three people 
who have died by suicide saw their primary care doctor within a month 
of their death. Let's be clear: this is not a blame game that falls on 
primary care doctors, who often have to see dozens of patients every 
day. The truth is that patients need more options.

    What's needed is a fresh strategy so that it's possible to get 
primary care and mental health care at almost the same time. Let's end 
the interminable delays that slow down badly needed help.

    Taking care integration beyond the doctor's office is another 
priority. In my home State, the CAHOOTS program takes mental health 
care to people where they are, and mental health providers and law 
enforcement are both for it. It's also essential to ensure there's 
follow-up care once the initial crisis has been stabilized.

    There's a lot of work ahead, but this committee is focused on 
guaranteeing that Americans can get the mental health care they need 
when they need it.

                                 ______
                                 

                             Communications

                              ----------                              


                                  AHIP

                      601 Pennsylvania Avenue, NW

                       South Building, Suite 500

                          Washington, DC 20004

AHIP is the national association whose members provide health care 
coverage, services, and solutions to hundreds of millions of Americans 
every day. We are committed to market-based solutions and public-
private partnerships that make health care better and coverage more 
affordable and accessible for everyone.

We are pleased to see the Committee's focus on the ongoing mental 
health crisis in the United States. Our members strongly support your 
effort to increase access to quality, affordable behavioral health 
care. Health insurance providers are committed to providing coverage 
for behavioral health and substance use disorder services on par with 
medical and surgical care, improving behavioral health care quality and 
outcomes, and eliminating the stigma often associated with accessing 
behavioral health care.

Behavioral Health Integration

AHIP appreciates the Committee's focus on behavioral health care 
integration with primary care. Because the front door to health care 
for most individuals is their primary care provider (PCP), making that 
primary care practice a one stop shop for people's physical and 
behavioral health needs can significantly increase the identification 
of behavioral health needs, reduce the time to receive treatment, and 
improve the accessibility of behavioral health services for all 
consumers.

That's why health insurance providers are exploring different ways to 
integrate behavioral health care with primary care leveraging 
collaborations with PCPs, including pediatricians, as an effective way 
to enhance access to behavioral health and improve overall health 
outcomes. Integrated behavioral health care blends care for physical 
conditions and behavioral health, such as mental health conditions and 
substance use disorders, life stressors and crises, or stress-related 
physical symptoms that affect a patient's health and well-being.\1\ 
Integration of behavioral health care with primary care has been 
identified by many stakeholders as a strategy not only to improve 
access and quality, but also to reduce disparities and promote 
equity.\2\, \3\ In addition, because PCPs are widely 
available, integrated care can substantially expand access, increasing 
the number and type of venues available to meet each person's needs.
---------------------------------------------------------------------------
    \1\ https://www.integrationacademy.ahrq.gov/about/integrated-
behavioral-health.
    \2\ https://www.chcs.org/media/PCI-Toolkit-BHI-Tool_090319.pdf.
    \3\ https://www.ama-assn.org/delivering-care/public-health/
behavioral-health-integration-physician-practices.

Integration of physical and behavioral health can provide multiple 
benefits to patients, including earlier diagnosis and treatment, better 
care coordination, timely information sharing, improved outcomes, and 
improved patient and provider satisfaction. Many people with behavioral 
health conditions also have other chronic medical conditions. 
Integrating behavioral health with primary care can allow for earlier 
diagnosis and better coordination of care for patients with multiple 
complex physical and behavioral health conditions. Also, while PCPs 
often prescribe many, if not most, medications used to treat behavioral 
health conditions, they often prefer consultation with psychiatrists/
clinical psychologists when prescribing for certain more serious mental 
health conditions and atypical psychotic drugs. Finally, PCPs are 
accustomed to doing measurement-based care and reporting quality 
metrics for other conditions. This experience can be particularly 
helpful as we drive toward greater use of measurement-based care and 
---------------------------------------------------------------------------
improved quality measurement in the area of behavioral health care.

The Center for Integrated Health Solutions, funded by the Substance 
Abuse and Mental Health Services Administration (SAMHSA) and the Health 
Resources and Services Administration (HRSA), has developed a framework 
\4\ for levels of integrated healthcare, on which the Center for Health 
Care Strategies has based its continuum \5\ of behavioral health 
integration models. This integration continuum includes models that 
emphasize coordinated care through screening and consultation, models 
that supplement that care coordination with care management and co- 
location, and models that are more fully integrated at the health home 
or system-level. Along this continuum, there are several best practices 
for integrating behavioral health with primary care.
---------------------------------------------------------------------------
    \4\ https://www.pcpcc.org/sites/default/files/resources/SAMHSA-
HRSA%202013%20Frame
work%20for%20Levels%20of%20Integrated%20Healthcare.pdf.
    \5\ https://www.chcs.org/media/PCI-Toolkit-BHI-Tool_090319.pdf.

The Collaborative Care Model \6\ (CoCM) is one such model designed to 
promote integration that many health insurance providers have 
implemented with their primary care partners. This model of integration 
includes care management support for patients receiving behavioral 
health treatment and psychiatric consultation. While some providers and 
health systems have implemented the CoCM, uptake among providers has 
been slow, with start-up costs, complexity, and the need for technical 
assistance often cited as barriers to more widespread adoption. Many 
health insurance providers reimburse the codes available to support 
CoCM and some also provide technical assistance to help providers 
implement this model. In addition, some health insurance providers are 
also partnering with technology companies that provide solutions to 
their provider partners to help them implement CoCM. Medicare covers 
services provided to beneficiaries receiving CoCM and other behavioral 
health integration (BHI) services.\7\
---------------------------------------------------------------------------
    \6\ https://www.chcs.org/media/
HH_IRC_Collaborative_Care_Model__052113_2.pdf.
    \7\ https://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLN
Products/Downloads/BehavioralHealthIntegration.pdf.

In addition to the CoCM, many health insurance providers have promoted 
integration and team-based care through other effective approaches, 
including enhanced referral, expanded case management specific to 
behavioral health conditions, and value-based payment arrangements. 
Many states have partnered with their Medicaid plans to implement 
behavioral health homes for enrollees with serious mental illness and 
chronic physical health conditions and/or functional impairments, often 
in combination with managed long-term services and supports (MLTSS), 
These programs integrate and coordinate care across a range of 
providers to respond to the range of an individual enrollee's care 
needs. These approaches rely on behavioral health and medical care 
managers coordinating and communicating across providers to support 
patients with co-morbid conditions and value-based payment incentives 
to encourage providers to integrate care for patients with both 
---------------------------------------------------------------------------
physical and behavioral health needs.

The range of approaches currently underway underscores the importance 
of flexibility and recognition that physician practices are at varying 
stages of readiness in their ability to deliver fully integrated 
physical and behavioral health care. It is important to note that all 
of these approaches rely on team-based care that includes PCPs using 
validated behavioral health screening and assessment tools to identify 
patients in need of services, referral/consultation arrangements and 
partnerships with behavioral health specialists, care management by 
health care professionals trained to coordinate care across behavioral 
and medical conditions, education and training resources to support 
providers, and, as discussed in more detail below, quality measurement 
to assess effectiveness.

Acknowledging the importance of patient-centered outcomes, AHIP 
recommends:

      Creating flexibilities in payment policies that allow Medicare, 
Medicaid, and the commercial plans the ability to innovate and test new 
care models;
      Additional research to further build the evidence base for 
effective models of integrated behavioral health care; and
      Increasing funding and/or incentives to support provider 
readiness for behavioral health integration with primary care, 
including start-up costs, care coordinators, educational resources for 
providers, and use of health information technology and electronic 
health records.

Commitment to Behavioral Health Parity

Health insurance providers are wholly supportive of parity between 
physical and behavioral health and are working diligently to achieve 
the goals of the Mental Health Parity and Addiction Equity Act 
(MHPAEA). For years, our members have supported and worked hard to 
comply with MHPAEA, as well as with other federal and state laws which 
ensure access to behavioral health care for millions of Americans.

Since MHPAEA's passage, our collective work has improved access to 
behavioral health and substance use disorder care for the families 
enrolled in the health care coverage we provide or sponsor. We have 
also worked diligently to address larger systemic issues that limit 
access to care, such as workforce shortages and the lack of integration 
and coordination between physical and behavioral health delivery.

Our members have expanded flexibility for, and use of, telehealth 
during the COVID-19 public health emergency, which has substantially 
improved access to treatment and laid a path for a positive way forward 
as the public health emergency winds down. Health plans leveraged the 
flexibility provided through the CARES Act to provide access to 
behavioral health care via telehealth pre-deductible. Ninety-five 
percent of plans surveyed provided this access.\8\ We recognize that 
additional systemic improvements are needed to build on the progress 
made, and we are committed to working with you and your staff as you 
examine bipartisan solutions to address behavioral health care for all 
Americans.
---------------------------------------------------------------------------
    \8\ https://www.ahip.org/documents/202203-CaW_TelehealthSurvey-
v04.pdf.

As the Committee continues its work crafting mental health legislation, 
we ask that you address the need for time and appropriate regulatory 
guidance so that health insurance providers' have a real opportunity to 
demonstrate MHPAEA compliance, particularly to federal agencies. 
Section 203 of the transparency provisions in the Consolidated 
Appropriations Act of 2021 (CAA) granted the Department of Labor (DOL), 
CMS, and states authority to request comprehensive comparative analyses 
of plans' application of non-quantitative treatment limitations (NQTLs) 
to behavioral health and medical/surgical benefits. In January, the 
Departments of Health and Human Services, Labor, and Treasury released 
their 2022 MHPAEA Report to Congress, which included updates on their 
work to implement Section 203 for federally regulated plans. CMS and 
DOL issued a combined 171 requests for comparative analyses from plans 
in their respective jurisdictions. None of the initial submissions met 
the Departments' standards of sufficiency for review. This finding of 
insufficiency does not mean that the plans were not in compliance with 
MHPAEA, but rather that the information submitted did not include all 
of the information required by the Departments to proceed with the 
---------------------------------------------------------------------------
review for compliance.

AHIP appreciates efforts by DOL and CMS to issue guidance for their 
expectations for these submissions; however more information is needed. 
While guidance like DOL's Self-Compliance tool and FAQs Part 45 offer 
some examples of compliant and noncompliant NQTLs, that none of the 
submitted analyses met the Departments' threshold for sufficiency 
indicates that more detailed instructions and examples are necessary. 
Congress should require DOL and CMS to develop and provide model or 
sample analyses that demonstrate compliance across the different types 
of NQTLs. These completed analyses should include checklists and 
samples of documentation and data that would support the analyses and 
the determination of compliance. DOL and CMS should provide plans with 
the information necessary and a reasonable opportunity to demonstrate 
compliance. If provided clear guidance, health insurance providers can 
demonstrate compliance with the provisions of MHPAEA and the CAA and 
consumers can be certain that the health insurance plan they rely on is 
delivering care in a manner consistent with the applicable law. Working 
together, we can improve both behavioral and physical health for every 
American.

Other Policy Recommendations

Strengthening the Mental Health Workforce
Challenges in accessing behavioral healthcare are longstanding and 
multifaceted. Key among them is the availability and supply of 
behavioral health providers. Action is urgently needed to expand the 
number of behavioral health providers of all types--from psychiatrists 
and psychologist to social workers and mental health counselors.

AHIP supports legislative policies that provide incentives for 
individuals to enter the behavioral health field. These could include:

      Increasing funding for loan repayment programs for providers who 
enter the behavioral health field;
      Expanding the eligible provider types for National Health 
Service Corp (NHSC) scholarships to include behavioral health care 
professions with an additional emphasis on promoting workforce 
diversity;
      Increasing the number of graduate medical education (GME) slots 
allotted to behavioral health providers;
      Expanding the behavioral health provider types covered under 
Medicare, such as certified peer support specialists, licensed 
professional counselors, and licensed mental health counselors; and,
      Providing funding to CMS to collect provider demographic 
information in NPPES and requiring CMS to share that information with 
all health plans.

In addition to expanding the number of providers AHIP members believe 
that every provider should receive training and be able to deliver 
culturally competent care. We support training of providers and staff 
on cultural competency, cultural humility, unconscious bias, and anti-
racism in order promote empathy, respect, and understanding among 
provider networks and between providers and their patients.

Moreover, AHIP members believe in promoting diverse provider networks 
that reflect the communities they serve so that beneficiaries can find 
providers that meet their needs and preferences. This includes provider 
and practitioner demographic diversity as well as diversity of staff 
and care team members.
Telehealth Is a Critical Tool to Behavioral Health
Consumers, health care providers, and health insurance providers all 
appreciate the value of telehealth. Patients can access telehealth from 
wherever they are, making it a vital tool to bridge health care gaps 
nationwide. Patients accept--and often prefer--digital technologies as 
an essential part of health care delivery including the delivery of 
mental health and substance use disorder (SUD) services. Those 
accessing behavioral health services via telehealth can do so from the 
privacy of their own homes and free from the stigma associated with 
seeking care in brick-and-mortar settings for mental health conditions. 
For patients in rural communities and other underserved areas with 
fewer practicing providers, telehealth can make behavioral health care 
more convenient, accessible, efficient, and sustainable. Patients who 
access care remotely can also avoid challenges associated with taking 
time off from work, arranging transportation, or finding childcare. For 
providers, telehealth also substantially reduces the number of no-shows 
assuring that the time made available for patient care is actually 
spent delivering services to the patients who need it.

Health insurance providers are committed to ensuring that the people 
they serve, regardless of where they live or their economic situation, 
can access high-quality, safe, and convenient care. That's why they 
embrace telehealth solutions that help increase access to care. The 
telehealth flexibilities put in place during the ongoing COVID-19 
public health emergency, such as waiving originating site requirements 
for telehealth services under Medicare and allowing reimbursement of 
more video-enabled telehealth and audio-only telehealth services have 
proven critically important to the delivery of care throughout the 
pandemic.

Taken together, actions taken by Congress and the Administration, many 
of which were adopted across Federal programs and in commercial plans, 
allowed for increased access to telehealth for both patients and 
providers, leading to exponential growth in use especially for those in 
need of behavioral health services. Data shows that over 60% of 
telehealth use is for behavioral health care.\9\
---------------------------------------------------------------------------
    \9\ https://s3.amazonaws.com/media2.fairhealth.org/infographic/
telehealth/nov-2021-national-telehealth.pdf.

However, legislation is required to permanently authorize key evidence-
based reforms under Medicare. We encourage Congress to act to protect 
health insurance providers' flexibilities in creating telehealth 
programs and other virtual care solutions that will best serve the 
needs of their members and can provide convenient access to high-
quality behavioral health services in an equitable manner across all 
---------------------------------------------------------------------------
populations and communities.

We encourage Congress to consider measures to permanently eliminate 
geographic restrictions for all telehealth services and to eliminate 
originating sites entirely, so that patients can access care where and 
when they need it. Additionally, the CARES Act permitted pre-deductible 
coverage of telehealth in high-deductible health plans in 2020 and 2021 
allowing millions of people increased access to care. While the 
Consolidated Appropriations Act 2022 signed into law on March 15th 
extended this flexibility from April through the end of the year, we 
support the bipartisan S. 1704, the Telehealth Expansion Act of 2021 
which would provide a permanent extension of that authority.

We also ask that Congress pass the bipartisan Ensuring Parity in MA for 
Audio Only-Telehealth Act (S. 150/ H.R. 2166). This legislation would 
help ensure seniors and individuals with disabilities continue to have 
access to clinically appropriate audio-only telehealth which, while 
less preferred than video enabled care, has proven to be an effective 
source of care for many Medicare beneficiaries throughout the course of 
the COVID-19 public health emergency, particularly individuals who are 
unable to use or access video enabled devices. This legislation would 
ensure that individuals who use audio-only telehealth services are 
treated by Medicare in exactly the same way as individuals who receive 
care and treatment in person or via video-enabled telehealth, ensuring 
that the high value care and important supplemental benefits provided 
by Medicare Advantage (MA) remain available to all beneficiaries 
regardless of how they choose to access care.

Conclusion

Behavioral health is an essential part of a person's overall health and 
well-being. Health insurance providers are working everyday with 
consumers, providers, and communities to ensure access to behavioral 
health care and support. As a result, we are making progress, and more 
people are getting the treatment they need. But we must recognize the 
multi-faceted nature of the challenges facing our nation's behavioral 
health and acknowledge the need for all stakeholders to do much more. 
We need more behavioral health experts, more robust accreditation 
standards to ensure patients are getting good care, and continued 
integration of behavioral health into patients' overall health care. 
AHIP appreciates the Committee's increased focus on this important 
issue. We look forward to working with you to develop solutions to 
enhance mental health care access and affordability.

                                 ______
                                 
                     American Ambulance Association

                         P.O. Box 96503 #72319

                       Washington, DC 20090-6503

                              202-802-9020

                           [email protected]

                         https://ambulance.org/

                  Statement of Shawn Baird, President

Chairman Wyden, Ranking Member Crapo, and members of the Committee, I 
am the president of the American Ambulance Association and on behalf of 
the members of the American Ambulance Association (AAA), I greatly 
appreciate the opportunity to provide you with a written statement on 
America's Mental Health Crisis. We commend the Committee for holding 
this hearing and earlier hearings addressing our current mental health 
crisis. Ensuring that healthcare plans provide adequate coverage and 
that the proper care is provided is a critical piece in assuring that 
our healthcare delivery system meets the need of individuals with 
mental health issues on a par with those having other types of 
healthcare needs. I want to focus my comments today on the mental 
health needs of our first responder community. Our emergency medical 
services and transitional care providers need Congress to recognize the 
significant stress and trauma paramedics and emergency medical 
technicians (EMTs) have experienced as a result of this pandemic. The 
AAA urges Members of Congress not to forget these heroes and to 
expressly include all ground ambulance personnel in efforts to address 
America's Mental Health Crisis.

Emergency medical services (EMS) professionals are ready at a moment's 
notice to provide life-saving and life-sustaining treatment and medical 
transportation for conditions ranging from heart attack, stroke, and 
trauma to childbirth and overdose. These first responders proudly serve 
their communities with on-demand mobile healthcare around the clock. 
Ground ambulance professionals have been at the forefront of our 
country's response to the mental health crisis in their local 
communities. Often, emergency calls related to mental health services 
are triaged to the local ground ambulance service to address.

While paramedics and EMTs provide important emergency health care 
services to those individuals suffering from a mental or behavioral 
health crisis, these front-line workers have been struggling to access 
the federal assistance they need to address the mental health strain 
providing 24-hour care, especially during a COVID-19 pandemic, has 
placed on them. We need to ensure that there is equal access to mental 
health funding for all EMS services, regardless of their form of 
corporate ownership so that all first responders can receive the help 
and support they need.

EMS's Enhanced Role in the Pandemic

As if traditional ambulance service responsibilities were not enough, 
Paramedics and Emergency Medical Technicians (EMTs) have taken on an 
even greater role on the very front lines of the COVID-19 pandemic. In 
many areas, EMS professionals lead Coronavirus vaccination, testing, 
and patient navigation. As part of the federal disaster response 
subcontract, EMS providers even deploy to pandemic hotspots and natural 
disasters to bolster local healthcare resources in the face of 
extraordinarily challenging circumstances.

EMS Response to Mental Health Patients

Paramedics and EMTs around the country respond every day to patients 
who have mental and behavioral health issues.

Historically, under the Medicare program, ambulance service providers 
and suppliers were required to transport mental and behavioral health 
patients to a hospital even though a psychiatric center might be the 
most appropriate destination at which they will be provided the best 
and most appropriate care. During the pandemic, the Centers for 
Medicare and Medicaid Services issued a waiver to allow for 
reimbursement under the Medicare ambulance fee schedule to alternative 
destinations such as psychiatric facilities. The Centers for Medicare 
and Medicaid Innovation is also currently piloting a program, the 
Emergency Triage, Treat, and Transport (ET3) Model, to evaluate the 
benefits of transporting patients to alternative destinations.

 Mental and Behavioral Health Challenges Drive Staffing Shortages on 
                    the Front Line

Myriad studies show that first responders face much higher-than-average 
rates of post-traumatic stress disorder,\1\ burnout,\2\ and suicidal 
ideation.\3\ These selfless professionals work in the field every day 
at great risk to their personal health and safety--and under extreme 
stress.
---------------------------------------------------------------------------
    \1\ Prevalence of PTSD and common mental disorders amongst 
ambulance personnel: A systematic review and meta-analysis. Soc 
Psychiatry Psychiatr Epidemiol. 2018;53(9):897-909.
    \2\ ALmutairi MN, El Mahalli AA. Burnout and Coping Methods among 
Emergency Medical Services Professionals. J Multidiscip Healthc. 
2020;13:271-279. Published 2020 March 16. doi:10.2147/JMDH.S244303.
    \3\ Stanley, I.H., Hom, M.A., and Joiner, T.E. (2016). A systematic 
review of suicidal thoughts and behaviors among police officers, 
firefighters, EMTs, and paramedics. Clinical Psychology Review, 44, 25-
44. https://doi.org/10.1016/j.cpr.2015.12.002.

Ambulance services and fire departments do not keep bankers' hours. By 
their very nature, EMS operations do not close during pandemic 
lockdowns or during extreme weather emergencies. ``Working from home'' 
is not an option for Paramedics and EMTs who serve at the intersection 
of public health and public safety. Many communities face a greater 
than 25% annual turnover \4\ of EMS staff because of these factors. In 
fact, across the nation EMS agencies face a 20% staffing shortage 
compounded by near 20% of employees on sick leave from COVID-19. This 
crisis-level staffing is unsustainable and threatens the public safety 
net of our cities and towns.
---------------------------------------------------------------------------
    \4\ Doverspike D, Moore S. 2021 Ambulance Industry Employee 
Turnover Study. 3rd ed. Washington, DC: American Ambulance Association; 
2021.

