[Senate Hearing 118-574]
[From the U.S. Government Publishing Office]
S. Hrg. 118-574
BARRIERS TO MENTAL HEALTH CARE: IMPROVING
PROVIDER DIRECTORY ACCURACY TO REDUCE
THE PREVALENCE OF GHOST NETWORKS
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HEARING
BEFORE THE
COMMITTEE ON FINANCE
UNITED STATES SENATE
ONE HUNDRED EIGHTEENTH CONGRESS
FIRST SESSION
__________
MAY 3, 2023
__________
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Finance
__________
U.S. GOVERNMENT PUBLISHING OFFICE
58-968 PDF WASHINGTON : 2025
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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 TIM SCOTT, South Carolina
SHERROD BROWN, Ohio BILL CASSIDY, Louisiana
MICHAEL F. BENNET, Colorado JAMES LANKFORD, Oklahoma
ROBERT P. CASEY, Jr., Pennsylvania STEVE DAINES, Montana
MARK R. WARNER, Virginia TODD YOUNG, Indiana
SHELDON WHITEHOUSE, Rhode Island JOHN BARRASSO, Wyoming
MAGGIE HASSAN, New Hampshire RON JOHNSON, Wisconsin
CATHERINE CORTEZ MASTO, Nevada THOM TILLIS, North Carolina
ELIZABETH WARREN, Massachusetts MARSHA BLACKBURN, Tennessee
Joshua Sheinkman, Staff Director
Gregg Richard, Republican Staff Director
(II)
C O N T E N T S
----------
OPENING STATEMENTS
Page
Wyden, Hon. Ron, a U.S. Senator from Oregon, chairman, Committee
on Finance..................................................... 1
Crapo, Hon. Mike, a U.S. Senator from Idaho...................... 3
WITNESSES
Myrick, Keris Jan, M.S., M.B.A., vice president of partnerships,
Inseparable, Washington, DC.................................... 4
Resneck, Jack, Jr., M.D., president, American Medical
Association, Chicago, IL....................................... 6
Trestman, Robert L., Ph.D., M.D., chair and professor, Department
of Psychiatry and Behavioral Medicine, Carilion Clinic,
Virginia Tech Carilion School of Medicine, on behalf of the
American Psychiatric Association, Washington, DC............... 8
Giliberti, Mary, J.D., chief public policy officer, Mental Health
America, Alexandria, VA........................................ 9
Rideout, Jeff, M.D., MA, FACP, president and CEO, Integrated
Healthcare Association, Oakland, CA............................ 11
ALPHABETICAL LISTING AND APPENDIX MATERIAL
Crapo, Hon. Mike:
Opening statement............................................ 3
Prepared statement........................................... 43
Giliberti, Mary, J.D.:
Testimony.................................................... 9
Prepared statement........................................... 43
Responses to questions from committee members................ 49
Myrick, Keris Jan, M.S., M.B.A.:
Testimony.................................................... 4
Prepared statement........................................... 52
Responses to questions from committee members................ 54
Resneck, Jack, Jr., M.D.:
Testimony.................................................... 6
Prepared statement........................................... 58
Responses to questions from committee members................ 64
Rideout, Jeff, M.D., MA, FACP:
Testimony.................................................... 11
Prepared statement........................................... 71
Responses to questions from committee members................ 76
Trestman, Robert L., Ph.D., M.D.:
Testimony.................................................... 8
Prepared statement........................................... 78
Responses to questions from committee members................ 83
Warren, Hon. Elizabeth:
``Majority Study Findings: Medicare Advantage Plan
Directories Haunted by Ghost Networks,'' May 3, 2023,
Senate Committee on Finance................................ 88
Wyden, Hon. Ron:
Opening statement............................................ 1
Prepared statement........................................... 93
Communications
AHIP............................................................. 95
American Association of Payers Administrators and Networks....... 100
American Medical Association..................................... 102
Association for Behavioral Health and Wellness................... 107
Blue Cross Blue Shield Association............................... 109
Center for Fiscal Equity......................................... 110
First Focus on Children.......................................... 113
Legal Action Center et al........................................ 115
Medicare Rights Center........................................... 118
Mental Health Association of Rhode Island........................ 123
National Association of Benefits and Insurance Professionals..... 125
Zocdoc........................................................... 128
BARRIERS TO MENTAL HEALTH CARE:
IMPROVING PROVIDER DIRECTORY
ACCURACY TO REDUCE THE PREVALENCE
OF GHOST NETWORKS
----------
WEDNESDAY, MAY 3, 2023
U.S. Senate,
Committee on Finance,
Washington, DC.
The hearing was convened, pursuant to notice, at 10 a.m.,
in Room SD-215, Dirksen Senate Office Building, Hon. Ron Wyden
(chairman of the committee) presiding.
Present: Senators Stabenow, Cantwell, Menendez, Carper,
Cardin, Brown, Bennet, Casey, Warner, Whitehouse, Hassan,
Cortez Masto, Warren, Crapo, Grassley, Cornyn, Thune, Cassidy,
Lankford, Johnson, Tillis, and Blackburn.
Also present: Democratic staff: Shawn Bishop, Chief Health
Advisor; Eva DuGoff, Senior Health Advisor; and Joshua
Sheinkman, Staff Director. 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 Finance Committee will come to order.
Today across America, insurance companies are selling
mental health coverage to our people worried about their mental
health or that of their loved ones. Unfortunately, too often,
after these insurers take big premiums from our people, they
let them down.
The providers they advertise are not available. They cannot
get appointments. The firm basically says, ``We are not taking
new patients,'' which of course was not represented to them
initially in that way. The fact is, these Americans are being
ripped off by what the Government Accountability Office has
described as a ``ghost network.'' Not my language, the language
of the Government Accountability Office.
Now to me, what a ghost network is all about is essentially
selling health coverage under false pretenses, because the
providers who have been advertised are not picking up the
phone, they are not picking up patients. And in any other
business, if a product or service does not meet expectations,
consumers get a refund.
In my view, it is a breach of contract for insurance
companies to sell their plans worth thousands of dollars each
month, while their product is unusable--unusable due to a ghost
network. So I am going to work with all of my colleagues here
on both sides, Democratic and Republican, to get some real
accountability for these patients who pay good money for mental
health coverage and then find that there is very little
``there'' there.
And in a moment of national crisis about mental health,
with the problem growing at such a rapid rate, the widespread
existence of ghost networks is unacceptable. When somebody is
worried about their mental health or the mental health of a
loved one, it is hard to work up the courage, hard to work up
the courage to step up and try to coordinate their care.
And if they cannot get help, the last thing they need from
a big insurance company is a symphony of ``please hold'' music
when they call, and nonworking numbers, and rejection. I think
we can all imagine, because we are all hearing from our
constituents--I am looking at my Republican colleagues. I have
talked to almost all of them personally about this mental
health challenge, and we have been working on it together.
But what I have described is not a hypothetical matter.
Last month, my staff conducted a secret shopper study. They
made over 100 calls to make an appointment with a mental health
provider for a family member with depression, and they looked
at 12 Medicare Advantage insurance plans in six States. The
results were clear. Our secret shoppers could get an
appointment--now this is after people had paid vast sums--they
could get an appointment only 18 percent of the time.
That means more than 8 in 10 mental health providers listed
in these insurance company materials were inaccurate or were
not taking appointments. A third of the time the phone number
they called was a dead end completely. In one instance, staff
trying to reach a mental health provider was connected to a
high school student health center. And Senator Cassidy is a
real pro at all this, all this health issue. I think both of us
have probably said we laughed, but we really feel like crying
for the patients, and I think it is kind of representative of
it.
By the way, in my home State--I am not very proud of what
our investigators found there too. My staff did not find that
we could make one successful appointment. Other secret shopper
studies looking at commercial health insurance found the same
thing. In 2017, researchers posing as parents seeking care for
a child with depression got an appointment 17 percent of the
time. In 2015, pretty much the same results.
Ghost networks are an ongoing, persistent problem. The
Finance Committee has been looking closely at this issue, and
we put a lot of sweat equity into developing legislation to
improve mental health care for all Americans, from telehealth
to youth mental health to workforce care, integration, and
parity.
I can look down the row starting with Senator Crapo and my
Republican colleagues, because we have been working on this on
a bipartisan basis, and we've got plenty more to do, as Senator
Crapo and I talk about in our weekly conversations.
Finally, just looking at the ghost network issue--to wrap
up--it is a three-legged approach. We have to have more
oversight, great transparency, and serious consequences for
insurance companies that are fleecing American consumers. I
believe, certainly, greater transparency, for example, ought to
be an easy one for members of this committee to get around.
I do not know anything about the accountability you get
with transparency being a partisan issue. So I want to work
with my colleagues on that issue, on the accountability
questions, and I want to look at this across the board, not
just with respect to Medicare and Medicaid. And many of my
colleagues have expressed interest in applying policies to
commercial insurance like employer-sponsored plans.
We have a lot of work to do. There is not going to be
anything partisan about it, and let me yield to my friend,
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, Senator Wyden. And you know, it
is no secret to anybody that you and I have prioritized mental
health delivery in America. In the last Congress, we got a
number of major initiatives through and signed into law, but
there are a number of major initiatives, such as this one, that
we still have work to do on, and I appreciate the opportunity
to work with you on it.
The last Congress, as I said, we came together to enact
dozens of bipartisan policies to expand access to mental
health-care services. These reforms will increase the number of
providers participating in Medicare, and allow patients to
receive care in more convenient locations, including through
telehealth.
However, in order for these improvements to achieve their
potential, patients need accurate and up-to-date information on
their health-care options. I have long championed Medicare
Advantage for its ability to offer patients choice and control
over their health care. Through robust competition and
innovative benefit offerings, Medicare Advantage provides
consumer-focused health coverage to millions of Americans.
As enrollment continues to grow, improving the accuracy of
provider directories could further strengthen Medicare
Advantage. The patient-provider relationship is the foundation
of the health-care system. Whether a patient is suffering a
mental health crisis or just received a troubling diagnosis,
directories should serve as crucial tools to help seniors
across the country.
While we work to better align incentives to improve
provider directory accuracy, we must also do so without
increasing burdensome requirements that will only weaken our
mental health workforce. Regulatory red tape and reimbursement
strain, among others, can also decrease patient access,
exacerbating physician shortages, compounding burnout, and
eroding health-care access and quality.
Congress should build on their targeted relief measures
like the ones we advanced last year, including temporary
physician fee schedule support and Medicare telehealth
expansion, to address these issues on a bipartisan and
sustainable basis. Physician payment stabilization and
telehealth coverage for seniors have received strong support
from members of both parties in both chambers.
As we look to enhance Medicare, we should prioritize these
and other bipartisan goals, and we must do so in a fiscally
responsible manner. I look forward to hearing from our
witnesses today about the opportunities to streamline and
improve provider reporting requirements, empower patients, and
give them accurate information to advance a more transparent
health-care system.
Thank you.
[The prepared statement of Senator Crapo appears in the
appendix.]
The Chairman. Thank you, Senator Crapo, and you have
certainly laid out a number of areas where we can continue our
bipartisan cooperation. I look forward to pursuing it with you
and with all our colleagues.
Let me introduce our witnesses briefly. Keris Myrick is
vice president of partnerships at Inseparable, a nonprofit
organization working to improve mental health care. We welcome
you, ma'am, and I know you are a leading mental health advocate
and executive.
Dr. Jack Resneck is here. He is the president of the
American Medical Association. Good to see you again, Dr.
Resneck. I know you are a professor and chair of the Department
of Dermatology at the University of California at San
Francisco, and you and I have been in health-care discussions a
number of times over the years, and we are glad you can be
here.
Robert Trestman, Ph.D., M.D., comes to us at the
recommendation of the American Psychiatric Association
organization, and is at the forefront of mental health parity
and provider health accuracy. We welcome you, Dr. Trestman. We
have a long relationship with the American Psychiatric
Association.
Mary Giliberti, J.D., serves as chief public policy officer
for Mental Health America. She is also author of an important
blog series called ``Designed to Fail,'' looking at how these
powerful special interests determine the quality and
accessibility of so much of mental health care in America.
And then we are glad to have Dr. Jeff Rideout, the
president and CEO of the Integrated Healthcare Association. He
is recognized for his work in provider data management utility.
That is a mouthful, but in plain, old English, it makes sure
that there is a focus on, particularly now, when there is so
much content out, making sure it is presented in an
intelligible way, and we appreciate it. Glad you are here.
Let us begin with you, Ms. Myrick.
STATEMENT OF KERIS JAN MYRICK, M.S., M.B.A., VICE PRESIDENT OF
PARTNERSHIPS, INSEPARABLE, WASHINGTON, DC
Ms. Myrick. Thank you, Chair Wyden, Ranking Member Crapo,
and members of the Senate Finance Committee. Thank you for
conducting this hearing today, and providing me the honor of
testifying regarding ghost networks and provider directories.
My name is Keris Myrick, and I am vice president of
partnerships for Inseparable, a nonprofit working to advance
policy that reflects the belief that the health of our minds
and our bodies is inseparable. I am also a mental health
advocate and survivor, with lived experience of ghost networks
in health plans.
I am here today to share my story and bring attention to
this very critical issue. Ghost networks erect invisible,
unexpected barriers within our health systems, preventing
people from accessing the care and support that they need. They
are particularly damaging for those of us who are living with
serious mental health conditions like me, as they can result in
delayed or inadequate treatment, or even going without, any of
which can be devastating and have devastating consequences.
My first experience with ghost networks occurred when I had
to change my health insurance due to a new position with the
Federal Government in 2014. Navigating the Blue Cross/Blue
Shield for Federal Employees provider directory to find a
psychiatrist in the DC or Maryland area turned into one
rejection after another.
Call after call resulted in the following types of
responses: ``Who? Hmm. She does not work here. No, I do not
know where they are.'' ``Who? I do not know who that is. I am
not sure they ever worked here. Hold please.'' Dial tone. Or a
recorded message: ``Dr. (fill in the blank) is no longer
accepting new patients. If this is an emergency, hang up and
dial 911.''
I spent countless days and hours scouring the networks and
finally found a psychiatrist who was taking new patients.
Success, though, was short-lived. In a call to set up an
appointment, I was asked about my diagnosis, and I responded
without any hesitation ``schizophrenia.''
A pause, a long silence, and then the response ``Oh, I do
not take patients with schizophrenia.'' I asked if they had any
suggestions or referrals to help me find a doctor who does, and
the answer was ``check the provider directory.'' Going back to
the directory was like looking for a needle in a haystack--lots
of hay, very few needles, and none that can stitch together the
needs of my schizophrenia garment.
Finally, I contacted my psychiatrist back in California and
asked if and how he could remain my doctor. I ended up flying
regularly to Los Angeles at my own expense for over a 4-year
period, to ensure that I could be and stay well. I also paid
high out-of-network copays, but at least I had a provider.
On the same plan, when I needed a doctor for what turned
out to be thyroid cancer, I was able to find an endocrinologist
the very same day. But for mental health, it was a very
different story, a story that continued throughout my career.
In 2018, I began working for the Los Angeles County Department
of Mental Health.
My L.A.-based psychiatrist now was my colleague, so I had
to find another psychiatrist. I searched the provider directory
with trepidation and received dead-end responses. In 2020 and
2022, I dealt with new insurance plans and new provider
directories. Each time, it felt like the movie ``Groundhog
Day''--with the all-too-
familiar responses: there is no provider here; no one by that
name; oh, they are retired or they are not taking new patients;
there is literally no ``there'' there.
Unfortunately, my story is not unique. Many of my peers
with mental health diagnoses face similar challenges,
regardless of whether they are covered by Medicare, Medicaid,
or private insurance. Even today, despite having health
insurance that is otherwise considered excellent, I have no
regular psychiatrist.
This leaves me with ongoing anxiety about what will happen
if I should need more intensive or ongoing care. I have
experienced being unhoused, unemployed, having interactions
with the criminal justice system, and involuntary
hospitalizations. I do not ever want to go through those
traumatizing experiences again, just because I was not able to
find a provider through my health plan's directory and get the
help I need to stay well.
I do not have to worry about this for my thyroid condition;
I have a specialist, an endocrinologist readily available under
every insurance plan. Why then do I not have the same for my
mental health?
Senator Wyden, you had said, ``Too often Americans who need
affordable mental health care hit a dead end when they try to
find a provider that is covered by their insurance. Ghost
networks mean that the lists of mental health providers in
insurance company directories are almost useless''; never a
truer word. As a survivor with lived experience of ghost
networks in health plans, I urge the committee to act on this
critical issue through policies, and I have three
recommendations.
One, provide the oversight, enforcement, and incentives
necessary to result in highly accurate provider directories.
Two, require the inclusion of psychiatric subspecialties in
directories. And three, implement a federally operated
mechanism like an online reporting system or dedicated 1-800
number for consumers and plan members to report their
experiences of ghost networks, and use that information to
enforce policy and inform policy and enforcement actions.
So, thank you again for the opportunity to share my story
today. Mr. Chair and members of the committee, I would be happy
to answer any questions that you may have for me at this time.
[The prepared statement of Ms. Myrick appears in the
appendix.]
The Chairman. I think it is very clear you are going to get
plenty of questions, Ms. Myrick, and we thank you very much for
being here.
Let's go to Dr. Resneck.
STATEMENT OF JACK RESNECK, JR., M.D., PRESIDENT, AMERICAN
MEDICAL ASSOCIATION, CHICAGO, IL
Dr. Resneck. Chairman Wyden, Ranking Member Crapo, thank
you for the invitation to participate in this hearing. I am
Jack Resneck, president of the American Medical Association. I
am a practicing physician and chair of the Department of
Dermatology at the University of California, San Francisco.
As you said, physician provider directories are critically
important tools. They help patients shop for and select
insurance products that cover physicians who are already part
of their health-care team, and find in-network care that they
need once they are covered. They help physicians make referrals
for our patients, and they serve as a representation of a
plan's network adequacy for regulators. So, when directory
information is incorrect, the results are costly and
devastating for patients, as you heard from Ms. Myrick and her
lived experience.
You know, at a time when our Nation is fighting a mental
and behavioral health crisis, inaccurate directories are not
only an absolutely infuriating barrier for patients and
families already in great periods of stress--who must waste
time calling practice after practice to find one that is
actually in-network and accepting new patients--but they help
mask the fact that insurers consistently and, frankly,
egregiously fail to provide adequate networks and comply with
parity laws, causing harm to millions of Americans. The problem
is not limited to mental health.
You know, not only have I read the many studies showing the
scope of problems with provider directories, but I conducted
one of these studies myself, so this hearing is of particular
interest to me. A few years ago, I had med students call every
dermatologist listed in directories for many of the largest
Medicare Advantage plans in a dozen U.S. metropolitan areas.
They sought appointments for a fictitious patient with a
severe rash, and the results were dismal. Of 4,754 listings,
almost half represented duplicates. Among the remaining
listings, many of those practices did not exist, had never
heard of the listed physician, or reported that they had died,
retired, or moved away. Others were not accepting new patients
or were the wrong subspecialty altogether.
So in the end, just 27 percent of listings were unique,
accepted the listed plan, and offered an appointment. And
sadly, more recent studies, including your own, Mr. Chairman,
demonstrate that these problems persist and maybe even are
worsening. Achieving directory accuracy is not simple, and I
acknowledge that physician practices do have a role to play.
But the responsibility of directory accuracy ultimately lies
with the plans.
Being listed correctly in the directory is a fundamental
component of a physician health plan contract, and health plans
are not making it easy for physicians to help. I work at a
pretty big academic medical center. You would think our big
staff devoted to this work would equate to more accurate
listings.
But health plans are typically taking 6 to 8 months to add
or delete physicians after we notify them of changes. They do
not use standardized formats, so we have to send different
rosters with different formatting to each and every one. For
big and small practices--typically contracting with 20 or more
plans--this amounts to a costly and just demoralizing
administrative burden.
It is happening at a time when the physician workforce,
emerging from the pandemic with skyrocketing levels of burnout,
is facing a web of growing and wasteful obstacles from these
same health plans, obstacles like prior authorization.
My physician colleagues, they need to be freed up to spend
time doing what drew us all to medicine in the first place:
taking great care of our patients. So what are some solutions?
Well first, in 2021, the AMA collaborated with CAQH to examine
the pain points for both physicians and health plans in
achieving directory accuracy, and I am here to urge all
organizations charged with regulating health plans to take a
more active role in regularly reviewing and assessing the
accuracy of directories.
For example, regulators should require health plans to
submit accurate directories every year--that is what patients
deserve; audit directory accuracy more frequently; take
enforcement action against plans that fail to maintain complete
and accurate directories, with monetary penalties; encourage
stakeholders to develop common standards for updating physician
information in their directories so practices like mine do not
have 20 different methods; and require plans to immediately
remove physicians who no longer participate in their network.
My study was in 2014, and here we are today. Enough is
enough. We can fix this. Moreover, I urge policymakers to
continue examining issues that phantom networks and inaccurate
directories may be masking, problems like overall workforce
shortages, a lack of network adequacy, and plans' rampant
failures to adhere to mental health parity laws.
Thank you so much for considering my comments. I am happy
to take questions, and I am looking forward to the discussion
later. Thank you.
[The prepared statement of Dr. Resneck appears in the
appendix.]
The Chairman. Great.
Dr. Trestman?
STATEMENT OF ROBERT L. TRESTMAN, Ph.D., M.D., CHAIR AND
PROFESSOR, DEPARTMENT OF PSYCHIATRY AND BEHAVIORAL MEDICINE,
CARILION CLINIC, VIRGINIA TECH CARILION SCHOOL OF MEDICINE, ON
BEHALF OF THE AMERICAN PSYCHIATRIC ASSOCIATION, WASHINGTON, DC
Dr. Trestman. Chairman Wyden, Ranking Member Crapo, and
members of the Senate Finance Committee, on behalf of the
American Psychiatric Association, I really want to thank you
for conducting this hearing, and for all of the work you have
been doing in this domain. We greatly appreciate your
continuing bipartisan efforts to confront the mental health and
substance use crises in our country, and we are grateful for
the opportunity to give testimony today.
