[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
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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
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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\
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\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\
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\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
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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\
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\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).
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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\
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\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/.
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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\
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\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.
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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\
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\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.
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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\
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\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.
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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\
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\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.
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\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.
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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.
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\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
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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.
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\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\
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\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).
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\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
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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.
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\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
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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.
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\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\
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\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\
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\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.
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\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.
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\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
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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.
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\39\ https://mmhpi.org/wp-content/uploads/2020/09/COVID-
MHSUDPrevention.pdf.
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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.
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\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.
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\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.
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\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
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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.
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\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.
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\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
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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\
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\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\
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\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
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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.
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\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
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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\
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\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-
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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\
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\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.''
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\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
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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\
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\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.
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\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
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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.
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\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
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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\
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\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\
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\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\
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\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\
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\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.
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\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\
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\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\
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\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\
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\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\
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\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\
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\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\
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\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
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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\
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\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\
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\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.
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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\
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\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.
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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.
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\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
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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\
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\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\
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\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\
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\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\
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\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/.
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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\
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\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\
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\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
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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\
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\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\
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\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.
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\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.
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\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\
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\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\
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\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
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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
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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.
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\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
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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\
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\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
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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.
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\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.
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\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.
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\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.
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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\
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\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.
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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\
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\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.
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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).
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\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.
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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.
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\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.
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\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.
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\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.
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\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
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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.
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\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\
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\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.
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\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.
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\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
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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.
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\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
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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.
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\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.
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\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
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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:
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\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:
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\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/.
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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.
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\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.
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\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:
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\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.
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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.
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\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,
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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\
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\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\
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\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
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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\
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\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
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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\
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\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
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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.
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\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
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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\
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\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
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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.
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\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.
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\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\
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\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
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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.
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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\
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\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]