Sadly, to date, too few resources have been allocated to support the 
mental and behavioral health of our frontline healthcare workers.

Equity for All Provider Types

Due to the inherently local nature of EMS, each American community 
chooses the ambulance service provider model that represents the best 
fit for its specific population, geography, and budget. From for-profit 
entities to municipally funded fire departments to volunteer rescue 
squads, EMS professionals share the same duties and responsibilities 
regardless of their organizational tax structure. They face the same 
mental health challenges and should have equal access to available 
behavioral health programs and services.

Many current federal first responder grant programs and resources 
exclude the tens of thousands of Paramedics and EMTs employed by for-
profit entities from access. These individuals respond to the same 911 
calls and provide the same interfacility mobile healthcare as their 
governmental brethren without receiving the same behavioral health 
support from Federal agencies. To remedy this and ensure equitable 
mental healthcare access for all first responders, we recommend that:

      During the current public health emergency and for at least two 
years thereafter, eligibility for first responder training and staffing 
grant programs administered by the U.S. Department of Health and Human 
Services (such as SAMHSA Rural EMS Training Grants and HHS Occupational 
Safety and Health Training Project Grants) should be expanded to 
include for-profit entities. Spending on training and services for 
mental health should also be included as eligible program expenses.

      Congress should authorize the establishment of a new HHS grant 
program (or increase funding and modify existing EMS programs such as 
the current ASPR healthcare readiness program) to open both public and 
private nonprofit and for-profit ambulance service providers to fund 
EMT and Paramedic recruitment and training, including employee 
education and peer-support programming to reduce and prevent suicide, 
burnout, mental health conditions and substance use disorders.

The rationale for the above requests is twofold. First, ensuring the 
mental health and wellness of all EMS professionals--regardless of 
their employer's tax status--is the right thing to do. Second, because 
private ambulance service providers offer critical assistance and vital 
support to overburdened local government agencies, assuring that EMTs 
and Paramedics on the front lines have access to the full range of 
mental health services will assure that we are able to provide the 
high-quality critical services the public expects.

Please do not hesitate to contact American Ambulance Association Senior 
Vice President of Government Affairs, Tristan North, at 
[email protected] or 202-486-4888 should you have any questions.

                                 ______
                                 
             American Association on Health and Disability

                 110 N. Washington Street, Suite 328-J

                          Rockville, MD 20850

                            T. 301-545-6140

                            F. 301-545-6144

                            https://aahd.us/

RE: Persons with Co-Occurring Mental Illness and Substance Abuse 
Disorder; Persons with Co-Occurring Mental Illness and Chronic Medical 
Conditions; Persons with Co-Occurring Mental Health and Intellectual 
and Other Developmental Disabilities; Persons with Co-Occurring 
Behavioral Health Conditions and Disabilities

E. Clarke Ross, D.P.A.
Public Policy Director
Washington Representative
Lakeshore Foundation
[email protected]

The American Association on Health and Disability (AAHD) (www.aahd.us) 
is a national non-profit organization of public health professionals, 
both practitioners and academics, with a primary concern for persons 
with disabilities. The AAHD mission is to advance health promotion and 
wellness initiatives for persons with disabilities. AAHD is 
specifically dedicated to integrating public health and disability into 
the overall public health agenda.

The Lakeshore Foundation (www.lakeshore.org) mission is to enable 
people with physical disability and chronic health conditions to lead 
healthy, active, and independent lifestyles through physical activity, 
sport, recreation and research. Lakeshore is a U.S. Olympic and 
Paralympic Training Site; the UAB/Lakeshore Research Collaborative is a 
world-class research program in physical activity, health promotion and 
disability linking Lakeshore's programs with the University of Alabama, 
Birmingham's research expertise.

We are active in the Mental Health Liaison Group (MHLG), Consortium for 
Citizens with Disabilities (CCD), Disability and Aging Collaborative 
(DAC), and Coalition for Whole Health (CWH). We have been involved with 
the MHLG since 1971 and are a CCD co-founder in 1973.

We work closely with the NHMH--No Health without Mental Health--
facilitated group promoting bi-directional integration of behavioral 
health-general health-primary care--NHMH, American Association on 
Health and Disability, Association of Medicine and Psychiatry, Clinical 
Social Workers Association, Lakeshore Foundation, and Maternal Mental 
Health Leadership Alliance. Likewise, we work closely on integration 
issues with NHMH and American Psychological Association.

Data Points on Persons with Co-Occurring Conditions

Given the Committee's instructions for submissions only as Word 
documents and no other file type being accepted, we have not attached 
data point charts. The Committee's report--Mental Health Care in the 
U.S.: The Case for Federal Action, references similar data. The data 
charts listed below are available upon request. Particularly relevant 
data points on co-occurring conditions include:

     1.  Co-Occurring Serious Mental Illness (SMI) and Substance Use 
Disorder (SUD)--chart from December 2017 Interdepartmental Serious 
Mental Illness Coordinating Committee report.

     2.  People with Serious Mental Illness have higher rates of 
chronic medical illness (and shorter life spans)--charts from February 
24, 2022 National Council on Mental Well-being webinars slides on 
integrating care.

     3.  Co-Occurring Mental Illness and ID/DD--from August 9, 2018 
SAMHSA webinar slides on emerging best practices.

     4.  Co-Occurring Mental Illness and ID/DD--ID/DD only vs dual 
diagnosis costs--Vaya Health Managed Care Plan, North Carolina; from 
SAMHSA April 19, 2017 webinar on the pivotal role of Medicaid in co-
occurring ID/DD and BH slides.

     5.  Co-Occurring Mental Illness and ID/DD--Demographic excerpts 
from NASDDDS-HSRI October 2019 National Core Indicators Data Brief.

     6.  Persons Dually Eligible for Medicare and Medicaid by Age and 
Chronic Conditions--February 2022 MACPAC Data Book on Persons Dually 
Eligible for Medicare and Medicaid.

AAHD and the Lakeshore Foundation appreciate the Senate Committee on 
Finance, chapter 5, pages 20-21 Mental Health Care in the U.S.: The 
Case for Federal Action, on integrating care for persons dually 
eligible for Medicare and Medicaid. We appreciated the Commonwealth 
Foundation addressing this population in response to hearing questions 
by Senators Cassidy and Casey.

There are 12.2 million individuals enrolled in both Medicare and 
Medicaid (dually eligible persons); 4.6 million are people with 
disabilities under age 65. Many dually eligible persons have complex 
care needs, including chronic illness, physical disabilities, 
behavioral health issues, and cognitive impairments; frequently these 
are co-occurring conditions. These persons, on average, use more 
services and have higher per capita costs than those beneficiaries 
enrolled in Medicare or Medicaid alone. Many live with major social 
risk factors. Although Congress created multiple authorities to 
integrate their care, in 2019 only about 10% of the dual-eligible 
population are enrolled in integrated care programs, such as the 
Medicare-Medicaid financial alignment initiative, PACE, dual eligible 
special needs plans (D-SNPs), and Medicaid Managed FFS programs. The 
division of coverage between Medicare and Medicaid results in 
fragmented care and cost shifting. A recent RAND study, commissioned by 
CMS, documented dually eligible persons in MA programs had much greater 
clinical care quality disparities (using HEDIS measures) than non-
dually eligible persons.

Co-Occurring Conditions: Some Analysis and White Papers

We bring to the Committee's attention; and, available upon request are:

     1.  NASMHPD August 2019 assessment paper #8--Co-Occurring Mental 
Health and Substance Use Conditions: What Is Known; What's New.

     2.  NASDDDS-NADD-NASMHPD paper: Supporting Individuals with Co-
Occurring Mental Health and ID/DD; May 2021.

     3.  NASMHPD August 2017 assessment paper #7: Co-Occurring 
Conditions--The Vital Role of Specialized Approaches.

     4.  NASMHPD August 2019 assessment paper #3: Developing a 
Behavioral Health Workforce Equipped To Serve Individuals with Co-
Occurring Mental Health and Substance Use Disorder.

     5.  Administration for Community Living (ACL) funded: Mental 
Health and Developmental Disabilities National Training Center: a joint 
project of the University of Kentucky, University of Alaska, and Utah 
State University.

     6.  Administration for Community Living (ACL) paper: ``Key 
Elements of a No Wrong Door System of Access to LTSS for All 
Populations and Payers.'' The ACL No Wrong Door web page has multiple 
resources, several by AARP.

     7.  Obesity Medicine, June 2021 article: Concurrent Mental Health 
Conditions and Severe Obesity.

     8.  CMS MMCO RIC summary, June 2020: Supporting Persons with Co-
Occurring ID/DD and Behavioral Health Needs--New York Partners in 
Health program.

     9.  National Academy of Medicine, December 2021 three-day summit--
Optimal Integrated Care for People with ID/DD. Specifically:
        a.  Sharon Lewis, HMA, on ``Rethinking Holistic Coordination.''
        b.  Charlene Wong, Duke University, on ``Reimaging Models of 
Care for People with ID/DD: Integrating Cross-Sector Data.''

    10.  HHS ASPE, September 22, 2021: ``Considerations for Building 
Federal Data Capacity for Patient-Centered Outcomes Research Related to 
ID/DD.''

    11.  The Arc: Support Needs of People with ID/DD and MH Needs and 
Their families.

    12.  The Arc: Training Needs of Professionals Serving People with 
ID/DD and Mental Health Needs.

    13.  PCORI, January 2022 Research Funding Announcement--Mental 
Health and Developmental Disabilities Research.

    14.  SAMHSA April 19, 2017 webinar slides (pivotal role of 
Medicaid) on addressing the needs of persons with co-occurring Mental 
Health and ID/DD:
        a.  Slide #28: specialized training and provider networks 
needed.
        b.  Slide #24: North Carolina Managed Care Organization serving 
persons with co-occurring ID/DD and Mental Illness: To serve a person 
with ID/DD ``only''--$48,000 a year. To serve a person with co-
occurring ID/DD and Mental Illness: $64,000 a year.

Persons with ``Complex Health and Social Needs.'' During the past two 
years, several national projects, funded by seven foundations, have 
focused on recognizing and addressing the needs of persons with complex 
health and social needs. These are folks living with co-occurring 
conditions and frequently severe conditions. Many of their work and 
ideas would appropriately serve persons with co-occurring BH, 
disability, and chronic medical conditions.

 Possible Federal Policy Initiatives Responding to the Challenges Faced 
                    by Persons with Co-Occurring Conditions

Possible policy ideas below are those of the American Association on 
Health and Disability and the Lakeshore Foundation and do ``not'' 
reflect the thinking or positions of leading behavioral health, 
disability, or developmental disabilities national organizations. 
Finding consensus by leading behavioral health and disability 
organizations on addressing the needs of persons with co-occurring 
conditions has been a challenge, given all the immediate issues facing 
these communities. During the past several months, we have been 
involved in discussions with some of these organizations but there is 
``no'' agreed upon proposals. Also, some of the possible policy ideas 
here are proposed in papers and webinars by some of these leading 
national organizations (some of these resources are identified below).

We hope these ideas stimulate your thinking about how to address the 
needs of persons with a variety of co-occurring conditions. Most of 
these ideas are more appropriate for the Senate Committee on HELP, as 
they consider the reauthorization of SAMHSA and related programs.

     1.  When I worked with NAMI (National Alliance on Mental Illness): 
in 1999-2000, I facilitated a group of advocates that suggested that, 
at state discretion, states could use their SAMHSA Mental Health Block 
funds to serve persons with co-occurring mental illness and SUD 
(primary diagnosis of SUD); and, at state discretion, states could use 
their SAMHSA Substance Use both Prevention and Treatment Block Grant 
funds to serve persons with co-
occurring SUD and mental illness (primary diagnosis of mental 
illness)--with appropriate, individualized, and effective support for 
each of the co-occurring conditions. Established providers and public 
officials opposed this idea.
        A.  Repeat the state flexibility discretion and require an 
annual public reporting of such fund use by persons with co-conditions 
(both primary diagnosis and secondary diagnoses).
        B.  Use the same process in the SAMHSA Block Grants and the ACL 
disability and aging grants to states for designated categories of 
persons with a variety of co-occurring conditions.

     2.  The ACL No Wrong Door initiative largely addresses intake and 
eligibility processing for state and county aging and disabilities 
programs, and as a possible gateway to long-term services and supports 
(LTSS). Consideration could be given to expanding No Wrong Door tasks 
and encouraging state MH and SUD agencies to expand No Wrong Door 
approaches.
        a.  National Association of Medicaid Directors, February 2021 
paper--``Medicaid Forward--Behavioral Health.'' Paper advocates stream-
line eligibility for services; and, continue to promote the integration 
of physical and behavioral health.
        b.  Consistent with the NAMD paper--reference the needs of 
persons with the variety of co-occurring conditions in proposals to 
expand behavioral health-general health-primary care bi-directional 
integration.

     3.  Council for Quality and Leadership (CQL) 2021 paper--
``Organizational Supports to Promote the Community Integration of 
People with Dual Diagnosis of ID/DD and Psychiatric Disabilities.'' 
Federal grant funds could support these organizational supports.

     4.  Consistent with: HHS ASPE, September 22, 2021: 
``Considerations for Building Federal Data Capacity for Patient-
Centered Outcomes Research Related To ID/DD''--Federal grant funds 
could support public sector service program data systems to 
specifically address persons with co-occurring conditions.

     5.  Consistent with: NASMHPD August 2019 assessment paper #3: 
Developing a Behavioral Health Workforce Equipped To Serve Individuals 
with Co-
Occurring Mental Health and Substance Use Disorder--Federal grant funds 
could support public sector service program workforce training.

Thank you for considering our ideas.

                                 ______
                                 
                    American Counseling Association

                         2461 Eisenhower Avenue

                          Alexandria, VA 22331

                            ph 703-823-9800

                              800-347-6647

                      https://www.counseling.org/

     Statement of Richard Yep, CAE, FASAE, Chief Executive Officer

INTRODUCTION

The American Counseling Association (ACA) is the world's largest 
professional home to more than 57,000 counseling professionals and 
counseling students who are members of ACA. In addition to our members, 
we advocate for the more than 200,000 counseling professionals in 
various practice settings. ACA's advocacy efforts focus on ensuring 
equitable, consistent, and adequate reimbursement for appropriately 
educated, trained, and Licensed Professional Counselors (LPCs) in all 
practice settings and supporting human rights and social justice issues 
and initiatives that reduce the challenges and barriers faced by 
clients, students, counselors, and communities.

The American Counseling Association (ACA) urges lawmakers to pass the 
Mental Health Access Improvement Act of 2021 (H.R. 432/S. 828),\1\ 
which would add LPCs and Licensed Marriage and Family Therapists 
(LMFTs) to the list of Medicare-
eligible mental health providers. This legislation is led by Senator 
Barrasso (R-WY) with Senator Stabenow (D-MI) as cosponsor, and has 
bipartisan support in both chambers of Congress. The Senate bill is 
currently pending before the Senate Finance Committee. The House bill, 
sponsored by Reps. Mike Thompson (D-CA) and John Katko (R-NY), was 
referred to the Ways and Means and the Energy and Commerce committees.
---------------------------------------------------------------------------
    \1\ Mental Health Access Improvement Act of 2021, S. 828, 117th 
Cong. (2021), https://www.congress.gov/bill/117th-congress/senate-bill/
828?q=%7B%22search%22%3A%5B%22s828%
22%5D%7D&r=1&s=3.
---------------------------------------------------------------------------

BACKGROUND

Medicare beneficiaries have fewer choices among mental health providers 
than do enrollees in other health plans. This can limit their access to 
less costly treatment, disrupt their continuity of care, and further 
frustrate their efforts to obtain needed mental health care, 
particularly in rural and underserved areas of the country already 
experiencing a shortage of providers. Medicare is the primary insurance 
provider for approximately 60 million Americans, providing health and 
mental health coverage for people age 65 and older (85 percent of 
beneficiaries), people under 65 with disabilities (15 percent), and 
people with end-stage renal failure. By 2030, Medicare is expected to 
cover nearly 80 million people (Medicare Payment Advisory Commission, 
2020).\2\
---------------------------------------------------------------------------
    \2\ Medicare Payment Advisory Commission. (2020, July). A data 
book: Health care spending and the Medicare program, http://
www.medpac.gov/docs/default-source/data-book/july2020_
databook_entirereport_sec.pdf?sfvrsn=0.
---------------------------------------------------------------------------

COVID-19 IMPACT

The COVID-19 pandemic has had a disparate impact on the mental health 
older adults, who have experienced increased social isolation, 
mortality risk and bereavement, financial instability, and other 
pandemic-related stressors. While Medicare covers mental health care, 
it only allows psychiatrists, psychologists, and clinical social 
workers to bill directly for diagnostic and therapeutic services. Yet, 
LPCs and LMFTs make up an estimated 40 percent of all master's level 
mental health professionals practicing nationwide. Their exclusion from 
Medicare makes it more difficult and expensive for beneficiaries to 
access care, compared to people who are covered by private health 
insurance or Medicaid.

RURAL IMPACT

In rural areas of the country, restricted access to mental health 
professionals is most acute for Medicare beneficiaries. More than 50 
percent of counties do not have any licensed mental health providers 
despite higher rates of substance use disorder and suicide (Tackling 
America's Mental Health and Addiction Crisis Through Primary Care 
Integration, Bipartisan Policy Center (BPC), 2021, p. 68).\3\ BPC's 
report also notes that more than 60 percent of non-metropolitan 
counties specifically do not have a psychiatrist, and almost half do 
not have a psychologist. Among those mental health providers who do 
work in rural communities, 59 percent are counselors (including LPCs, 
LMFTs, and others), which suggests that counselors play a key role in 
providing rural mental health services outside of Medicare (Larson, et 
al., Supply and Distribution of the Behavioral Health Workforce in 
Rural America, 2016, as cited in Fullen, et al., The Impact of the 
Medicare Mental Health Coverage Gap on Rural Mental Health Access, 
2020).\4\ Without access to mental health professionals, people in 
rural areas often rely on general practitioners for behavioral and 
mental health diagnosis and treatment (Report to Congress on Medicaid 
and CHIP, Medicaid and CHIP Payment and Access Commission [MACPAC], 
2021) \5\ and, as a result, may not receive the specific treatment 
needed for their condition (Rural Health Information Hub, n.d.-a).\6\
---------------------------------------------------------------------------
    \3\ Bipartisan Policy Center. (2021). Tackling America's mental 
health and addiction crisis through primary care integration, https://
bipartisanpolicy.org/download/?file=/wp-content/uploads/2021/03/
BPC_Behavioral-Health-Integration-report_R03.pdf.
    \4\ Fullen, M.C., Brossoie, N., Dolbin-MacNab, M.L., Lawson, G., 
and Wiley, J.D. (2020). The impact of the Medicare mental health 
coverage gap on rural mental health care access. Journal of Rural 
Mental Health, 44(4), 243-251, http://www.doi.org/10.1037/rmh0000161.
    \5\ Fullen, M.C., Brossoie, N., Dolbin-MacNab, M.L., Lawson, G., 
and Wiley, J.D. (2020). The impact of the Medicare mental health 
coverage gap on rural mental health care access. Journal of Rural 
Mental Health, 44(4), 243-251, http://www.doi.org/10.1037/rmh0000161.
    \6\ Rural Health Information Hub. (n.d.-a). Barriers to mental 
health treatment in rural areas. https://www.ruralhealthinfo.org/
toolkits/mental-health/1/barriers; Rural Health Information Hub. (n.d.-
b). Telehealth use in rural areas, https://www.ruralhealthinfo.org/
topics/telehealth
#challenge.
---------------------------------------------------------------------------

PROGRAM PARITY

The exclusion of LPCs and LMFTs from Medicare also results in a lack of 
``program compatibility'' between Medicare and Medicaid (Fullen, et 
al., 2020, p. 247). Licensed Professional Counselors (LPCs) whose 
services were covered under their state's Medicaid program may be 
forced to refer a client who becomes covered under Medicare to another 
provider (Fullen, et al., 2019). These dually eligible beneficiaries 
have found that their inability to produce a claim denial for 
counseling services under Medicare (because Medicare does not recognize 
claims from these providers) means Medicaid will not cover the service 
instead. This can occur even though Medicaid might otherwise cover the 
claim if it were the sole source of coverage. Further, the greater 
prevalence of serious mental health conditions and negative encounters 
with the criminal justice system involving some Medicaid beneficiaries 
battling serious mental illness (MACPAC, 2021) makes any disruptions to 
their mental health care concerning.