Ghost networks affect private-sector health plans purchased
by individuals and employers and public plans like Medicaid and
Medicare Advantage. My written testimony references data from
several studies about the ubiquitous nature of directory
inaccuracies. These include, as we have already heard,
misrepresentations that clinicians are accepting new patients,
wrong phone numbers, and even listings for clinicians who are
no longer in the State. But I would like to speak to you about
my personal experience with how phantom networks affect our
patients, burden physicians and other providers, and increase
costs.
My department at Carilion Clinic is in rural Virginia. We
deliver over 90,000 care visits per year to individuals living
with a broad range of complex mental illnesses and substance
use disorders. Access to care in rural settings like mine is
particularly challenging.
These areas are generally physician shortage areas to begin
with, and patients can be required to travel for hours to find
psychiatric care. Finding anyone who is accepting new patients
can be nearly impossible. Carilion Clinic is the region's only
tertiary center, and we function as the public health point of
access for so many people.
My clinic is in almost all networks, and our waiting list
for patients currently numbers over 800 people. For those who
are healthy and well-educated, going through an inaccurate
provider list and being told repeatedly that we are not taking
new patients, this provider is retired, we no longer accept
your insurance, or leaving a message that no one returns, is
frustrating.
But for people experiencing significant mental illness or
substance use disorders, the process, at best, is demoralizing
and, at worst, is a set-up for clinical deterioration and a
preventable crisis. Many are already experiencing profound
feelings of worthlessness, grief from loss and trauma, and/or
the impact of substance use. Patients have shared with me that
they felt themselves repeatedly rejected, and that somehow the
fact that they could not find a provider was their fault.
Some give up looking for care. At Carilion, keeping our
credentialing updated with insurance plans is time-consuming
and expensive. We have multiple full-time employees doing
nothing but maintaining our credentialing with insurance
companies and public payers, including Medicaid and Medicare
Advantage. This is a burden insurance companies, I believe,
should bear, not those of us trying to provide desperately
needed care.
The national administrative burden for physician practices
to send directory updates to insurers through disparate
technologies, schedules, and formats is $2.76 billion annually.
Not all mental health clinicians practice in settings like mine
that are willing and able to invest the resources needed to
participate in the networks.
Private practitioners make up a significant portion of the
psychiatric workforce, and many do not participate in the
networks because of the administrative burden. Ghost networks
are both a cause and a symptom of a system that has
shortchanged mental health care for decades. We need the help
of Congress to change that. My written testimony includes
recommendations that we ask the committee to consider, many of
which you are already pursuing.
It is time to hold plans accountable for maintaining
accurate directories and making accurate representations to
patients, to clinicians, and to employers. Our patients also
need public and private-sector plans to be held accountable to
the mental health parity law.
Further investment in expanding the mental health
workforce, particularly in underserved areas, is vital. Our
Congress might further incentivize the adoption of models of
integrated care like the collaborative care model that improves
outcomes and expands access, while furthering the support of
our primary care physicians in their ability to deliver a lot
of the care.
Thank you for the opportunity to testify. I look forward to
your questions.
[The prepared statement of Dr. Trestman appears in the
appendix.]
The Chairman. Great. Thank you, Doctor.
Ms. Giliberti?
STATEMENT OF MARY GILIBERTI, J.D., CHIEF PUBLIC POLICY OFFICER,
MENTAL HEALTH AMERICA, ALEXANDRIA, VA
Ms. Giliberti. Chair Wyden, Ranking Member Crapo, and
members of the Senate Finance Committee, thank you for the
opportunity to testify today regarding provider directory
inaccuracies and ghost networks--issues that my organization
has been working on for over a decade--that cause great harm.
My name is Mary Giliberti, and I lead the public policy
efforts for Mental Health America. My written testimony details
my experiences helping friends, families, and community members
access mental health providers. The very first question I ask
them is, ``Do you need these services covered by insurance?''
I ask that question because I know it is going to be
quicker and less effort if they can pay out of pocket, but so
much more expensive. For example, I was helping one young woman
who, like many others, found that her mental health condition
was deteriorating during COVID, and her therapist recommended
that she seek medication.
Not surprisingly, she wanted to pay a minimal copay and not
hundreds of dollars each visit. So I helped her make a list of
recommended psychiatrists that were on her directory, and by
now you have heard the story many times. She started making
calls. Some did not call her back. Others told her they were
not on her network, even though they were in her directory.
Weeks went by, and her condition only worsened.
Fortunately, somebody at work knew of a telehealth option
in her plan, and she was able to get in-network care, but only
after a very painful delay. Some people, as was noted, give up
entirely after making these unsuccessful calls. When you are
experiencing symptoms like lack of motivation, anxiety, and
psychosis and you are getting worse, you are least able to
navigate these inaccurate directories.
And these are not just anecdotes. They are supported by
many studies, and unfortunately, Chair Wyden, your State did
not do very well either in this study of Medicare managed care
programs. Using claims data, researchers found that two-thirds
of the mental health prescribers listed in the plan directories
were phantoms who were not billing the plan--two-thirds.
Reviews of Medicare Advantage plans also show high levels of
inaccuracies.
So what can be done? We know from studies of State statutes
that it is not enough to just require accurate directories.
That has been done, and over this past decade has not worked.
We have three recommendations for policy change. First, the
data must be verified by a reliable method, such as an
independent audit and claims data. At nonprofit organizations
like mine, we cannot just submit our financial data. We have to
have it audited by somebody.
Last week, CMS issued a proposed Medicaid managed care
access rule requiring States to use secret shopper surveys by
an independent entity. The surveys would determine the accuracy
of directories and wait times for mental health and substance
use services, among others. This policy is an important step
forward and should be finalized, but CMS also needs to require
audits of Medicare Advantage plans through its own review and
those of independent entities.
Plans also should be required to use their claims data to
periodically reconcile these directories. With the workforce
shortages we have, if they are not seeing somebody--you know,
we know that if they are not filing claims, they are not seeing
people; they are not in the directory.
Second, the information should be transparent. In other
areas of health care, CMS requires transparency. This area
needs more sunlight. The proposed Medicaid rule requires secret
shopper information to be posted on a State website. That
should be very easily understood by consumers and regulators,
and we should have that kind of transparency across all plans
regulated by CMS, so we can see what is going on by plan. Not
in the aggregate, but by plan.
Third and most importantly, plans have to be fiscally
incentivized to provide accurate directories. This requires
carrots and sticks. On the carrot side, we can incorporate
accuracy rates into overall quality ratings that affect which
plans consumers choose and bonus payments like the star rating
system. It is important that the plans that are doing well are
rewarded for doing well.
Then we should have penalties for those that are not doing
so well, similar to HIPAA's enforcement provisions, with
compliance reviews, clear benchmarks, and civil monetary
penalties that are enough to change behavior. An individual
should always have financial protection if they rely on an
inaccurate directory.
In my written testimony, I reference related areas that
would also affect directories, including reimbursement rates,
integrated care, telehealth flexibilities, and expanding parity
coverage to Medicare Advantage and Medicaid and Medicare fee-
for-service.
In conclusion, there will always be some provider directory
inaccuracies. But the high rates consistently revealed in
recent studies are not minimal errors. They are consumer and
government deception, misrepresenting the value of the plan,
undermining consumer choice, and causing great suffering. With
the right verification of data, transparency requirements, and
fiscal incentives, we can do so much better.
Thank you, and I look forward to your questions.
[The prepared statement of Ms. Giliberti appears in the
appendix.]
The Chairman. Thank you, Ms. Giliberti, and we will have
questions, for sure.
Dr. Rideout?
STATEMENT OF JEFF RIDEOUT, M.D., MA, FACP, PRESIDENT AND CEO,
INTEGRATED HEALTHCARE ASSOCIATION, OAKLAND, CA
Dr. Rideout. Good morning, Chairman Wyden, Ranking Member
Crapo, and members of the committee. Thank you for inviting me
here today. I am Dr. Jeff Rideout, president and CEO of the
Integrated Healthcare Association, a California leadership
group whose members include physician groups, health plans,
hospital systems, regulatory agencies, and other health-care
stakeholders.
Among our many programs, IHA manages a California-wide
provider data management program called Symphony, which is the
focus of my remarks today. The issue of provider information
accuracy is of great professional concern to me. Prior to
joining IHA, I was the first senior medical advisor at Covered
California, our State's insurance exchange, overseeing the
launch and shortly following the wind-down of its first online
provider directory.
So I am very familiar with the challenges in creating
accurate provider information. The problem is real and
pervasive. The key question is how to solve for it. The
accuracy challenges that were exposed in that early Covered
California effort led to new regulatory requirements in
California through Senate Bill 137. It also led to a
comprehensive industry effort to address the longstanding
challenges in provider data accuracy, which became the Symphony
program.
Symphony's goal is to simplify and unify how providers and
health plans share, reconcile, and validate provider directory
information. With our technology partner Availity, we are
creating a single utility designed to be the primary source of
information, which will replace existing and nonaligned
processes between health plans and providers.
As an output of the process, Symphony creates a ``golden
record'' by applying a strict set of agreed-upon rules that
determine what the best information is when the information
from multiple organizations is conflicting. It is a form of
machine learning. The more organizations, the greater the
likelihood of finding errors before this information goes back
to the plans and providers for inclusion in their directories.
Symphony now has 17 contracted health plans, more than 100
contracted provider organizations, and is also engaged with
Covered California. In fact, participation in Symphony is a
Covered California contractual requirement for all
participating plans. Symphony currently maintains over 170,000
unique provider records and supports more than 300 data
elements, such as ``license verification'' and ``accepting new
patients.'' Ultimately, sustainable provider data improvement
requires a collaborative solution.
The Centers for Medicare and Medicaid Services said it best
in a 2018 report: ``It has become that a centralized repository
for provider data is a key component missing from the accurate
provider directory equation.'' Symphony is exactly that type of
centralized repository.
What have we learned so far? Provider data encompass
literally hundreds of specific data elements, and most need to
be verified on a very frequent basis. We need more. We need
more data elements related to LGBT support. We need more data
elements related to race and ethnicity. So this problem of the
data elements will just grow, not shrink.
In addition to the data itself, providers need to attest to
the accuracy of the information every 90 days or sooner. Under
these conditions, providers are much more willing to do so if
they can attest once for multiple plans. Understand it is the
provider data that is ultimately populating a provider
directory, and it is the ultimate source of accuracy.
Based on the number of different data elements, all
Symphony stakeholders now have agreed to prioritize the data
elements most important to consumers, such as ``accepting new
patients.'' Symphony is a dynamic process that continues to
adapt. Before Symphony could even get started processing data,
we had to first create standards that conform with regulatory
requirements. These include standards for timeliness, data
quality and completeness, and data accuracy. Critically these
are the same across multiple plans and provider organizations.
This allows Symphony to provide a mastering process to identify
inconsistencies and resolve them.
Identifying inaccuracies and correcting them is necessary,
and it is feasible. In the last 30-day period for Symphony,
provider data from 169,000 unique providers identified over
138,000 inconsistent data elements, which we call updates or
corrections, that require health plan and provider changes.
Of these, 5,000 were errors in physical office address,
which is an access issue, while nearly 2,200 were related to
license issues. We do this every 90 days; improving provider
data accuracy is a complex undertaking. For independent
providers, which mental health providers are more likely to be,
this can be cost-prohibitive.
Without a centralized data repository that supports a
multiplan provider directory, health plans and providers will
be unable to maintain accurate provider data and directories
individually, even with the best of intentions. This is
critical for mental and behavioral providers, who are
increasingly less likely to be in health plan networks, making
it even more critical for them to be able to update their data
in a convenient, single, centralized repository.
Thank you for your attention.
[The prepared statement of Dr. Rideout appears in the
appendix.]
The Chairman. Thank you very much.
Ms. Myrick, I was listening to your eloquent statement, and
I was saying to myself, ``What is it like in America when
someone like you who was in the Obama administration, who
specializes in health care, gets bounced around the mental
health system the way you described?'' I just kept thinking to
myself, ``What is it like for the typical person and the
typical family if they go through what you describe?''
I think the question I have for you--because I think you
are Exhibit A for why we so desperately need reform--is, what
is going to be the consequence of doing nothing? What if the
insurance companies just keep doing business as usual, what are
going to be the consequences, because it seems to me the
problem you describe--intersecting with the tremendous increase
in demand--is a big problem for the country.
So just if you would, paint the picture of what happens if
we do not do the kinds of reforms that you and your colleagues
are talking about.
Ms. Myrick. Thank you for the question. I do not know that
I am a soothsayer, but I think--you know, if I think about the
consequences, much of what I talked about in my testimony, that
if you are going without health care and you are going without
mental health care, the consequences are dire.
We see them in our statistics related to people with mental
health conditions who become unhoused, who are criminalized,
who end their own lives. And so really, I think the
consequences, at the end of the day, are about the difference
between life and death, and that is pretty dire.
The Chairman. We may have to put you in charge of the
Federal Government. By the way----
Ms. Myrick. No thank you.
The Chairman. That's right. You want to be in California.
When you were making those comments, your colleagues,
particularly the physicians on the panel, everybody was
nodding. So, thank you for that.
Let me go to you, Ms. Giliberti, with respect to the
financial burden of these ghost networks. As I mentioned, you
know, the Finance Committee made, it felt like a gazillion
calls, but 120 looked for an appointment for a senior with
depression. The vast majority of cases, the vast majority--it
would be one thing if it was incidental--resulted in a dead-end
phone call. We were able to make an appointment 18 percent of
the time after hours and hours on the phone.
And the reason I wanted to talk to you is because it
reminded me a little bit of my Gray Panthers experiences, what
you were talking about, and kind of crunching some of the
numbers. For some patients who were able to make an
appointment, they found out that the provider they saw, who was
listed in their plan's directory, was actually out of network.
So the patient gets stuck with the bill. Now why should the
patient be on the hook here? The insurance company is not doing
what they purported to do when they were taking the consumer's
money. And yet the patient--and what you have been describing
and others who are advocating for consumers, which seems to me
actually backwards, is the insurance company has not done what
they indicated that they would do, but it is the patient who is
on the hook when they desperately need coverage and they have
to go out of network. What should the committee do in a
situation like this?
I want to--my friend Senator Crapo has always been so
constructive on this. We work in a bipartisan way. So, when we
see a problem, we say, ``Hey, where is the common ground we can
get Democrats and Republicans to be for? What is that kind of
common ground here, so that we can actually help that patient,
who in my view is just being fleeced?''
That is what we said back when I was codirector of the Gray
Panthers. We did not talk health lingo. We said, ``This person
is just being fleeced.'' But now we have to figure out how to
navigate reforms. What kind of reform should Senator Crapo and
I pursue here with our colleagues?
Ms. Giliberti. Well, first of all, it should not be the
responsibility of the individual, right? In my view, they
should be compensated for the stress that comes when you get a
bill like that. You open the paper, and it is like, you know,
hundreds of dollars. You expect a $25 copay, and you are
looking at hundreds of dollars. They should compensate you for
that stress, and instead, you are expected to pay that.
So, if the directory is inaccurate, the consumers should
pay in-network prices--so, their regular old copay--and the
plan should have to cover the rest of that cost, because their
directory was inaccurate. So it should not fall on the person
who is least able to bear this cost, right?
I mean, if you think about these companies, who is in the
best position to bear the cost, the individual or the company
where the mistake was made, and they represent this network.
That is part of what you are paying for when you choose that
plan, when a consumer goes to the website to choose a Medicare
Advantage plan.
And that is one of the advantages, right? They can pick
one. But they pick based on what they see, and then if it is
not accurate, that should not be their problem. They should not
have to pay for that.
The Chairman. I am over my time. Thank you all. The panel
has been excellent.
Senator Crapo?
Senator Crapo. Thank you, Senator Wyden.
And, Dr. Rideout, I would like to start with you. And I am
going to ask a question similar to the one that Senator Wyden
just asked Ms. Giliberti, and that is--well, first of all,
thank you for the work that you have done on the ground in
terms of helping to improve the accuracy of provider
directories.
You talked about a lot of important things in your
testimony. If you could just summarize for us, what are some of
the key practices that we need to be focusing on here as the
solution? Bring it down to some of the best.
Dr. Rideout. Well, I think you highlighted several of them,
transparency being one: better auditing being one; potentially,
penalties being another. My concern would be, if this is done
without sort of on-the-ground operational solutions, you would
double down on bad practices.
We will get more intensity from health plans to avoid
penalties. We will get more suppression of networks,
potentially. We will get more urgency and challenges for the
physicians and other providers who cannot afford it and are
really being distracted from what they are doing.
So I think, ultimately, having a single source of truth,
however that is organized--whether by State or nationally--
gives everybody a fighting chance to say this problem is about
intentions or it is about accuracy, or it is a combination of
both. So I would say it is hard work, but you have to kind of
get that part fixed as well, or else we will just double down
on what is happening now.
Senator Crapo. Well, thank you.
And, Dr. Resneck, again following up on the same thing. You
mentioned in your testimony that the physicians are facing a
crisis here themselves, trying to deal with the solution, and
we are seeing a lot of unprecedented stress and burnout
exacerbated by administrative burdens.
We do not want another government program or another
government mandate that just puts burdens on everybody and does
not get to the solution. If you could just concisely bring it
down to what are some of the best things we should consider
here to achieve this objective, without causing the damage that
could be caused?
Dr. Resneck. We appreciate your leadership on this, and the
bipartisan engagement. There are some things we think you can
do, and there are some excess regulations to reduce. We would
love to talk about it at another hearing. This is one area
where we actually need congressional help, and I think there
are some straightforward things.
We hear from HHS that they do not think they have the tools
to audit and enforce and impose monetary penalties on the MA
plans and the exchange plans that they have oversight of. I
know it may not be in this committee's jurisdiction, but the
Department of Labor needs additional authority around ERISA
plans. And then we at the American Medical Association are
putting in a lot of work with our colleagues in State medical
associations and specialty societies, going to States to make
sure that insurance commissioners also at the State level have
increased authority.
If we do not have monetary penalties on these plans for
continuing to put out these fake directories to make their
networks look bigger than they are, we are not going to make
progress.
Senator Crapo. Well, thank you.
And, Dr. Trestman, according to the National Institutes of
Health, Americans in rural communities, as you indicated in
your testimony, experience a significant disparity in mental
health outcomes, even though the rates of mental illness are
consistent in rural and metropolitan areas.
Over the course of the past two Congresses, we have
explored how different problems within our mental health-care
system disproportionately impact rural communities. Could you
just tell us, from your experience in practicing psychiatry in
a rural community, how do inaccurate provider directories and
other access issues impact these areas differently than
metropolitan areas?
Dr. Trestman. Thank you, Senator. I think many of the
issues are identical. The challenge is that provider
directories are even more sparse for us, and the geography is
really challenging. The challenges that our patients have faced
have driven us to many limited resolutions.
Oftentimes, their primary care physicians have been tasked
to take care of the psychiatric issues because there is no one
else available. Helping us to empower them is really critical
as well.
I think that telehealth has been another extraordinary
advantage--for people with broadband access and the ability to
afford data plans. They have telehealth with video, which is
wonderful. But in many rural areas, including mine, they do
not. This last week, I did some of my visits by audio-only,
because that is all that was available.
Senator Crapo. All right; thank you. Thank you very much.
The Chairman. A very important point. Senator Crapo and I,
during our telehealth discussion, we heard consistently from
rural communities that they support broadband, but if they do
not have it, they want audio-only.
Senator Cornyn is next.
Senator Cornyn. Thank you, Mr. Chairman, for this hearing
today. Thanks to all the witnesses. This is a disturbing issue,
the ghost networks.
I wanted to ask, though, there is a bill that Senator
Cortez Masto and I have introduced--and, Dr. Trestman, you
happened to mention this in your written testimony--the
Complete Care Act.
I know the nature of practicing medicine has evolved a lot,
probably during your professional career, both yours and Dr.
Resneck's. But one of the things that seems to make a lot of
sense to me--as we now are embracing the whole person and not
just dealing with physical health but mental health too--is to
find ways to integrate mental health into physician practices.
Could you share more about how you think the bill might be
able to help, Dr. Trestman?
Dr. Trestman. Absolutely, and thank you so much for your
work on this. As I understand the bill, the opportunity is with
the partnership between primary care and psychiatry.
We have seen some challenges over the years, and I worked
closely with our colleagues who developed the collaborative
care model at the University of Washington. I have worked with
people around the country, and I have tried to implement the
collaborative care model in my own health system.
It is challenging, and frankly, the challenge is not so
much on the side of psychiatry. The challenge is on the side of
primary care. It is hard to change work flows. It is hard to
have an integration and support system. So I think that the
complete proposal that you and Senator Cortez Masto have
developed is critical, because it front-loads reimbursement and
support for primary care, to make this real for the first few
years. That is central and a wonderful opportunity.
Senator Cornyn. Well, we look forward to working with you
and others on that. I know the chairman and ranking member have
talked about things that Congress has done recently in the
mental health area, and certainly I agree with them that the
status quo is completely unacceptable. We have failed to
provide that mental health safety net.
But one of the things that I would just draw your attention
to or refresh your memory on is, we passed the Bipartisan Safer
Communities Act last year. It was Senator Tillis and I who were
involved in hot and heavy negotiations with Senator Sinema and
Senator Murphy on this, after the terrible shooting in Uvalde.
But one of the most overlooked aspects of that, I think,
happens to be one of the most important aspects of it, that is:
expanding the Certified Community Behavioral Health Clinics and
the funding for that. As you know, that had been a pilot
program. Senator Stabenow and Senator Blunt had been taking the
leadership on that for many years, and I congratulate them for
that. They have really led the way.
But we made, I think, the single largest investment in
mental health delivery in American history, which is incredible
and great. But here is the challenge. Dr. Resneck, where are we
going to find the workforce? Where are we going to find the
trained physicians, psychologists, counselors, and the like?
Dr. Resneck. It is a great question, and I am glad you
brought it up, Senator. As you all probably know and we have
talked with all of you about over the years--and many of you
have led in this area--we have a graduate medical education
crisis in the United States as well, and psychiatry is a part
of it.
But it is really across all specialties where we are now
seeing shortages. Patients are facing long wait times. I think
about this in a few ways. So, there is the front end, as you
mentioned: training more physicians and non-physician
clinicians and nurses, et cetera. We need more GME dollars. We
need support for that big bill that will help to accomplish
that.
Training physicians does take a while. We need immigration
reform and additional resources for the Conrad 30 program, to
help to grow that as well. That provides critical physician
access in cities around the country. I also think about
workforce as sort of the tail end of the pipeline. I am worried
because, as I look at my colleagues around the country, I see
soaring rates of burnout in the last few years.
We know all the things that contribute to that. But, if we
continue to have health plans adding burdens to physicians,
whether it is prior auth, whether it is inaccurate directories,
we have one in five physicians telling us that they are likely
to retire in the next 2 years.
So we could acutely lose a lot of that workforce too. So it
is important that we think both about the training end, and
about getting those obstacles and burdens out of the way, so we
retain the workforce we have.
Senator Cornyn. Thank you. And of course, that applies, as
you have indicated, not just to physicians, but to allied
health-care professionals and even school counselors, where
part of the problem is. We made an investment in safer schools
too, because that is where most of the mental health problems,
I believe, are likely to be identified and then referred for
the kind of care that these kids need in order to get well and
not get sicker and sicker and be a danger to themselves and
perhaps others.
Thank you, Mr. Chairman.
The Chairman. I thank my colleague. And my colleague, who
spent a lot of time on these mental health issues and, with
Senator Stabenow, has been doing some good work, is making a
very important point. That is, we have a big challenge ahead of
us, some serious lifting with respect to workforce.
That is why Senator Crapo and I so appreciated the chance
to work with the two of you, Senator Stabenow and yourself, on
those workforce issues. The fact is, in the gun safety bill,
the reason we were able to get it in was we had taken the time
to write black letter law and we were ready to go, and the two
of you spearheaded the effort. We are going to build on it.
I do want to make sure that, apropos of my approach to
this, I am going to be all in, all in on these workforce
issues. But that is not the same thing as running a ghost
network, which is misrepresentation. So we've got to deal with
both of these issues, and I look forward to working with my
colleagues in a bipartisan way on both of these questions.
Senator Grassley is next.
Senator Grassley. Well, can you skip me?
The Chairman. Of course.
Senator Grassley. There is nobody to skip to, right?
The Chairman. No, we have plenty of people. What we will do
is, because Senator Grassley has strong views on these issues,
we will have Senator Tillis now, and then Senator Stabenow, and
if other colleagues are on the way, let us get Senator Tillis
and Senator Stabenow and Senator Grassley in, and then I hope
other colleagues will come.
Senator Tillis?
Senator Tillis. Thank you, Mr. Chair. Thank you all for
being here.
I am glad that Senator Cornyn brought up the Safer
Communities Act. People call it a gun safety bill; I call it a
mental health and safer communities bill, because it is an
extraordinary investment. And I am proud that North Carolina is
one of the first 10 States to receive the tranche of funding to
expand behavioral health access, particularly in rural
communities, but across the board.
Ms. Myrick, back in 2007 I was diagnosed with an illness
that required me to take medications that caused me to have
pharmacologically induced mania, followed by clinical
depression, so I got a window into mental health that I
consider to be a blessing.
Had I not had a wife--you know, when I was in mania, I felt
like I could fix any problem anyway--I simply would not have
sought a health-care or a behavioral health professional. When
I was in depression, if I went to a website, went through what
you did, I would have said, ``What's the use?''
So we need to understand, this has real-life consequences,
and you are in the worst possible state to have the complexity
and maybe even have it in the middle of depression, finding out
that you have to pay out-of-network costs. So now you have
financial stressors, you have whatever the underlying condition
is. The insurers, the providers, everybody needs to understand
that.
I want to get to getting regulations right. I think if we
are punitive, then the resources to the health care, to the
insurers are going to come from somewhere, and most likely they
are going to come from the pockets of patients at the end of
the day or from providers by lower provider rates.
So we have to get this right, but we have to do something.
What would be wrong with HHS and CMS--I worked for Big Four
audit firms in management consulting for most of my
professional career, and for one thing, it is shocking to me
that the insurers would not have it as a part of their annual
audit regimen. All of them have internal audits, they have the
skill. They have to have it, and compliance.
It is shocking to me that they do not have an audit program
of record where they are going through their provider networks.
So rather than mandating that, why could we not move towards
mandating to CMS--and giving CMS the technology, the resources
necessary to do it--that we are going to perform audits? We are
going to determine--I think in one example of Medicare provider
information, we found that they are about 50 percent accurate.
What would be wrong with an audit or a review by CMS giving
them an F, because they have a failing grade, and having that
published on the website?
A part of the carrot--and I think a competitive advantage
for the insurers--would be go to the CMS website, see our
rating. We have an A, B, C grade, one star, two stars. But why
not a kind of an incentive for them to just make this a part of
standard operating procedure, auditing it and then getting the
underlying information systems that they have in place to get a
higher grade?
Because if we come down with a heavy hammer, they are going
to comply, but that is also taking their attention away from
finding additional providers, driving down the cost of
insurance, and a number of other things. What would be wrong
with a light regulatory regimen as a way to start that I think,
generally, would get bipartisan support?
Ms. Giliberti. Well, I think that that is absolutely an
important component, so it would be a great advance forward.
Senator Tillis. Yes.
Ms. Giliberti. You know, obviously, we would like the whole
piece, but I think that having that would be very, very
helpful. CMS has done some auditing, but they did not identify
the plans, which I think is what you are saying, Senator----
Senator Tillis. Yes, but I think if you can do that, you
are going to find the audit at a test ecosystem very quickly
come up with advisory services that are going to go after these
companies and figure out how they can accelerate it, get beta
integrity right, get out of the over-promising and under-
delivering that we have today.
And I also think you said something that is very important.
If you have somebody select a plan--maybe because they looked
and saw a very large provider network and that proves not to be
the case--and they have to go out of network, I think that is a
legitimate case where the person who sold you the expectation
that you had these options, and when you came into crisis you
have those, that should be the insurer's problem, not the
insured--the insurer's problem.
But to me, those are relatively modest changes that, if
they are implemented properly, I think could have a significant
behavioral impact that benefits the insured.
I have no more time left, but on the workforce thing, if we
want to get this right, it cannot be just about educating more
doctors, because we simply will not get the pipeline.
I spent a lot of time--I have a couple of schools you may
have heard of: Duke, Chapel Hill. They train a lot of doctors.
They tell me that the outlook is bleak. So, if we knock the
cover off the ball, we are still not going to have enough, and
we are not going to knock the cover off the ball getting people
into this profession if we do not deal with a number of other
underlying reasons why people are leaving earlier and not
getting into the profession.
The Chairman. Thank you, Senator Tillis.
Senator Tillis. So those are the things we have to talk
about if we are seriously going to get it done.
Thank you, Mr. Chairman.
The Chairman. We are going to work with you.
Senator Grassley?
Senator Grassley. I am ready now.
I am a strong supporter of telehealth, and when I was
Finance Committee chairman, I helped make it permanent in
Medicare. Several States have followed suit in their Medicaid
programs. I supported making telehealth permanent for all
services. Mental telehealth is an important tool to improve
access, especially in rural America.
So, I am going to give one question to Ms. Giliberti and
then another question to Dr. Trestman. The questions--I am
going to state both of these now. Ms. Giliberti, in your
written testimony you said nearly half of the adults and youth
with mental health needs do not receive treatment. Access to
care can have many challenges. Have telehealth and the
investments in broadband helped improve the access issue?
And for Mr. Trestman, in your written testimony you said
access to care in rural settings is challenging. You
specifically highlighted how telehealth improves access to more
timely care. Given the recent expansion of telehealth, are
patients getting the best mental health care, and if not, what
can we do to improve the quality of care?
Ms. Giliberti?
Ms. Giliberti. Yes, Senator; absolutely telehealth has had
a tremendous effect on access. In fact, the story that I told--
the young woman actually finally got care using telehealth. So
it has disproportionately affected the mental health community.
You want to have access to in-person as well, but having
telehealth, particularly in rural areas, has definitely been a
game-changer.
We need to extend those flexibilities and make them
permanent. We also need to worry about licensing between
States, because that becomes a problem as the emergency ends.
Senator Grassley. Now Dr. Trestman.
Dr. Trestman. Senator, thank you, and thank you for your
work on this issue. It is enormously challenging, and as Ms.
Giliberti has said, the benefits of telehealth during the
pandemic have been demonstrated. They are substantial. Many
people in rural areas are simply unable to meaningfully come to
us without telehealth, without taking off days of work. Many do
not have paid medical leave. They lose a lot of money coming to
see us. The opportunity with telehealth is really substantial
in providing appropriate care.
The data is still evolving as to who is best served in
person, who is adequately or appropriately served by video, and
who is adequately served by audio-only, and in what conditions.
But in my own experience--and I still see a lot of patients--I
have had insights into people's lives by seeing them in their
homes that I otherwise never would have gotten if they traveled
to me.
So, I have had the opportunities that have benefited both
me as the doctor as well as our patients, by having access to
them in a timely way, and a way that does not put additional
burdens of cost and time on them, and that allows me to see
them in the environment in which they live.
Thank you.
Senator Grassley. Yes. I have heard from Iowans about the
challenges finding in-network providers, including mental
health services. There are many reasons for the bad provider
directories. Even the best information may not be user-
friendly. Patients may have to navigate pages and pages of
information.
For any of you witnesses who want to comment on this
question, are government regulations or incentives preventing
the private sector from solving this problem? I do not care
which one of you or two of you comment on it. Okay.
Dr. Rideout. I would say the lack of standardization is a
problem, and several panel members discussed this. The fact is
that a provider may have to--whether it is a physician
provider, a mental health provider of any type--may have to
deal with literally dozens of health plan requirements that
come at them--different elements, different times, different
submission standards, different expectations--and then have to
repeat that over and over again every time something is
potentially wrong.
It is just a burden that they cannot absorb, even the
largest organizations, and that is what we see in our work. We
have to fix the accuracy problem together.
The Chairman. Thank you, Senator Grassley.
We have to call a lot of audibles around here, and because
of Senator Casey's graciousness, Senator Stabenow will go next.
Senator Stabenow. Well, thank you so much, and thank you to
all of you. It is so important that we actually have accurate
provider directories, and this is just part of the whole big
picture. I remember back in this committee when we were writing
the Affordable Care Act and I authored the provisions on mental
health parity.
We are still finding this. I mean it is just--it is in
every way that we are coming back all the time to health care
above the neck not being treated as well as health care below
the neck. And, Ms. Myrick, thank you for your testimony and
sharing with us. I am sorry you had to go through all of this.
I do want to expand a couple of things, because I am all
in, Mr. Chairman, on what you want to do--absolutely all in. I
do want to stress, as Senator Cornyn was talking about, that we
have made progress. Frankly, one of the alternatives--I would
love, Ms. Myrick, for you to be able to contact your local
Certified Community Behavioral Health Clinic. They are in areas
now where we have them fully funded.
They are funded like health care. You can walk in the door
a third of the time--in Michigan, one of the 10 States where we
are fully funding it, a third of the time people are seen
immediately, and people are seen within 10 days as required. I
mean, there are a whole bunch of things there.
But we have 10 more States coming on in the beginning of
the year. We are moving to get all the States engaged--largest
investment in permanent mental health funding ever for the
country that is coming. So, step by step by step, this is part
of the answer. It is not the whole answer but, if they want to
put up ghost registries, go to your CCBHC and we will get you
some care as a start.
But I want to talk--and certainly we can come back to that.
But I wanted to follow up also on the issue of providers,
because we have the provider networks. We have these ghost
lists, and then we just do not have enough providers, right? We
know this. And one of the things I so appreciated that we
worked on last year, Senator Daines and I as co-chairs of a
workforce working group that Senator Wyden and Senator Crapo
set up, a really important part of our mental health work--we
actually did a few things, but there are some more things to
do. We were able to get a small number of graduate medical
education slots, 200 slots, and half of those were
psychiatrists--small, but it was the first time we designated
psychiatric slots. So that was something. We were able to get
Medicare coverage for licensed professional counselors and
marriage and family therapists.
But I wanted to ask, Ms. Giliberti, one of the things that
Senator Barrasso and I have introduced--and it has been around
for a long time--relates to social workers. We have the
Improving Access to Mental Health Act as it relates to Medicare
beneficiaries being able to access social workers and the
complete set of services they provide, as well as appropriately
compensating social workers.
And so, I wonder if you might speak to that, because it
seems to me that is a big hole we have here when we are talking
about providers in mental health as well, and how could this
help meet the demand on behavioral health?
Ms. Giliberti. Oh, absolutely; social workers are critical.
You know, as I talked about how hard it is to find providers,
they are particularly helpful if you have a chronic health
condition or you have a disability and you have to find
multiple providers.
Social workers can help you with that coordination. They
provide treatment, as you mentioned, and we do not have enough
people doing that. So they provide an important role there.
They are very important with the social determinants of health,
right? We know that housing, food insecurity, transportation,
all those things affect people.
Social workers can help people get connected and really
serve underserved communities that disproportionately are not
able to access those kinds of things, and it affects health and
mental health. And integrated care, which we have talked about
today, they provide some of those services. They coordinate
care.
So social workers have an important role to play, and we
definitely need them in that continuum of care.
Senator Stabenow. Okay; thank you so much. I have limited
time.
Dr. Trestman, just a couple of things. One, in our
discussion draft on workforce, Senator Daines and I proposed
raising physician bonus payments in shortage areas, and
allowing non-physician providers to receive bonus payments,
really focused on rural and underserved areas.
Any thoughts on that, and also CCBHCs? Any comments you
would have on that as part of what we need to be doing?
Dr. Trestman. Senator Stabenow, yes and yes, the short
answer clearly. Having additional compensation and
encouragement for people to join us in rural areas is
phenomenally valuable. Helping them pay down their sometimes
profound student loans, hundreds of thousands of dollars, is an
enormous incentive to allow them to do what they want to do in
the first place, but frequently cannot do because of their
financial status.
And with regard to the new access issues and opportunities,
these are phenomenal programs. Our challenge will be, where do
you go for an FQHC, where do you go to these, when do you go
in-network, when do you go for Medicaid--helping us understand
what is what.
Senator Stabenow. Right. Well, the great thing is FQHCs--
and our mouthful, CCBHCs--are now funded structurally the same.
It is the same. High quality standards, full Medicaid
reimbursement, and so on. And what we are seeing is, they are
oftentimes together at the same site, which is really the long-
term goal.
Thank you, Mr. Chairman.
The Chairman. I thank my colleague.
Senator Casey is going to be next, and just so we are
clear, after Senator Casey the next would be Senator Brown and
Senator Bennet in order of appearance.
Senator Casey?
Senator Casey. Mr. Chairman, thanks very much, and happy
birthday.
The Chairman. Thank you.
Senator Casey. I know that might have been indicated
earlier.
The Chairman. Thank you.
Senator Casey. I will not sing. Do not worry about it.
I want to thank the panel for being here, and I will direct
my--I think I have two questions for Ms. Giliberti, and I just
wanted to thank you and the whole panel for the work you are
doing.
As many of you know, so many of our colleagues in both
parties support making investments that shore up the number--
the number--of mental health providers in integrated physical
and mental health. Last year for example--last Congress, I
should say--Senator Cassidy and I introduced a bill called the
Health Care Capacity for Pediatric Mental Health Act. It was a
bipartisan bill to increase investment in children's behavioral
health integration, also workforce development, and health
system infrastructure.
As your testimony indicated, so many people do not have
access to that integrated care, yet the process of finding a
mental health provider can be overwhelming for people suffering
from mental health challenges. Someone who needs help has to
sort through provider lists and make lots of phone calls to
find a provider with affordable pricing and availability. I
know you have covered this.
It is especially hard when these lists have countless
errors in them. One constituent who reached out to my office
was already very well-acquainted with a top health system, but
it still took her months to find a mental health provider for
her daughter. As you indicated, you get calls from family and
friends for that kind of help.
So, I guess my first question is, how can we work together
to help people find the provider who has both availability, as
well as one who accepts insurance? I know this is by way of
reiteration, but I think it bears emphasis.
Ms. Giliberti. Yes, I think that--well, just to talk about
integrated care for a moment, if you go to primary care, most
of that is in-network, right? So that is a way that, if you
could expand that, we would have more providers--it would be
easy for a family with a child. They would already be there to
be able to get that care in network. So that would be one way.
But then of course, we need these directories to be
accurate. So we need audits, we need them to be using their
claims data. If there are no claims, they are not seeing
people, right? With the shortages that we have, and the mental
health crisis for children in particular, if they are not
seeing patients, we know that they are not in-network.
So they need to clean up those provider directories, make
them very clear, and that will help people find care. And then
we need to expand integrated care, because I think most
families would just love to be able to go their pediatrician
and get the care.
Senator Casey. Yes. The other question I have is, how can
we help people find primary care practices that offer this
integrated mental health care, such as practices that have
telehealth partnerships with mental health providers?
Ms. Giliberti. I think that would be very helpful to have
on the directories--when a primary care practice has integrated
care capacity--and I think that the barriers that we see often
are just the rates at this point, and we just need to put more
financing into integrated care as well if we really want to see
it happen.
Senator Casey. Great.
Mr. Chairman, thanks. I will yield back my time.
The Chairman. I thank my colleague.
The next three in order of appearance would be Cardin,
Brown, and Bennet, and those three are not here.
Let's see. That would then mean Senator Cassidy is next.
Senator Cassidy. Hey, all. Thank you for being here.
I actually have two issues here. One is the ghost
networking, which could be false advertising, and, Ms. Myrick,
your experience is so typical. Thank you for sharing it. It
takes courage to do so, but just thank you for doing so.
Second is access itself, because Ms. Myrick speaks of both:
the false advertising and the lack of access. I think you set
the tone for the questions, if you will.
Now, one thing that I am struck by, Dr. Trestman, is when I
would speak to--I am a physician, so I would speak to my
colleagues back home who are in psychiatry, and they would say
that Medicaid and Medicare rates were so poor, and they have to
pay the bills, et cetera, so they typically went to either
private insurance or to cash pay.
Then I have heard the reimbursement has been mentioned. But
one thing that has not been mentioned in this is that in
traditional Medicare--which actually does not have a provider
panel per se--the access is equally poor for the traditional
Medicare if you are speaking about something such as mental
health providers. Is that a fair statement?
Dr. Trestman. Yes, sir, it is.
Senator Cassidy. I asked my staff, because we did a
literature review beforehand, but they were not quite sure if
there had been kind of a cross-tab, if you will, of access for
Medicare patients, MA versus traditional Medicare. And I would
not be surprised if they are kind of roughly the same. Your
thoughts on that?
Dr. Trestman. I expect that they are, sir. The challenge in
so many situations really is the administrative burden, it is
the access, the management. So I think that the MA versus
Medicare traditional plans have some of the same challenges.
Senator Cassidy. Now theoretically, an MA plan, if they are
challenged to increase their provider panel, they could
actually pay better than Medicare rates in order to achieve
that. If you will, the Medicare MA model, if done right,
actually addresses the market issue; correct?
Dr. Trestman. Absolutely true, and supply and demand is
what this country was built on. But I do not think that has
applied appropriately to insurance plans. You know, I think
that part of the challenge for us is to come up with an
appropriate strategy where people--I mean, psychiatrists have
told me repeatedly ``You know, I wish I could afford to be in
the insurance plans, in Medicare, in MA. But it costs me more
to deliver the care.''
Senator Cassidy. Oh, I get that, believe me. I hear that
too, so I am not disputing that.
Dr. Resneck, as you are kind of representing the entirety
of health care, at least physicians, you can speak to this.
There is also a little bit of a quandary that a doctor will see
a Medicaid patient because her friend asked her if she will see
the Medicaid patient.
She does not really see Medicaid, but she is going to see
this particular Medicaid patient because her friend asked her
to, and so she remains on the Medicaid provider panel, but she
does not really see it. I think Ms. Giliberti said something
along the lines of they are not seeing patients, so therefore
they are not in-network.
Technically that is not necessarily true. If I will see
three patients a month on Medicaid because my friend whom I
have known since we were both in kindergarten together calls me
and says, ``Please see this patient for me,'' would you accept
that as a valid kind of ``occasionally occurs'' at least?
Dr. Resneck. Yes. I think--thank you, Senator Cassidy. You
know, I have such pride in my colleagues on the front line
around the country who are doing their best every day to take
care of their communities and the patients who present, and the
primary care colleagues who call to refer those patients.
But as you have identified, payment rates are an issue, and
we have, as we have talked about, 3 decades of stagnant rates
in traditional Medicare. We have Medicare Advantage plans. In
some markets they are so consolidated that they are paying less
than Medicare rates.
Senator Cassidy. So, let me ask you this. My wife--a
retired general surgeon, once said, ``If they pay you below
your cost, you cannot make it up on volume.''
Dr. Resneck. That is true.
Senator Cassidy. And so, to that point, and knowing that
there are people who--yes, I am on the provider panel because I
still have some patients whom I see, and I will occasionally
see a new patient under certain circumstances. It almost seems,
though, that we have to have some sort of threshold to analyze
this. Yes, they are open for new patients, but how many new
patients will they receive a year from this particular payment
plan?
Because I think we have to bring sophistication to this
analysis, as opposed to ``insurance claims are all bad,'' for
example. Your thoughts on that?
Dr. Resneck. Well, there are physicians on panels who have
not seen any patients for years----
Senator Cassidy. I get that.
Dr. Resneck [continuing]. And so that is fixable by the
health plan. If it is a small number, then I think we need to
turn to the physician. And there is a difference between being
contracted--and we see this also with physicians at multiple
locations, right, where they are contracted at 30 spots in case
they go there, but they would not want to be listed on the
directory because they literally go cover for a colleague every
couple of years.
So I think this is where we need a low-burden way for
physicians to have input and actually be able to tell the plans
when and if they want to appear on those directories based on
whether they are accepting new patients in that plan.