COST OF CARE BARRIERS

One barrier to access to mental health care is the cost and 
affordability on ongoing therapy for many older adult Medicare 
beneficiaries, according to the PAN Foundation poll and Morning Consult 
(2021).\7\ Furthermore, many health care providers limit their number 
of Medicare patients because of lower reimbursement rates compared with 
private insurance. Psychiatrists are the most likely of any physician 
specialty to opt out of Medicare (Koma, et al., 2020).\8\ In 2014-2015, 
only 62 percent of psychiatrists accepted new patients with Medicare or 
private insurance, and only 36 percent accepted patients on Medicaid 
(Holgash and Heberlein, 2019).\9\ Given that 40 percent of the mental 
health workforce already cannot provide services to Medicare 
beneficiaries, this suggests that the shortage of mental health 
providers is even greater than estimated. In rural areas, this shortage 
of providers may be especially burdensome for beneficiaries in rural 
areas (Fullen, et al., 2020), although primary care providers in these 
areas may handle some of their patients' behavioral and mental health 
needs, those providers report ``feeling overwhelmed, ill-equipped, and 
underpaid'' (Bipartisan Policy Center, 2021, p. 11). Thus, adding LPCs 
to the list of Medicare mental health providers would help to relieve 
this strain on primary care in rural areas, chiefly those that lack 
access to adequate technology (Rural Health Information Hub, n.d.-b).
---------------------------------------------------------------------------
    \7\ Morning Consult. (2021, May). Mental health concerns among 
seniors with chronic illnesses. PAN Foundation, https://
www.panfoundation.org/app/uploads/2021/05/PAN-Mental-Health-
Analysis.pdf.
    \8\ Koma, W., True, S., Biniek, J.F., Cubanski, J., Orgera, K., and 
Garfield, R. (2020, October 9). One in four older adults report anxiety 
or depression amid the COVID-19 pandemic. Kaiser Family Foundation, 
https://www.kff.org/medicare/issue-brief/one-in-four-older-adults-
report-anxiety-or-depression-amid-thecovid-19-pandemic/.
    \9\ Holgash, K., and Heberlein, M. (2019, April 10). Physician 
acceptance of new Medicaid patients: What matters and what doesn't. 
Health Affairs Blog, https://www.healthaffairs.org/do/10.1377/
hblog20190401.678690/full.
---------------------------------------------------------------------------

THE MENTAL HEALTH IMPROVEMENT ACT OF 2021

The Mental Health Access Improvement Act of 2021 (S. 828/H.R. 432), 
would close the gap in mental health care coverage for Medicare 
beneficiaries by:

      Providing more than 140,000 LPCs the option to participate in 
the Medicare program, significantly alleviating current barriers and 
offering less costly choices to older adults and people with 
disabilities;
      Increasing access in rural areas underserved by currently 
recognized Medicare providers;
      Allowing LPCs and LMFTs to directly bill Medicare for their 
services, similar to social workers, psychologists, and psychiatrists; 
and
      Lowering the cost of care with early interventions that can 
improve outcomes before conditions worsen.

SUPPORTING RECOMMENDATIONS

In 2017, the Interdepartmental Serious Mental Illness Coordinating 
Committee recommended that Congress ``remove exclusions that disallow 
payment to certain qualified mental health professionals, such as 
[MFTs] and [LPCs], within Medicare'' (p. 83).\10\ A 2020 Commonwealth 
Fund report (McGinty, 2020) \11\ recommended that policy makers close 
the remaining gap in Medicare by allowing reimbursement for mental 
health services by the more than 140,000 LPCs in the United States and 
noted that, although LPC participation could increase Medicare costs, 
mental health services account for only 1% of program expenditures 
overall.
---------------------------------------------------------------------------
    \10\ Interdepartmental Serious Mental Illness Coordinating 
Committee. (2017). The way forward: Federal action for a system that 
works for all people living with SMI and SED and their families and 
caregivers. Substance Abuse and Mental Health Services Administration, 
https://www.samhsa.gov/sites/default/files/programs_campaigns/
ismicc_2017_report_to_congress.pdf.
    \11\ McGinty, B. (2020, July 9). Medicare's mental health coverage: 
How COVID-19 highlights gaps and opportunities for improvement. 
Commonwealth Fund, https://www.commonwealth
fund.org/publications/issue-briefs/2020/jul/medicare-mental-health-
coverage-covid-19-gaps-opportunities.

Most recently, in 2021, a Bipartisan Policy Center task force 
recommended that Congress expand the mental health provider types 
covered under Medicare, thereby addressing shortages in rural areas 
while dissolving some federal reimbursement barriers to integrated 
primary and mental health care. Enhanced integration of primary and 
behavioral health care is a cost-effective approach to federal health 
spending that reduces disparities and improves patient outcomes.

CONCLUSION

The primary goal of integrated care through improved care coordination 
can neither exist nor be sustained if there can be no improved 
communication between behavioral health and primary care providers 
under the currently increasing mental health provider shortage. 
Excluding Licensed Professional Counselors from the list of covered 
providers under Medicare significantly limits the options beneficiaries 
have when choosing among mental health providers.

Congress has an opportunity to close the Medicare coverage gap and end 
disruption in continuity of care and the lack of access to counseling 
therapy for beneficiaries in support of the goal of integrating care. 
The Mental Health Access Improvement Act of 2021 (S. 828/H.R. 432) 
would significantly alleviate current barriers to care and offer less 
costly choices to older adults and people with disabilities by giving 
more than 200,000 LPCs the option to participate in the Medicare 
network and improve care. It would increase access in rural areas 
underserved by currently recognized Medicare providers and lower the 
cost of care with interventions that can improve both physical and 
mental health outcomes. Now is the time to take this crucial step 
toward ensuring mental health equity in America.

We thank the Committee for the opportunity to submit this statement for 
the record and for the Committee's continued support and interest in 
addressing behavioral health care parity in the United States. We look 
forward to working with the Committee and Senate and House sponsors to 
pass the important and impactful Mental Health Access Improvement Act 
of 2021.

                                 ______
                                 
             Association for Behavioral Health and Wellness

                     700 12th Street, NW, Suite 700

                          Washington, DC 20005

                              202-499-2280

                           https://abhw.org/

U.S. Senate
Committee on Finance

Chair Wyden and Ranking Member Crapo,

The Association for Behavioral Health and Wellness (ABHW) appreciates 
the Committee's support and leadership on addressing mental health (MH) 
and substance use disorder (SUD) issues. ABHW is the national voice for 
payers that manage behavioral health insurance benefits. ABHW member 
companies provide coverage to approximately 200 million people both in 
the public and private sectors to treat MH, SUD, and other behaviors 
that impact health and wellness.

We appreciate the opportunity to submit a statement for the record 
supporting the Committee's efforts to identify solutions and 
opportunities to integrate care and implement parity in the spirit in 
which the Mental Health Parity and Addiction Equity Act (MHPAEA) was 
passed.

Promote the integration of care

As we work to recruit and train practitioners to be part of the mental 
health and substance use disorder workforce, patients need immediate, 
as well as long-term solutions. One of the most promising solutions to 
get patients the care that they need in an unimpeded, timely manner is 
the broad implementation of coordinated primary and behavioral health 
care models. The most promising strategy for providing prevention, 
early intervention, and timely treatment of mental illness and 
substance use disorders is the implementation of evidence-based 
integrated care models using a population-based approach. The 
Collaborative Care Model (CoCM) is a proven, measurement-based approach 
to providing treatment in a primary care office that is evidenced-based 
and already reimbursed by Medicare, with established CPT codes.

CoCM involves a primary care physician working collaboratively with a 
psychiatric consultant and a care manager to manage the clinical care 
of behavioral health patient caseloads. This model allows patients to 
receive behavioral health care through their primary care doctor, 
alleviating the need to seek care elsewhere unless behavioral health 
needs are more serious. CoCM demonstrably improves patient outcomes 
because it facilitates adjustment to treatment by using measurement-
based care. Unlike other models of integrated behavioral health care so 
far, CoCM is supported by over 90 randomized control studies which 
indicate that implementing the model improves access to care and has 
been shown to reduce depression symptoms by fifty percent. It is 
currently being implemented in many large health care systems and group 
practices throughout the country and is also reimbursed by several 
private insurers and Medicaid programs. Accordingly, we urge the 
Committee to include the Collaborate in an Orderly and Cohesive Manner 
(COCM) Act (H.R. 5218) in your MH and SUD legislative package, and 
explore proposals that would help expand the use and adoption of CoCM 
and other evidence-based integrated care models.
 Incentives for Behavioral Health Providers to Obtain Electronic Health 
        Record (EHR) Systems
ABHW also encourages the Committee to examine opportunities to increase 
the use of electronic health records (EHRs) by behavioral health 
providers. The Health Information Technology for Economic and Clinical 
Health (HITECH) Act of 2009 provided funding for primary health care 
providers to adopt EHR technology. Unfortunately, most behavioral 
health providers were not eligible to participate in this program. To 
date, behavioral health providers still substantially lag behind 
primary care providers in adoption rates of EHR systems due to this 
exclusion from available funding.

In its March 2021 report to Congress, titled: Tackling America's Mental 
Health and Addiction Crisis Through Primary Care Integration,\1\ the 
Bipartisan Policy Center (BPC) suggested Congress establish ``a 
targeted funding structure to assist behavioral health providers with 
startup costs, maintenance, and training for health IT in behavioral 
health settings.'' BPC found integrating care would improve health 
disparities, raise the outcome of treatments, and support cost-
effective care. Specifically, BPC recommended that Congress finance the 
Center for Medicare and Medicaid Innovation (CMMI) demonstration 
program authorized in Sec. 6001 of the SUPPORT Act (Pub. L. 115-271) 
that offers behavioral health IT incentives to psychologists and 
clinical social workers as well as Community Mental Health Centers, 
psychiatric hospitals, and residential treatment centers.
---------------------------------------------------------------------------
    \1\ https://bipartisanpolicy.org/download/?file=/wp-content/
uploads/2021/03/BPC_Behavior
al-Health-Integration-report_R03.pdf.

In June 2021, the Medicaid and CHIP Payment and Access Commission 
(MACPAC) released a report chapter titled: Integrating Clinical Care 
through Greater Use of EHR for Behavioral Health.\2\ MACPAC 
additionally noted that behavioral health integration of EHRs would 
increase clinical integration and achieve cost savings, enable 
participation in value-based payment, and improve the quality of health 
reporting.
---------------------------------------------------------------------------
    \2\ https://www.macpac.gov/publication/integrating-clinical-care-
through-greater-use-of-electronic-health-records-for-behavioral-
health/.

We encourage the Committee to consider the Behavioral Health 
Information Technologies Now (BHIT NOW) Act, recently introduced in the 
U.S. House of Representatives. This legislation would help propel 
broader certified EHR adoption among behavioral health providers and 
improve integrated, coordinated, and accessible care for individuals 
seeking MH and SUD treatment.
 Expand the Certified Community Behavioral Health Clinic (CCBHC) Model
To better promote expanded access to comprehensive and evidence-based 
MH and SUD care, we support the nationwide expansion of the Certified 
Community Behavioral Health Clinic (CCBHC) Medicaid demonstration 
program through the bipartisan Excellence in Mental Health and 
Addiction Treatment Act of 2021 (S. 2069/H.R. 4323). CCBHCs offer a 
comprehensive array of services needed to improve access, stabilize 
people in crisis, and provide essential treatment for those with the 
most serious, complex mental illnesses and substance use disorders. 
CCBHCs integrate additional services to ensure a community-based, 
holistic, and innovative approach to behavioral health care that 
emphasizes recovery, wellness, trauma-
informed care, and physical-behavioral health integration, as well as 
coordination with hospitals, emergency departments, and law 
enforcement.

Ensuring Parity

For the last two decades, ABHW has supported mental health and 
addiction parity. We were an original member of the Coalition for 
Fairness in Mental Illness Coverage (Fairness Coalition), a coalition 
developed to win equitable coverage of mental health treatment. ABHW 
served as the Chair of the Fairness Coalition in the four years prior 
to the passage of MHPAEA. We were closely involved in the writing of 
the Senate legislation that became MHPAEA and actively participated in 
the negotiations of the final bill that became law.

ABHW's members provide value to their beneficiaries by designing and 
implementing plan benefits and limits to serve the triple aim for 
health care delivery by reducing the cost per member of health care, 
ensuring that health care services are high quality and well-
coordinated, and improving population health through the efficient use 
of limited resources. We are fully committed to ensuring that these 
design and implementation strategies do not create limits on access to 
MH/SUD benefits that are incomparable to or more stringent than the 
limits on medical/surgical (M/S) benefits.

ABHW member companies have always supported MH and SUD parity and 
continue to strive to ensure patients receive the behavioral health 
services they need in a manner that complies with parity requirements. 
We agree with the determinations of noncompliance for blanket 
exclusions, and blanket pre-certification requirements for MH/SUD 
benefits that are cited in the recent Department of Labor's (DOL), U.S. 
Department of Health and Human Services' (HHS), and Department of 
Treasury's (collectively, ``the tri-Departments'') 2022 Mental Health 
Parity and Addiction Equity Act (MHPAEA) Report to Congress published 
on January 25, 2022 (Report); however, we believe that our 
recommendations for additional guidance are necessary to achieve full 
parity compliance.
 Develop a Clear, Universal Compliance Standard Related to Mental 
        Health and Addiction Parity
ABHW member companies continue to invest significant time and resources 
to understand and implement MHPAEA. Our member companies have teams of 
dozens of people working diligently to implement and provide MH/SUD 
parity benefits to their consumers. We have also had numerous meetings 
with the regulators to help us better comprehend the regulatory 
guidance and discuss how plans can operationalize the regulations.

While parity has progressed in meaningful ways since its adoption and 
access to MH and SUD treatment providers has greatly expanded, systemic 
issues continue to be a challenge due to other non-parity factors such 
as the looming shortage of physicians (both psychiatrists as well as 
other MH and SUD providers). Examples of key changes since the parity 
law and regulations were enacted include: the fact that routine MH 
outpatient treatment no longer habitually requires prior authorization 
or has explicit quantitative treatment limits; evidence-based levels of 
care for MH conditions are no longer subject to blanket exclusions 
(e.g., residential treatment for eating disorders); and transparency, 
documentation, attention to medical necessity criteria all have 
improved.

However, despite these gains and the parity language in the 21st 
Century Cures Act, aspects of the law and regulations remain overly 
complex and technical. As a result, compliance is a moving target 
through a patchwork of conflicting and changing guidance. New parity 
language was included in Section 203 of the Consolidated Appropriations 
Act of 2021 (CAA), and the DOL issued a Frequently Asked Questions 
(FAQs) document to help clarify the CAA provisions. While the FAQs are 
a step in the right direction, we believe further regulations are 
necessary to provide the clarity payers need to implement MHPAEA 
appropriately. We strongly support the flexibility built into the law. 
Yet, there has been a proliferation of different compliance approaches, 
tools, and interpretations, which leads to confusion in implementation, 
is costly for stakeholders, and ultimately hinders patient care. We 
would like to work with you and the Administration to re-invigorate 
efforts to clarify and improve the application of the law for the 
benefit of all.

We strongly support ensuring access to behavioral health services and 
believe that addressing the following would improve compliance.

      Develop a core list of non-quantitative treatment limitations 
(NQTLs) for which documentation may be expected to be available upon 
request. The final rule defines NQTLs circularly, and there is no 
guidance to date that explains what can constitute a ``limit on the 
scope or duration of benefits for treatment under a plan or coverage.'' 
As such, it has not been possible to develop a 5-step analysis for all 
NQTLs proactively. Congress should encourage regulators to develop a 
focused list of NQTLs to better understand what defines this analysis.

      Provide a clear, comprehensive example NQTL analysis that would 
meet the tri-Departments' standards under the requirements of the CAA 
for each NQTL on the focused list. Given the new requirements mandated 
by the CAA to utilize the 5-step framework and that it is materially 
different from the guidance contained in the DOL Self Compliance Guide, 
comprehensive NQTL examples would significantly improve the NQTL 
analyses themselves and ensure efficient use of the tri-Departments' 
resources. We appreciate the guidance published over the years. Still, 
significant ambiguity remains about the actual breadth and depth of 
details and supporting documentation required for each component of the 
CAA's five-step analyses. Model NQTL analyses would help clarify 
expectations, promote uniformity, and ultimately improve parity 
compliance. Accordingly, for each NQTL on the focused list, we believe 
the tri-Departments should provide at least one complete example of a 
compliant analysis.

       Additionally, during this latest round of audits, the tri-
Departments sent letters of insufficiency with a great level of detail 
on what is missing in the documentation for a given NQTL. Congress 
should urge regulators to use this as a basis for future guidance and 
in developing best practice examples for NQTL analyses.

      Define a standard by which NQTL analyses are evaluated and a 
process by which examinations are pursued. In FAQ 45, Q2 and Q4, the 
tri-Departments address the information that must be made available to 
regulators and the types of documents that should be prepared to submit 
in support of a given NQTL analysis. In practice, however, the back and 
forth with the regulators during examinations can be confusing due to 
the lack of a defined process for NQTL documentation requests. ABHW is 
willing to work with the regulators to determine the most efficient 
process to avoid confusion and better implement MHPAEA and asks 
Congress to support these efforts.

      Proactively promote uniformity between state and federal 
requirements. It is also critical to note that some state parity 
policies and compliance approaches differ significantly from federal 
policies and enforcement even when based upon federal parity standards, 
creating confusion in understanding how to achieve and demonstrate 
compliance at the state level even if federal requirements are 
clarified. In fact, there are discrepancies in how NQTLs are 
interpreted not only between a federal and state level and across 
states but within states as well. As such, we urge Congress to stress 
to the tri-Departments to proactively coordinate with state regulators 
to help ease the issues surrounding parity compliance.

ABHW recently sent a detailed letter to the tri-Departments outlining 
our specific guidance requests, which can be viewed here.

We look forward to working with you to ensure that individuals seeking 
MH and SUD treatment have improved integrated, coordinated, and 
accessible care. Please reach out to Maeghan Gilmore, [email protected], 
or 202-503-6999 with any questions or concerns.

Sincerely,

Pamela Greenberg, MPP
President and CEO

                                 ______
                                 
                             Bamboo Health

                         9901 Linn Station Road

                          Louisville, KY 40223

             Statement of Brad Bauer, Senior Vice President

Bamboo Health thanks Chairman Ron Wyden, Ranking Member Mike Crapo, and 
members of the Senate Finance Committee (``the Committee'') for holding 
this important hearing about behavioral health care, the third in a 
series of hearings on this topic. Bamboo Health provides trusted 
technology solutions to federal and state governments, payers, health 
systems, clinicians, pharmacies, and health information exchanges 
working to improve public health. Through our offerings, we are 
implementing the solutions to identify patients in need of help and 
connect them to medical and behavioral health services to improve their 
well-being. Through this work, we are committed to integrating 
behavioral and physical health to improve whole-person care.

Bamboo Health appreciates the complexity of developing policies that 
best serve patients with mental health and substance use disorders and 
is pleased that the Committee is exploring how to better integrate 
behavioral health care into the delivery system. Each of our solutions, 
highlighted below, plays a key role in coordinating patient care, and 
patients will benefit should these or similar solutions be more widely 
adopted. We have a nationwide network connecting hospitals, pharmacies, 
and payers with over 1 billion patient encounters per year across 50 
states, 1 million clinicians, over 11,000 facilities, over 25,000 
pharmacies, 52 PDMPs networked, and work with over 130 different EMRs.

Through the PatientPing platform, providers can better coordinate care, 
thereby improving outcomes and reducing health care costs; it also 
allows providers to leverage admission, discharge, and transfer data in 
a timely manner. Additionally, our OpenBeds product facilitates 
decision support, rapid digital referrals, and collaboration among 
behavioral health providers by identifying, unifying, and tracking all 
behavioral health treatment and support resources in a trusted network. 
Insert a sentence on the adoption of both products. In conjunction, 
Bamboo Health's Crisis Management System expedites access to assessment 
and treatment for those in behavioral health crisis, tracks their 
journey from call to treatment, and coordinates all stakeholders within 
one system. Where these solutions have been adopted, they demonstrate 
the value of integrating these care coordination systems and behavioral 
health information into electronic health records and clinical 
workflows.

This Committee is demonstrating its commitment to improving behavioral 
health care through its thorough consideration of the issue beginning 
with the request for information on mental health and substance use 
disorders released last fall and this series of hearings on the topic. 
Bamboo Health also recognizes the Biden administration's commitment to 
addressing this topic through the actions it has taken and the 
recommended investments in the president's Fiscal Year 2023 budget 
proposal. However, any programs and investments must support an 
expeditious referral to treatment to improve outcomes; otherwise, 
patients may opt to discontinue their treatment falling out of the 
referral and health care systems. Providers generally do not have 
insight into available beds and service providers for mental health and 
substance use disorder referrals and coordinated care, resulting in 
major barriers to appropriate and timely care. Without integrating this 
information into their clinical workflow, a patient's care team cannot 
communicate and appropriately coordinate a patient's care.

The coordination challenges are not limited to providers' ability to 
find available facilities and providers to refer patients for mental 
health services but also applies to coordination and the handoff 
between primary care and mental health providers. Primary care 
providers serve as an entry point for patients to the mental health 
care system, and they need to be empowered to make the connections 
necessary to support their patients. Integrating mental health 
information into electronic medical records and other workflows is 
vital to ensuring primary care providers, who may be a patient's first 
contact when seeking mental health care, can make timely and 
appropriate referrals and coordinate care. As the Committee considers 
this issue, it should be addressed in a manner that does not place 
additional administrative burden on primary care providers who already 
have many requirements that must be met in a single visit. Bamboo 
Health is committed to supporting primary and behavioral health care 
integration and coordination as we believe it is a critical component 
of improving patient outcomes.

To meaningfully improve mental health care and outcomes, the federal 
government must take the steps, including making the financial 
investment, to integrate mental health information in an actionable 
manner. While most providers utilize electronic medical records, 
supporting interoperable systems that integrate mental health data and 
facilitate warm handoffs will require Congress and the administration 
to explore additional incentives since these additional tools come with 
an additional cost. Financial incentives have helped increase the 
adoption of electronic medical records; however, adoption is still 
limited for behavioral health both in hospitals and office-based 
practices. Mental health providers were ineligible for the federal 
financial incentives provided by the Health Information Technology for 
Economic and Clinical Health Act enacted as part of the American 
Recovery and Reinvestment Act of 2009 (Pub. L. 111-5) that supported 
electronic medical record adoption in other sectors of the health care 
system. Without this support, mental health providers were not able to 
make the investment required because of the narrow margins associated 
with this care.\1\ The Committee will have to support meaningful 
solutions to improve adoption to achieve true integration and care 
coordination.
---------------------------------------------------------------------------
    \1\ https://www.macpac.gov/wp-content/uploads/2021/09/Behavioral-
health-IT-adoption-and-care-integration.pdf.