Senator Cassidy. Well, so with my last--I am over time--but
5 more seconds, send me that low-burden way. If AMA has a way
that we could somehow add sophistication to this analysis, we
would like to hear from the front-line providers.
Dr. Resneck. We will be convening stakeholders to help you
to that point.
Senator Cassidy. I appreciate that, and I yield.
The Chairman. Thank you, Dr. Cassidy.
Senator Cortez Masto?
Senator Cortez Masto. Thank you, Mr. Chairman, and thank
you to the panel. It is a great discussion. I had the
opportunity to listen in my office to a lot of the discussion
this morning, particularly the integrated model concept that we
are talking about today, and I am so appreciative of my
colleague Senator Cornyn asking Dr. Trestman a question about
why it is important, and that is where we need to start,
obviously.
But let me ask you this, Dr. Trestman. How would this
integrated model help us alleviate the existing workforce
shortage? Would it?
Dr. Trestman. I think it would go a long way to helping,
Senator, and thank you for all of your work in this domain. The
opportunity is this: if we partner psychiatrists with
appropriate support staff, embedding them into primary care, we
can keep people in primary care without them having to
physically be seen by psychiatry. One psychiatrist for 2 or 3
hours a week can review a panel of between 40 and 60 patients
to provide adequate support to the primary care team so that we
can give guidance and support them.
Additionally, something that was already addressed is
workforce burnout, keeping people in play, keeping them
satisfied with their work. It is morally frustrating not to be
able to refer someone to care if you are the primary care doc.
You see someone who needs care, it is beyond your scope, and
you cannot do it.
The collaborative care model and other potential models
allow primary care docs to do what they want to do.
Senator Cortez Masto. Thank you.
And, Dr. Resneck, I appreciate your comments regarding the
burnout issue and the preauthorization. I just had some doctors
in my office talking about the concerns about this prior
authorization requirement and how frustrating it can be. So,
thank you.
But can I jump to--I only have about 5 minutes--I want to
jump to rural Nevada, which is similar to northern California.
And so, Dr. Rideout, let me ask you this, because, as with the
integrated primary care, telehealth has proven to be a valuable
tool for rural Nevada in my State, and essentially to also
extend our mental health workforce.
And, while we are making steps in the right direction, I am
concerned that the telehealth and expanded primary care alone
will not meet our workforce needs, particularly in our rural
communities, when it comes to behavioral health professionals,
in the long term.
So, in your view, how are contracting issues driving the
supply problem in rural areas? How do we address that?
Dr. Rideout. Well, I would agree with you that, despite the
huge uptick in telehealth visits, it is not going to be enough
to solve the supply problem. And, as I think a number of
panelists have mentioned, primary care physicians--and I am one
of them--do provide a certain level of mental health care. But
they too are burning out; they too are aging out.
So you have essentially stopgap measures, and I think in
terms of contracting, my experience across plans, purchasers,
and providers is that the conditions of participation,
including rates but not limited to rates, really drive whether
people want to participate or not.
We have heard for psychiatrists, which are actually a
relatively small percentage of the total mental health
providers, it just costs too much to do it. I would bring back
a thought of integrated care. We have talked a lot about
integrated care in terms of medical and behavioral integration.
There is also an integrated care model where physicians of
multiple specialties practice under one organizational
structure, in an organization that is large enough to provide
telehealth, large enough to provide data analytics, and large
enough to essentially cover some of the shortages through
better contracting or better load management within the group.
So I think that is hard in a rural area, because people do
not concentrate that way in terms of practice very well.
Senator Cortez Masto. Thank you.
Dr. Resneck, did you have a comment?
Dr. Resneck. Well, Senator, I am really glad you brought up
contracting, because when we look at the data--and the AMA
produces these data every year--most areas around this country
have highly concentrated insurance markets, where one or two
plans cover the vast majority of patients in that area.
So in rural Nevada or in big urban centers, there is not
meaningful contracting. We have physicians who have a big panel
of patients, and the insurer just sends them a letter at the
end of the year that says, ``Thanks very much, we are done with
you.'' Or it is really take-it-or-leave-it contracts that they
present, that increasingly are lower and lower percents of
Medicare.
So it is not a level playing field between the physicians
who actually want to be contracted to be able to take care of
their patients and the health plans.
Senator Cortez Masto. Well, it sounds like we need another
panel of health-plan providers to be able to talk to, and I
look forward to that opportunity.
Thank you, Mr. Chairman. Thank you.
The Chairman. Thank you.
Senator Brown will be next, and I understand one of our
colleagues on the Republican side is coming back as well. But
with that, unless there are people we do not know about, we
will wrap up, and there is a vote on.
Senator Brown?
Senator Brown. Thank you, Mr. Chairman, and I am glad I got
here in time. Welcome, all of you. Thanks for joining us and
for the service you provide to so many people. And it is more
important than ever. I mean we all--living through the
pandemic, we all saw different parts of the health-care system
perhaps, and it is more important than ever that people in my
State, in Nevada, in Oregon, and Idaho get the mental health
care when they need it.
We know that we did not pay enough attention to mental
health during the pandemic, and mental health is fundamental
basic health care. It works; it saves lives. Too many families
though, as you know, cannot get this lifesaving care. Finding
someone to help is hard enough--trying to call for an
appointment with a doctor who does not exist or does not exist
at this number and is a so-called ghost.
We agree, we spend too much time trying to schedule
doctor's visits. For most people, it is far too troubling and
difficult and Rube Goldberg-like to get through. The problem
worsens when we cannot be sure that the doctor listed in the
insurance directory is actually practicing medicine in the
place that we think that person is.
Doctors listed are not taking patients sometimes. In other
cases, the doctors have retired or are practicing at altogether
different locations, sometimes in a different State. I mean, it
is infuriating. It is also preventable.
So, Dr. Trestman, what should Congress do to make it easier
for you to work with plans to make sure they have the right
information? How would you feel if you tried to call a doctor,
only to realize the number--I mean, you know where I am going
on this. So talk to me.
Dr. Trestman. Thank you, Senator. You know this--to be very
trite, this is complicated. There are many, many opportunities.
But I do think some of the things we have heard today are
really critical. The first is, if Congress could pass a
standard that everyone shares to reduce the inconsistencies in
format and reporting time and sequence.
The more we can have consistency and essentially
interoperability, making it electronic, making it as close to
real time as possible, that would be of enormous benefit to
everyone. So I think it is some of the things that Dr. Rideout
mentioned, in one form or fashion, that could be transformative
for our Nation, if we have a standard. That would really reduce
some of the challenges.
Sharing the burden between the physicians and the insurance
plans so that we own responsibility for how many patients can
we see? How much can we afford to see of which plans? I think
that a standard that would be federally structured and guided
would help all of us. Thank you.
Senator Brown. Thank you, Dr. Trestman.
Ms. Myrick, kind of along those lines, let us continue down
that path. First, thank you for sharing your story to this
committee. It always takes guts to talk about personal stories
in public and in Congress. No one should have to fly--of
course, no one should have to fly across the country at her own
expense because she cannot find a psychiatrist to treat her.
Ohioans just want to get the treatment they need using the
benefits that they actually paid for. Several years ago, we
passed a law making sure all of the patients are held harmless
when they relied upon an incorrect insurance directory. Sadly,
patients must file an appeal with their insurer, the same
insurer that made the error.
So, Ms. Giliberti, isn't this approach, isn't this appeals
process just one more annoying, time-consuming--I hate to use
the words Rube Goldberg again--but kind of a hurdle that
Ohioans and others should not have to face when they want to
get mental health treatment?
Ms. Giliberti. These kinds of processes can also be very
difficult for people. So we talk a lot about making sure people
know their rights. It is clear. You know, we have been talking
about financial protection. If you use somebody in a directory,
that should be really clear to you that you have a right to get
that reimbursed.
So we need to make things clear to people, and I agree that
a lot of these procedures wind up making it rather difficult
for the person, and the insurance companies really need to bear
the burden here.
Senator Brown. Thank you for that.
Mr. Chairman, thank you.
The Chairman. I thank my colleague.
Senator Lankford is next. Oh, excuse me, Senator Warner is
next, and we are going to go in order of appearance. Senator
Warner is next.
Senator Warner. Well, thank you, Mr. Chairman, and I am
sure others have already mentioned this, but happy birthday.
And you know, I really do appreciate the fact that you and
Senator Crapo are holding these hearings. I mean, this issue is
around mental health. I think we always knew it was a huge
issue, but in a post-COVID world, I do not know any family,
including mine, that does not have some challenges around
mental health.
I want to also acknowledge Ms. Giliberti and Dr. Trestman,
who are both in service in Virginia. You have a lot of great
talent there. I wanted to raise quickly--I am going to go to
Dr. Rideout on a question, but I want to brag for a moment
about something we started in Virginia.
Way back in the 1990s, I had started something called the
Virginia Health Care Foundation. And then subsequent to that,
seeing how my dad was trying to take care of my mom and access
services, we started something called Senior Navigator, you
know, providing the kind of directory issues we are talking
about on a real time basis, linking up services.
That Virginia Senior Navigator program grew into something
called Virginia Navigator, and it is now up to 9,000 service
providers who provide 26,000 programs. We have kind of taken
this high-tech, high-touch approach. And you know, it is one of
the things that kind of makes me crazy, that these insurance
companies and providers do not update.
I know everybody--this has been the focus of the whole
hearing: how you update these directories, how we make sure
there is that navigator role, rather than simply putting out a
tech site.
Dr. Rideout, I know you have had some experience in this,
and how do you--how do we--do a better job on these high-tech,
high-touch approaches, so we can get the incentives right so
that people can access these services out of these directories
in a user-friendly way?
Dr. Rideout. I would answer that, Senator Warner, by saying
I do not think it is the tech or the touch that matters. It is
the quality of the information and the willingness of the
participants to share that information before it gets
published. I know there are many ways to do that, but in our
experience with Symphony, you have to get it right before you
start pushing it back to the plans or the providers as right.
And then, if the patient is experiencing a disconnect, they
are not taking a new patient when they said they were, then you
can resolve those, I think, on more of a one-on-one basis. But
I think if the core problem is 80 percent of the information is
wrong to begin with, I do not know that technology is going to
solve that.
I think navigators are great. We have used those in many
settings in health care and housing and other things. But then
what you have is, is the energy of the individual, of the
navigator to kind of hang in there, better than the patient's?
The answer may be ``yes,'' but they may not have any more
success.
Senator Warner. But don't you think even if you get the
information right, the amount of time that that information
stays right is going to be a short term? So one of the things
that I think that is important is--you know, I agree with you:
you have to get the information right.
But, boy oh boy, you also have to make sure that there is
an update process. Have you found in your experience with
Symphony how you make sure that data is constantly updated?
Dr. Rideout. We update pretty much weekly, and then
physicians attest at least every 3 months, because they only
have to attest once. Imagine if you were having every health
plan and every large provider organization ask the same
physicians for the same information over and over and over
again. A lot of times they will just stop providing it.
So I think you have to do it very frequently--not quite
real time, but pretty much closer to that, to get it right.
Senator Warner. And, Ms. Giliberti, I was interested in
your testimony when you said that there was a California
consumer protection law that basically said that if a plan does
not provide these mental health services, there is almost a
consumer protection law that says the plan has an obligation to
define that service.
Has that been a good way to keep the plans a bit honest
or----
Ms. Giliberti. I think it is a relatively new requirement,
Senator, but the idea is that they have to arrange for it, and
then if they cannot find it in network, they have to pay the
out-of-network charge for the person that they found, the
provider that they found. So, like you are saying, it takes the
burden, again, off the person.
Senator Warner. Yes, it shifts the burden to the----
Ms. Giliberti. It shifts the burden to the plan to help you
find it. Again though, it has to be really clear on your
directory that they can provide this help to you, right,
because otherwise people will not know about it. So I think it
is really important that people know about it and that they are
actually going to be able to get that kind of help.
Senator Warner. I do think, and again we are--I may take a
little issue with Dr. Rideout's position, because I do think
you have to get the information right. But Lord knows, there
are plenty of user-friendly sites that invite a user in and do
not make it this technology opaqueness, and I think again there
are examples across the spectrum that we can look at for best
practices.
But I do appreciate the chair and vice-chair holding this
hearing.
The Chairman. Thank you, Senator Warner. And you are being
logical, and heaven forbid that logic should break out over
this, because I too believe in these navigator approaches. The
reason that it has been an important issue is there has been a
misrepresentation, not something that spells out what you are
talking about. So we are going to look at it.
Senator Lankford?
Senator Lankford. Thank you, Mr. Chairman. Happy birthday
as well, and thanks for holding the hearing. Thank you all for
the testimony today.
Exceptionally important to be able to get out there--all of
us deal with this. We all have casework staff to try to help
chase through things, so we hear it as well. This is really
important that this gets out, and we find ways that are
practical, realistic ways to be able to actually process this.
Dr. Resneck, I want to try to drill down a little bit from
the physician side of this. So, an insurance plan reaches out,
let us say early summer, and says, ``We are looking to be able
to put all our networks together for next year. Do you want to
be in-network or out-of-network,'' and they negotiate with you.
They tell you this is what we are going to pay you flat
out, and no, we will not negotiate. Then you go through all
that back and forth on it, finally resolve it. By the end of
the summer they put out their open season plan with their list
of all their providers on it for the next year. People select
their plan based on who their providers are, if they are near
them, or if their own physician is there. And then they pick up
the phone and start calling people.
Is there a requirement for physicians, if they say, ``I am
going to be in a plan,'' to actually be in that plan for the
next year, or can a physician say, ``Yes, I will be in the
plan,'' and then let us say January, February, March decide no,
I really do not feel like being in this plan?
Are they locked in typically--again, company to company it
may be different. But is there a commitment on the physician's
side, if I said I am going to be in this plan for a year, I am
actually going to be in the----
Dr. Resneck. In general, physicians contract on an annual
basis, but I think this probably varies by State and by type of
plan. And we see plans terminate plans midyear for no reason,
which is the other piece of that as well. But we will get back
to you with more information.
Senator Lankford. That is right. That is helpful, because
that is one of the areas where we have to be able to resolve
this. Is there a commitment from the physician to also be in
the plan? We have heard several times from different plans, or
from individuals who will say by the time that they actually
pursued the plan and got into the plan and starting in January-
February started calling people, they said, ``Oh no, I actually
dropped out last year,'' but they are still listed. Or, ``I
just changed and shifted over,'' and we are trying to figure
out the mechanics of where all the players are.
Dr. Resneck. And if you talk to that physician, they
probably called the plan--just like your office staff helping
people in your district and the State have--and probably sat on
hold for 3 hours and then got disconnected, trying to update
the directory themselves. So the plans have made it really
difficult for the docs.
Senator Lankford. Yes, really difficult for the patient and
for the docs, and that is what has been the challenge on this.
So the next layer in this, and, Dr. Rideout, let me ask you
about this as well.
From the industry side--and you are dealing with this--
there is a lot of insurance companies right now that are not
following the current CMS regulations even. So the issue always
comes back to us. They are not following it currently; let us
add one more and see if they will follow that one as well.
What do you see as the solution here in this process,
because I do not want a single constituent to call and hear,
``I do not know who that is.'' Ms. Myrick's testimony was
powerful, to be able to say, ``I do not know who that is. That
person died. Sorry, we do not take people anymore. We have not
been on that for years.''
That is plans just not updating and doing their work, but
they are already violating CMS rules. So, from the industry
perspective, what is the answer on this?
Dr. Rideout. Standardization across the board, and that is
a challenge because most plans are regulated on a State basis,
and States have their own variations on what they do or do not
want.
Senator Lankford. Right.
Dr. Rideout. But I think it starts with very, very
detailed, aligned standards. And the old adage is, ``standards
are great because there are so many of them,'' and that is the
problem. We are now dealing with Medicaid standards, CMS
standards, Medicare Advantage standards, State standards. So,
it is----
Senator Lankford. Yes. There are State regulations, but
this is Medicare Advantage. This is unique--this falls right
into this committee, what is happening in Medicare, Medicare
Advantage, and creating a centralized standard for that.
Dr. Resneck, do you want to say something?
Dr. Resneck. Well, your colleague earlier mentioned carrots
and sticks, and liking carrots, I completely agree.
Transparency would be great. Carrots are very helpful. My fear
is I am going to be walking around with a backpack of carrots
for another 10 years, and they are going to rot in my backpack
because I will not have any to give out.
The plans are so consolidated and have such an incentive to
look like they have a full network when they do not, that I
think--in the Medicare Advantage space that you have
jurisdiction over, and the exchange space that you have
jurisdiction over--we do need some sticks. We do need monetary
fines.
These are big plans with big resources that have the
capability and responsibility to put out accurate records.
Senator Lankford. So the sense would be, like the chairman
was saying before, if we end up calling with secret shopper-
type calls--or whatever process that we do from a third party
or whether it be a Federal agency--and find out these folks do
not actually exist, then they get a fine to be able to come in,
so it is a requirement on them to be able to fulfill that.
Dr. Resneck. Right, right. There is always going to be a
little background noise and a few inaccuracies, but when 80
percent of the directory is inaccurate, I think you can say
that is a plan failure.
Senator Lankford. That is a massive issue, and it is a big
issue for us in rural Oklahoma that there will be companies
that will put out a plan, and then everyone looks at it and
selects a plan. Then they get into that plan in January and
find out it is not real, and they cannot go anywhere. Or if
they are going to go anywhere, they are going to have to drive
150 miles to be able to get to someone. They assumed the people
who were listed locally actually existed, and they accepted the
process.
So, I appreciate your testimony today.
The Chairman. And, Senator Lankford, you have just given a
snapshot of why this issue is so important in rural America,
and I appreciate it.
Senator Whitehouse is next.
Senator Whitehouse. Thanks. I will be very brief, because I
know Senator Menendez has a lot to do, but I wanted to flag,
not exactly the topic of this hearing, but it has been
extremely important in Rhode Island to have had mental health
access through COVID through telehealth.
It has been extremely important for people who are in
recovery to be able to talk to their peer recovery coaches and
to the people who are providing them treatment. I just wanted
to take a moment--I am seeing a lot of heads nodding, that this
is a good thing, that we need to extend those telehealth
protections and waivers. Because the information I have is not
only did compliance, ``attendance,'' improve compared to having
to come into the office but--and I know this is anecdotal and
there is no way to put a scientific proof behind it--over and
over again I have heard from the professionals in the community
that the quality of the engagement increased with telehealth.
I suspect that is just the human aspect of not having to
drive someplace, not having to wait in the waiting room, not
having to fill out a clipboard, not having to be in unfamiliar
territory. Instead, you just go to your quiet place in your own
residence, you click on, and there you are. So I wanted to make
that pitch.
I also wanted to try to make the point that this problem of
required networks and fake networks, in essence, is part of a
suite of payment and cost-saving strategies that have developed
in our current health-care system. They include just plain
payment denial and delay.
We have an enormous armada of insurance efforts to slow or
deny payment to providers, obliging providers to then stand up
a whole countermeasure apparatus. I remember years ago going to
the Cranston Community Health Center and finding out that they
actually had more personnel on staff who are devoted to trying
to get paid than they had devoted to providing the health care
that the Cranston Community Health Center provided.
So there is an enormous, enormous burden of unnecessary
administrative cost from that. There is an enormous burden of
administrative cost and pain from these fake networks. And I
think that prior authorizations are another vehicle frequently
used by the insurance industry to evade and avoid payment for
services that are pretty clearly required.
What I would really like to have anyone who is interested
do--and you can do this as a response in writing, consider this
a question for the record--I think the way out of most of those
problems is comprehensive payment reform.
The more we get away from fee-for-service, the less ability
there is to deny and delay the payments for those services, to
shrink networks, and to impose prior authorization restrictions
that foul up treatment. So, we are continuing to work to get
that done here.
I think the ACOs, the Accountable Care Organizations,
provided a good lead, have provided, particularly in Rhode
Island through Coastal Medical and Integra, some really good
results showing what is possible.
But I would love to have your careful thoughts on that, and
is this area of reducing the deadweight cost burden of the
administrative warfare between insurers and providers likely to
be alleviated by payment reform, and if so, what payment
reforms are likely to alleviate it most?
With that, I will yield back to Senator Menendez, I guess.
I am not sure who is next.
Senator Cardin. Senator Cardin. We are going way up the
line here.
So first, I want to thank you all for your testimony. I
just really want to add one other dimension to these ghost
networks. My colleagues have heard me talk frequently about the
tragedy in dental care with Deamonte Driver losing his life in
2007, a 12 year-old, because he could not get access to dental
care.
I know that our focus here is on a broad range of services,
particularly mental health services. But Deamonte Driver's
death had many contributing factors. One was that his mom
really could not find a dentist who would treat him. There was
not an accurate directory available that could provide
guidance, and she could not find a dentist who would be willing
to provide services.
I guess what I just want to underscore is that this topic
is critically important for health care throughout our country,
but particularly in underserved communities. They need help,
and if we do not have accurate directories, if they have a list
that does not have accurate telephone numbers, or the provider
is not taking any new patients, and it may be somewhat
redlined, it makes it even more challenging.
So I just really wanted to add that into the record, and I
thank you all for your participation. But as we look at ways to
solve the issues, let us not lose sight of the fact that it is
not equal throughout this country. Underserved communities are
suffering the most.
So with that, I will yield back.
Senator Menendez. Thank you very much.
The problem of ghost networks is particularly harmful in
mental health care, and one arguably made worse in recent
years. Amid the Nation's ongoing mental health crisis, though
the pandemic and beyond, those desperate for health care
continue to get ghosted.
The reality is that there are just not enough providers. I
was proud to secure--with my colleagues on the committee--100
new graduate medical education slots reserved for psychiatry in
last year's Consolidated Appropriations Act. Last week, I
reintroduced my Resident Physician Shortage Reduction Act
alongside Senators Boozman, Schumer, and Collins. It is a
bipartisan bill that would raise the number of GME positions by
an additional 14,000 over 7 years.