Besides financial support, Bamboo Health urges the Committee to 
carefully consider how to balance policies that encourage integration 
and care coordination and the unique privacy concerns related to mental 
health data. Privacy concerns have limited the exchange of this data to 
date. In many instances, state privacy laws are more stringent than 
federal laws further limiting care coordination and integration. This 
Committee and the administration must carefully consider how to protect 
this data while still allowing the exchanges necessary to coordinate 
care. A first step to accomplishing this may be working with and 
encouraging states to adopt more unified guidelines in this area. The 
country's experience during the COVID-19 pandemic, particularly as 
Americans have quickly adopted with virtual care, has demonstrated why 
---------------------------------------------------------------------------
a responsible solution must be adopted as quickly as possible.

                                 ______
                                 
                    Children's Hospital Association

                      600 13th St., NW, Suite 500

                          Washington, DC 20005

                              202-753-5500

                       www.childrenshospitals.org

On behalf of the nation's more than 220 children's hospitals and the 
children and families we serve, thank you for holding this hearing, 
``Behavioral Health Care When Americans Need It: Ensuring Parity and 
Care Integration.'' As you consider policy options to ensure mental 
health parity and access to the full continuum of services, we urge you 
to recognize the tailored and dedicated mental health support and care 
that children, adolescents and young people need and to advance 
meaningful and transformational solutions.

The statistics illustrate an alarming picture for our children. Prior 
to the pandemic, almost half of children with mental health disorders 
did not receive care they needed.\1\ Although the trends in pediatric 
mental health were worrying before the COVID-19 emergency, demand over 
the past two years for all levels of crisis care for children and teens 
has risen significantly. According to a recent study in JAMA 
Pediatrics, there was an alarming increase in children diagnosed with 
anxiety (27%) and depression (24%) between 2016 and 2020.\2\ In 2021, 
children's hospitals reported emergency department visits for self-
injury and suicidal ideation and behavior in children ages 5-18 at a 
44% higher rate than during 2019.\3\ There was also a more than 50% 
increase in suspected suicide attempt emergency department visits among 
girls ages 12-17 in early 2021, as compared to the same period in 2019.
---------------------------------------------------------------------------
    \1\ Daniel G. Whitney and Mark D. Peterson, ``US National and 
State-Level Prevalence of Mental Health Disorders and Disparities of 
Mental Health Care Use in Children,'' JAMA Pediatrics 173, no. 4 
(2019): 389-391, doi:10.1001/jamapediatrics.2018.5399, https://
jamanetwork.com/journals/jamapediatrics/fullarticle/2724377.
    \2\ Lebrun-Harris L.A., Ghandour R.M., Kogan M.D., Warren M.D., 
Five-Year Trends in US Children's Health and Well-being, 2016-2020. 
JAMA Pediatr. Published online March 14, 2022. doi:10.1001/
jamapediatrics.2022.0056.
    \3\ Children's Hospital Association (CHA), analysis of CHA PHIS 
database, n=38 children's hospitals.

Demand for care is outstripping supply, leaving far too many children 
waiting for needed mental and behavioral health care and ``boarding'' 
in emergency departments until an appropriate placement becomes 
available. This is not limited to one state or one community--children 
in states across the country face similar challenges accessing the 
necessary mental health care to address their needs.\4\ Fifty percent 
of all mental illness begins before age 14 \5\ and, on average, 11 
years pass after the first symptoms appear before treatments begins.\6\
---------------------------------------------------------------------------
    \4\ Ibid.
    \5\ Substance Abuse and Mental Health Services Administration 
(SAMHSA), Adolescent Mental Health Service Use and Reasons for Using 
Services in Specialty, Educational, and General Medicaid Settings, 
March 5, 2016, https://www.samhsa.gov/data/sites/default/files/
report_1973/ShortReport-1973.html.
    \6\ National Alliance on Mental Illness, ``Mental Health 
Screening,'' accessed on November 10, 2021, https://www.nami.org/
Advocacy/Policy-Priorities/Improving-Health/Mental-Health-Screening.

Investments in the full spectrum of pediatric mental health services 
are critical in making immediate strides to address the crisis end of 
the continuum, which is overstretched right now, and prevent 
emergencies in the future. While the COVID-19 pandemic has certainly 
contributed to the crisis in child and adolescent mental health, we 
know that this problem and its root causes, which includes inadequate 
and restrictive insurance practices and a lack of a youth-specific 
mental health care across the full continuum of service needs, predate 
the pandemic. The challenges and limitations of the current mental 
health care system are affecting all children, but the pandemic has 
exacerbated and highlighted existing disparities for children of color 
in mental health outcomes and access to high-quality mental health care 
services. In 2019, the Congressional Black Caucus found that the rate 
of death by suicide was growing at a faster rate among Black children 
and adolescents, and that Black children were more than twice as likely 
to die by suicide before age 13, than their white peers.\7\ Studies of 
Latino communities have found higher reported rates of depression 
symptoms and thoughts of suicide among Latino youth, but comparatively 
lower rates of mental health care utilization. The needs of children 
from racial and ethnic minority communities and the added barriers they 
frequently face in accessing needed services must be addressed in any 
and all approaches to strengthen mental health parity enforcement and 
strengthen care models.
---------------------------------------------------------------------------
    \7\ Congressional Black Caucus, Ring the Alarm: The Crisis of Black 
Youth Suicide in America, December 17, 2019, https://
watsoncoleman.house.gov/uploadedfiles/full_taskforce_report.pdf.

The national state of children's mental, emotional and behavioral 
health is so dire that we joined the American Academy of Pediatrics and 
American Academy of Child and Adolescent Psychiatry in declaring a 
national emergency \8\ in child and adolescent mental health last fall. 
On the same day that we declared a national emergency, we launched the 
Sound the Alarm for Kids initiative \9\ to raise the visibility of the 
children's mental health crisis and build momentum for action. 
Significant investments are needed now to better support and sustain 
the full continuum of care needed for children's mental health. These 
investments will significantly impact our children and our country for 
the better as we avoid more serious and costly outcomes later--such as 
suicidal ideation and death by suicide. The emergency for our children 
is broadly recognized--now we need to work together on immediate 
action.
---------------------------------------------------------------------------
    \8\ https://www.aap.org/en/advocacy/child-and-adolescent-healthy-
mental-development/aap-aacap-cha-declaration-of-a-national-emergency-
in-child-and-adolescent-mental-health/.
    \9\ https://www.soundthealarmforkids.org/.

We applaud the committee for your attention to strengthening the Mental 
Health Parity and Addiction Equity Act (MHPAEA) and enhancing care 
integration through expanded implementation of effective models of 
integrated behavioral health care. We strongly encourage the committee 
to put forward tailored and dedicated policies and support for children 
and youth to better address their emotional, mental and behavioral 
health needs. The current mental health system for children has been 
---------------------------------------------------------------------------
under-resourced for years and now requires significant attention.

Strong enforcement of the MHPAEA is critical to the ability of children 
and youth to access needed mental health services without unnecessary 
delays due to plan limits or other requirements that are not applied to 
medical/surgical plans. As we note above, far too many children with 
mental health needs do not receive the care that they need, with 
children commonly waiting years to receive treatment after symptoms 
first appear. Problematic payer practices, including inadequate 
provider networks and strict utilization controls, among others, 
further limit children's access.

In addition, greater investments are urgently needed to develop and 
enhance 
community-based systems of care, including resources and technical 
assistance to support the implementation of integrated care models, 
care coordination services and other collaborative partnerships so 
children have access to the right care, in the right setting, at the 
right time. Children experience better outcomes when their mental and 
behavioral health needs are identified earlier on, and they are 
connected to the care they need to manage their mental and emotional 
health. Unfortunately, in many communities there are gaps within the 
continuum of care for children and adolescents and a lack of 
coordination between existing providers and systems. At the core of a 
strong pediatric mental health care delivery system is a strong, 
interconnected network of pediatric mental health providers and 
supportive services that are available to deliver high-quality, 
developmentally appropriate care. Integrated care is an effective 
method of meeting families where they are to facilitate preventive 
interventions, early identification and treatment.

We appreciate the Finance Committee's attention to the need to bolster 
compliance with the MHPAEA and to advance care integration models that 
can help address mental health concerns early and comprehensively. As 
you work to develop legislative solutions, we ask you to consider the 
following policy priorities that will result in improved access to 
appropriate mental health services for children and youth, from 
promotion and prevention through needed treatments.

Recommendations to address mental health parity

      Congress should give the Department of Labor (DOL) and states 
the tools they need to enforce parity requirements. The DOL annual 
report on private health plan compliance with the MHPAEA \10\ clearly 
shows that health plans miss the mark on parity. The recent GAO report, 
Mental Health Care: Access Challenges for Covered Consumers and 
Relevant Federal Efforts, \11\ similarly documented plan practices that 
restrict access to needed care. Though that report focuses on adults, 
the 43% of the nation's children who have private insurance coverage 
are also impacted. The violations cited in these reports mean needless 
delays in care or no access to care at all, particularly due to payers' 
non-quantitative treatment limits, not otherwise seen in medical and 
surgical benefits.
---------------------------------------------------------------------------
    \10\ https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-
regulations/laws/mental-health-parity/report-to-congress-2022-
realizing-parity-reducing-stigma-and-raising-awareness.pdf.
    \11\ https://www.gao.gov/products/gao-22-104597.

      Congress should prioritize actions that address current 
inadequacies and inequities in reimbursement rates and policies. Rates 
of reimbursement have historically been lower for mental health 
services in Medicaid and CHIP, as well as in private insurance. Low 
reimbursement rates contribute to difficulty in both recruitment and 
retention into mental health fields and lead to fewer providers 
participating in Medicaid, CHIP and commercial health plans--a 
significant barrier to care for children. Since the Medicaid program is 
the single largest payer of pediatric mental health services, we 
recommend increasing Medicaid reimbursement rates for pediatric mental 
and behavioral health services to Medicare levels or increasing the 
federal medical assistance percentage for pediatric mental and 
behavioral health services to 100%. We also encourage Congress to place 
a priority on the examination of commercial payment policies as part of 
---------------------------------------------------------------------------
any initiatives to strengthen MHPAEA enforcement and compliance.

       In addition, more oversight of payment procedures is needed to 
ensure that children, particularly those in mental health crisis, are 
not waiting for care due to payment and other unnecessary insurance 
delays that are wholly unrelated to their mental health needs. 
Children's hospitals often face numerous challenges navigating health 
plan payment policies for mental health services that are more 
complicated and restrictive than those imposed on medical/surgical 
benefits. In particular, the administrative burden associated with 
medical management policies, such as prior authorizations, claims 
processes and approvals for care transitions, often do not exist to the 
same extent for coverage of treatment for physical health conditions. 
These additional requirements are time-consuming for providers to 
navigate and can lead to delays in care for children and slower claims 
processing.

      Congress should direct CMS to review how the Early and Periodic 
Screening, Diagnostic and Treatment (EPSDT) benefit is implemented to 
ensure that children have access to the mental health services to which 
they are entitled. CMS has determined that EPSDT fulfills the mental 
health parity requirements under the MHPAEA and requires states and 
Medicaid managed care plans to analyze limits placed on mental health 
benefits under Medicaid and CHIP. However, as the Medicaid and CHIP 
Payment and Access Commission has noted, the MHPAEA has not had a 
substantial impact on improving access to behavioral health services 
for the 39% of all children covered by Medicaid. Children's hospitals 
have noted significant gaps in access for children, particularly to the 
intermediate level of care--including intensive outpatient services and 
day programs--which can prevent hospitalizations and help transition 
children back to their homes and community after a hospitalization.

      Congress should ensure that pediatric mental health network 
adequacy standards are sufficient to ensure that all children and youth 
have appropriate access to needed mental health services. Robust 
pediatric network adequacy standards and assessments are a key aspect 
of ensuring compliance with the MHPAEA by public and private payers. 
Those standards should include specific requirements that health plans 
demonstrate they contract with an appropriate number of trained mental 
health professionals with expertise in child and adolescent mental and 
behavioral health. Currently, it is not unusual for health plans to 
have many fewer providers at all levels of care in their mental health 
networks than they do in their medical/surgical networks. In addition 
to quantitative metrics to measure network adequacy, standards related 
to mental health services should prohibit the imposition of more 
restrictive limitations and exclusions on facility types and clinically 
recognized levels of care, such as residential treatment programs, or 
the establishment of more stringent payment policies and procedures 
than those that are applied to medical/surgical benefits. Furthermore, 
network adequacy reviews must include assessments of claims processing 
policies and payment rates. Reimbursement delays due to overly 
burdensome utilization reviews and slow and complicated claims 
processing, combined with historically low reimbursement rates, are 
contributing factors to mental health providers not participating in 
private and public plans' provider networks.

      Congress should expand MHPAEA to all children and adolescents 
enrolled in Medicaid fee-for-service. By specifically requiring in 
statute that parity protections apply across all Medicaid payment and 
delivery models, Congress can help ensure that all children and youth 
in need of mental health services are afforded the same parity 
protections regardless of the state they live in. At a minimum, 
Congress could direct CMS to provide guidance to states on how to 
ensure consistent application on what is required under EPSDT to meet 
MHPAEA requirements, so children have timely access to the full range 
of mental health services without unnecessary administrative delays or 
arbitrary service restrictions. Even though children enrolled in 
Medicaid fee-for-service programs are guaranteed needed mental health 
services under the EPSDT benefit, state implementation has been 
inconsistent. Over the years, families have had to sue to receive 
necessary behavioral health care services, particularly recommended 
intensive home and community-based services to correct or ameliorate 
their child's disorders. Consistent application of what is required 
under EPSDT, regardless of Medicaid payment structure, will help ensure 
that children have access to the full range of mental health services, 
including intensive outpatient services, partial hospitalization and 
other stepdown levels of care that bridge inpatient care and home and 
community.

Recommendations to facilitate care integration and improve coordination

      Congress must support legislative reforms and investments which 
improve access and quality across the full continuum of pediatric 
mental health services. To address the crisis in child and adolescent 
mental health now and into the future, Congress must support innovative 
methods of enhancing service delivery to children with both public and 
private coverage, scale up community-based prevention and treatment 
services, ensure adequate capacity to provide care to children with 
more intensive needs and invest in the pediatric mental health 
workforce. We support enactment of legislation that has been introduced 
in the House, H.R. 4944, Helping Kids Cope Act, \12\ and H.R. 7236, 
Strengthen Kids' Mental Health Now Act. \13\ Both bipartisan bills 
would create unique programs within the Health Resources and Services 
Administration to fund projects to improve the availability of mental 
health services and supports for children based on communities' 
particular needs and improve recruitment, retention, training and 
diversity within pediatric mental health professions.
---------------------------------------------------------------------------
    \12\ https://www.congress.gov/bill/117th-congress/house-bill/
4944?s=1&r=2.
    \13\ https://www.congress.gov/bill/117th-congress/house-bill/7236.

      Congress should explore and advance payment models for all 
payers that incentivize and include mechanisms to reimburse for care 
coordination services, community partnership and consultative services. 
While there are well-established, evidence-based practices in providing 
coordinated and integrated care to facilitate access for children, 
reimbursement is a significant challenge to increasing preventive care, 
standing up care coordination services, implementing integrated care 
models and facilitating partnerships between schools and community-
based mental health professionals. Reimbursement policies that support 
integrated care across a variety of settings, including through 
telehealth and consultation services, can improve identification of 
mental and behavioral health needs in children and streamline 
connections to care. For example, schools can play a critical role in 
primary prevention and early identification, especially through school-
based health centers and partnerships between schools and local 
providers, including children's hospitals. We support S. 3864/H.R. 
7076, Supporting Children's Mental Health Care Access Act, \14\ which 
will reauthorize the Pediatric Mental Health Care Access Grant, an 
important and effective program that supports care integration and 
early intervention in primary care through behavioral health 
teleconsultation. Critically, S. 3864/H.R. 7076 \15\ would also extend 
these programs into schools and emergency departments to serve more 
children across settings.
---------------------------------------------------------------------------
    \14\ https://www.congress.gov/bill/117th-congress/senate-bill/3864.
    \15\ https://www.congress.gov/bill/117th-congress/senate-bill/3864.

       There is also a critical need to fund care coordination services 
that can identify and mitigate gaps within the continuum of care that 
often lead to children waiting for treatment they need to overcome 
mental health challenges. Care coordinators, in particular, provide 
crucial support by conducting follow-up with patients discharged from 
inpatient care or crisis stabilization. Professional peer support and 
family peer support specialists can also be critical members of a care 
team, supporting children and their caregivers with helpful insights, 
often from lived experience and strong community connections. Too 
often, this work is not reimbursable despite its value to the care 
---------------------------------------------------------------------------
relationships that benefit children and families.

      Congress should work to address payment policies that hinder 
access to mental health services. Pediatricians and other primary care 
providers can play a critical role in early identification and 
intervention for children experiencing mental health symptoms and 
conditions. With proper training and support, some children's mental 
health needs can be well managed by primary care, especially when 
providers have access to mental health consultation services. However, 
public and private payers routinely exclude payment for mental health 
services provided by a primary care provider, putting unnecessary 
burden on providers prepared to conduct screenings and assessments that 
are convenient and beneficial to their patients. Additionally, same-day 
billing limitations persists in some state Medicaid plans, and 
children's hospitals have reported that they can prevent effective 
implementation of integrated care and cause delays in a patient's 
connection to care.

Children's hospitals are eager to partner with you to advance policies 
that can make measurable improvements in children's lives. Please call 
on us and our members as you develop these important policy 
improvements to stem the tide of the national emergency for children's 
mental health. Children need your help now.

                                 ______
                                 
                            COMPASS Pathways

                        3rd Floor, 1 Ashley Road

                      Altrincham, Cheshire WA142DT

Dear Chairman Wyden and Ranking Member Crapo:

COMPASS Pathways appreciates the opportunity to provide feedback on the 
current state of mental health care in the United States and how 
Congress can help to address existing barriers to care. In November, 
COMPASS Pathways submitted comments to the Finance Committee in 
response to the Committee's request for information on mental health 
policy solutions. We continue to believe that a comprehensive approach 
to mental and behavioral health care is necessary and appreciate the 
opportunity to provide a statement for the record to the Committee as 
you work to ensure behavioral health parity and integration. COMPASS 
Pathways (Nasdaq: CMPS) is a mental health company dedicated to 
accelerating patient access to 
evidence-based innovation in mental health.

COMPASS' focus is on improving the lives of those who are suffering 
with mental health challenges and who are not helped by current 
treatments. A vital part of this focus is creating equitable patient 
access through collaboration, partnership across industries, and 
advocacy for policies that support mental health care professionals, 
patients, caregivers, and communities. An important aspect of 
bolstering equitable patient access is ensuring parity between mental/
behavioral health care and physical health care benefits. As the 
Finance Committee continues to address mental and behavioral health, we 
urge the Finance Committee to take a comprehensive approach to ensuring 
mental and behavioral health services are covered in parity with 
physical health services. COMPASS has identified the following policy 
solutions to help ensure parity:

      Improve enforcement and oversight of parity laws currently on 
the books.
      Improve payment policies that contribute to better parity.
      Expand telehealth to ensure parity.

Below, we examine each of these themes in further detail, providing 
specific policy solutions that will ensure greater parity between 
mental/behavioral health care and physical health care.

Improving Enforcement and Oversight

In 2008 the Mental Health Parity and Addiction Act was enacted, 
requiring insurance coverage for mental health conditions, including 
substance use disorders, to be no more restrictive than insurance 
coverage for medical conditions. Since its inception, plans have 
struggled to fully comply with such parity requirements. The federal 
government as well as state governments, tasked with enforcing such 
parity laws, have also struggled to enforce them.

Currently, the Department of Labor (DOL) is unable to enforce the MHPA 
directly against insurance companies that offer the plans. This leaves 
DOL with no front-end enforcement mechanism to ensure there is 
compliance with existing mental health and substance-use parity 
requirements. To remedy this, Congress should provide this front-end 
authority to DOL. The House of Representatives is currently considering 
legislation that would do this. H.R. 1364, Parity Enforcement Act of 
2021 would provide DOL the authority to enforce the parity requirements 
for group health plans directly, not relying upon employers to 
reimburse their workers after there are parity violations. The Finance 
Committee should work directly with the HELP Committee to consider 
similar legislation that would provide DOL this front-end authority.

Congress can also bolster state enforcement of the current laws by 
providing grants to states directly that support's their oversight of 
health insurance plan compliance with mental health parity 
requirements. S. 1962, sponsored by Senator Chris Murphy and currently 
being considered by the Senate HELP Committee would authorize $25 
million in grants to states to support their oversight of health 
insurance plan compliance with such mental health parity requirements. 
Though, not within Senate Finance's jurisdiction, the Finance Committee 
should commit to working closely with Sen. Murphy and the HELP 
committee to ensure passage of this legislation or similar legislation. 
Additionally, Congress should work to collect better qualitative and 
quantitative data from on shortfalls in compliance with parity laws.