So, Dr. Resneck, would you agree that increasing graduate
medical education positions would complement efforts to improve
provider directories and mental health access overall?
Dr. Resneck. Senator, I cannot thank you enough and agree
enough, and the 100 additional slots for psychiatry--every
little bit helps. But the larger act is absolutely necessary as
we face an aging population. We need more physicians for this
country, so thank you.
Senator Menendez. Thank you.
Dr. Trestman, for children in need of care, the problem is
even worse. According to the data by the American Psychological
Association, only 4,000 out of more than 100,000 U.S. clinical
psychologists are child and adolescent clinicians.
What can Congress do to specifically address the workforce
shortage of child and adolescent mental health clinicians?
Dr. Trestman. Senator, I think that the trajectory that you
and your colleagues have started has been wonderful. We need to
think broadly about the needs of health care in this society--
so training at the community college level, the college level,
getting people in, the people for allied health professions,
whether it is nursing, social work, community health workers,
as well as psychologists and physicians.
We need to think broadly so that we can provide adequate
care. And many professions other than physicians can be trained
in a timelier way, and any of the ability that they have to
provide care, whether through social work or others, can make a
profound difference and really expand and leverage the care
that only physicians can provide.
Thank you.
Senator Menendez. Yes, yes. Well, imagine for a moment that
you or someone you love is in the midst of a mental health
crisis. You call 70-plus doctors listed in your insurance
plan's network. Not one is available for an appointment within
2 months. Most never call you back. Some are retired. Others
are deceased. Some phone lines are disconnected.
This is a reality for far too many people seeking mental
health-care services in New Jersey and across the country. It
is critical that people seeking mental health services have
access to accurate, up-to-date provider directories. This
outdated information hurts people who are desperate to get help
for themselves or a loved one.
Ms. Giliberti, what mechanisms can Federal regulators use
to hold those responsible for provider lists accountable? How
can we highlight how CMS can better enforce regulation and
oversight of provider directories?
Ms. Giliberti. Well, I think they could do several things.
One, we could have audits of these plans for their behavioral
health networks, and those audits could be done either by CMS
itself or by a third party--and transparency, right, the
results of that.
We have also talked about making sure it is included in the
star rating system, so that they get incentivized to make those
changes.
And we have talked about civil monetary penalties, which
currently do not exist, right? So that is another way, and it
would have to be sufficient to affect behavior.
So those are an array of choices that could make a
difference if they were combined together.
Senator Menendez. And finally, we have to address the
challenges of ghost networks, but we must also prioritize
policy to support low-income and marginalized populations.
Last week, HHS released proposed access and quality
standards for Medicaid and CHIP. Among other things, these
proposals would require States to conduct ``secret shopper
surveys of Medicaid and CHIP managed care plans, to verify
compliance with appointment wait time standards, and to
identify where provider directories are inaccurate.''
How would these requirements mitigate impacts of ghost
networks for low-income communities, Ms. Myrick?
Ms. Myrick. Thank you very much for asking that question.
And I think anything that can help, especially folks of color,
people in low-income communities, to be able to get the
accurate information that they need in order to get the care
when and where and how they need it, is going to be critical.
And I also add to that being able to empower the consumer. The
word consumer, I actually like it. I know in our community
sometimes it is a little--people do not like it. But the reason
I like it is, I think of John F. Kennedy's consumer rights bill
and what he talked about in 1962, about the consumers' rights
to be heard, the consumers' rights to have information to make
a choice, and then lastly the U.N.-added, to redress.
I think the things that you are talking about give us those
rights, especially if we have something like a 1-800 number or
an online portal to report when we are not able to get our
needs met because of the ghost network. Because we want to
inform too. We want to be empowered to inform, so that either
the carrots or the sticks can happen.
So, thank you.
Senator Menendez. Thank you very much for your insights.
Senator Warren. On behalf of the chairman, I call on
Senator Blackburn.
Senator Blackburn. And thank you so much, and thank you to
each of you for being here. Ms. Myrick, thank you for sharing
your story. I appreciate hearing that.
I know we are talking about Medicare, Medicare Advantage.
But Senator Blumenthal and I have been busy today introducing
the Kids Online Safety Act.
And, Ms. Myrick, as I was listening to your testimony, I
thought how closely it mirrors what I hear, not only from moms
and parents, but the teens themselves. I hear it from the
psychiatrist and psychologist, from principals, that there is
not enough access, and that there seems to be complete
confusion when you call the insurance company and say, ``We are
desperate for help. I have my child, we are here at the
emergency room. We are not getting any answers,'' and it is
just so imperative that we look holistically at this system.
And I appreciate it, hearing from you on this issue.
Dr. Resneck, let me come to you, because telehealth is
something--even when I was in the House and we were working on
21st Century Cures, then I did not get my telehealth bill in
there, but we got it across the line during COVID. During
COVID, people really began to use telehealth. What I hear from
providers, especially down in Shelby County, Memphis, that
area, where you are dealing with Mississippi, Arkansas--and, of
course the MED is there in Memphis.
And they talk a lot about interstate licensure
requirements. So just very briefly, if you would talk to me a
minute about what you are hearing from providers when it comes
to that licensure issue, and also what you are hearing about
the digital therapeutics and their utilization in these
instances.
Dr. Resneck. Thank you, Senator. My dad grew up in
Clarksdale, MS, so I know the Memphis area well, even though I
am now a Californian. And I am always reluctant to use the term
``bright spot'' about anything in the pandemic, but telehealth
clearly opening up coverage, whether it was Medicare or
commercial insurers, was a huge bright spot. Thank you for your
leadership in that area.
We have seen not only patients learn how to use it well and
discover when it is convenient, but we have seen physicians in
every specialty, psychiatry included, learn how to integrate it
seamlessly into a care plan, because sometimes patients need to
be seen in person, and now we know more about what those
instances are and what they are not.
You mentioned licensure. We still believe in maintaining
State licensure, and that it exists in the place where the
patient is. The reason we believe in that is, if I am taking
care of a patient in Florida, I believe I have a responsibility
to follow Florida's rules and that that patient needs to be
able to go to their State insurance commissioner if I provide
lousy care, to seek redress.
But we have some really cool stuff going on to aid in
people being able to do telehealth in multiple States. We have
the interstate medical licensure compact, where it makes it
much easier for many physicians to just click off several
States that they want to be licensed in and agree to follow
those rules. We also--lastly, I will just quickly say----
Senator Blackburn. Is that the reciprocity model?
Dr. Resneck. It is not pure reciprocity. It is not like the
nursing reciprocity model because individual States do still
maintain the ability to police what happens in their States and
take your license away. But it makes it much easier to get
multiple licenses.
The other thing is, we have seen the medical boards, the
Federation of State Medical Boards, agree unanimously
nationally, and now it has to be implemented in the States, on
reasonable exceptions. If I am taking care of a patient and
they go off to college and they happen to be out of State, or
they are vacationing or spend 3 months a year in Arizona, that
is not really practicing across State lines. I have an
established relationship.
If a patient needs to go to a center of excellence and
wants to do one pre-visit via telehealth across State lines,
that should be okay. But we do want to protect patients and
make sure they have local care.
Senator Blackburn. All right.
Do you want to weigh in on this, either of you? Go ahead.
Dr. Trestman. Telehealth has been transformative.
Senator Blackburn. Okay. You were nodding your head, and I
thought you might have a little something to say.
Dr. Trestman. Yes. Thank you, yes. And the continuing
availability, particularly in rural areas, is extraordinarily
valuable, but also, even in urban areas, where it may take
people 2 hours to take three buses to get to us.
Senator Blackburn. Okay.
Dr. Trestman. And by the way, I trained at the Elvis
Presley Memorial Trauma Center in Memphis, so----
Senator Blackburn. God bless you.
Ms. Giliberti, did you want--I saw you nodding your head.
Ms. Giliberti. I was just going to say that I am very glad
to hear about the college students, because we hear that all
the time about college students who have a provider, and then
they lose access to them. I think that this idea really needs
to be thought through, particularly for mental health--you
know, the issues in a State.
I really do not understand why we cannot get more
reciprocity and more ability to go across State lines with
mental health care, because it is very problematic.
Senator Blackburn. Increasing access is what we ought to
do.
Thank you, Madam Chair.
Senator Warren. Thank you.
So, America is facing a mental health crisis. One in five
Americans live with a mental illness, and for Medicare
beneficiaries, it is one in four. Federal law requires Medicare
to cover mental health services in both traditional Medicare
and Medicare Advantage, or MA, the program that allows private
insurance companies to offer Medicare coverage.
Now, unlike traditional Medicare, the private insurance
companies in Medicare Advantage can establish networks to
restrict the doctors and facilities that beneficiaries can use.
So, if your doctor is in-network, the plan will cover those
services for a small copay, but an out-of-network doctor can
leave patients with skyrocketing costs.
This can be especially devastating for seniors or for
people with disabilities who are more likely to be living on
fixed incomes. To help beneficiaries avoid these surprise
costs, MA plans are required to publish directories which
enrollees can use to find new doctors, to make sure their
existing doctors are covered.
So let us start with what we know about the accuracy of
these directories. There have been some references to them,
but, Ms. Giliberti, what do we know about the accuracy of the
provider directories in Medicare Advantage?
Ms. Giliberti. So CMS has done some audits, Senator, and
what they found was, on average, the accuracy rate was about 45
percent.
Senator Warren. What does that mean, that the accuracy rate
was 45 percent?
Ms. Giliberti. You know, they found, in 2018 I think it
was, almost 50 percent had at least one inaccuracy. So we are
seeing a good deal of inaccuracies. That is with physical
health care. Let's just say there is a gap in data, because
they have not done this for behavioral health.
Senator Warren. And might we surmise that behavioral health
accuracy----
Ms. Giliberti. It is always worse.
Senator Warren. It is always worse; it is always worse.
Okay.
So, you think you have a list of people you can go to, and
the odds are actually in favor of the list being wrong, and
probably even worse on behavioral health. All right.
So here we have a patient who does everything right. They
still may be hit with a huge bill, because a directory has
outdated or inaccurate information. Or they might call up every
doctor, only to find out what we have heard about some of this:
phone numbers do not work; they are not accepting new patients.
I think we have heard the story about this, and I appreciate
your being here to talk about your story, Ms. Myrick.
We know that MA plans use all kinds of tricks and traps to
squeeze more money out of Medicare. They have a lot of
different ways that they do this to boost their numbers. But
here is the one I want to focus on. Do these MA plans stand to
gain anything from having inaccurate information? In other
words, is it inaccurate because they just have not spent enough
money to make it accurate, or is it inaccurate by design?
Ms. Giliberti. Well, I think there are advantages that they
have when their directories, unfortunately, are inaccurate. If
they use those directories for network adequacy standards, for
example, they might meet the standards, but they are not
accurate. People make choices based on what they see as their
network, so if it looks like a bigger network but it is not
real, people are choosing a plan----
Senator Warren. Okay, so it is a way to defraud consumers,
to say you have this really big list of people you could go to
if you had a problem. And it turns out that really big list, if
it were accurate, is actually this little tiny list, right?
Ms. Giliberti. Right, right.
Senator Warren. Okay. So that is one way it is to the
advantage of the Medicare Advantage plan, in order to be
inaccurate. They get paid, in effect, or they make more money
by being inaccurate. Did you have another one?
Ms. Giliberti. Well, just that--oh, I think it is about 60
percent of the plans do not have out-of-network coverage. So,
if you get really frustrated and you pay on your own, then they
are not paying anything.
Senator Warren. So, the more I can frustrate you, the more
that I--meaning the Medicare Advantage plan--the more the
Medicare Advantage plan can frustrate you, the more you will
just go somewhere else, and that means it is not money out of
their pockets.
Did we get the two main ones? You wanted to add----
Dr. Resneck. Well, I just was going to add, Senator, this
is--yes, we see this all the time. This is health plans
delaying and denying care.
That same patient--once they finally find the needle in the
haystack and even get to a physician who is in network and sit
down and get a diagnosis and a treatment plan--then goes to the
pharmacy and discovers the health plan requires prior auth for
the treatment for that condition, which then takes weeks to get
approved.
Sometimes they never go back to the pharmacy. They give up.
Their mental health or other chronic condition gets worse.
Senator Warren. Right. So conditions get worse, and they do
not have to pay for the treatment, the Medicare Advantage plan.
So look, what we are really saying here is that it is in the
financial interest of these Medicare Advantage plans to
discourage beneficiaries from accessing care.
We also know that the Medicare Advantage plans are paid a
set amount per beneficiary, which can be dialed up if the
beneficiary is sicker. So the more diagnosis codes that a
beneficiary has, the higher the payment. The insurance
companies have built entire businesses around making these
beneficiaries look as sick as possible, and they are
overcharging taxpayers by hundreds of billions of dollars,
because here is the key that underlines this.
Whatever insurers do not spend on care as a result of
tactics like outdated provider directories or overly restricted
networks or inaccurate information, whatever they do not spend
on care they get to keep. So let me ask you one last question
on this. What penalties, Ms. Giliberti, do MA plans face for
being out of compliance with regulations and provider
directories and network adequacy?
So we have a bunch of rules. When they are in violation of
the rules, what is the consequence?
Ms. Giliberti. I am not aware of any penalties, Senator.
The audit that I mentioned earlier talks about notices of
noncompliance and warning letters, but they do not mention
anything about penalties. So I know there have been some
legislative proposals to that effect, but I am just not aware
of any penalties that are being assessed.
Senator Warren. I tell you, nobody is jumping in with any
other answer. You know, this is the part that just drives me
crazy. People look at the regulation, they think, ``Oh, well we
are going to be okay, because this is regulated.'' But we are
not okay if there is no enforcement.
Now, to the extent they have enforcement tools, CMS really
needs to step up the enforcement here. At a minimum,
beneficiaries should not be on the hook for out-of-network
costs that were incurred because of the inaccurate directories.
That would be a nice starting place on this.
CMS should also penalize Medicare Advantage plans that are
out of compliance, just put penalties on these guys, and it is
Congress's job to put tougher regulations in place. I also want
to say this.
If these Medicare Advantage plans continue to mislead
beneficiaries about covered providers, at the same time that
they are overcharging taxpayers for this crumby coverage, then
we should be taking another look at whether or not MA plans
should continue to enjoy the privilege of restricting provider
networks at all.
Now there is a serious question that should be on the
table. If they cannot do better in managing these restricted
networks, then maybe they ought to have to cover anyone who is
a licensed practitioner that you go to see.
So, with that, I will now say I am finished, and I will put
on the hat of the chair and say, without objection, I would
like to submit the majority staff report into the record.
[The report appears in the appendix beginning on p. 88.]
Senator Warren. Anybody object? No.
Senators have 1 week from today to submit questions for the
record. Those will be due at 5 p.m., and this hearing stands
adjourned.
Thank you all.
[Whereupon, at 12:13 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
Last Congress, this committee came together to enact dozens of
bipartisan policies to expand access to mental health-care services.
These reforms will increase the number of providers participating in
Medicare and allow patients to receive care in more convenient
locations, including through telehealth. However, in order for these
improvements to achieve their potential, patients need accurate and up-
to-date information on their health-care options.
I have long championed Medicare Advantage for its ability to offer
patients choice and control over their health care. Through robust
competition and innovative benefit offerings, Medicare Advantage
provides consumer-focused health coverage to millions of Americans. As
enrollment continues to grow, improving the accuracy of provider
directories could further strengthen Medicare Advantage.
The patient-provider relationship is the foundation of the health-
care system. Whether a patient is suffering a mental health crisis or
just received a troubling diagnosis, directories should serve as
crucial tools to help seniors across the country. While we work to
better align incentives to improve provider directory accuracy,
however, we must do so without increasing burdensome requirements that
will only weaken our mental health workforce.
Regulatory red tape and reimbursement strain, among other factors,
can also decrease patient access, exacerbating physician shortages,
compounding burnout, and eroding health-care access and quality.
Congress should build on the targeted relief measures we advanced last
year, including temporary physician fee schedule support and Medicare
telehealth expansion, to address these issues on a bipartisan and
sustainable basis.
Physician payment stabilization and telehealth coverage for seniors
have received strong support from members of both parties and in both
chambers. As we look to enhance Medicare, we should prioritize these
and other bipartisan goals, and we must do so in a fiscally responsible
manner.
I look forward to hearing from our witnesses today about
opportunities to streamline provider reporting requirements, empower
patients with accurate information, and advance a more transparent
health-care system.
______
Prepared Statement of Mary Giliberti, J.D.,
Chief Public Policy Officer, Mental Health America
Chair Wyden, Ranking Member Crapo, and members of the Senate
Finance Committee, thank you for the opportunity to testify today
regarding ghost networks--an issue that my organization and our
affiliates have been working on for decades. We are so grateful for
your leadership in recognizing that this is a problem that causes much
suffering and can be addressed through legislative solutions.
My name is Mary Giliberti, and I lead the public policy efforts at
Mental Health America (MHA), a national non-profit with approximately
150 affiliates in 38 States. We were founded over 100 years ago by
Clifford Beers, who had a mental health condition and suffered abuse in
mental health facilities. He spoke out about this injustice and over
100 years later, MHA continues to address issues that harm people with
mental health conditions and limit access to mental health care, such
as ghost networks.
the effect of ghost networks on mental and economic health
Due to my work at MHA and, previously, at the National Alliance on
Mental Illness, I am asked by friends, family, and people in my
community for help finding mental health providers. Unfortunately, one
of the first questions I ask is, ``Do you need these services to be
covered by insurance?'' This is because I know that the time and effort
it takes to receive the services they need will be reduced
substantially if they are able to pay out of pocket. My colleagues who
work in physical health care do not have to ask this question, and
until those of us working in mental health care no longer have to ask
it either, we will not know true parity between physical and mental
health.
The Nation's mental health needs and the continued effects of the
COVID-19 pandemic make the issue of ghost networks particularly
important to address. According to the Substance Abuse and Mental
Health Administration, nearly one in four adults aged 18 and older and
one in three adults aged 18 to 25 had a mental health condition in the
previous year.\1\ The pandemic has exacerbated mental health conditions
in youth, with 2021 CDC data showing 40 percent of high school youth
feeling persistently sad and 22 percent seriously considering
attempting suicide.\2\
---------------------------------------------------------------------------
\1\ Substance Abuse and Mental Health Services Administration
(SAMHSA). ``SAMHSA Announces National Survey on Drug Use and Health
(NSDUH) Results Detailing Mental Illness and Substance Use Levels in
2021.'' HHS.gov. January 4, 2023. Retrieved from: https://www.
hhs.gov/about/news/2023/01/04/samhsa-announces-national-survey-drug-
use-health-results-detailing-mental-illness-substance-use-levels-
2021.html#::text=Nearly%201%20in%204%20adults,
those%20with%20any%20mental%20illness.
\2\ Centers for Diseases Control (CDC). Youth Risk Behavior Survey:
Data Summary and Trends Report 2011-2021. February 13, 2023. Retrieved
from: https://www.cdc.gov/healthy
youth/data/yrbs/pdf/YRBS_Data-Summary-Trends_Report2023_508.pdf.
I recently helped a young woman navigate the process of finding a
psychiatrist after her symptoms deteriorated during the pandemic and
her therapist recommended she consider medication. She called
psychiatrists in her plan directory. Some did not call her back. Some
turned out not to be in her network after all. What I remember most
about that experience was how her symptoms got worse as she got more
and more worried about finding help. The same symptoms that she, and
many others with mental health conditions, needed help with--lack of
motivation, anxiety, psychosis--make it very difficult, if not
impossible, to call providers repeatedly to get a timely and affordable
appointment. Fortunately for the young woman I was helping, someone at
work mentioned an online telehealth solution available under her plan
and she was eventually able to access the services she needed, but not
before going through this very difficult and stressful period of
---------------------------------------------------------------------------
delayed care.
Ghost networks can exacerbate mental health conditions, creating
additional anxiety and feelings of hopelessness. They delay care and
can even lead to individuals deciding to forego care altogether, due
either to the difficulty of accessing services, the cost, or both.
SAMHSA's data show that nearly half of adults with mental health needs
do not receive treatment and the percentage of youth who received
treatment for major depression has remained at roughly 40 percent for
the past 6 years, indicating that over half of youth with mental health
needs are also not getting the help that they need.\3\
---------------------------------------------------------------------------
\3\ Substance Abuse and Mental Health Services Administration
(SAMHSA). Highlights for the 2021 National Survey on Drug Use and
Health. N.d. Retrieved from: https://www.samhsa.gov/data/sites/default/
files/2022-12/2021NSDUHFFRHighlights092722.pdf.
Ghost networks also have a financial cost on individuals and
distort the market for health insurance. Studies by Milliman,\4\
researchers from the Congressional Budget Office,\5\ and NAMI \6\
indicate that people with mental health conditions are more likely to
use out-of-network providers. This places a discriminatory financial
burden on these individuals because of the high costs of such
providers.
---------------------------------------------------------------------------
\4\ Melek, S., Davenport, S. and Gray, T.J. (2019). ``Addiction and
Mental Health vs. Physical Health: Widening Disparities in Network Use
and Provider Reimbursement.'' Retrieved from: https://
assets.milliman.com/ektron/
Addiction_and_mental_health_vs_physical_health_Widening
_disparities_in_network_use_and_provider_reimbursement.pdf.
\5\ Pelech, D., and Hayford, T. (2019). ``Medicare Advantage and
Commercial Prices for Mental Health Services.'' Health Affairs, 38(2),
262-267. Retrieved from: https://doi.org/10.1377/hlthaff.2018.05226.
\6\ National Alliance on Mental Illness. ``Out-of-Network, Out-of-
Pocket, Out-of-Options: The Unfulfilled Promise of Parity.'' November
2016. Retrieved from: https://www.nami.org/Support-Education/
Publications-Reports/Public-Policy-Reports/Out-of-Network-Out-of-
Pocket-Out-of-Options-The/Mental_Health_Parity2016.pdf.