 Payment Policies to Contribute to Better Mental Health Parity in 
                    Practice

Generally, claims payment delays occur in all sectors of the medical 
field and reimbursement for mental health services tend to be lower 
than others. The lack of sufficient payment rates for mental health, 
and the undervaluing of mental health services has disincentivized 
providers to accept insurance or participate in federal programs. A 
transactional relationship between payers and providers makes billing 
and reimbursement a priority over the outcomes for the patient and the 
patient experience. Behavioral health providers do not want to be 
required to prioritize adequate compensation for their services over 
caring for those in need. Further a lack of innovation in this space, 
especially regarding updated coding practices for the valuation of the 
mental health practitioner's time and the type of treatment covered, 
undermines the relationship between behavioral health care providers 
and payers.

The Finance Committee should consider the following policies to improve 
payment practices in a way that benefits the patient and encourage 
innovation:

      Support for more enforcement of mental health parity laws.
      Support for the generation of real-world evidence to reflect the 
value of physician work and coverage of mental health treatments.
      Creating a standard set of quality metrics and measurable 
outcomes agreed upon by payers to improve willingness to pay for 
innovative mental health care services.

Telehealth Parity

Over the last 2 years, we've seen the vast expansion of telehealth 
services across the health care system, most notably the mental health 
care space. As Congress continues to weigh further telehealth expansion 
as a means to expand access to mental health services, payment parity 
must be a top consideration. Current payment policies act as a barrier 
to ensuring access to mental health services. As you know many mental 
health providers do not work within the Medicare and Medicaid programs 
due to lack of payment incentives. The same principle applies to 
services offered via telehealth. Regardless of whether telehealth is 
expanded permanently, if payment parity does not follow, providers will 
continue to withhold their services from federal health programs. That 
is why it is imperative that in any expansion of telehealth, Congress 
include policies that require the Medicare program to ensure payment 
parity.

COMPASS is working to transform the patient experience of mental health 
care, creating a world of mental well-being. In doing so, active 
collaboration, innovation, research, and integration across systems is 
a priority; the Finance Committee's commitment to identifying the 
challenges and creating lasting solutions for patients in need of care 
is encouraging and the opportunity to provide a statement for the 
record is appreciated. COMPASS looks forward to working with the 
Committee toward enactment of innovative policy solutions. If you have 
any questions, please contact Steve Levine at 
[email protected].

Sincerely,

George Goldsmith
Co-founder, CEO, and Chairman of the Board

                                 ______
                                 
                 Statement Submitted by John D. Curtis

U.S. Senate
Committee on Finance

            Behavioral Health Care When Americans Need It: 
                  Ensuring Parity and Care Integration

One way to ensure parity would be for Medicare beneficiaries to have 
access to the same counselors that Medicaid reimburses. Another would 
be for these providers to be paid the same. And another would be for 
that reimbursement rate to be little more than 85%.

                                 ______
                                 
                        ERISA Industry Committee

                     701 8th Street, NW, Suite 610

                          Washington, DC 20001

                           Main 202-789-1400

                          http://www.eric.org/

Chairman Wyden, Ranking Member Crapo, and Members of the Committee, 
thank you for the opportunity to submit a statement for the record on 
behalf of The ERISA Industry Committee (ERIC) for the hearing entitled 
``Behavioral Health Care When Americans Need It: Ensuring Parity and 
Care Integration,'' providing specific recommendations to improve 
mental and behavioral health access and quality.

ERIC is a national nonprofit organization exclusively representing the 
largest employers in the United States in their capacity as sponsors of 
employee benefit plans for their nationwide workforces. With member 
companies that are leaders in every economic sector, ERIC is the voice 
of large employer plan sponsors on federal, state, and local public 
policies impacting their ability to sponsor benefit plans and to 
lawfully operate under ERISA's protection from a patchwork of different 
and conflicting state and local laws, in addition to federal law.

Americans engage with an ERIC member company many times a day, such as 
when they drive a car or fill it with gas, use a cell phone or a 
computer, watch TV, dine out or at home, enjoy a beverage or snack, use 
cosmetics, fly on an airplane, visit a bank or hotel, benefit from our 
national defense, receive or send a package, or go shopping.

ERIC member companies voluntarily offer comprehensive health benefits 
to millions of active and retired workers and their families across the 
country. Our members offer great health benefits to attract and retain 
employees, be competitive for human capital, and improve health and 
provide peace of mind. On average, large employers pay around 75 
percent of health care costs on behalf of 181 million beneficiaries.

Employers like ERIC member companies roll up their sleeves to improve 
how physical, mental, behavioral health care is delivered in 
communities across the country. They do this by developing value-driven 
and coordinated care programs, implementing employee wellness programs, 
providing transparency tools, and adopting a myriad of other 
innovations that improve quality and value to drive down costs. These 
efforts often use networks to guide our employees and their family 
members to providers that offer high-value care.

ERIC member companies understand the shortage of mental and behavioral 
health providers and offered policy solutions \1\ to address the crisis 
and long wait times. This included the following policy recommendations 
that will help ensure that Americans are better able to access the 
mental and behavioral health services they need, when and where they 
need them, without excess financial burden:
---------------------------------------------------------------------------
    \1\ https://www.eric.org/wp-content/uploads/2021/07/ERIC-Mental-
Health-Task-Force-Report-2021.pdf.

      Allow mental health providers to practice across state lines to 
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improve access to care.

      Expand telehealth benefits for all employees to improve access 
to providers.

      Incentivize more practitioners to enter the mental health field 
by increasing education funding and tuition reimbursement.

      Require provider transparency around the ability to accept new 
patients, reducing patient uncertainty and frustration.

      Integrate multiple health care disciplines through collaboration 
to provide patients with higher quality care.

      Ensure patients and plan sponsors have access to meaningful 
provider quality and safety information.

      Modernize health care account rules to increase flexibility for 
employees and improve access to mental and behavioral health.

      Reduce regulatory barriers to encourage employer innovation.

      Apply lessons learned from COVID-19 to advance health equity and 
better prepare for the future.

      Encourage the transition to value-based payments to better 
manage the costs of mental and behavioral health.

Our policy recommendations require a collaborative approach from 
Congress, employers, and providers, but many providers eschew insurance 
networks \2\ since they can make more money without a prohibition on 
balance billing (due to lack of competition). Others move to a cash-
only model that greatly reduces their administrative burdens, but 
obviously is a significant hardship for patients. We urge the Committee 
to develop legislation that will:
---------------------------------------------------------------------------
    \2\ Bishop, Tara F et al. ``Acceptance of insurance by 
psychiatrists and the implications for access to mental health care.'' 
JAMA psychiatry vol. 71,2 (2014): 176-81. doi:10.1001/
jamapsychiatry.2013.2862, https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC3967759/.

---------------------------------------------------------------------------
      Require that mental health facilities accept private insurance.

      Increase telehealth access for employers' workforces and address 
unnecessary state and federal government barriers such as licensure and 
specific technology requirements.

      Integrate multiple health care disciplines through collaboration 
to provide patients with higher quality care.

We also request that Congress steer clear of policies that establish 
counterproductive mandates that are likely to increase costs without 
improving access or care. We specifically request that the Committee 
refrain from advancing policies that use civil monetary penalties 
(CMPs) for mental health parity violations in favor of clear-cut 
policies that promote access and affordability of care.

        Avoid Mandating a One-Sided Network Adequacy Requirement

Some have proposed that the way to provide more access to providers is 
to mandate a network adequacy requirement on health plans. We oppose 
this approach in favor of policies that allow more providers to reach 
patients in need such as through telehealth and cross-border licensing. 
ERISA plans do not profit from denying care to beneficiaries, and they 
do not seek to limit access to needed care. In fact, to do so would be 
completely counterproductive. Employers strive to ensure that 
beneficiaries have access to the type and volume of care they need, 
when they need it, as they want their employees and families healthy 
physically and mentally. This is why we have continually worked to 
improve access and quality in all aspects of the health care system.

As mentioned before, many mental and behavioral health providers choose 
not to participate in any insurance network. This could be for a 
variety of reasons--perhaps they prefer to accept out-of-network rates 
and balance bill patients. Perhaps they choose to take cash only. Or 
perhaps they simply recognize that due to provider shortages, they 
wield such market power that agreeing to anything other than the price 
they want, is unnecessary. In a 2017 Milliman report, 17.2 percent of 
behavioral health office visits were to an out-of-network provider 
showing that more patients are paying higher costs to get the care they 
need.\3\ Regardless, many mental and behavioral health providers are 
charging high rates as payment in full, and as such, do not participate 
in networks. Enabling more providers to practice such as across state 
lines will give patients more affordable choices.
---------------------------------------------------------------------------
    \3\ Melek, Steve, Davenport, Stoddard, and Gray, T.J., ``Addiction 
and Mental Health vs. Physical Health: Widening Disparities in Network 
Use and Provider Reimbursement.'' Milliman. November 19, 2019, https://
www.milliman.com//media/milliman/importedfiles/ektron/addiction
andmentalhealthvsphysicalhealthwideningdi_sparitiesinnet_workuseandprovi
derreimbursement.
ashx.

Simply requiring insurers to include these providers in-network will 
necessarily lead to price increases for patients. If providers know an 
insurer has to bring them in-network, they have an incentive to demand 
prices higher than what the market would otherwise bear, thus leading 
to higher costs for all insured beneficiaries due to premium increases. 
This approach hits patients in self-insured plans especially hard. 
After all, with half the workforce in high-deductible health plans, and 
a significant portion of other beneficiaries whose cost-sharing is 
based on the cost of care, these price increases will serve to increase 
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out-of-pocket costs for those who need the care most.

Any effort to implement a requirement that insurance networks include 
more mental and behavioral health providers must be a fair, two-sided 
requirement: it must be paired with a requirement that providers 
themselves participate in networks and show their willingness to be a 
part of the solution for mental and behavioral health care access and 
affordability. If not, Congress must take action by requiring that 
providers go in-network in at least a few plans. If Congress does this, 
it will show lawmakers are addressing the patient needs and should 
encourage good faith negotiations between providers and health plans. 
If providers are going to demand that a mandate be placed on health 
plans, providers should be prepared to also participate in this 
mandate, for the benefit of their patients, not providers' pockets.

    Telehealth Innovation Can Improve Behavioral Health Care Access

ERIC's member companies are pioneers in offering robust telehealth 
benefits. Telehealth enables individuals to obtain the care they need, 
when and where they need it, affordably and conveniently. Telehealth 
visits are generally less expensive than in-person visits and 
significantly less expensive than urgent care or emergency room visits. 
Telehealth visits allow individuals who may not have a primary care 
provider and are experiencing medical symptoms an affordable option of 
care rather than an emergency room visit. Access to telehealth benefits 
saves individuals significant money and time, and reduces the cost to 
the plan which ultimately lowers health plan premiums.

As in most health insurance and value-driven plan design, self-insured 
employers have been the early adopters and drivers of telehealth 
expansion. Some employers also have value-based care and worksite 
health centers that have utilized clinic-based and specialty telehealth 
services during the pandemic, with the services rising to 78 percent in 
2021 compared to 21 percent in 2018.\4\ ERIC's member companies 
continued to lead the way in rolling out telehealth improvements--held 
back only by various federal and state government barriers. This 
includes provider licensing, unnecessary barriers, such as banning 
store and forward communications, or implementing specific technology 
requirements, and offering telehealth to certain sectors of the 
employer's workforce. These impediments to provider licensing seriously 
impact telehealth coverage offered to employees from state to state.
---------------------------------------------------------------------------
    \4\ Mercer, National Association for Worksite Health Centers, 
Worksite Health Centers 2021 Survey Report, https://www.mercer.us/
content/dam/mercer/attachments/north-america/us/us-2021-worksite-
health-centerssurvey-report.pdf.

We encourage Congress to pass the following pieces of legislation to 
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permanently increase telehealth care for individuals:

      Telehealth Expansion Act (S. 1704). The legislation would allow 
for individuals enrolled in a high-deductible health plan to have 
access to telehealth benefits at a low cost or free of charge before 
their deductible is met and continue to maintain Health Savings Account 
eligibility.

      Telehealth Benefit Expansion for Workers Act. This bill would 
allow employers to offer standalone telehealth benefits to millions of 
individuals who are not enrolled on their full medical plan, such as 
part-time workers, interns, seasonal workers, persons on a waiting 
period, and more by removing barriers currently presented under current 
law, such as the Affordable Care Act.

      A permanent solution to interstate licensure that could be 
addressed by either:

          National reciprocity for medical provider 
licenses;

          A new national license specifically for 
telehealth;

          One comprehensive interstate compact with 
financial incentives for states; or

          Update and pass the TELE-MED Act and TREAT Act.

Telehealth is currently regulated only at the state level. As a result, 
individuals in national, ERISA governed self-insured health plans, face 
many barriers to care and other limitations, which vary state by state. 
This kind of regulation may be appropriate for individuals enrolled in 
(and providers contracting with) fully-insured plans, which are 
regulated at the state level. However, it creates uneven care for 
workers, families, and retirees who get their health insurance through 
self-insured health plans, which are regulated at the federal level. 
This unfairness is exactly what ERISA preemption was intended to 
prevent.

Congress could fix this inequity by creating a new national standard 
for telehealth benefits offered under an ERISA governed self-insured 
health plan. Such a standard should consider the following tenets 
(which are the key areas in which state laws currently conflict and 
disadvantage telehealth patients):

      Specifically allow telehealth to establish a patient-provider 
relationship.

      Apply the same standard of care to in-person visits and 
telehealth visits.

      Do not require reimbursement for telehealth visits to be at the 
same rate as reimbursement for in-person visits.

      Encourage interstate practice among providers.

      Coordinate between the patient's telemedicine provider and 
primary care provider is encouraged.

      Simply define ``telehealth'' and ``telemedicine'' and apply the 
terms to broadly include all types of care that use technology to 
connect a provider in one location and a patient in a different 
location.

      Do not require or encourage patients to travel to specific 
``originating sites'' to access telehealth services.

      Apply the same informed consent requirements to in-person visits 
and telehealth visits.

      Allow prescribing via telemedicine.

Congress can develop a set of rules that protect patients while 
maximizing flexibility and care, rather than some of the current 
protectionist rules that serve to block patients from care onthe state 
level. These simple, streamlined set of rules will provide clarity to 
providers and maximize access for patients.

              Improving Care Integration for All Patients

As the access to psychologists and psychiatrists, in particular, has 
proven a challenge to plan beneficiaries, many have utilized other 
health care providers, such as those in primary care, to take care of 
their mental and behavioral needs. Congress can facilitate the 
transition of some mental and behavioral health services to 
nontraditional providers, such as to:

      Pursue efforts to ease a transition for coordinated care between 
interdisciplinary teams.

      Direct CMS to pursue new opportunities for mental and behavioral 
health to be included in accountable care organization (ACO) type 
arrangements.

      Eliminate regulatory barriers to creating capitated models that 
include mental and behavioral health professionals and condition some 
portion of public program reimbursement on participation in these types 
of models for mental health professionals and facilities.

      Create incentives for states to broaden ``scope of practice'' 
laws that currently hinder the ability of various medical providers (a 
prime example being nurse practitioners) from meeting unmet mental and 
behavioral health needs.

      Mandate fully interoperable electronic medical records (EMRs), 
and redesign the Meaningful Use program to ensure that every provider 
or facility participating in CMS programs transitions to a fully 
interoperable system so that a patient's entire interdisciplinary care 
team can access and contribute to the same EMR.

      Explore how coverage rules may be applied or expanded in order 
to encourage and facilitate behavioral health options such as attending 
group meetings or therapy sessions.

While not every provider can address all health care matters, ensuring 
that medical teams have proper systems and relationships is crucial in 
making sure that patients receive the best care.

           Do Not Implement Civil Monetary Penalties (CMPs) 
               for Mental Health Parity (MHP) Violations

One oft-repeated idea to improve access to mental health providers and 
treatments for beneficiaries of employer-sponsored health insurance has 
been to implement a monetary penalty regime to punish insurance 
companies and employers who are found to have fallen short of parity 
requirement.

We are deeply troubled by the Department of Labor's (DOL) 
recommendation encouraging Congress to authorize the agency to assess 
civil monetary penalties for parity violations, as mentioned in their 
2022 Mental Health Parity and Addiction Equity Act (MHPAEA) Report. 
Penalties are not the answer. Rather, what is needed is clearcut, 
comprehensive guidance that helps employers support their workforce and 
mental health providers that support patients over their bottom line.

It is our understanding that problems in the large-group market among 
self-insured plans are primarily a result of non-quantitative treatment 
limitations (NQTLs), a requirement that was never contemplated in the 
original MHP legislation, but instead developed by the federal 
agencies.

Employers looking for a firm understanding of what is allowed, and what 
is not, have to resort to third-party publications, consultants, and 
outside vendors. In the large-group market, employers who are found to 
have parity violations inevitably have relied on outside counsel.

Large employers have continually made available the newly required 
comparative analyses upon request from DOL. However, despite extensive 
good faith efforts to comply, our member companies have reported that 
upon submitting analyses, DOL staff sent back dozens of questions and 
requests for substantially more documentation without explanation of 
what changes employers can make to comply with parity rules.

As such, penalizing employers for these violations are unlikely to 
prevent them in the future. Rather than implementing CMPs, if the goal 
is to reduce MHP violations through NQTLs, Congress should consider 
mandating that DOL provide much clearer, simpler guidance, that 
includes examples of what is actually allowed--rather than just citing 
various impermissible plan design elements.

                               Conclusion

Thank you for this opportunity to share our views with the Committee. 
The ERISA Industry Committee and our member companies are committed to 
working with Congress to meaningfully improve access to quality 
behavioral health care for our employees, their families, and retirees. 
We look forward to working with the Committee to enact legislation to 
meet the behavioral health needs of Americans.

                                 ______
                                 

                     Healthcare Leadership Council
April 11, 2022

The Honorable Ron Wyden             The Honorable Mike Crapo
Chair                               Ranking Member
U.S. Senate                         U.S. Senate
Committee on Finance                Committee on Finance
Washington, DC 20510                Washington, DC 20510

RE: March 30th ``Behavioral Health Care When Americans Need It: 
Ensuring Parity and Care Integration'' Hearing

Dear Chair Wyden and Ranking Member Crapo:

The Healthcare Leadership Council (HLC) thanks you for holding a 
hearing on, ``Behavioral Health Care When Americans Need It: Ensuring 
Parity and Care Integration.''

HLC is a coalition of chief executives from all disciplines within 
American healthcare. It is the exclusive forum for the nation's 
healthcare leaders to jointly develop policies, plans, and programs to 
achieve their vision of a 21st century healthcare system that makes 
affordable high-quality care accessible to all Americans. Members of 
HLC--hospitals, academic health centers, health plans, pharmaceutical 
companies, medical device manufacturers, laboratories, biotech firms, 
health product distributors, post-acute care providers, homecare 
providers, and information technology companies--advocate for measures 
to increase the quality and efficiency of healthcare through a patient-
centered approach.

The COVID-19 health pandemic has created significant barriers to 
accessing mental health services. A December 2021 report by the 
Government Accountability Office (GAO) found that over 43% of adults 
have reported struggling with anxiety or depression since the beginning 
of the pandemic.\1\ The impact of COVID-19 on mental health is expected 
to continue to be a challenge in the coming years. We applaud Congress 
for providing over $4 billion in the Consolidated Appropriations Act 
and $3.8 billion in the American Rescue Plan Act for mental health 
services. These investments will provide much-needed assistance to 
struggling individuals and communities. HLC also supports your work to 
examine how to improve mental health services, particularly by ensuring 
parity and care integration. We offer the following proposals as you 
deliberate on these areas of care:
---------------------------------------------------------------------------
    \1\ ``Behavioral Health and COVID-19: Higher-Risk Populations and 
Related Federal Relief Funding,'' Government Accountability Office 
(December 10, 2021), https://www.gao.gov/assets/gao-22-104437.pdf.
---------------------------------------------------------------------------

Ensuring Parity

Ensuring parity for patients struggling with behavioral health 
challenges is an important step in providing necessary care. We thank 
Congress and federal agencies for their work to reduce disparities in 
care delivery. As you examine additional steps to ensure better parity 
for patients, we encourage you to examine how regulatory guidance can 
be better leveraged to provide clarity to stakeholders. Recent changes 
in the ``Consolidated Appropriations Act, 2021,'' impose significant 
new compliance requirements on ensuring parity. Additionally, 
regulatory oversight for this area spans across several federal 
agencies including the Departments of Health and Human Services, Labor, 
and the Treasury. HLC encourages further action to provide more 
guidance on how to comply with new regulations and ensure that these 
actions educate rather than unnecessarily penalize impacted entities 
and achieve the desired goal.

Care Integration

Integrating mental health treatment within primary care visits has been 
shown to have benefits for patient health outcomes. By treating mental 
health challenges separately from other medical conditions, patients 
miss out on the benefits of care coordination. For example, separating 
care creates logistical challenges related to seeking care from 
different providers. Notably, 67% of patients do not typically receive 
treatment from their primary care providers (PCPs) for mental health 
challenges, while 80% of those patients visit a PCP at least once a 
year.\2\ Studies have found that integrating these appointments leads 
to a 16% reduction in the use of separate behavioral health services 
that can be handled by a PCP.\3\ Additionally, patients suffering from 
depression saw an average of $3,300 in decreased costs over a 2-year 
period when mental healthcare was integrated into primary care 
visits.\4\ Combining primary care and mental healthcare has proven 
successful with certain patients and should be encouraged when 
appropriate.
---------------------------------------------------------------------------
    \2\ Alexander Kieu, ``Now More Than Ever, Mental Health Care Needs 
Family Medicine,'' American Association of Family Physicians (May 
2021), https://www.aafp.org/fpm/2021/0500/oa1.html.
    \3\ ``Benefits of Integration of Behavioral Health,'' Primary Care 
Collaborative, https://www.
pcpcc.org/content/benefits-integration-behavioral-health.
    \4\ Id.