Ghost networks are particularly harmful to low-income people, those
with disabilities, and women. As researchers have noted, people of
color and individuals with disabilities are disproportionately
represented in the Medicaid program and among low-income beneficiaries
who are least able to afford the cost of out-of-network care.\7\ People
with disabilities often have complex health needs that require finding
multiple providers to treat them. Women are more likely to be
responsible for family medical appointments and spend additional time,
stress, and resources to secure timely care.\8\ This has become
increasingly burdensome as children's mental health has worsened and
providers for children and adolescents are even more difficult to
access.
---------------------------------------------------------------------------
\7\ Burman, A. (2021). ``Laying Ghost Networks to Rest: Combating
Deceptive Health Plan Provider Directories.'' Social Science Research
Network. Retrieved from: https://doi.org/10.2139/ssrn.3869806.
\8\ Id., citing Sharma, N., Chakrabar, S., Grover, S., Sharma, N.,
Chakrabar, S., Grover S. ``Gender differences in caregiving among
family-caregivers of people with mental illnesses.'' World Journal of
Psychiatry. March 22, 2016 [explaining that women are more likely than
men to be informal caregivers for people with mental illnesses];
Grigoryeva, A., ``When Gender Trumps Everything: The Division of Parent
Care among Siblings.'' Center for the Study of Social Organization,
Working Paper No. 9. 2014 [finding that women are twice as likely as
men to act as caregivers for their parents.]
Inaccurate provider directories also distort the market for
insurance plans and erode consumer choice.\9\ Individuals use provider
directories to choose insurance plans, especially in Medicare, where
individuals may be choosing among Medicare Advantage (MA) plans or
between MA and fee-for-service Medicare. Plans have an incentive to
show broad provider directories, but when there are high percentages of
inaccuracies, these directories misrepresent the value of a plan and
undermine consumer choice.
---------------------------------------------------------------------------
\9\ Id. at 82-83.
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research studies indicate that ghost networks are widespread and the
problem persists despite requirements for provider directory accuracy
It is important to note that the individual stories of frustrating
experiences with directories are not just anecdotes. They are examples
of a widespread problem that has been studied in programs under the
jurisdiction of this committee. One of the most telling is a recent
study of the Oregon Medicaid program by Dr. Jane Zhu and
colleagues.\10\ They found that 67.4 percent--more than two-thirds--of
mental health prescribers and 59 percent of other mental health
professionals listed in the directories of Medicaid managed care
organizations were phantoms. These providers had not submitted claims
and billed for more than five unique individuals over a 1-year period.
I want to underscore that this study used claims data, which is
information that every insurance company has access to if they want to
verify their provider directories.
---------------------------------------------------------------------------
\10\ Zhu, J.M., et al. (2022). ``Phantom Networks: Discrepancies
Between Reported and Realized Mental Health Care Access in Oregon
Medicaid.'' Health Affairs, 41(7), 1013-1022. Retrieved from: https://
doi.org/10.1377/hlthaff.2022.00052.
CMS has conducted audits of Medicare Advantage Organization (MAO)
provider directories. They have looked at various providers, including
cardiology, oncology, ophthalmology, and primary care providers and
found high rates of inaccuracies with an average deficiency rate of
over 40 percent.\11\ They have not, to my knowledge, audited
specifically for behavioral health, but they should.
---------------------------------------------------------------------------
\11\ Centers for Medicare and Medicaid Services. Online Provider
Directory Review Report. 2018. Retrieved from: https://www.cms.gov/
Medicare/Health-Plans/ManagedCareMarketing/Downloads/
Provider_Directory_Review_Industry_Report_Round_3_11-28-2018.pdf.
In addition to the high rate of deficiencies, there are three
important conclusions from the CMS audits. First, it is possible to
audit accuracies in directories and CMS has done this before and
developed a composite measure of deficiencies based on how harmful the
inaccuracies were to accessing care. Second, plans can improve the
accuracy of their directories. The CMS audits showed significant
variation with CMS highlighting two MA plans with deficiencies of less
than 10 percent and two MA plans with deficiency rates above 90
percent. As CMS noted in its recommendations, ``MAOs that take a
reactionary approach by relying solely on provider-based notification
will not have valid provider directories. MAOs must proactively reach
out to providers for updated information on a routine basis. They
should actively use the data available to them, such as claims, to
identify any provider inactivity that could prompt further
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investigation.''
Finally, continuing to audit with no transparency or consequences
was not very effective, as the average inaccuracy rate in 2018 was
worse than the rate in 2016 despite CMS emphasizing the importance of
this issue in several call letters and memos to plans. Despite its
efforts to improve provider directory accuracy, CMS concluded that its
2018 review revealed significant errors that were likely to frustrate
Medicare Advantage members.
An analysis of State laws confirms that having a requirement for
accurate directories does not lead to compliance. Laws were passed in
California, Louisiana, and Maryland requiring accurate directories, but
the problems continued despite the legislation. The researcher studying
these efforts concluded that the lack of progress was directly related
to weak enforcement mechanisms, minimal penalties, and the lack of
critical tools to improve compliance.\12\
---------------------------------------------------------------------------
\12\ Burman, A. (2021). ``Laying Ghost Networks to Rest: Combating
Deceptive Health Plan Provider Directories.'' Social Science Research
Network. Retrieved from: https://doi.org/10.2139/ssrn.3869806.
MHA affiliates in Maryland and New Jersey conducted secret shopper
surveys of psychiatrists in provider directories in 2014 and 2013. The
Maryland study assessed provider directories for qualified health plans
and found that only 43 percent of listed psychiatrists were reachable,
with many out-of-date phone numbers or addresses.\13\ More than 10
percent of providers who could be reached indicated that they were not
even psychiatrists. Many of the doctors contacted had extremely long
wait times. The New Jersey study found that one-third of the network
entries for psychiatrists in HMO plans had incorrect phone numbers.\14\
These studies show that inaccurate directories have been problematic
for decades.
---------------------------------------------------------------------------
\13\ Mental Health Association of Maryland. ``Access to
Psychiatrists in 2014 Qualified Health Plans.'' The Maryland Parity
Project. January 26, 2015. Retrieved from: https://www.mhamd.
org/what-we-do/services-oversight/maryland-parity-project/.
\14\ Mental Health Association in New Jersey. Managed Care Network
Adequacy Report. 2013. Retrieved from: https://www.mhanj.org/content/
uploads/2022/07/MHANJ-Managed-Care-Network-Adequacy-Report-7-13.pdf.
legislative and administrative solutions
Despite the longstanding problem, there are potential solutions.
MHA recommends the following three policy changes:
First, the data must be verified using reliable methods such as
audits and claims data. At all non-profit organizations, including
Mental Health America, we cannot just submit financial data. We are
required to have an independent audit. The Medicare Advantage Plans and
Medicaid plans should have verified directories. This can be
accomplished by a third-party independent audit or by CMS for MA plans.
Last week, CMS issued a proposed Medicaid access rule requiring States
to use secret shopper surveys by an independent entity for managed care
plan directories for accuracy and wait time for appointments for
outpatient mental health and substance use providers and several other
categories of providers. The surveys would verify active network
status, street address, phone number, and whether the provider is
taking new patients.\15\ This policy should be finalized, and a similar
policy enacted for Medicare Advantage.
---------------------------------------------------------------------------
\15\ Medicaid and Children's Health Insurance Program (CHIP).
``Managed Care Access, Finance and Quality.'' Centers for Medicare and
Medicaid Services. Retrieved from: https://public-
inspection.federalregister.gov/2023-08961.pdf.
Plans also should be required on an annual basis to reconcile their
directories with claims data. If a provider has not billed in the
previous year, then the insurer should have to remove them from the
directory and the network unless they can prove that they will begin
---------------------------------------------------------------------------
taking patients. Plans have full access to their claims data.
Second, the information should be transparent. In its audits of MA
plans, CMS did not name the plans, referring to them as A, B, and C. In
other areas of health care, CMS requires transparency--in Hospital
Compare and Star Ratings. This area also needs more sunlight. CMS has
shown that it can develop a scoring system to distinguish among plans.
This information on provider directory accuracy rates should be
available to anyone choosing a plan. The proposed Medicaid rule
requires the secret shopper information to be posted on a State
website. This requirement should be finalized, and CMS should continue
to work with States to ensure that the information is displayed in a
manner that is easily understood by individuals choosing plans and by
State and Federal regulators.
CMS should ensure similar transparency for Medicare Advantage. A
recent brief from the Kaiser Family Foundation concluded, ``There is
not much information on whether Medicare Advantage enrollees are
experiencing barriers accessing mental health providers in their plan's
network and the extent to which enrollees use in-network and out-of-
network providers for these services.''\16\
\16\ Kaiser Family Foundation. ``Mental Health and Substance Use
Disorder Coverage in Medicare Advantage Plans.'' 2023. Retrieved from:
https://www.kff.org/medicare/issue-brief/mental-health-and-substance-
use-disorder-coverage-in-medicare-advantage-plans/.
Third, and most importantly, plans must be fiscally incentivized to
provide accurate directories. This would include weighing the
deficiency rate heavily in overall quality measures, such as how many
stars an MA plan receives or a composite quality score for Medicaid
plans. This policy would affect the plan's competitiveness in the
market and potential bonus payments and would have the advantage of
---------------------------------------------------------------------------
rewarding plans that do a good job.
It is very important that plans that work hard to provide accurate
directories and networks are rewarded for their efforts. The plan's
reimbursement rates, and the ease and frequency of their prior
authorization process, can also influence whether providers are willing
to participate in-network and plans that improve these policies also
should be rewarded for their efforts. Plans with consistent error rates
over a benchmark set by CMS after a corrective action plan could be
ineligible to participate or lose bonus payments.
For Medicaid plans, CMS could provide technical assistance and
additional matching funds to incentivize States to pay for performance
or withhold some percentage of Medicaid payment until plans meet
reporting and accuracy requirements. States have withheld payment to
Medicaid managed care organizations contingent on reporting accurate
and timely data.
Congress could also look to effective enforcement legislation, such
as the Health Insurance Portability and Accountability Act (HIPAA),
which includes compliance reviews and civil monetary penalties for
violations. Additional policies could provide financial protection and
reduce administrative burdens on individuals. If a person relies upon
an inaccurate directory, the individual should only be responsible for
in-network cost sharing. Congress passed legislation applying this
requirement to commercial plans and should extend it to all plans.
California has passed a law requiring plans to ``arrange coverage'' of
services when an individual cannot find a provider for mental health
and substance use disorder services. The plan must find in-network
providers who can provide timely care or provide out-of-network care
with no more cost sharing than an in-network provider.\17\
---------------------------------------------------------------------------
\17\ SB 855, Sec. 4, adding section 1372(d). Retrieved from:
https://leginfo.legislature.ca.gov/faces/
billTextClient.xhtml?bill_id=201920200SB855.
---------------------------------------------------------------------------
related issues that would improve directories, networks, and access to
care
Although this hearing is focused on inaccurate provider
directories, there are four related issues for the committee to
consider for future legislation that would improve provider directory
inaccuracies and, most importantly, access to behavioral health care:
provider rates, telehealth, integrated care, and extension of parity
requirements to Medicare Advantage Plans and Medicare and Medicaid fee-
for-service programs.
A recent Government Accountability Office (GAO) report revealed
that mental health stakeholders cited inadequate reimbursement rates
for services as one of the main reasons providers do not participate in
networks and individuals cannot access mental health care, even when
they have insurance.\18\ A study by the Kaiser Family Foundation found
that only 1 percent of physicians have opted out of the Medicare
program, but psychiatrists were disproportionately represented, making
up 42 percent of those opting out, followed by physicians in family
medicine (19 percent), internal medicine (12 percent), and obstetrics/
gynecology (7 percent).\19\ Medicare's process for setting rates
devalues cognitive work and fails to adjust for increased demand,
relying only on supply factors. In addition, researchers found that
commercial and Medicare Advantage plans paid an average of 13-14
percent less than fee-for-service reimbursement rates for in-network
mental health services while paying up to 12 percent more when care was
provided by physicians in other areas of health care.\20\
---------------------------------------------------------------------------
\18\ U.S. GAO. ``Mental Health Care: Access Challenges for Covered
Consumers and Relevant Federal Efforts.'' March 30, 2022. Retrieved
from: https://www.gao.gov/products/gao-22-104597.
\19\ Ochieng, N., Schwartz, K., and Neuman, T. (2020). ``How Many
Physicians Have Opted Out of the Medicare Program.'' Kaiser Family
Foundation. Retrieved from: https://www.kff.org/medicare/issue-brief/
how-many-physicians-have-opted-out-of-the-medicare-program/.
\20\ Pelech, D., and Hayford, T. (2019). ``Medicare Advantage and
Commercial Prices for Mental Health Services.'' Health Affairs, 38 (2),
262-267. Retrieved from: https://doi.org/10.1377/hlthaff.2018.05226.
Data clearly demonstrate that Medicaid programs in most States pay
less than Medicare, with some States paying less than half of Medicare
reimbursement rates for primary and maternity care.\21\ Although this
study did not analyze mental health rates, we can infer from studies of
commercial plans that these disparities are equal or worse in
behavioral health care.\22\ The Senate Finance Committee Task Force on
Workforce proposed a Medicaid State demonstration program with
increased Federal matching resources to improve rates and training of
the behavioral health workforce. This policy change would significantly
improve access if enacted and would complement recently proposed
Medicaid access regulations which increase rate transparency for
outpatient mental health and substance use services and compare these
rates to Medicare fee-for-service reimbursement rates.
---------------------------------------------------------------------------
\21\ Kaiser Family Foundation. ``Medicaid to Medicare Fee Index.''
2019. Retrieved from: https:
//www.kff.org/medicaid/state-indicator/medicaid-to-medicare-fee-index/
?currentTimeframe=0&
sortModel=%7B%22colId%22:%22Loca.on%22,%22sort%22:%22asc%22%7D.
\22\ Melek, S., Davenport, S. and Gray, T.J. (2019). ``Addiction
and Mental Health vs. Physical Health: Widening Disparities in Network
Use and Provider Reimbursement.'' Retrieved from: https://
assets.milliman.com/ektron/
Addiction_and_mental_health_vs_physical_health_Widening
_disparities_in_network_use_and_provider_reimbursement.pdf [finding
that in-network behavioral health reimbursement rates are lower than
medical/surgical rates (as a percentage of Medicare-allowed amounts)
and the disparity has been increasing.]
When I was helping the young woman access psychiatric services, she
was finally able to get assistance from a telehealth platform and
provider. Unlike dialing endlessly for help, the platform showed which
providers were available and allowed her to make an appointment online.
Some individuals prefer or need in-person care, so it is critical to
maintain requirements for in-person networks. At the same time,
allowing robust telehealth options streamlines the process for getting
care quickly and efficiently. Congress extended the Medicare telehealth
flexibilities and waived in-person requirements until 2024. Such
changes should be permanent to provide greater access and Congress
should incentivize States to make it easier for providers to practice
---------------------------------------------------------------------------
across State lines.
Primary care providers are easily accessible, and many individuals
already have an in-network primary care provider. Although strong
models have been developed to integrate behavioral health into primary
care for children and adults, there has been slow adoption due to low
reimbursement rates, high startup costs, and cost-sharing barriers. The
Senate Finance Task Force recommendations on integrated care and other
legislative proposals would address these impediments and should also
be enacted to increase access to services.
Finally, the exclusion of certain plans and programs from parity
requirements is unfair to individuals with behavioral health conditions
in those programs. There is no explanation for why Medicaid managed
care plans are covered by parity requirements, but Medicare Advantage
plans are not. People who get their care through Medicare are no less
deserving of equal coverage of mental health and substance use
services. In addition, both the Medicaid and Medicare fee-for-service
programs are excluded. The rights of people in Medicaid should not
depend on whether their State has chosen to use managed care plans.
Similarly, people in Medicare should not have to factor in parity
requirements when making their choices.
conclusion
There will always be some provider directory inaccuracies, but the
high rates consistently revealed in recent studies and audits are not
minimal errors. They are consumer and government deception
misrepresenting the value of the plan and the breadth of its offerings.
And this misrepresentation is particularly troubling because it causes
great suffering for people who are already struggling. With the right
verification of data, transparency requirements, and fiscal incentives,
we can do better.
Thank you again for your attention to this issue.
______
Questions Submitted for the Record to Mary Giliberti, J.D.
Questions Submitted by Hon. Michael F. Bennet
mental and behavioral health parity
Question. The Mental Health Parity and Addiction Equity Act of 2008
requires insurers to cover mental and behavioral health conditions
equal to coverage of any other medical conditions. However, these
protections only apply to private and
employer-provided plans. Medicare beneficiaries need these protections
as well. An estimated one in four Medicare beneficiaries live with
mental illness, and almost half of beneficiaries don't receive
treatment for their mental health conditions.\1\ I introduced the
Better Mental Health Care for Americans Act with Chair Wyden this year
to address this issue. One of the provisions of the legislation would
extend parity requirements to Medicare Advantage.
---------------------------------------------------------------------------
\1\ https://jamanetwork.com/journals/jamanetworkopen/fullarticle/
2771518.
Is there any reason why Medicare Advantage should treat mental and
---------------------------------------------------------------------------
behavioral health services differently than physical health services?
Answer. There is absolutely no reason why Medicare Advantage plans
should treat mental and behavioral health services differently than
physical health services. Currently, the parity requirements apply to
Medicaid managed care plans and to Affordable Care Act plans offered in
the marketplace. There is no reason that Medicaid managed care and
marketplace plans are required to treat mental health the same as
physical health, but Medicare Advantage plans are allowed to
discriminate and are not subject to the same requirements of fairness
between mental and physical health care.
medicare advantage provider directory requirements
Question. Senate Finance Committee staff recently conducted a
secret shopper survey of Medicare Advantage (MA) plans to understand
responsiveness and appointment availability.\2\ Their results were
similar to other studies conducted over the last decade.\3\ The staff
selected the two largest non-employer MA plans in Denver and called a
total of 20 providers posing as the adult child of a parent with the
given MA plan, seeking treatment for the parent's depression. Of the 20
calls, 5 went unanswered. Of the calls that were answered, 50 percent
of them were not successful either because the provider was out-of-
network (despite being listed in the plan's directory), the provider
was not accepting new patients, or the provider required a referral to
set an appointment. The results of this study are troubling for
Coloradans. One of the provisions in my mental and behavioral health
bill would address the issue of provider directory inaccuracy by
strengthening requirements for MA plans.
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\2\ https://www.finance.senate.gov/imo/media/doc/
050323%20Ghost%20Network%20
Hearing%20-%20Secret%20Shopper%20Study%20Report.pdf.
\3\ https://pubmed.ncbi.nlm.nih.gov/25354035/.
What more can Congress do to ensure patients have access to
---------------------------------------------------------------------------
accurate directories?
Answer. The struggles of families across the Nation must be
addressed so it is easier to access mental health services. I recommend
three categories of solutions. First, it is important to hold plans
accountable for accurate information. This can be accomplished through
secret shopper surveys and audits by third parties or CMS. Another
solution in this category is requiring plans to use their claims data
and adjust their provider directories and network adequacy submissions
accordingly.
Second, this is an area that needs more sunlight. Any audit results
around inaccuracies in the provider directory and long wait times for
services should be publicly available by plan.
Finally, to ensure that transparency does not lead to adverse
selection and reward plans that make it difficult to get care,
financial incentives must be aligned. This can be accomplished in
several ways. Penalties can be assessed against plans that exceed
benchmarks for accuracy and wait times. Another solution is adjusting
the Star rating system, which gives plans a 1-5 star rating. No plan
should get a high rating if it has inaccurate provider directories and
long wait times for care. Factoring these into the Star ratings at a
meaningful level of input (making accuracy and wait times count for a
lot in the Star system) would help consumers make better decisions.
mental and behavioral health integration
Question. In order to access care, a patient first needs to be able
to find a provider. In 2020, a third of adults aged 18 or older
reported having a mental illness but not receiving care because they
did not know where to go for services.\4\ Primary care providers are
often more accessible for patients, and studies have shown that
patients with mental health illnesses are more likely to discuss them
with a primary care doctor than with psychiatrists or other health
professionals.\5\ But our current system is not designed for
collaboration to coordinate a patient's care. Mental health illnesses
are often diagnosed and treated separately from physical health
services.
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\4\ https://www.aamc.org/advocacy-policy/aamc-research-and-action-
institute/barriers-mental-health-care.
\5\ https://www.aamc.org/media/62886/download.
Given how frequently individuals bring up mental health concerns in
primary care settings, could a behavioral health integration model work
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to increase services in rural areas?
Answer. Yes, a primary care integration model is particularly well-
suited for rural areas. People much prefer going to their primary care
practice, rather than specialty mental health providers and, given
workforce shortages, mental health providers are often unavailable. The
problem, however, is that primary care practices operate on very low
margins and the rates for compensating integrated care have not been
sufficient to incentivize these services. As a result, I strongly
recommend the committee increase payment for integrated care services
and for practices that have integrated behavioral health care.
Question. Are there other models that could increase access to
mental and behavioral health services?
Answer. In addition to primary care, young people are in school
settings. Accordingly, models that integrate behavioral health care
into school settings have been effective. This includes school-linked
services where a community mental health provider has an agreement with
the school to operate in the school, either in person or virtually.
Parents and students prefer to receive services in school because it
reduces transportation time and is convenient. In addition, studies
have shown school-based services reduce disparities and increase access
for children from underserved communities.
______
Questions Submitted by Hon. Sheldon Whitehouse
Question. What is the impact of prior authorization requirements on
access to mental health care?
Answer. Prior authorization policies have severely restricted
access to mental health care in several ways. First, onerous prior
authorization requirements disincentivize providers to take insurance.
Many behavioral health providers cite the time and effort required by
burdensome prior authorization processes as critical factors in their
decision not to participate in Medicaid, Medicare, and private
insurance. These prior authorization delays affect access to services
and medication and behavioral health providers are very frustrated by
the amount of time they must divert from patient care to arguing with
insurance reviewers, who often do not have the appropriate background
to make these decisions.