Successful integration of behavioral health services within primary 
care also requires robust collection of patient information. HLC 
supports efforts to improve health information interoperability among 
providers, particularly social determinants of health (SDOH) data 
capture and sharing. This data should include standardized information 
on race, ethnicity, and language and be tracked throughout all federal 
programs. Despite the numerous initiatives to address SDOH in patient 
care, providers still struggle to incorporate SDOH into care delivery 
because this information is oftentimes not part of the patient's 
electronic health record. It is critical that providers are able to 
uniformly assess and identify potential social risk factors among all 
patients. Standardization of this data is vital to providers' success 
in moving toward greater health equity, as it will foster the 
development and sharing of best practices within clinical settings, 
---------------------------------------------------------------------------
health systems, and delivery designs.

We encourage the Committee to examine ways to further strengthen 
information sharing among providers so that they can make informed 
decisions about patient care. However, any proposals should ensure that 
patient information receives robust privacy and security protections. 
Special focus should be given to health information not governed by the 
HIPAA regulatory framework to build patient trust in information 
sharing.

HLC appreciates your work on improving mental health outcomes for 
patients and looks forward to working with you on future solutions. 
Please contact Tina Grande at 202-449-3433 or [email protected] with any 
questions.

Sincerely,

Mary R. Grealy
President

                                 ______
                                 
                         HR Policy Association

                   1101 19th Street North, Suite 1002

                          Arlington, VA 22209

                                  and

                    American Health Policy Institute

                   1101 19th Street North, Suite 1002

                          Arlington, VA 22209

    The HR Policy Association (Association) and the American Health 
Policy Institute (Institute) appreciate the Committee holding this 
important hearing on behavioral and mental health care issues.

    The Association is the leading organization representing chief 
human resource officers of 400 of the largest employers in the United 
States. Collectively, their companies provide health care coverage to 
over 20 million employees and dependents in the United States. The 
Institute, a part of the Association, examines the challenges employers 
face in providing health care to their employees and recommends policy 
solutions to promote affordable, high-quality, employer-based health 
care. The Institute serves to provide thought leadership grounded in 
the practical experience of America's largest employers.

    Congress should enact the following policy recommendations to 
improve access to behavioral and mental health care services.

 More Guidance Will Achieve Mental Health Parity, Not Civil Monetary 
                    Penalties

    HR Policy strongly opposes enacting civil monetary penalties for 
mental health parity violations before the Department of Labor (DOL) 
publishes and implements its parity rulemaking and the additional 
guidance that is required by the Consolidated Appropriations Act of 
2021 (CAA).

    Congress recognized that employers needed substantially more 
guidance to implement the complicated mental health parity requirements 
for non-quantitative treatment limitations (NQTLs) when it enacted the 
CAA. Specifically, Congress required DOL to publish a ``compliance 
program guidance document'' that provides ``illustrative, de-identified 
examples'' of previous findings of compliance and noncompliance, 
including:

        Examples illustrating requirements for information disclosures 
and non-
quantitative treatment limitations; and

        Descriptions of the violations uncovered during the course of 
such investigations.\1\
---------------------------------------------------------------------------
    \1\ 29 U.S.C. 1185a(a)(6)(B)(i).

    Importantly, the CAA requires the examples to ``provide sufficient 
detail to fully explain such finding, including a full description of 
the criteria involved for approving medical and surgical benefits and 
the criteria involved for approving mental health and substance use 
disorder benefits.''\2\
---------------------------------------------------------------------------
    \2\ 29 U.S.C. 1185a(a)(6)(B)(ii).

    Congress also required DOL to publish ``additional guidance'' that 
``shall include clarifying information and illustrative examples of 
methods that group health plans and health insurance issuers . . . may 
use for disclosing information to ensure compliance'' with their parity 
requirements.\3\ Specifically, ``[s]uch guidance shall include 
information that is comparative in nature with respect to--
---------------------------------------------------------------------------
    \3\ 29 U.S.C. 1185a(a)(7)(B)(i).

        (I) non-quantitative treatment limitations for both medical and 
        surgical benefits and mental health and substance use disorder 
---------------------------------------------------------------------------
        benefits;

        (II) the processes, strategies, evidentiary standards, and 
        other factors used to apply the limitations described in 
        subclause (I); and

        (III) the application of the limitations described in subclause 
        (I) to ensure that such limitations are applied in parity with 
        respect to both medical and surgical benefits and mental health 
        and substance use disorder benefits.''\4\
---------------------------------------------------------------------------
    \4\ 29 U.S.C. 1185a(a)(7)(B)(ii).

Regarding non-quantitative treatment limitations, the CAA also requires 
DOL to publish guidance that provides clarifying information and 
illustrative examples of methods, processes, strategies, evidentiary 
standards, and other factors that group health plans and health 
insurance issuers may use regarding the development and application of 
non-quantitative treatment limitations to ensure compliance with their 
---------------------------------------------------------------------------
parity requirements, ``including--

        (i) examples of methods of determining appropriate types of 
        non-quantitative treatment limitations with respect to both 
        medical and surgical benefits and mental health and substance 
        use disorder benefits, including non-quantitative treatment 
        limitations pertaining to--

           (I) medical management standards based on medical necessity 
        or appropriateness, or whether a treatment is experimental or 
        investigative;

           (II) limitations with respect to prescription drug formulary 
        design; and

           (III) use of fail-first or step therapy protocols;

        (ii) examples of methods of determining--

           (I) network admission standards (such as credentialing); and

           (II) factors used in provider reimbursement methodologies 
        (such as service type, geographic market, demand for services, 
        and provider supply, practice size, training, experience, and 
        licensure) as such factors apply to network adequacy;

        (iii) examples of sources of information that may serve as 
        evidentiary standards for the purposes of making determinations 
        regarding the development and application of non-quantitative 
        treatment limitations;

        (iv) examples of specific factors, and the evidentiary 
        standards used to evaluate such factors, used by such plans or 
        issuers in performing a nonquantitative treatment limitation 
        analysis;

        (v) examples of how specific evidentiary standards may be used 
        to determine whether treatments are considered experimental or 
        investigative;

        (vi) examples of how specific evidentiary standards may be 
        applied to each service category or classification of benefits;

        (vii) examples of methods of reaching appropriate coverage 
        determinations for new mental health or substance use disorder 
        treatments, such as evidence-based early intervention programs 
        for individuals with a serious mental illness and types of 
        medical management techniques;

        (viii) examples of methods of reaching appropriate coverage 
        determinations for which there is an indirect relationship 
        between the covered mental health or substance use disorder 
        benefit and a traditional covered medical and surgical benefit, 
        such as residential treatment or hospitalizations involving 
        voluntary or involuntary commitment; and

        (ix) additional illustrative examples of methods, processes, 
        strategies, evidentiary standards, and other factors for which 
        the Secretary determines that additional guidance is necessary 
        to improve compliance. . . .''\5\
---------------------------------------------------------------------------
    \5\ 29 U.S.C. 1185a(a)(7)(C).

    Under the CAA, DOL is supposed to publish this guidance 18 months 
after the CAA was enacted (July 2022) and is required to provide at 
least a 60-day public comment period before issuing any final guidance. 
DOL is also required to update this guidance every 2 years. According 
to DOL's latest regulatory agenda, the Department is currently 
scheduled to publish a proposed mental health parity rule that 
incorporates examples and modifications to account for the CAA in July 
---------------------------------------------------------------------------
2022.

    The need for this guidance before imposing any civil monetary 
penalties is abundantly clear from DOL's 2022 MHPAEA Report to Congress 
(https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/
mental-health-parity/report-to-congress-2022-realizing-parity-reducing-
stigma-and-raising-awareness.pdf). The report shows none of the 134 
self-funded employer plans' NQTL comparative analyses ``contained 
sufficient information'' despite the nine sets of FAQs, draft and final 
Disclosure Templates, and several enforcement fact-sheets DOL has 
published. When not one employer plan has a sufficient comparative 
analysis, it is not because none of them want to comply. It is because 
they do not know how to comply.

    Moreover, imposing civil monetary penalties on plan sponsors will 
not solve the serious problem of provider shortages. According to HHS, 
129.\6\ million Americans live in areas designated as Mental Health 
Professional Shortage Areas,6 and 6,559 additional behavioral health 
providers \7\ are needed to fill these provider gaps.\8\ Addressing 
this long-term problem will require significant investments by the 
federal government.
---------------------------------------------------------------------------
    \6\ Bureau of Health Workforce Health Resources and Services 
Administration, U.S. Department of Health and Human Services, 
``Designated Health Professional Shortage Areas Statistics,'' September 
30, 2021, available at: https://data.hrsa.gov/Default/
GenerateHPSAQuarterly
Report.
    \7\ Behavioral health providers are health care practitioners or 
social and human services providers who offer services for the purpose 
of treating mental disorders including: psychiatrists, clinical social 
workers, psychologists, counselors, credentialed substance use 
specialists, peer support providers, and psychiatric nurse providers.
    \8\ Bureau of Health Workforce Health Resources and Services 
Administration, U.S. Department of Health and Human Services, 
``Designated Health Professional Shortage Areas Statistics,'' September 
30, 2021

    Employers have innovated and invested in significant new behavioral 
health benefits during the COVID pandemic. Addressing the current 
mental health care crisis and achieving mental health parity compliance 
will require significant efforts in partnership between employers, 
providers, government, patient groups and other stakeholders. We 
believe that enacting punitive legislative provisions like civil 
monetary penalties at this point will poison these efforts and serve 
---------------------------------------------------------------------------
only to hurt patients.

    To achieve mental health parity compliance, Congress should:

        Encourage DOL to publish the guidance required by the CAA and 
additional de-identified examples of comparative parity analyses that 
are compliant under a final determination letter; and

        Focus on fostering partnerships between employers, providers, 
and carriers rather than punitive legislative provisions which further 
push stakeholders into their respective corners.

Expand the Collaborative Care Model (CoCM)

    To increase access to behavioral health services the Association 
urges Congress to enact the bipartisan Collaborate in an Orderly and 
Cohesive Manner Act (H.R. 5218) to promote the uptake of the 
collaborative care model by providing grant funding to remove the 
barriers that primary care practices face when trying to implement the 
model. The collaborative care model increases access by creating a care 
team comprised of a primary care provider, a psychiatric consultant and 
care manager working together in a coordinated fashion. Over 90 
randomized controlled trials have demonstrated collaborative care 
models are more effective and cost efficient than usual care.\9\
---------------------------------------------------------------------------
    \9\ Jurgen Unutzer, et al., The Collaborative Care Model: An 
Approach for Integrating Physical and Mental Health Care in Medicaid 
Health Homes, Health Home Information Resource Center, May 2013, 
available at: https://www.chcs.org/media/
HH_IRC_Collaborative_Care_Model__
052113_2.pdf.

    Behavioral health conditions often initially appear in a primary 
care setting and primary care clinicians provide mental health and 
substance use care to most people with behavioral disorders, as well as 
prescribe the majority of psychotropic medications. An integrative 
model that joins behavioral health and primary care would significantly 
improve behavioral health services, reduce the burden of other illness, 
lower medical costs, and reduce disparities in the identification and 
---------------------------------------------------------------------------
effectiveness of treatment for behavioral health issues.

    The stigma surrounding mental health and substance use disorders 
results in patients not seeking treatment and even when they do, it can 
be difficult to find a provider in a timely manner. The collaborative 
care model provides a strong building block to address these problems 
by ensuring that patients can receive expeditious behavioral health 
treatment within the office of their primary care physician. 
Importantly, the team members also use measurement-based care to ensure 
that patients are progressing, and when they are not, treatment is 
adjusted.

    In addition to increasing access, the collaborative care model has 
tremendous cost savings potential. For example, cost/benefit analysis 
demonstrates that this model has a 12:1 benefit to cost ratio for the 
treatment of depression in adults.\10\ Furthermore, the model greatly 
increases the number of patients being treated for mental health and 
substance use disorders when compared to traditional 1:1 treatment. 
Lastly but no less important, the model has been shown to increase 
physician and patient satisfaction and reduce stress among primary care 
physicians.
---------------------------------------------------------------------------
    \10\ Washington State Institute for Public Policy Benefit-Cost 
Results for Adult Mental Health. Retrieved from: https://
www.wsipp.wa.gov/BenefitCost?topicId=8.

    Despite its strong evidence base and availability of reimbursement, 
uptake of the collaborative care model by primary care physicians and 
practices remains low due to the up-front costs associated with 
implementing the model. Additionally, many primary care physicians and 
practices may be interested in adopting the model but are unsure of 
next steps. The Collaborate in an Orderly and Cohesive Manner Act 
addresses both potential roadblocks by providing grants to primary care 
practices to cover start-up costs and by establishing technical 
assistance centers to provide support as practices implement the model. 
Moreover, the bill promotes research to identify additional evidence-
based models of integrated care.

 Remove Barriers to Providing and Expanding Telebehavioral Health

    To help improve access to behavioral health care when Americans 
need it Congress should eliminate restrictions that impede an 
employer's ability to provide employees with telehealth services. 
During the COVID pandemic, telehealth became the preferred way for 
patients to see providers and liberalized telehealth rules resulted in 
an exponential growth in the use of telehealth, particularly 
telebehavioral health.\11\ It allowed access to needed care while 
meeting patients' needs of convenience and safety as the virus spread.
---------------------------------------------------------------------------
    \11\ Bestsennyy, O., Gilbert, G., Harris, A., and Rost, J. (2021). 
Telehealth: A quarter-trillion-dollar-post-COVID-19 reality? McKinsey 
and Company. https://www.mckinsey.com/industries/healthcare-systems-
and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-
covid-19-reality.

    A survey of HR Policy members showed that 79 percent of respondents 
offered mental health virtual care and telebehavioral health services 
to their employees to address access challenges.\12\ Telebehavioral 
health has the potential to overcome patient stigma and improve access 
and efficiency of care for behavioral health services. Since the public 
health emergency, there has been a significant increase in patients 
keeping their behavioral health appointments. When patients keep their 
first appointment, they are more likely to keep subsequent appointments 
and patients satisfied with their treatment are more likely to continue 
with their course of therapy. Research also suggests that 
telebehavioral health results in better medication compliance, fewer 
visits to the emergency department, fewer patient admissions to 
inpatient units, and fewer subsequent readmissions.\13\
---------------------------------------------------------------------------
    \12\ HR Policy Association, CHRO Survey 2021.
    \13\ Hilty, D.M., Ferrer, D.C., Parish, M.B., Johnston, B., 
Callahan, E.J. and Yellowlees, P.M. (2013). The effectiveness of 
telemental health: A 2013 review. https://www.liebertpub.com/doi/
10.1089/tmj.2013.0075.

    Despite the positive impact of expanded telebehavioral health, 
state and federal barriers continue to limit employers' ability to 
innovate in the telehealth space. While many positive steps were taken 
to increase flexibility around telehealth offerings during the public 
health emergency, several permanent changes are needed so employers can 
expand the scope of their telehealth offerings. Our recommendations for 
changes to expand access to affordable coverage and care through 
---------------------------------------------------------------------------
telehealth are below.

    Pass the Primary and Virtual Care Affordability Act (H.R. 5541): 
Under the CARES Act, employees with a high-deductible health plan 
(HDHP) were able to access first-dollar coverage of telehealth visits 
through December 31, 2021. Its expiration left many employees without 
the ability to seek care through telehealth without first meeting their 
deductible. While an extension was included in the Omnibus package, it 
was only extended through the end of 2022. For behavioral health 
services, permanent change is especially important as provider 
shortages, in conjunction with limited in-network providers, makes it 
difficult for patients to find affordable in-network providers.

    Allow telehealth services to be treated as an excepted benefit. 
Currently, stand-alone telehealth programs are considered excepted 
benefits and can only be provided to full-time employees enrolled in 
the employer health plan. Part-time, seasonal, and full-time employees 
that declined the employer medical plan cannot access these telehealth 
programs because it violates coverage rules under the ACA employer 
mandate. This was removed temporarily during the COVID-19 pandemic, but 
a permanent solution would allow employers to expand access to 
telehealth services to more employees, specifically younger workers and 
economically disadvantaged workers.

    Allow providers in good standing with a valid license in at least 
one state provide telehealth services to patients in other states. 
While states should remain able to determine licensure requirements 
around prescribing ability or scope of practice, a state should not be 
able to prohibit a provider that is deemed qualified in another state 
from operating according to their licensure. Telehealth increases 
patients' ability to get adequate care from a qualified provider in 
another state. Additionally, cumbersome and expensive credentialing and 
licensing processes disincentivize many providers from obtaining 
licenses in multiple states. Congress should encourage states to join 
interstate medical licensure compacts to expedite the process for 
providers that want to practice in multiple states and expand the 
accessibility of providers for patients in need.

    Enact the Telemental Health Care Access Act (S. 2061, H.R. 4058). 
This legislation will ensure Medicare beneficiaries can access 
telemental health services post-pandemic without satisfying the 
unnecessary and restrictive in-person requirement that was passed into 
law at the end of 2020 that requires physicians to see their patients 
in-person at least six months prior to their telemental visit before a 
Medicare will reimburse for the telehealth visit. Congress should also 
ensure similar restrictions are not imposed on employer plans and 
individual coverage.

    Enact the Telehealth Response for E-prescribing Addiction Therapy 
Services Act or TREATS Act (S. 340, H.R. 1647). This legislation would 
allow certain controlled substances specifically schedules III and IV 
to be prescribed via telehealth without an in-person requirement. It 
also allows telehealth services to be provided via audio-only 
technology, if a physician has already conducted a video or in-person 
visit.

    Enable ERISA plans to offer a uniform set of telehealth benefits. 
Congress passed the Employee Retirement Income Security Act (ERISA) to 
enable employers to provide uniform health care benefits to their 
employees. While health care reforms should offer states greater 
flexibility regarding their individual and small group health insurance 
markets, creating a uniform set to telehealth rules will enable multi-
state employers to create and expand valuable telehealth benefits for 
their plan participants.

Expand the Use of Measurement-Based Care

    It is estimated that only 18% and 11% of psychiatrists and 
psychologists, respectively, use assessment tools regularly.\14\ When 
such tools are used in initial assessments, earlier diagnosis is more 
likely and can prevent conditions from becoming more severe. Outcomes 
improve 20-60% when such tools are used over the course of treatment 
because the provider has additional evidence on the effectiveness of 
the course of treatment.\15\ Measurement-based care provides an 
objective tool for providers, mitigating inherent biases and resulting 
disparities in treatment. Measurement-based care is also a critical 
component of the collaborative care model above.
---------------------------------------------------------------------------
    \14\ Wood, J. and Gupta, S. Using Rating Scales in a Clinical 
Setting. Current Psychiatry 2017; 16[2]: 21-25. Retrieved on January 
14th from https://mdedge-files-live.s3.us-east-2.amazonaws.
com/files/s3fs-public/Document/August-2017/CR02709028.PDF.
    \15\ Fortney, J., et al. A Tipping Point for Measurement-Based 
Care. Psychiatry Serv. 2017 Feb 1;68(2):179-188. doi: 10.1176/
appi.ps.201500439. Epub 2016 Sep 1. PMID: 27582237.
---------------------------------------------------------------------------
Policy Recommendations
        Establish incentives with carriers (e.g., star ratings) and 
providers (e.g., pay for performance) to increase the use of 
appropriate measurement tools when providing care.

        Allocate funds to support a change effort to educate and 
implement measurement-based care across the country. A portion of such 
funds should be allocated to virtual programs such as telebehavioral 
interventions and digital behavioral apps to facilitate behavioral 
health integration models to add measurement-based care for small and 
rural practices in addition to larger practices.

        Instruct the CMS Office of the National Coordinator for Health 
Information Technology (ONC) Health IT Certification Program to mandate 
that certified electronic health record (EHR) vendors must include 
screening and symptom follow up tools using standardized measures (PHQ-
9, https://www.ncbi.nlm.
nih.gov/pmc/articles/PMC1495268/, GAD-7, https://jamanetwork.com/
journals/jamainternalmedicine/fullarticle/410326) for major mental 
health and substance use disorders, including depression, suicide, 
anxiety, PTSD, mania, addiction, and psychotic disorders at no cost to 
providers. Supports for documentation, billing, panel management, and 
tracking measure scores over time should also be included.

        Increase incentives for using existing CPT Codes such as 
GO444, 96127, 96160, 96161, 96130, 96139.

        Include measurement-based care as a standard of care 
regardless of the modality.

    The HR Policy Association and the American Health Policy Institute 
welcome any opportunity to provide input and speak in further detail 
about improving access to behavioral and mental health care services. 
We look forward to working with you on this important topic.

Sincerely,

D. Mark Wilson
President and CEO,
American Health Policy Institute
Vice President, Health and Employment Policy
HR Policy Association

Margaret Faso
Director, Health Care Research and Policy
HR Policy Association
American Health Policy Institute

                                 ______
                                 
           Michael J. Fox Foundation for Parkinson's Research
April 11, 2022

The Honorable Ron Wyden             The Honorable Mike Crapo
Chairman                            Ranking Member
U.S. Senate                         U.S. Senate
Committee on Finance                Committee on Finance
Dirksen Senate Office Building, SD-
211                                 Dirksen Senate Office Building, S-
                                    239
Washington, DC 20510                Washington, DC 20510

RE: Senate Finance Committee hearing titled ``Behavioral Health Care 
When Americans Need It: Ensuring Parity and Care Integration'' hosted 
March 30, 2022

Dear Chairman Wyden and Ranking Member Crapo,

On behalf of The Michael J. Fox Foundation for Parkinson's Research 
(MJFF), I write to express my appreciation to you and the members of 
the committee for hosting a hearing on ``Behavioral Health Care When 
Americans Need It: Ensuring Parity and Care Integration.'' Access to 
behavioral health care is essential for people with Parkinson's disease 
(PD) because the disease makes them prone to adverse mental health 
conditions. We urge the committee to pass legislation to expand the 
behavioral health workforce and remove barriers to accessing behavioral 
health services via telehealth so people with Parkinson's can access 
behavioral health care when and where they need it.

PD is a chronic, progressive neurological disorder affecting over one 
million people in the United States. Currently, there is no treatment 
to slow, stop, or reverse the progression of the disease, nor is there 
a cure. PD is the fastest growing neurological disease in the world and 
is the second most common condition after Alzheimer's disease. 
Currently, PD costs Americans at least $52 billion each year--roughly 
half of which is through Medicare in caring for people living with PD. 
By 2037--just 15 years from now--that cost will balloon to around $80 
billion when more than 1.6 million Americans are projected to be living 
with PD.

PD is often characterized by motor (movement-related) symptoms like 
tremor, stiffness, and walking problems, but the disease also has non-
motor symptoms, including anxiety, depression, and dementia, among 
others. There is an interplay between Parkinson's motor and non-motor 
symptoms, and access to behavioral health services is vital to ensuring 
people with Parkinson's can manage their symptoms and lead healthy 
lives. To ensure people with Parkinson's can access these services, 
MJFF urges the committee to support two key pieces of legislation: the 
Telemental Health Care Access Act of 2021 (S. 2061) and the Mental 
Health Access Improvement Act of 2021 (S. 828).

The Telemental Health Care Access Act of 2021

In the Consolidated Appropriations Act of 2021, Congress included a 
requirement that prevents Medicare from covering telemental health 
services for beneficiaries that have not seen their provider in person 
in the 6 months prior to their telehealth visit once the COVID-19 
public health emergency expires. This in-person requirement for 
telemental health services is the first and only instance of a federal 
statute expressly mandating an in-person exam as a condition for 
Medicare coverage of a telehealth-based service.

MJFF urges the committee to pass the Telemental Health Care Access Act 
of 2021, led by Senators Cassidy (R-LA), Smith (D-MN), Cardin (D-MD), 
and Thune (R-SD), to remove the arbitrary and unnecessary in-person 
requirement for telemental health services. This will allow Medicare 
beneficiaries to maintain access to needed mental health services 
without having to make an in-person visit with their provider. 
Additionally, as expert witness Dr. Anna Ratzliff testified during the 
committee hearing, this is a parity issue and the decision to meet in 
person or via telehealth should be between the provider and their 
patient.

Nearly 90 percent of people with Parkinson's rely on Medicare for their 
health care coverage, and they are prone to mental health conditions 
because of how the disease impacts the brain. In-person requirements 
create barriers to patients seeking care, especially for mental health 
services and patients with disabilities. By passing the Telemental 
Health Care Access Act of 2021, Congress would allow people with 
Parkinson's to maintain access to telemental health services without 
being required to make unnecessary and burdensome trips to see their 
providers in person.

The Mental Health Access Improvement Act of 2021

About one in four Medicare beneficiaries live with a mental illness, 
but a majority (71 percent) of seniors have never been screened for a 
mental health condition. Lack of access to mental health providers 
contributes to this problem. Poor mental health can lead to worse 
health outcomes and greater use of health care services, as well as 
more expensive interventions for non-mental health conditions, for 
older and disabled adults on Medicare, including those living with 
Parkinson's.

MJFF urges the committee to pass the Mental Health Access Improvement 
Act of 2021, led by Senators Barrasso (R-WY) and Stabenow (D-MI), to 
close the gap in federal law that excludes licensed professional mental 
health counselors (LPCs) and licensed professional marriage and family 
therapists (LMFTs) from participating in the Medicare program. LPCs and 
LMFTs participate in virtually all other health plans, including 
Tricare, the Veterans Administration, Medicaid, and most Medicare 
Advantage, commercial, and employer plans. The Mental Health Access 
Improvement of 2021 would expand access to mental health services for 
people with Parkinson's by allowing 225,000 additional licensed and 
highly qualified mental health professionals to participate in the 
Medicare program.

Once again, thank you for hosting this important hearing and allowing 
MJFF the opportunity to recommend policy solutions that will help 
people with Parkinson's access mental health services when and where 
they need them. Please contact Mason Zeagler at 
[email protected] should you have any questions or require 
further information.

Sincerely,

Ted Thompson, JD
Senior Vice President
Public Policy

                                 ______
                                 
              National Association of Health Underwriters

                      999 E Street, NW, Suite 400

                          Washington, DC 20004

                              202-552-5060

                           https://nahu.org/

I am writing on behalf of the National Association of Health 
Underwriters (NAHU), a professional association representing licensed 
health insurance agents, brokers, general agents, consultants and 
employee benefits specialists. The members of NAHU work daily to help 
millions of individuals and employers of all sizes purchase, administer 
and utilize health plans of all types. The health insurance agents and 
brokers that NAHU represents are a vital piece of the health insurance 
market and play an instrumental role in assisting employers and 
individual consumers select health plans that are best for them. These 
plans include coverage for mental and behavioral health benefits as is 
required by law. Eighty-two percent of all firms use a broker or 
consultant to assist in choosing a health plan for their employees \1\ 
and 84 percent of people shopping for individual exchange plans found 
brokers helpful--the highest rating for any group assisting 
consumers.\2\
---------------------------------------------------------------------------
    \1\ Kaiser Family Foundation. Employee Health Benefits Annual 
Survey. October 2013, https://www.kff.org/wp-content/uploads/2012/09/
8465-employer-health-benefits-2013.pdf.
    \2\ Blavin, Fredric, et al. Obtaining Information on Marketplace 
Health Plans: Websites Dominate but Key Groups Also Use Other Sources. 
Urban Institute. June 2014, https://hrms.urban.org/briefs/obtaining-
information-on-marketplace.html.

Access to mental health services is a crucial component of health care. 
National discussion has addressed mental health care for years, but 
often focuses more on physical health. The COVID-19 pandemic has 
reminded us of the importance of adequate mental health care and 
exposed a mental health crisis: About 4 in 10 adults in the U.S. have 
reported symptoms of anxiety or depressive disorder, a share that has 
been largely consistent, up from 1 in 10 adults who reported these 
symptoms from January to June 2019.\3\ For these reasons it is more 
vital than ever that consumers can access and afford behavioral health 
services. These recommendations were put together with the help of 
NAHU's Mental Health Task Force, a legislative working group comprised 
of NAHU members with an advanced understanding of mental and behavioral 
health services and how they are provided and used in health plans.
---------------------------------------------------------------------------
    \3\ Kaiser Family Foundation. Adults Reporting Symptoms of Anxiety 
or Depressive Disorder During COVID-19 Pandemic. 27 September 2021, 
https://www.kff.org/other/state-indicator/adults-reporting-symptoms-of-
anxiety-or-depressive-disorder-during-covid-19-pandemic/?current
Timeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22
%7D.

The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) 
created standards for the financial requirements and treatment 
limitations that a group health plan or group health plan issuer may 
impose on mental health and substance use disorder (MHSUD) benefits. 
MHPAEA established those financial requirements (such as copayments, 
coinsurance) and treatment limitations (such as limits on the number of 
outpatient visits, or prior authorization requirements) cannot be more 
restrictive than those that apply to medical and surgical benefits. 
Regarding financial requirements or quantitative treatment limitations 
(such as the number of inpatient days covered), a plan cannot impose a 
requirement or limitation on MHSUD benefits that is more restrictive 
than what is imposed on two-thirds of the medical and surgical benefits 
---------------------------------------------------------------------------
in the same classification

Most recently, the Consolidated Appropriations Act of 2021 mandated 
that employers offering medical, surgical, and mental health and 
substance use disorder coverage provide comparative analyses and 
relevant supporting documentation demonstrating compliance with mental 
health parity requirements to the Department of Labor upon request. 
Both fully insured and self-funded ERISA plan sponsors are required to 
comply with the quantitative treatment limits imposed by the Mental 
Health Parity Act. Complying with the new CAA mandates and in 
particular the non-quantitative treatment limits (NQTL) reporting is 
challenging for many employers, who, because of their size, must rely 
on their intermediaries such as third-party administrators to monitor 
and comply with network adequacy requirements for access to mental and 
behavioral health care. Smaller plans with fewer compliance resources 
particularly struggle with the complexity of the MHPAEA rules, but the 
complexity concerns in this area extend to plans of all sizes. In the 
event of a Department of Labor request, these employers often will need 
to work with legal counsel to identify treatment limitations and 
contact multiple providers to request information necessary to complete 
comparative analyses. This makes compliance particularly difficult for 
employers who already face other compliance requirements relating to 
the plans they sponsor for employees. To assist employers in this 
regard, NAHU recommends that reporting requirements for ERISA plan 
sponsors be lessened by reducing the number of notices, as well as 
allowing disclosures to be made electronically.

Earlier this year, the Department of Labor, Department of Health and 
Human Services, and Department of the Treasury released the first 
Annual Report to Congress on the Mental Health Parity and Addiction 
Equity Act. Out of the 216 NQTL analyses reviewed by DOL and 21 NQTL 
analyses reviewed by CMS, none were found to meet regulators' 
expectations.\4\ The Report noted that most of the initial findings of 
noncompliance were due to incomplete comparative analyses, which did 
not provide the information, analyses, and supporting documentation the 
Departments anticipated. These findings underscore the difficulties and 
complexities that employers are facing as they try to meet MHPAEA and 
CAA obligations, with employers struggling to determine what is 
necessary to satisfy these requirements.
---------------------------------------------------------------------------
    \4\ https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-
regulations/laws/mental-health-parity/report-to-congress-2022-
realizing-parity-reducing-stigma-and-raising-awareness.pdf.

NAHU also recommends that Congress look at easing certain regulatory 
burdens to allow employers to create new and innovative mental health 
benefits for their employees. Employers want their employees to 
experience the best possible physical and mental health. These healthy 
employees make the best workers and increase productivity in the 
workplace. Because each workforce, workplace and community are 
different and offer different challenges and opportunities, the lack of 
flexibility in meeting mental health parity requirements can make it 
difficult and cumbersome for employers to develop comprehensive mental 
health benefit programs, as there is concern that they could come in 
conflict with one of the many regulations in this area. NAHU recommends 
that employers be given greater flexibility to create new mental health 
benefit programs outside of the current benefits structure. While these 
benefits programs would still be subject to the ACA, MHPAEA, and other 
relevant statutes, the establishment of new stand-alone mental health 
benefit programs separate from group health plans would be of immense 
value for Americans seeking MHSUD services and could even be expanded 
to offer access to mental health care to employees who aren't eligible 
---------------------------------------------------------------------------
for the employer's health plan(s).

Another way in which Congress can improve Americans' access to mental 
and behavioral health services is by addressing the shortage of MHSUD 
providers. While attempts have been made to make improvements in this 
area, there is still a significant amount of ground to cover. 119 
million Americans live in areas designated as ``Mental Health 
Professional Shortage Areas.''\5\ Often it is difficult for patient to 
locate a provider that accepts insurance at all, much less participates 
in their insurer's network. If a provider does participate, that 
participation may not be consistent resulting in provider directory 
inadequacy. A survey of privately insured patients found that 53 
percent of those that used provider directories found inaccuracies in 
their insurer's provider directory, often leading them to receive care 
from out-of-
network providers.\6\ Additionally, recent American Academy of 
Pediatrics data shows that there are, on average, just 9.75 child 
psychiatrists per 100,000 children, and child psychiatrists are 
disproportionately located in larger urban centers; more than two-
thirds of U.S. counties don't have even a single child psychiatrist.\7\ 
According to the Health Resources and Services Administration, an 
additional 6,586 providers would be needed to bridge the gap for 
consumers living in these shortage areas.\8\
---------------------------------------------------------------------------
    \5\ Kaiser Family Foundation. Mental Health Care Health 
Professional Shortage Areas (HPSAs). 30 September 2020, https://
www.kff.org/other/state-indicator/mental-health-care-health-
professional-shortage-areas-hpsas/
?currentTimeframe=0&sortModel=%7B%22colId%22:%
22Location%22,%22sort%22:%22asc%22%7D.
    \6\ Busch, Susan, et al. Incorrect Provider Directories Associated 
with Out-of-Network Mental Health Care and Outpatient Surprise Bills. 
Health Affairs. June 2020, https://www.
healthaffairs.org/doi/10.1377/hlthaff.2019.01501.
    \7\ McBain, Ryan, et al. Growth and Distribution of Child 
Psychiatrists in the United States: 2007-2016. American Academy of 
Pediatrics, https://publications.aap.org/pediatrics/article/144/6/
e20191576/77002/Growth-and-Distribution-of-Child-Psychiatrists-
in?autologincheck=re
directed?nfToken=00000000-0000-0000-0000-000000000000.
    \8\ Health Resources and Services Administration. Shortage Areas, 
https://data.hrsa.gov/topics/health-workforce/shortage-areas.

The workforce shortage is not only an issue in the mental and 
behavioral health sphere. The United States could see an estimated 
shortage of between 37,800 and 124,000 physicians by 2034, including a 
shortfall of between 17,800 and 48,000 primary care physicians.\9\ 
Prior to the COVID-19 pandemic, physician shortages were already 
evident, with 35 percent of voters in 2019 saying they had trouble 
finding a doctor in the previous two or three years. This was a 10-
point jump from when the question was asked in 2015.\10\ To enhance 
Americans' access to mental and behavioral health care, strengthening 
both the mental health and primary care workforce must be a top 
priority. NAHU supports workforce development and training programs 
that aim to increase the amount of MHSUD and primary care 
professionals.
---------------------------------------------------------------------------
    \9\ The Complexities of Physician Supply and Demand: Projections 
From 2019 to 2034. Association of American Medical Colleges. June 2021, 
https://www.aamc.org/media/54681/download
?attachment.
    \10\ Ibid.

Strengthening the workforce of both mental health and primary care 
providers is vital, as a further source of inefficiency impeding 
Americans' access to mental and behavioral health is the lack of 
communication between behavioral health and primary care providers. 
Approximately two-thirds of primary care physicians are unable to 
connect their patients to outpatient mental health services.\11\ Since 
mental and behavioral health is often not integrated with primary care, 
this leaves patients with undiagnosed or poorly managed mental and 
behavioral health conditions, even though mental and behavioral health 
conditions often initially appear in a primary care setting. Currently, 
primary care clinicians provide mental health and substance use care to 
many people with mental and behavioral disorders and prescribe the 
majority of psychotropic medications. NAHU believes that a 
collaborative care model that incorporates behavioral health and 
primary care could significantly decrease the weight of other illness, 
lessen the demand for mental and behavioral health services, and 
thereby lower medical costs and reduce disparities in identification 
and the effectiveness of treatment for behavioral health issues. 
Collaborative care models such as Direct Primary Care arrangements and 
employer-run Accountable Care Organizations would also assist in 
improving collaboration between primary care and behavioral health 
providers.
---------------------------------------------------------------------------
    \11\ Cunningham, Peter. Beyond Parity: Primary Care Physicians' 
Perspectives on Access to Mental Health Care. Health Affairs. 2009, 
https://www.healthaffairs.org/doi/10.1377/hlthaff.
28.3.w490.

State licensure requirements and cross-state-border restrictions also 
remain some of the largest, most complex barriers within the mental 
health space as well as the telemedicine space broadly. Due to the 
COVID-19 pandemic CMS, along with a handful of states, decided to relax 
regulations around telehealth and state-licensure requirements, 
temporarily waiving requirements for licensure in the state where the 
patient was located. This added flexibility was of great benefit to 
patients across the country, particularly MHSUD consumers. For these 
reasons, NAHU recommends that Congress look at ways to facilitate 
reciprocity of state-provided licenses and other ways to ease cross-
state-border restrictions on tele-behavioral health and telehealth 
---------------------------------------------------------------------------
generally.

We appreciate the opportunity to provide these comments and would be 
pleased to respond to any additional questions or concerns of the 
committee. If you have any questions about our comments or if NAHU can 
be of assistance as you move forward, please do not hesitate to contact 
me at either (202) 595-0639 or [email protected].

Sincerely,

Janet Stokes Trautwein
CEO

                                 ______
                                 
    National Center on Domestic Violence, Trauma, and Mental Health

                  55 East Jackson Boulevard, Suite 301

                        Chicago, Illinois 60604

Re: Behavioral Health Care When Americans Need It: Ensuring Parity and 
Care Integration

Domestic and sexual violence and other lifetime trauma can have 
significant mental health and substance use-related consequences for 
survivors. On behalf of the National Center on Domestic Violence, 
Trauma, and Mental Health (NCDVTMH), one of four national Special Issue 
Resource Centers funded by the U.S. Department of Health and Human 
Services' Family Violence Prevention and Services Program, we thank you 
for your focus on behavioral health care. Safe use of telehealth can 
provide domestic violence (DV) survivors access to much needed 
behavioral health services. We are grateful for the opportunity to 
share NCDVTMH's insight which is guided by the experiences of DV 
survivors, up-to-date research, and by an intersectional analysis of 
how systems impact the lives of survivors and their families.

DV is common. According to the Centers for Disease Control and 
Prevention, about 1 in 5 women, 1 in 10 men, and 26%-61% of LTBTQ 
individuals (43.8% of lesbian women; 61.1% of bisexual women; 26.0% of 
gay men; 37.3% of bisexual men; 25%-54% of trans individuals) have 
experienced violence and/or stalking by an intimate partner. DV has 
serious mental health consequences. Abuse by an intimate partner 
significantly increases a person's risk for developing a range of 
mental health conditions, including depression, anxiety, PSTD, eating 
disorders, chronic pain, insomnia, substance use disorders, psychotic 
episodes, and suicide attempts. There are high rates of DV among people 
accessing mental health and substance use disorder treatment. Across 
studies, lifetime DV prevalence rates average 30% for outpatient 
settings, 33% for inpatient settings, and 60% for psychiatric emergency 
settings. Individual inpatient studies report significantly higher 
rates (e.g., 70% of women admitted for a first psychotic episode and 
90% of women admitted for suicidal ideation). Among women accessing 
substance use disorder treatment, 47%-90% reported experiencing DV in 
their lifetimes and 31%-67% in the past year. Furthermore, abuse 
targeting a partner's mental health or substance use are common forms 
of DV. These forms of abuse--referred to as mental health and substance 
use coercion--occur with disturbing frequency. Preventing a partner 
from accessing services, attempting to control providers' perceptions, 
and trying to obtain information about a partner's treatment to use 
against them, particularly in relation to child custody not only 
jeopardizes the well-being of DV survivors and their children, but also 
compromises the effectiveness of mental health and substance use 
disorder treatment.

Telehealth services are critical to ensuring that people who experience 
DV have access to needed mental health and substance use care. At the 
same time, DV survivors report consistent challenges to accessing care 
due to interference by abusive partners (e.g., monitoring or listening-
in to sessions, trying to prevent or disrupt participation, threatening 
the treatment provider). Behaviors such as tracking access to 
technology, monitoring phone and Internet usage, attempting to access 
electronic health records, impersonation, and location surveillance are 
common. Given the widespread adoption of telehealth services and 
efforts to support expanded access, it is crucial that telehealth 
services are both widely accessible and safe. Providing options and 
flexible access to services while maximizing safety, privacy and 
confidentiality are critical. Policies should allow for a wide range of 
telehealth modalities so that patients' evolving personal circumstances 
and/or lack of access to technology, internet, or sufficient broadband 
infrastructure are not limiting factors for safer access to services 
and do not exacerbate existing disparities.

Unauthorized access to personal health information places people who 
experience DV at substantial risk. It is crucial that providers 
mitigate the risk of the misuse of personal health information by 
employing technology and process safeguards that offer the strongest 
possible privacy protections for shielding sensitive information. HIPAA 
protections do not necessarily include enhanced security features that 
are critical for people at risk from disclosure of personal 
information. Therefore, mental health and substance use disorder 
treatment providers serving survivors of DV should be incentivized to 
use technology platforms that offer enhanced privacy protections (e.g., 
protective segmentation and restricted provider/patient-only access to 
personal information, increased levels of encryption, advanced 
authentication tools with flags for when breaches occur, zero-knowledge 
encryption, as well as liability for unauthorized access). These 
protections are necessary in order to shield DV survivors from 
unauthorized disclosure and minimize the avenues through which access 
to personal information can occur. Given that DV is highly prevalent 
and treatment providers are often unaware that a patient is 
experiencing DV, a universal precaution approach is recommended.

NCDVTMH urges Congress to use this opportunity to ensure that where 
behavioral health and telehealth policy overlap that attention is paid 
to the importance of both increasing access to services and protecting 
patient safety. If both of these concerns are not addressed, DV 
survivors are put at greater risk when attempting to receive crucial 
services. We stand ready to be of assistance. Please feel free to 
contact Carole Warshaw, MD, Director of the National Center on Domestic 
Violence, Trauma, and Mental Health at [email protected] should you 
have additional questions.

Enclosure:
Telehealth Recommendations to Support Survivors of Domestic Violence

  Telehealth Recommendations to Support Survivors of Domestic Violence

Why Should Telehealth Policy Consider the Needs of Domestic Violence 
Survivors?