Second, insurers use medical necessity standards in their prior
authorization processes that are designed to deny services. A district
court in Wit v. United Healthcare, found that United Healthcare had
ignored medical association guidelines and instead, specifically
designed its criteria for financial gain by denying care. CMS has
recently proposed requiring Medicare Advantage plans to use clinical
guidelines in making medical necessity determinations.
Question. What are the largest sources of administrative and
payment-recovery costs for mental health providers, and how do these
affect their ability to serve patients and communities?
Answer. Burdensome prior authorization processes lead to high costs
for mental health providers and make it difficult for them to serve
patients and communities by taking needed time away from patient care
and disincentivizing taking insurance.
A recent article \6\ by Kaiser Health News noted that health
insurance denials are increasing and cost millions for doctors and
patients to address. They note that some insurers use automated reviews
to deny services at high rates and with little review of the person's
individual circumstances.
---------------------------------------------------------------------------
\6\ https://kffhealthnews.org/news/article/denials-of-health-
insurance-claims-are-rising-and-getting-weirder/.
Providers also find step therapy and fail first policies for
medication particularly problematic from administrative and human cost
perspectives. If the provider has clinical reason to recommend a
particular treatment, it is not cost effective or humane to require the
individual to decline in mental health before they can access the
medication that their provider recommends. Providers are often forced
to prescribe medications according to insurance coverage that have not
previously worked for people or that are contra-indicated due to
adverse interactions with medications the person is taking for other
conditions, allergies, or if the person is pregnant. These policies are
often shortsighted because medical costs increase and unnecessary time
and suffering results from increased emergency service use and hospital
---------------------------------------------------------------------------
costs.
Question. What payment reforms have reduced these administrative
costs, and which models hold the greatest promise to reduce the
administrative burden on mental health providers?
Answer. Policies have required that insurers make decisions based
on clinical guidelines of medical associations, rather than making up
the medical necessity criteria. Requiring the appropriate educational
background and a review of the individual's record is also helpful.
The Kaiser Health News article noted that information on denials is
required to be public and reported by plan, but HHS has not implemented
and enforced these policies. The author writes:
The Affordable Care Act clearly stated that HHS ``shall''
collect the data on denials from private health insurers and
group health plans and is supposed to make that information
publicly available. (Who would choose a plan that denied half
of patients' claims?) The data is also supposed to be available
to state insurance commissioners, who share with HHS the duties
of oversight and trying to curb abuse.
To date, such information-gathering has been haphazard and
limited to a small subset of plans, and the data isn't audited
to ensure it is complete, according to Karen Pollitz, a senior
fellow at KFF and one of the authors of the KFF study. Federal
oversight and enforcement based on the data are, therefore,
more or less nonexistent.
States have taken a number of legislative approaches to lessen the
administrative burden, and the burden of denial and delay for
medication access for individuals experiencing serious mental illness.
Examples include:
No step therapy or prior authorization for medications for
serious mental illness in private insurance (ME).
No step therapy or prior authorization for medications for
serious mental illness in Medicaid (TX).
Disallowing therapeutic substitution for medications for
serious mental illness for people who are stabilized on a
medication (WA).
Partial remedies, such as mandating that no more that one
step before access to clinically indicated and prescribed
medication for serious mental illness (CO--awaiting the
Governor's signature).
______
Question Submitted by Hon. Chuck Grassley
Question. Are government regulations or policies preventing the
private sector from solving the problem of inaccurate provider
directories?
Answer. I am not aware of any government regulation or policy that
prevents the private sector from solving the problem of inaccurate
provider directories, but there are policies that incentivize them not
to solve the problem. If a plan has an inaccurate directory, it is
likely that the person will not be able to find in-network help. Given
that 60 percent of Medicare Advantage plans do not offer out-of-network
coverage, the plan pays nothing if the individual either goes out of
network or does not receive care. So current policy gives plans fiscal
incentive to have inaccurate directories and no fiscal incentive to
correct the problem.
If a plan with inaccurate directories was no longer able to get a
high Star rating and the corresponding bonus payments, then there would
be a financial incentive to fix the problem. Similarly, a significant
penalty payment would also be a financial incentive to fix the problem.
______
Prepared Statement of Keris Jan Myrick, M.S., M.B.A.,
Vice President of Partnerships, Inseparable
Chair Wyden, Ranking Member Crapo, and members of the Senate
Finance Committee, thank you for conducting this hearing today and
providing me the honor of testifying regarding ghost networks and
provider directories.
My name is Keris Myrick, and I am the vice president of
partnerships for Inseparable, a nonprofit organization working to
advance policy that reflects the belief that the health of our minds
and our bodies is inseparable. We are focused on closing the treatment
gap for the many people who need mental health services and aren't
getting them, improving crisis response, and promoting prevention and
early intervention. I am also a mental health advocate and survivor
with lived experience of ghost networks in health plans. I am here
today to share my story and bring attention to this critical issue that
affects so many people living with mental health conditions.
Ghost networks and inaccurate provider directories erect invisible,
unexpected barriers within our health system, preventing people from
accessing the care and support they need. They are particularly
damaging for those of us living with serious mental health conditions,
like me, as they can result in delayed or inadequate treatment or even
going without treatment, any of which can have devastating
consequences.
My first experience with ghost networks occurred when I had to
change my health insurance due to a move and a new job in 2014. Leaving
California to work for the Federal Government was both exciting and
daunting. It was imperative that I find the health-care professionals
that I needed, especially a psychiatrist who could provide the
continuity of care that was essential to my ongoing mental health
recovery.
My California-based psychiatrist provided me with a few DC-based
recommendations. However, those providers were not accepting new
patients. I was left to navigate the Blue Cross Blue Shield for Federal
Employees provider directory to find a psychiatrist. Calling
psychiatrists within DC and Maryland, selected out of what was like a
digital white-pages phone book, turned into one rejection after
another. Call after call resulted in the following types of responses:
``Who? Hmm, s/he doesn't work here. No, I don't know where s/he
works now.''
``Who? I don't know who that is, not sure they ever worked
here. Hold please . . .'' [dial tone].
Recorded message: ``Dr _____ is no longer accepting new
patients. If this is an emergency, hang up and call 911.''
I spent countless days and hours scouring the network, despite
working long hours in a high-level management position. When was there
time to find a psychiatrist? I had to make the time, though, as my job,
and more importantly my life, depended on it. Continued attempts
finally lead me to a psychiatrist who was taking new patients. Success,
though, was short-lived. In our phone conversation to set up an initial
in-person appointment, I was asked about my diagnosis. I had no worry
or fear; this doctor, this psychiatrist, was taking new patients. I
respond without hesitation--schizophrenia. A pause, a long silence . .
. and then the response: ``Oh. . . . I do not take patients with a
schizophrenia diagnosis.''
I ask if they have any suggestions or referrals to help me find a
doctor who does. The answer is: ``Check the provider directory.''
I am back at the beginning now with a heightened fear of rejection.
Going back to the directory was like looking for a needle in a
haystack. Lots of hay, very few needles, and none that can stitch
together the needs of my schizophrenia garment.
Finally, I contacted my psychiatrist in California and asked if and
how he could remain my doctor. While in the DC area, I had regular
appointments with this psychiatrist and flew at my own expense to Los
Angeles over a 4-year period to ensure that I could be and stay well. I
also paid high copays for my out-of-network provider, but I HAD a
provider.
On the same plan, when I needed a doctor for what turned out to be
thyroid cancer, I was able to find an endocrinologist the very same
day. There was no guessing in the directory how to find that type of
specialist or to find one that was taking new patients. But for mental
health, it was a very different story--a story that continued
throughout my career.
In 2018, I left the Federal Government to work for Los Angeles
County Department of Mental Health, leaving me with new insurance and a
new provider directory to navigate. My L.A.-based psychiatrist was now
a colleague, so I had to find a new psychiatrist. I searched the
directory with trepidation and the response to my calls led to all-too-
familiar dead ends. In 2020, I accepted a position with the Mental
Health Strategic Initiative, and, in 2022, began my current role with
Inseparable. Again, new insurance plans and new provider directories.
Each time, it felt like the movie, ``Groundhog Day,'' with the same
responses--there is no provider here by that name, they are retired,
and/or they aren't taking new patients, especially not one with a
diagnosis of schizophrenia.
Unfortunately, my story is not unique. Many of my peers with mental
health diagnoses face similar challenges when seeking care, regardless
of whether they are covered by Medicaid, Medicare, or private
insurance. I know I have been extremely fortunate that I could bear the
expense of out-of-network care and that I have not had a psychiatric
emergency. Many are not so lucky and the outcomes can be terrible, even
tragic. As you know, people with serious mental health conditions have
disproportionately high rates of being unhoused, unemployed,
incarcerated, hospitalized, disabled, or dying early of treatable
medical conditions or by suicide. And the difference between
maintaining a life of our dreams and unimaginable outcomes can come
down to whether a person is able to get the care they need.
Health plans, you are not doing the job you are paid to do. My
health plans were supposed to cover mental health care, yet I was left
without reasonable access to providers. I'm also covered for my thyroid
condition, but have always had ready access to a specialist, an
endocrinologist. But for mental health, it's been a different story.
Even today, despite having health insurance that is otherwise
considered ``excellent,'' I have no regular psychiatrist. This leaves
me with ongoing anxiety about what will happen if I should need more
intensive and ongoing care. I have experienced being unhoused,
unemployed, having interactions with the criminal justice system and
involuntary hospitalizations. I don't ever want to go through those
traumatizing experiences again because I wasn't able to find a provider
through my health plan's directory and get the help I need to stay
well.
I do not have this worry about my thyroid condition; I have had a
specialist, an endocrinologist, readily available under every insurance
plan. Why, then, do I not have the same for my mental health? Senator
Wyden, you stated: ``Too often, Americans who need affordable mental
health care hit a dead end when they try to find a provider that's
covered by their insurance. Ghost networks mean that the lists of
mental health providers in insurance company directories are almost
useless.'' Never a truer word.
It is time to require health plans and insurance companies to take
responsibility and be accountable for providing accurate and timely
information to their members and for maintaining adequate networks of
providers. We are no longer patient--we demand to see improvements. As
a survivor with lived experience of ghost networks in health plans, I
urge you to take action on this critical issue. The Senate Finance
Committee can play a vital role in promoting access to mental health
care, especially for someone, like me, living with a diagnosis of
schizophrenia, through policies that:
1. Provide the oversight, enforcement, and incentives and/or
penalties necessary to result in highly accurate provider
directories;
2. Require the inclusion of psychiatric subspecialties in
provider directories; and
3. Implement a federally operated mechanism (online reporting
system or dedicated 1-800 number) for consumers/plan members to
report their experiences of ghost networks and use this data to
inform policy and enforcement actions.
I encourage you to consider the impact of ghost networks on
individuals with mental illness and their families and adopt solutions
that ensure that everyone has access to the care and support they need
to thrive.
______
Questions Submitted for the Record to Keris Jan Myrick, M.S., M.B.A.
Questions Submitted by Hon. Sheldon Whitehouse
Question. What is the impact of prior authorization requirements on
access to mental health care?
Answer. Prior authorization requirements, a process that requires
patients and health-care providers to obtain approval from insurance
companies before certain treatments or services can be covered, can
have a significant impact on access to mental health care. While prior
authorization is intended to manage costs and ensure appropriate care,
it can create barriers and delays in accessing mental health services.
Here are some specific impacts:
1. Delays in treatment: The prior authorization process often
involves paperwork, documentation, and review by insurance
companies. This can lead to delays in receiving mental health
care, which is especially problematic for individuals who need
timely intervention or are in crisis situations.
2. Administrative burden: Mental health providers may spend a
significant amount of time and resources dealing with prior
authorization requests. This can divert them away from
providing direct care to patients, leading to decreased
capacity to serve patients, as well as increased administrative
burden and potential burnout.
3. Limited provider options: Insurance companies typically
have a list of preferred providers or a network of contracted
mental health professionals. If a patient's preferred provider
is not in-network, they may have to switch to a different
provider or face higher out-of-pocket costs. This can limit
patients' choices and disrupt established therapeutic
relationships.
4. Discontinuity of care: Prior authorization requirements can
disrupt the continuity of mental health treatment. If a patient
needs to change providers or if there are delays in obtaining
authorization for ongoing treatment, it can result in
interruptions in care, which can be detrimental to the
patient's progress--or even result in crises and other harmful
outcomes.
5. Stigma and privacy concerns: The prior authorization
process may require patients, when contesting a denial of prior
authorization, to disclose personal and sensitive information
about their mental health conditions to their insurance plan.
This can create privacy concerns and potential stigma,
discouraging individuals from seeking the care they need.
6. Inconsistent criteria and denials: Prior authorization
requirements can vary across insurance plans, leading to
inconsistencies in approval criteria. Denials for coverage may
occur even when treatment is deemed necessary by mental health
professionals, leading to additional challenges in accessing
appropriate care.
These factors collectively contribute to decreased access to mental
health care and may negatively impact individuals seeking help for
mental health conditions.
Question. What are the largest sources of administrative and
payment-recovery costs for mental health providers, and how do these
affect their ability to serve patients and communities?
Answer. The largest sources of administrative and payment-recovery
costs for mental health providers can vary, but some common factors
include:
1. Prior authorization requirements: As mentioned earlier,
prior authorization requirements imposed by insurance companies
can create significant administrative burdens for mental health
providers. The process involves paperwork, documentation, and
communication with insurance companies to obtain approval for
specific treatments or services. This administrative workload
can divert resources and time away from patient care.
2. Insurance claim processing: Mental health providers often
need to submit claims to insurance companies for reimbursement
of services provided. The administrative tasks involved in
claim submission, coding, and documentation can be time-
consuming and costly. Providers may need to hire additional
staff or invest in electronic health record systems to manage
these processes efficiently.
3. Billing and collections: Mental health providers must
handle billing and collections processes to receive payment for
their services. This includes verifying insurance coverage,
processing claims, following up on denied or unpaid claims, and
managing patient payments. These tasks require dedicated
administrative staff and can be complex and time-consuming.
4. Compliance and regulatory requirements: Mental health
providers are subject to various compliance and regulatory
requirements, such as those related to privacy (HIPAA), billing
practices, and documentation standards. Ensuring compliance
with these regulations often involves additional administrative
efforts and costs, including staff training, audits, and
maintaining adequate documentation.
These administrative and payment-recovery costs can have several
effects on mental health providers' ability to serve patients and
communities:
1. Financial strain: The costs associated with administrative
tasks and payment recovery can strain the financial resources
of mental health providers, particularly smaller practices or
those serving underserved communities. Providers may have
limited resources available for hiring qualified staff,
investing in technology, or expanding their services.
2. Reduced capacity and access: The administrative burden
placed on mental health providers can limit their capacity to
see and serve patients. Providers may have to spend more time
on administrative tasks, leading to fewer available appointment
slots and longer wait times for patients. This can impede
timely access to mental health services, particularly in areas
already facing shortages of mental health providers.
3. Increased operational costs: Administrative tasks and
payment recovery processes require additional staff, software,
and infrastructure, all of which contribute to increased
operational costs for mental health providers. These costs may
need to be passed on to patients through higher fees or
copayments, making mental health care less affordable.
4. Burnout and job dissatisfaction: The heavy administrative
burden placed on mental health providers can lead to burnout
and job dissatisfaction. Providers may feel overwhelmed by the
administrative tasks, spending less time on direct patient care
and the therapeutic aspects of their work. This can negatively
impact their overall well-being and ability to provide quality
care.
5. Disparities in care: The administrative and payment
challenges faced by mental health providers can
disproportionately affect underserved populations and
communities with limited access to mental health services.
Providers in these areas may struggle to sustain their
practices or may be unable to accept certain insurance plans,
exacerbating existing disparities in access to care.
Efforts to streamline administrative processes, simplify billing
and reimbursement, and reduce regulatory burdens can help alleviate
some of these challenges and enable mental health providers to focus
more on delivering quality care to their patients and communities.
Question. What payment reforms have reduced these administrative
costs, and which models hold the greatest promise to reduce the
administrative burden on mental health providers?
Answer. Several payment reforms have been implemented to reduce
administrative costs and streamline billing processes in health care,
including mental health. Here are some payment models that have shown
promise in reducing the administrative burden on mental health
providers:
1. Value-based care and alternative payment models: Value-
based care models, such as accountable care organizations
(ACOs) and bundled payments, aim to shift the focus from fee-
for-service reimbursement to paying providers based on quality
and outcomes. These models incentivize coordination of care,
reducing the need for excessive administrative tasks associated
with billing and claims processing. By aligning payment
incentives with patient outcomes, value-based care models can
promote efficiency and reduce administrative burdens.
2. Integrated care and collaborative models: Integration of
mental health services within primary care settings or through
collaborative care models can streamline administrative
processes. In these models, mental health providers work
closely with primary care providers, sharing information and
coordinating care. This integrated approach can reduce
administrative tasks related to referral processes, claim
submissions, and coordination of benefits across different
providers.
3. Telehealth and digital health solutions: The increased
utilization of telehealth and digital health technologies has
the potential to streamline administrative processes.
Telehealth allows providers to deliver mental health services
remotely, reducing the need for in-person administrative tasks.
Digital health solutions, such as electronic health records
(EHRs) and online billing systems, can automate administrative
processes, improve billing accuracy, and simplify claims
submissions.
4. Simplified billing and coding practices: Simplifying
billing and coding practices can significantly reduce
administrative burdens. Standardizing billing codes,
implementing electronic claims submission, and adopting clear
and uniform reimbursement guidelines can streamline the payment
process and reduce administrative complexities for mental
health providers.
5. Reduced prior authorization requirements: Revising and
reducing prior authorization requirements can alleviate the
administrative burden on mental health providers. Simplifying
the criteria, implementing evidence-based guidelines, and
adopting streamlined processes can expedite access to mental
health services, reducing the administrative workload for
providers.
Administrative simplification initiatives: Various administrative
simplification initiatives, such as the adoption of standard
transaction formats (e.g., HIPAA EDI) and electronic funds transfer
(EFT) for reimbursement, aim to streamline administrative processes and
reduce paperwork. These initiatives focus on standardizing
communication and transactional processes between providers and
insurance companies, which can improve efficiency and reduce
administrative costs. It's important to note that the effectiveness of
these payment models in reducing administrative burdens may vary based
on the specific health-care system, insurance practices, and regulatory
environment in different regions. Continued collaboration among
policymakers, payers, and providers is crucial to identify and
implement payment reforms that effectively reduce administrative costs
and improve the overall delivery of mental health care.
______
Questions Submitted by Hon. Chuck Grassley
Question. Are government regulations or policies preventing the
private sector from solving the problem of inaccurate provider
directories?
Answer. Inaccurate provider directories have been a longstanding
issue in the health-care industry. While government regulations and
policies can play a role in shaping the health-care landscape, this is
a complex issue that involves various factors. Government regulations
and policies can play a role in helping the private sector address the
problem of inaccurate provider directories. Inaccurate provider
directories can cause significant challenges for patients seeking
health-care services, leading to frustration, delays in care, and
potential health risks. Here are a few ways in which government
regulations and policies can assist in resolving this issue:
1. Data Accuracy Standards: Governments can establish
standards and regulations requiring insurers, and health plans
to maintain accurate and up-to-date provider directories and
for health-care providers to assist by providing timely and
accurate information to insurers and health plans. This can
include guidelines on data quality, regular verification
processes, and penalties for noncompliance.
2. Transparency Requirements: Governments can mandate
transparency in provider directory information, ensuring that
accurate and relevant details are accessible to the public.
This can include requirements for providers and insurers to
disclose information such as location, contact details,
specialties, and accepted insurance plans.
3. Reporting and Auditing: Governments can implement
mechanisms for reporting and auditing provider directories to
identify inaccuracies and monitor compliance. Regular audits
and assessments can help identify areas for improvement, hold
accountable entities responsible for maintaining accurate
directories, and ensure that corrective measures are taken.
4. Collaboration and Information Sharing: Governments can
facilitate collaboration between private health-care
organizations, insurers, and other stakeholders to share
accurate provider data. This can involve the development of
standardized data formats and interoperability standards to
enable seamless exchange of provider information.
5. Consumer Protection Measures: Governments can introduce
consumer protection measures to address the consequences of
inaccurate provider directories. This may include provisions
for patients to report inaccuracies, seek remedies, or file
complaints against providers or insurers that consistently
provide incorrect or misleading information.
6. Incentives and Rewards: Governments can offer incentives or
rewards to private entities that maintain accurate and up-to-
date provider directories. This can encourage compliance with
regulations, spur competition among providers and insurers to
improve data quality, and ultimately benefit patients. For
example, in the United States, the Centers for Medicare and
Medicaid Services (CMS) has established guidelines for Medicare
Advantage plans to maintain accurate directories. These
regulations can incentivize private insurers and providers to
improve the quality of their directories.
Government regulations and policies can have both positive and
negative impacts on the private sector's ability to address inaccurate
provider directories. On one hand, regulations can introduce standards
and requirements for provider directories, aiming to ensure accuracy
and transparency. On the other hand, compliance with regulations can
sometimes be burdensome and costly for private entities. Strict
regulations may impose administrative requirements and reporting
obligations that could divert resources away from addressing specific
problems like inaccurate provider directories. Additionally, regulatory
frameworks can vary across different jurisdictions, making it
challenging for the private sector to develop standardized solutions.
It's important to note that inaccurate provider directories can
result from a range of factors, including the dynamic nature of health-
care networks, changes in provider information, outdated technology,
and data management challenges. Addressing these issues requires
collaboration between government entities, private insurers, health-
care providers, and technology companies.
Government regulations and policies can influence the public and
private sector's ability to address inaccurate provider directories. A
comprehensive and balanced approach involving government regulations
and oversite, collaboration between public and private entities, along
with advancements in technology, is necessary to tackle this complex
problem.
Question. In your written testimony, you offered ideas to improve
provider directories. How do your solutions account for rural patients'
needs?