      Domestic violence is common. According to the Centers for 
Disease Control and Prevention, about 1 in 5 women, 1 in 10 men, and 
26%-61% of LTBTQ individuals (43.8% of lesbian women; 61.1% of bisexual 
women; 26.0% of gay men; 37.3% of bisexual men; 25%-54% of trans 
individuals) have experienced violence and/or stalking by an intimate 
partner.
      Domestic violence impacts health, mental health, and substance 
use disorder treatment systems. In addition to the physical health 
impacts, over 50% of survivors of domestic violence have experienced 
depression, PTSD, substance use, and suicidality. Research over the 
past 35 years has consistently demonstrated that people receiving 
services in mental health and substance use disorder treatment settings 
also experience high rates of domestic violence.
      Abuse targeted toward a partner's mental health or substance use 
is common. Preventing a partner from accessing treatment, attempting to 
control providers' perceptions, and trying to obtain information about 
a partner's treatment to use against them--particularly in relation to 
child custody--are common forms of domestic violence.
      Technological abuse is part of domestic violence. Domestic 
violence survivors commonly experience tech abuse from abusive partners 
(e.g., tracking access to technology, monitoring phone and internet 
usage, or location surveillance).

Key Policy Principles and Priorities

The National Center on Domestic Violence, Trauma, and Mental Health 
(NCDVTMH) considers telehealth a valuable care delivery method for 
improving access to safe and timely services for survivors of domestic 
violence (DV) who need health, mental health, and substance use care. 
At the same time, given the safety risks survivors face, telehealth 
legislation should consider DV survivors as a special population with 
unique needs. Here are some specific principles and priorities to 
consider:

 Flexibility Is Necessary to Provide Safer Access to More Comprehensive 
                    Services

Accessing services from home when an abusive partner is present poses 
safety, security, and privacy risks to DV survivors and to other 
household members. At the same time, abusive partners often interfere 
with DV survivors' ability to access in-person services. Providing 
options and flexible access to services while maximizing safety, 
privacy and confidentiality are critical. Policies should allow for a 
wide range of telehealth modalities so that patients' evolving personal 
circumstances and/or lack of access to technology, internet, or 
sufficient broadband infrastructure are not limiting factors for safer 
access to services and do not exacerbate existing disparities.

      Extend access of audio-only communications to all survivors of 
DV accessing mental health or substance use disorder-related telehealth 
services. Many individuals in need of services are not yet established 
patients; therefore, limiting access to audio-only telehealth services 
to established patients only or requiring an in-person visit before 
accessing care via telehealth, could present insurmountable and life-
threatening service barriers for survivors of DV. Additionally, the 
flexibility to extend the 6-month check-in to 12 months should not be 
limited to only existing patients.
      DV survivor safety requires additional originating site 
flexibility. While originating site restrictions have been largely 
removed for mental health and substance use disorder treatment, it is 
imperative that survivors are able to access necessary health, mental 
health and substance use care from any location in which they feel 
safe. This includes allowing established patients to receive care from 
their trusted providers--even if that location is not a ``short 
distance'' from their home.
      Prohibit utilization management tools for mental health or 
substance use-related services. Limiting the frequency of visits or 
restricting sites of service imposes unnecessary barriers to care and 
reduces the likelihood that DV survivors will be able to safely access 
needed services. Both of these obstacles place them at greater risk 
from abusive partners.
      Because survivors of domestic violence are at increased risk for 
experiencing a range of mental health and substance use-related 
conditions, policies should ensure parity of access to all necessary 
services.
          Invest in culturally competent resources and 
translation/interpretation services to support availability of 
telehealth services for all, including people with disabilities, people 
with limited English proficiency, and people who are Deaf or hard of 
hearing.
          Guarantee that services are available in-person, 
via telehealth, or a combination of both.

 Ensure Telehealth Policy Addresses Safety, Privacy, and 
                    Confidentiality Needs of Survivors of DV

DV survivors report consistent challenges to accessing care due to 
interference by abusive partners (e.g., monitoring or listening-in on 
sessions, tracking phone or internet usage, trying to prevent or 
disrupt participation, threatening the treatment provider, attempting 
to access electronic health records).\1\ These tactics--known as mental 
health and substance use coercion--are part of a broader pattern of 
abuse and control designed to undermine a partner's sanity, trap them 
into using substances, control their ability to engage in treatment, 
sabotage their recovery, and use information about their mental health 
or substance use condition to discredit them with friends, family, 
service providers, and the courts. Threats related to child custody and 
retaliation for seeking help are additional tactics of control. 
Protecting the safety and well-being of DV survivors is a critical 
concern for Telehealth policy.
---------------------------------------------------------------------------
    \1\ NCDVTMH, ``Substance Use Coercion as a Barrier to Safety, 
Recovery, and Economic Stability: Implications for Policy, Research, 
and Practice,'' http://www.nationalcenterdvtraumamh.
org/publications-products/su-coercion-reports/.

In order to minimize the risk of retaliation for disclosing abuse and 
to prevent the misuse of personal health information, telehealth 
---------------------------------------------------------------------------
policies should:

      Grant survivors additional protections to shield sensitive 
information and engage in DV-specific informed consent that addresses 
DV safety, privacy, confidentiality concerns; centers survivors' 
individual safety needs; and includes strategies to mitigate risks 
associated with disclosure of personal health information.
      Maintain strict privacy and confidentiality protections in all 
efforts to connect survivors to clinical and non-clinical services and 
supports.

Require Technology and Process Safeguards to Protect Survivor Safety

Unauthorized access to personal information places a survivor of DV at 
substantial risk. It is imperative that policies expanding access to 
telehealth require sensible and potentially life-saving safeguards.

      Establish stricter privacy standards for telehealth technology 
platforms. While HIPAA compliant telehealth platforms offer important 
privacy protections, HIPAA protections do not necessarily include 
enhanced security features that are critical for people at risk from 
disclosure of personal information. Therefore, healthcare, mental 
health and substance use disorder treatment providers serving survivors 
of DV should be required to use secure technology platforms that offer 
enhanced privacy protection (e.g., protective segmentation and 
restricted provider/patient-only access to personal information, 
increased levels of encryption, advanced authentication tools with 
flags for when breaches occur, as well as liability for unauthorized 
access) in order to shield victims from unauthorized disclosure and 
minimize the avenues through which access to personal information can 
occur. Given that DV is highly prevalent and healthcare providers are 
often unaware that a patient is experiencing DV, a universal precaution 
approach is strongly advised.
      Prohibit third-party vendors from accessing patient information. 
Restrictions should include barring third-party vendors from being able 
to access, retain, data mine, or monetize personal information 
contained within the database they sell or support. To reduce access to 
sensitive information by anyone aside from the provider and patient, 
additional protections such as zero-
knowledge encryption must be offered to providers by third-party 
vendors.
      Require providers to receive training on safe use of telehealth, 
including strategies to optimize safety, privacy, and access (e.g., 
timing, location, headphones, code words, safety plans) and strategies 
to address potential technology monitoring concerns (e.g., ensuring 
digital communications do not leave an online trail, enabling and 
rechecking privacy settings, using password protected devices and WiFi 
and/or obtaining secure devices for patients to use during telehealth 
encounters).
      Require the incorporation of DV-specific safety, privacy, and 
confidentiality concerns into informed consent processes.
      Authorize a study to identify best practices for both providers 
and DV survivors to minimize privacy risks when using telehealth.

If you have any questions, please contact Carole Warshaw, M.D., 
Director of the National Center on Domestic Violence, Trauma, and 
Mental Health, at cwarshaw@
ncdvtmh.org.

                                 ______
                                 
              Partnership for Employer-Sponsored Coverage

                            999 E Street, NW

                          Washington, DC 20004

                              703-517-3692

                             www.p4esc.org

April 5, 2022

The Honorable Ron Wyden             The Honorable Mike Crapo
Chairman                            Ranking Member
U.S. Senate                         U.S. Senate
Committee on Finance                Committee on Finance
219 Dirksen Senate Office Building  219 Dirksen Senate Office Building
Washington, DC 20510                Washington, DC 20510

Dear Chairman Wyden and Ranking Member Crapo:

We write to share concerns regarding your March 30, 2022 hearing: 
``Behavioral Health Care When Americans Need It: Ensuring Parity and 
Care Integration.'' The Partnership for Employer-Sponsored Coverage 
(P4ESC) is an advocacy alliance of employment-based organizations and 
trade associations representing businesses of all sizes and the over 
181 million American workers and their families who rely on employer-
sponsored coverage every day. We are committed to ensuring that 
employer-sponsored coverage is strengthened and remains a viable, 
affordable option for decades to come.

We are concerned that this hearing--like so many others concerning 
access to mental health care--is wrongly and punitively focused on 
employers and other payers for health care and mental health care 
benefits. The bigger barriers to access to care come from acute 
shortages of mental health care providers and mental health care 
providers, many who refuse to enter our networks so that employees can 
access care. Telemedicine has been one positive exception to the 
shortages during the pandemic; it is our hope that telemedicine access 
to mental health care services can be made permanent.

Employers work tirelessly to provide quality mental health and 
substance use disorder coverage for our employees and their families. 
Employers have innovated and invested in significant new programs 
during the COVID pandemic. Addressing the current mental health care 
crisis will require significant efforts in partnership between 
employers, providers, government, patient groups and other 
stakeholders. We believe that punitive legislative provisions like 
civil monetary penalties will poison these efforts and serve only to 
hurt patients.

Employers and mental health care providers worked together to build the 
compromise that became the Mental Health Parity and Addiction Equity 
Act of 2008. Employers and providers worked closely with the late 
former Senators Edward Kennedy (D-MA) and Pete Domenici (R-NM) to build 
compromise language that balanced financial parity in coverage with 
health plan and insurer's retained ability to medically manage that 
coverage. It is this latter element--particularly as regards 
noneconomic factors, such as network adequacy, formulary design, and 
step therapy--that is at issue now.

Civil monetary penalty enforcement proposes to impose network adequacy 
requirements by penalizing employers based on the raw number of mental 
health or substance use disorder providers in network. Yet, employer 
networks consistently report that these providers refuse to bargain in 
good faith and decline to participate in our networks at reasonable 
rates. Provider shortages--inside as well as outside networks--are 
rampant. According to HHS, 129.6 million Americans live in areas 
designated as Mental Health Professional Shortage Areas.\1\ There are 
6,559 additional BHC providers \2\ needed to fill these provider 
gaps.\3\ Provider shortages, in conjunction with limited in-network 
providers, make it difficult for patients to find affordable in-network 
providers.
---------------------------------------------------------------------------
    \1\ Bureau of Health Workforce Health Resources and Services 
Administration, U.S. Department of Health and Human Services, 
``Designated Health Professional Shortage Areas Statistics,'' September 
30, 2021, available at: https://data.hrsa.gov/Default/
GenerateHPSAQuarterly
Report.
    \2\ Behavioral health providers are health care practitioners or 
social and human services providers who offer services for the purpose 
of treating mental disorders including: psychiatrists, clinical social 
workers, psychologists, counselors, credentialed substance use 
specialists, peer support providers, and psychiatric nurse providers.
    \3\ Bureau of Health Workforce Health Resources and Services 
Administration, U.S. Department of Health and Human Services, 
``Designated Health Professional Shortage Areas Statistics,'' September 
30, 2021.

Additionally, employers and other issuers have repeatedly and earnestly 
urged the DOL's Employee Benefits Security Administration to provide 
adequate guidance regarding the applicable mental health parity 
standards.  As evidenced by the DOL's recent 2022 MHPAEA Report to 
Congress in which NO plans were without findings under agency review--
we believe the agency has failed to provide sufficient implementing 
guidance for any plan to truly comply.  While we believe employers and 
other payers wish to comply, there is and will continue to be no way to 
do so without additional rulemaking guidance and time to come into 
---------------------------------------------------------------------------
compliance.

We implore you to call on the agency to work in partnership with all 
the stakeholders and provide additional guidance. Without this guidance 
we will continue to see the intent of MHPAEA inadvertently frustrated 
by well-intentioned employers and other payers who are trying to do 
their best in the absence of adequate agency implementation. We are 
concerned and wary of the defeating cycle of attempting to comply, but 
perpetually being found lacking because the rules are not adequate or 
clear.

We believe the call for civil monetary penalties is premature. Civil 
monetary penalties, at this point, will add unnecessary tension and 
fear into what we think should be a partnership to breathe life into 
the MHPAEA requirements in a fulsome and sustainable way. Penalties 
distract from and compound the absence of guidance and may make a 
confusing situation into chaos. Plans and payers are doing their best 
to build a house without adequate blueprints and calling for civil 
monetary penalties is like the designer standing on the sidewalk, 
yelling ``you're doing it wrong,'' and then charging for design changes 
after the fact. It's not fair, efficient, or good for the system as a 
whole.

Imposing penalties on plan sponsors cannot solve provider shortages. 
The federal government should not put its thumb on the scale in private 
negotiations between providers and employers. In keeping with the 
spirit of the mental health parity law, employers should be treated on 
par with providers.

We would welcome the opportunity to discuss these issues with you or 
your respective staff. If such a meeting would be of interest to you, 
please have your staff contact P4ESC's Executive Director Neil 
Trautwein at [email protected].

Sincerely,

Partnership for Employee-Sponsored Coverage (P4ESC)

                                 ______
                                 
                     Smarter Health Care Coalition

                     900 16th Street, NW, Suite 400

                          Washington, DC 20006

             Statement of Andrew MacPherson, Ray Quintero, 
                    and Katy Spangler, Co-Directors

Chairman Wyden, Ranking Member Crapo, and Members of the Senate Finance 
Committee, it is our pleasure on behalf of the Smarter Health Care 
Coalition (``the Coalition''), to submit this testimony to provide 
input on the behavioral health care needs of the nation and how 
Congress can ensure that they are appropriately addressed through 
policy changes. The Coalition represents a broad-based, diverse group 
of health care stakeholders, including consumer groups, employers, 
health plans, life science companies, provider organizations, and 
academic centers. We urge Congress to include the Chronic Disease 
Management Act of 2021 \1\ in the upcoming mental health package to 
improve access to critical mental and behavioral health prescription 
drugs and services.
---------------------------------------------------------------------------
    \1\ https://www.congress.gov/bill/117th-congress/house-bill/3563/
text?r=15&s=1#::text=Intro
duced%20in%20House%20(05%2F28%2F2021)&text=To%20amend%20the%20Internal%2
0Reve
nue,to%20satisfying%20their%20plan%20deductible.

A key area of focus for the Coalition is ensuring patients have access 
to high-value health care services. Based on research conducted over 
several decades, many employers and health plans have changed their 
plan designs to remove cost-sharing for high-value drugs and services 
that treat populations with chronic conditions, who recent studies have 
suggested are more likely to also suffer from behavioral health 
disorders such as depression.\2\ Regulatory and legislative barriers, 
however, have continued to inhibit some of these value-based plan 
designs. Specifically, Health Savings Account (HSA)-eligible plans have 
limited ability to offer services and medications to manage chronic 
conditions on a pre-deductible basis.
---------------------------------------------------------------------------
    \2\ http://www.cdc.gov/pcd/issues/2005/jan/04_0066.htm.

Guidance issued in 2019 by the Internal Revenue Service,\3\ Notice 
2019-45, was a helpful step in granting more flexibility to employers 
and health plans to offer certain chronic disease prevention pre-
deductible, but more work remains. The Chronic Disease Management Act 
of 2021 builds on and expands the flexibility included in Notice 2019-
45 by granting health plans and employers more flexibility to vary 
their benefit designs and offer high-value care pre-
deductible. The rapid expansion of plans with high deductibles, in 
conjunction with the global COVID-19 pandemic, makes enacting this 
policy even more timely and important.
---------------------------------------------------------------------------
    \3\ https://www.irs.gov/pub/irs-drop/n-19-45.pdf.

The COVID-19 pandemic has claimed more than 900,000 lives in the United 
States, and its stressors have exacerbated the behavioral health 
crisis, affecting thousands.\4\ More than 42% of people surveyed by the 
US Census Bureau in December 2020 reported symptoms of anxiety or 
depression, an increase from 11% the previous year.\5\ Notably, this 
crisis disproportionately affects certain populations, such as those 
that have historically been underserved within the health care system. 
Nearly half of all Black, Hispanic, Asian, Native American and LGBTQ+ 
individuals say they have personally experienced increased mental 
health challenges over the past 12 months, but few received treatment, 
according to a poll by the National Council for Mental Wellbeing.\6\ 
For those who have tried to seek treatment, many are faced with 
challenges related to inaccessibility and unaffordability.
---------------------------------------------------------------------------
    \4\ https://www.kff.org/coronavirus-covid-19/issue-brief/the-
implications-of-covid-19-for-mental-health-and-substance-use/.
    \5\ https://www.nature.com/articles/d41586-021-00175-z.
    \6\ https://www.thenationalcouncil.org/wp-content/uploads/2021/07/
National-Council-Minority-Mental-Health-PPT-Analysis-July-
2021-.pdf?daf=375ateTbd56.

In 2013 mental disorders topped the list of most costly conditions, 
with spending at $201 billion.\7\ Despite over 90% of general health 
care services being billed through insurance plans, an estimated 45% of 
psychiatrists do not accept any form of insurance and a much larger 
portion accept only a very limited set of plans.\8\ The statistics 
illustrate the need for additional flexibility allowing employers and 
health plans to offer mental and behavioral health drugs and services 
pre-deductible for Health Savings Account-eligible plans.
---------------------------------------------------------------------------
    \7\ https://www.healthaffairs.org/doi/full/10.1377/
hlthaff.2015.1659.
    \8\ https://jamanetwork.com/journals/jamapsychiatry/article-
abstract/1785174.

Survey results from various publications have shown an overwhelming 
positive response to Notice 2019-45 in the form of employers and health 
plans making changes to their plan designs to cover more high-value 
services pre-deductible. The 2021 AHIP and Smarter Health Care 
Coalition survey found that 75% of health insurance plans responding 
covered additional services pre-deductible in their fully insured 
products and 80% of plans covered additional services pre-deductible in 
their self-insured products.\9\ The 2021 Employee Benefit Research 
Institute (EBRI) survey of employers found three in four employers 
(76%) say that they have added pre-deductible coverage as a result of 
IRS Notice 2019-45.\10\ These results highlight how much interest 
exists among health plans and employers to make it easier for their 
enrollees and employees with chronic conditions to access high-value 
health care that will prevent exacerbation of their conditions, 
especially those related to mental and behavioral health, including 
depression, anxiety, opioid use disorder, and many other conditions.
---------------------------------------------------------------------------
    \9\ https://www.ahip.org/wp-content/uploads/202109-AHIP_HDHP-
Survey-v03.pdf.
    \10\ https://www.ebri.org/docs/default-source/ebri-issue-brief/
ebri_ib_542_hsaemployersur-14oct21.pdf?sfvrsn=73563b2f_2.

The Coalition greatly appreciates your leadership to improve access to 
health care services for Americans with mental health and substance use 
disorders. Given the overwhelming, positive response to Notice 2019-45, 
the very high number of employers and health plans who modified their 
benefits to make it easier for patients with chronic disease to afford 
care, as well as the nation's growing mental and behavioral health 
needs tied to COVID-19, we urge Congress to include the Chronic Disease 
Management Act of 2021 in the upcoming mental health package as one 
small step to improve access to critical mental and behavioral health 
---------------------------------------------------------------------------
drugs and services.

                                 ______
                                 
                 Society for Human Resource Management

                            1800 Duke Street

                       Alexandria, VA 22314-3499

                            +1-703-548-3440

                          +1-703-535-6490 Fax

                        +1-703-548-6999 TTY/TDD

                           https://shrm.org/

April 7, 2022

The Honorable Ron Wyden             The Honorable Mike Crapo
Chairman                            Ranking Member
U.S. Senate                         U.S. Senate
Committee on Finance                Committee on Finance
219 Dirksen Senate Office Building  219 Dirksen Senate Office Building
Washington, DC 20510                Washington, DC 20510

Dear Chairman Wyden and Ranking Member Crapo:

SHRM (the Society for Human Resource Management) thanks you for your 
interest in expanding access to mental health services and holding the 
hearing titled ``Behavioral Health Care When Americans Need It: 
Ensuring Parity and Care Integration'' on March 30. As the voice of all 
things work, workers and the workplace, SHRM is committed to preserving 
and improving critical employer-sponsored benefits like health care. 
However, we have concerns with proposals that have the potential to 
increase costs for both workers and employers rather than improving 
network adequacy and access to mental health providers.

The Mental Health Parity and Addiction Equity Act already requires that 
financial and treatment limitations applied to mental health and 
substance use disorder benefits and services are no more restrictive 
than for medical or surgical benefits and services. We believe there 
are better policies to expand access to mental health benefits without 
imposing arbitrary and punitive fines. The committee should explore 
network adequacy, the talent pipeline for mental health providers and 
the ability of telehealth services to increase access to care.

SHRM appreciates that Congress recently restored the ability of 
employers to offer health plans that provide pre-deductible telehealth 
services for workers with high-deductible health plans and health 
savings accounts (HDHP-HSAs). This policy expires on December 31, 2022, 
and a permanent extension would provide both workers and employers the 
necessary certainty regarding the availability of these benefits. SHRM 
research shows that 43 percent of our members increased the 
telemedicine services available to employees during the COVID-19 
pandemic and that health care is the employer-provided benefit that 
employers believe is the most important to their workforce.

SHRM and our members stand ready to be a resource for the Senate 
Committee on Finance in your work to expand access to mental health 
services. Please contact us any time we can be of assistance to the 
committee.

Sincerely,

Emily M. Dickens
Chief of Staff, Head of Government Affairs, and Corporate Secretary

                                 [all]