Answer. When considering the solutions I provided to improve
provider directories, it is important to account for the specific needs
of rural patients. Rural areas often face unique challenges in
accessing health-care services, including a shortage of providers and
limited network options. Here's how each solution could address rural
patient needs:
1. Provide oversight, enforcement, incentives, and penalties:
This solution aims to ensure highly accurate provider
directories across the board. In rural areas, where provider
shortages are more pronounced, it becomes even more critical to
maintain accurate and up-to-date directories. By enforcing
regulations and incentivizing accurate reporting, rural
patients can have better access to reliable information about
available providers and services. Examples include:
a. Incentives for Data Reporting: Create incentives
for health-care plans and providers, especially those
in rural areas, to regularly update and maintain
accurate information in the directories. Incentives
could include reduced administrative burden, financial
incentives, or improved visibility for plans and
providers who actively participate in maintaining
directory accuracy.
b. Data Verification and Validation: Implement robust
mechanisms to verify and validate provider information
regularly. This can involve cross-referencing
information from multiple sources, leveraging data
analytics to identify discrepancies, and employing
automated processes to flag potential inaccuracies for
manual review.
2. Require inclusion of psychiatric subspecialties: Mental
health services are crucial in rural areas, where access to
specialized psychiatric care can be limited. By mandating the
inclusion of psychiatric subspecialties in provider
directories, rural patients can have clearer visibility into
the availability and specialty of mental health professionals
especially providers that specialize in schizophrenia disorders
which are woefully underrepresented in all areas of the
country. Further, by promoting and integrating telehealth
services into provider directories inclusive of subspecialties
should be part of this solution for rural communities.
Telehealth can play a crucial role in delivering health-care
services to rural areas where access to specialists and
subspecialties may be limited. Including telehealth providers
and their subspecialties in directories can provide rural
patients with more options for receiving care remotely.
Supporting the development of user-friendly mobile applications
and online platforms that are easily accessible to rural
patients can also facilitate access to psychiatric
subspecialties. These platforms can provide real-time
information about available providers, their specialties,
appointment availability, and other relevant details such as
search functionalities, location mapping, and filtering options
to help patients find nearby providers and understand the
services they offer. Designing these tools to be compatible
with low-bandwidth Internet connections or offline access can
be beneficial for rural areas with limited connectivity. It's
crucial to ensure that these platforms are designed with
simplicity and accessibility in mind, considering potential
limitations in Internet connectivity and technology usage in
rural areas. Requiring psychiatric subspecialties and tools to
access them can help people in rural communities to make
informed decisions and identify providers who can address their
specific needs.
3. Implement a federally operated reporting mechanism:
Establishing a dedicated reporting system for consumers to
share their experiences, such as encountering ghost networks
(insufficient provider networks), can be beneficial for rural
patients. It allows them to voice their concerns and provide
valuable feedback about their access to care.
Conducting community outreach programs with Peer Supporters
and Community Health Workers (CHWs) can raise awareness among
rural populations about the importance of accurate provider
directories and can educate patients about how to navigate the
directories, understand provider information and report
inaccuracies easily through the federally operated reporting
mechanism. Empowering rural patients with the knowledge to
utilize and contribute to improving provider directories is
invaluable. By incorporating rural patient experiences into the
reporting system, policymakers can gain insights into the
unique challenges faced by rural communities and take targeted
actions to address them. This data can inform policy decisions,
enforcement actions, and potentially lead to interventions that
improve network adequacy in rural areas.
It's crucial to recognize that rural health-care challenges are
multifaceted. Addressing the needs of rural patients requires a
comprehensive approach that encompasses factors like provider
recruitment, telehealth solutions, transportation infrastructure, and
financial incentives. The solutions provided for improving provider
directories can serve as a part of a broader strategy to enhance rural
health-care access. Continuous collaboration between government,
health-care stakeholders inclusive of peers and people living with
mental health conditions and rural communities is essential to tailor
and implement effective solutions that meet the unique needs of rural
patients.
______
Prepared Statement of Jack Resneck, Jr., M.D.,
President, American Medical Association
I appreciate the opportunity on behalf of the American Medical
Association (AMA) to provide testimony to the U.S. Senate Committee on
Finance as part of the hearing entitled, ``Barriers to Mental Health
Care: Improving Provider Directory Accuracy to Reduce the Prevalence of
Ghost Networks.'' In addition to my position as president of the AMA, I
am a practicing dermatologist and the chair of the Department of
Dermatology at the University of California, San Francisco.
As the president of the largest professional association for
physicians and the umbrella organization for State and national
specialty medical societies, I am acutely aware that provider
directories are critically important tools to help patients find a
physician when they need one. Directories allow patients to search and
view information about in-network providers, including the practice
location, phone number, specialty, hospital affiliations, whether they
are accepting new patients, and other details. Some directories also
provide information on health equity and accessibility issues, such as
public transportation options, languages spoken, experience with
specific patient populations, and the ability to provide specific
services.
Directories can help physicians make referrals for their patients,
serving as a primary source of network information for patients' health
plans. Directories also serve as a representation of a plan network and
the network's adequacy for regulators.
Importantly, directories can help patients purchase the health
insurance product that is right for them. A patient with psoriatic
arthritis may select a product that appears to have their
rheumatologist and dermatologist in the network. A family without a car
may select a product because the pediatrician down the street is in-
network. A 26-year-old may not choose to put money in her flexible
savings account this year because all of her physicians appear to be
contracted under her new plan. And patients being treated for opioid
use disorder may pick a product because it appears that the mental and
behavioral health-care services they require are available through the
plan's network providers.
Therefore, when directory information is incorrect, the results can
be complicated, irritating, expensive, and potentially devastating,
especially to patients. Inaccurate directories shift the responsibility
onto patients to locate a plan's network or pay for out-of-network
care. Patients are financially impacted and may be prevented from
receiving timely care.
Moreover, in the long run, continuing to allow inaccuracies makes
it easier for plans to fail to build networks that are adequate and
responsive to enrollees' needs. Accurate directories are a basic
function and responsibility of health plans offering network products.
It should be noted that directory accuracy seems of particular
importance in the immediate term, as we face the end of the Medicaid
continuous enrollment provision, and many Medicaid recipients begin to
transition off Medicaid and onto private health insurance plans. It is
critical that directories provide accurate information for individuals
who are entering the private market, especially those who may have
chronic conditions or significant health-care needs and are looking to
ensure that their physicians and other health-care providers are in-
network.
i. scope of the problem
There have been dozens of studies over the last 10 years looking at
the scope of the provider directory problem and nearly all of them
point to serious inaccuracies with physicians' locations, as well as
inaccurate physicians' network status, physicians' availability to
accept new enrollees, physicians' specialties, or all of the above.
In October 2014, I published a study with several colleagues in the
Journal of the American Medical Association Dermatology.\1\ We
specifically studied Medicare Advantage (MA) plan directories of
participating dermatologists and the appointment availability of those
dermatologists listed. Our ``secret-shopper'' research first found that
about 45 percent of the listings included duplicates--multiple office
listings at different addresses for the same physician, or the same
physicians at the same addresses with slightly different versions of
their names. This, of course, created the appearance of more robust
networks than were in place.
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\1\ J. Resneck, A. Quiggle, M. Liu, D. Brewster, ``The Accuracy of
Dermatology Network Physician Directories Posted by Medicare Advantage
Health Plans in an Era of Narrow Networks,'' JAMA Dermatology (October
24, 2014).
After accounting for those duplicates, we found that they were
unable to contact nearly 18 percent of physicians either because the
numbers were wrong, or the office had never heard of that physician.
Furthermore, 8.5 percent reported that the listed physicians had died,
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retired, or moved out of the area.
After that, we found that 8.5 percent of those physicians were not
accepting new patients, and more than 10 percent were not the right
type of physician to address the condition for which we were seeking
care (an itchy rash)--e.g., they were subspecialists, dermatologic
surgeons, pediatric dermatologists, etc. In the end, we found that
about 26.6 percent of the individual directory listings were unique,
accepting the patient's insurance, and offering a medical dermatology
appointment. However, the average wait time to get that appointment was
45.5 days.
Since I published that study, I fear that the situation has not
improved. In 2018, the Centers for Medicare and Medicaid Services
(CMS), in a review of 52 MA organizations (MAOs) (approximately one-
third of MAOs at the time), found that nearly 49 percent of the
provider directory locations listed had at least one inaccuracy.\2\
Specifically, providers should not have been listed at 33 percent of
the locations because the provider did not work at the location or
because the provider did not accept the plan at the location. CMS also
found a high number of instances where phone numbers were wrong or
disconnected and incorrect addresses were listed. Similarly, CMS
reported cases where the provider was found not to be accepting new
patients, although the directory indicated that the provider was
accepting new patients.
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\2\ ``Online Provider Directory Review Report,'' CMS, November 28,
2018, https://www.
cms.gov/Medicare/Health-Plans/ManagedCareMarketing/Downloads/
Provider_Directory_
Review_Industry_Report_Round_3_11-28-2018.pdf.
Errors in location and contact information can lead to patient
frustration and, in many cases, delays in accessing care. It can also
result in higher costs for patients. The AMA fielded a survey between
2017 and 2018 where 52 percent of physicians reported that their
patients encountered coverage issues due to inaccurate information in
provider directories at least once per month.\3\ And a 2020 study in
the Journal of General Internal Medicine found that, of patients
receiving unexpected bills, 30 percent noted errors in their health
plan's provider directory.\4\
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\3\ ``What Physicians are Saying About Directories,'' Power Point
summary, American Medical Association, 2018.
\4\ K.A. Kyanko, S.H Busch, ``Surprise Bills from Outpatient
Providers: A National Survey,'' J Gen Intern Med 36, 846-848 (2021),
https://doi.org/10.1007/s11606-020-06024-5.
Imagine selecting a health plan and paying health insurance
premiums only to find out that you relied on erroneous information.
Imagine the sense of helplessness and frustration amongst patients when
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they cannot access the care on which they were counting.
Directory inaccuracy issues do not seem to be specific to any type
of physician specialist or patient care, but in a moment where we are
facing a mental health crisis, it is imperative that health plans offer
adequate networks that are accurately reflected in their directories so
that patients can access timely mental and behavioral health care.
Unfortunately, this does not seem to be happening. For example, a March
2022 Government Accountability Office (GAO) report to this committee
\5\ highlighted patient challenges with accessing mental health care.
Stakeholders reported that inaccurate or out-of-date information on
mental health providers in a health plan's network contributes to
ongoing access issues for consumers and may lead consumers to obtain
out-of-network care at higher costs.
---------------------------------------------------------------------------
\5\ Mental health care: Access Challenges for Covered Consumers and
Relevant Federal Efforts, GAO, March 2022. https://www.gao.gov/assets/
gao-22-104597.pdf.
Similarly, a 2020 Health Affairs study found that 44 percent of the
patients surveyed had used a mental health provider directory and 53
percent of those had encountered directory inaccuracies.\6\ Those who
encountered at least one directory inaccuracy were four times more
likely to have an out-of-network bill for the care.
---------------------------------------------------------------------------
\6\ S.H. Busch, K.A. Kyanko, ``Incorrect Provider Directories
Associated with Out-of-Network Mental Health Care and Outpatient
Surprise Bills,'' Health Affairs Vol. 39 No. 6, June 2020, https://
www.healthaffairs.org/doi/10.1377/hlthaff.2019.01501.
In 2022, another study published in Health Affairs looked at mental
health-care directories in Oregon Medicaid managed care
organizations.\7\ The study found that 58.2 percent of network
directory listings were ``phantom'' providers who did not see Medicaid
patients, including 67.4 percent of mental health prescribers, 59.0
percent of mental health non-prescribers, and 54.0 percent of primary
care providers.
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\7\ J.M. Zhu, C. Charlesworth, D. Polsky, K.J. McConnell, ``Phantom
Networks: Discrepancies Between Reported and Realized Mental Health
Care Access in Oregon Medicaid,'' Health Affairs Vol. 41 No. 7, July
2022, https://www.healthaffairs.org/doi/10.1377/hlthaff.2022.00052.
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ii. identifying the problems without pointing fingers
I am not here to try and convince you that achieving provider
directory accuracy is easy, and I acknowledge that physicians and
practices have a role to play in achieving accuracy. That is why in
2021 the AMA collaborated with CAQH to examine the pain points for both
physicians and health plans in achieving directory accuracy and
published a white paper \8\ with the hopes of identifying how insurers
and physicians can work together to improve the data collection and
directory updating processes.
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\8\ ``Improving Health Plan Provider Directories and the Need for
Health Plan-Practice Alignment, Automation and Streamlined Workflows,''
AMA, CAQH, https://www.ama-assn.org/system/files/improving-health-plan-
provider-directories.pdf (2021).
Physicians have a responsibility to notify health plans when a
physician leaves a group, is no longer practicing at a certain
location, and when contact information changes. However, it is
important to recognize the burden on practices that comes with these
obligations. Practices on average contract with more than 20 plans, and
even more products per plan, and can be inundated with requests for
updates through phone calls, emails, or health plan-specific portals.
And even when new information is provided, practices report that the
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updates do not always appear in the directories.
Additionally, many practices separate their credentialing
information (about the clinician) from contracting information (about
practice locations and health plan participation) and appointment
scheduling data (on availability). When information is siloed, a
practice may struggle to bring the disparate data together accurately
and make it available to health plans and other parties.
Finally, because the relationship between a plan and a physician
practice is a financial one, and because some plans contract and
adjudicate claims by location, practices may list all clinicians at
every location when, in fact, each clinician primarily practices at
only one or two. Practices may do this in the event a clinician
provides care or coverage at a location other than his or her primary
site(s). While this approach may help avoid claim denials and payment
delays, it has the unintended consequence of contributing to directory
inaccuracy. With ever-decreasing reimbursement rates plaguing
practices, a reality exacerbated by the COVID-19 pandemic, physicians
are often forced to take certain actions to ensure timely payment.
For health plans, the provider directory is the most public-facing
data that health plans provide, and patients are dependent on accurate
directories to access care. Likewise, being listed correctly in a
directory is a fundamental component of a
practice-health plan contract. As a result, most directory regulation
and legislation appropriately identify health plans as the party
accountable for provider directory accuracy. Consequently, many plans
have devoted resources to comply.
While the contract between the health plan and practice is the
authoritative source on which clinicians may see patients in certain
plans and products, plans also maintain claims data that provide a
variety of other insights into the practice, care provided to patients,
and billing activities. While pockets of high-quality data exist, the
industry has yet to converge upon a widely recognized ``source-of-
truth'' and the proliferation of data collection channels and
correction methods has made it more difficult for an authoritative
source to emerge.
Similarly, while some health plans have worked towards establishing
an internal source of truth, many face their own internal data silos
that result in delayed updates and inaccurate data overwriting good
data. This internal misalignment of data requires health plans to take
additional steps to re-validate information, which places an additional
burden on physician practices and can dilute the effect of data quality
improvements.
In addition to siloed data sources, adjacent regulatory
requirements also affect improvement efforts. Regulators like CMS have
established requirements for both network adequacy and directory
accuracy for health plans. While these requirements go hand-in-hand,
efforts to improve directory accuracy and network adequacy can impact
each other. The confluence of industry data silos and misalignment
between health plans and practices on roles, responsibilities, and
compliance with regulatory requirements has created barriers to
improvements in provider directory accuracy.
iii. working toward solutions
In its research with CAQH, the AMA identified a number of solutions
aimed at simplifying and standardizing the data, the data requests, and
the data systems with the goal of a solid foundation of basic provider
directory information. For example, the AMA suggests that practices
should identify the best sources for directory data, make timely and
accurate updates when offices move or physicians leave the practice,
and establish the right processes so that their teams and vendors can
deliver the best data possible for provider directories. Likewise,
health plans should similarly make timely updates, streamline processes
for practices to submit the data, permit practices to report all
locations associated with a physician to enable coverage when necessary
while accurately indicating the practice locations that should appear
in the directories, and leverage interoperability and automation where
possible so that updates are made as quickly as possible.
In a recent response to a CMS Request for Information (RFI) seeking
public input on the concept of CMS creating a directory with
information on health-care providers and services or a ``National
Directory of Healthcare Providers and Services'' (NDH), the AMA doubled
down on its call for increased data standardization and highlighted a
lack of data reporting standards as a barrier to accuracy. For example,
each payer's directory requires that physicians provide different types
of data, similar data but named differently, or requires that
physicians report their information using different data formats.
Policymakers, including CMS and State regulators, should consider
standardizing physician data elements with the most impact on accuracy
and standardizing reporting formats in all common business
transactions.
It is also critical that policymakers and health plans take
meaningful steps to reduce other administrative burdens on physician
practices, especially those that directly impact patient care and
coverage and, thus, are likely prioritized over the directory burden by
practices. The clearest example of such a burden is prior
authorization. Practices are completing 45 prior authorizations per
week per physician, adding up to 2 business days per week spent on
prior authorization alone.\9\ With hours spent on the phone with
insurance companies, endless paperwork for initial reviews and appeals,
and constant updating of requirements and repeat submissions just to
get patients the care they need, is it any wonder that added
administrative burdens on practices may not be getting the attention
they should?
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\9\ 2022 AMA prior authorization (PA) physician survey, https://
www.ama-assn.org/system/files/prior-authorization-survey.pdf.
Last Congress, the House of Representatives sought to address the
burden of prior authorization with the passage of the ``Improving
Seniors' Timely Access to Care Act.'' In fact, key members of the
Finance Committee, including Senators Sherrod Brown (D-OH) and John
Thune (R-SD), worked together to introduce this important legislation
in the Senate. While the bill ultimately failed to pass both chambers,
this legislation sought to simplify, streamline, and standardize prior
authorization processes in the MA program to help ease the burden on
physicians and ensure no patient is inappropriately denied medically
appropriate services. CMS has subsequently taken action toward ensuring
timely access to health care by proposing rules similar to the
aforementioned legislation to streamline prior authorization protocols
for individuals enrolled in federally sponsored health insurance
programs, including MA plans. The AMA is urging CMS to promptly
finalize and implement these changes to increase transparency and
improve the prior authorization process for patients, providers, and
health plans. It is also urging CMS to expand on these proposed rules
by: (1) establishing a mechanism for real-time electronic prior
authorization (e-PA) decisions for routinely approved items and
services; (2) requiring that plans respond to prior authorization
requests within 24 hours for urgently needed care; and (3) requiring
detailed transparency metrics. I applaud CMS's recent finalization of
regulations that will ensure a sound clinical basis and improved
transparency for criteria used in MA prior authorization programs, as
well as protect continuity of ongoing care for patients changing
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between plans.
Finally, a new approach to regulation and enforcement that includes
proactive solutions is needed. Most enforcement currently is reliant on
patient reporting, which is inconsistent and likely underestimates the
scope of the issue. For example, the 2020 study in Health Affairs
mentioned above found that, among those patients who encountered
inaccuracies in the mental health directories, only 3 percent reported
that they had filed a complaint with a government agency and only 9
percent said that they had submitted a grievance or complaint form to
their insurer. Sixteen percent said they had complained to their
insurer by phone. Ultimately, we have no way of knowing how frequently
a plan is contacted by a patient who is unable to find the right
physician using the directory, or how often a physician refers a
patient to another physician who appeared in-network under the
directory but was ultimately not, or how often a patient pays the out-
of-network rate because they relied on erroneous directory information.
Secret shopper studies and CMS reports published on the scope of the
problem are important, but they are not fixing the deficiency for any
individual patient who is in need of in-network care.
Given the limitations of the current complaint-based system, I urge
all organizations charged with regulating health plans--whether it be
CMS, State departments of insurance, or the Department of Labor--to
take a more active role in regularly reviewing and assessing the
accuracy of directories. For example, regulators should: require health
plans to submit accurate network directories every year prior to the
open enrollment period and whenever there is a significant change to
the status of the physicians included in the network; audit directory
accuracy more frequently for plans that have had deficiencies; take
enforcement action against plans that fail to either maintain complete
and accurate directories or have a sufficient number of in-network
physician practices open and accepting new patients; encourage
stakeholders to develop a common system to update physician information
in their directories; and require plans to immediately remove from
network directories physicians who no longer participate in their
network. This enhanced oversight will drive the needed improvement in
directories to ensure that patients have access to current, accurate
information about in-network physicians.
iv. conclusion
Implementing solutions to provider directory inaccuracies is a
critical component of improving patient access to timely, convenient,
and affordable care. Policymakers and other stakeholders must take
action to improve the data, standardize the data collection and
maintenance, reduce burden on physician practices, and protect patients
from errors in real time.
However, in order to truly address the real harms, it is also
critical that we address the network and access issues that directory
inaccuracies may mask. For example, a bloated provider directory may be
hiding a network that is wholly inadequate to serve the needs of the
plan's enrollees. Requiring and enforcing adherence to quantitative
network adequacy standards, including wait-time requirements, is
critical. Additionally, updating directories when there is a change to
the network is essential, but that should be followed by a notification
to regulators if the change is material, continuity of care protections
for patients to continue with the provider if they wish, and a
reevaluation of the network's ability to continue providing timely and
convenient access to care. I am glad to see that CMS, generally, is
more recently making progress on network adequacy requirements for MA
plans, as well as Qualified Health Plans (QHPs). For example, just
recently CMS finalized stronger behavioral health network requirements
in MA plans and codified standards for appointment wait times for
primary care and behavioral health services in these plans. And for the
2024 plan year, CMS will begin evaluating QHPs for compliance with
appointment wait time standards, in addition to time and distance
standards. However, these requirements are only as good as their
enforcement, and right now there is simply not enough. States and
Federal regulators should work together to ensure that health plans are
meeting minimum quantitative requirements before they go to market and
tough penalties are assessed when violations are found. Patients must
be getting value for their premiums paid by being able to access the
care they need--when they need it--within their networks.
Given recent reports of ghost mental health networks in provider
directories, network evaluation is also important in the context of
mental health parity compliance. Behind these misleading mental and
behavioral health directories are potential plan processes that have
more restrictive strategies and standards, or lower payment for
behavioral health providers in their networks compared with physical
health providers. I am gravely concerned by the findings of the 2022
Mental Health Parity and Addiction Equity Act (MHPAEA) Report to
Congress, which found that insurers' parity violations have continued
and become worse since the MHPAEA was enacted in 2008, and it is
important that policymakers continue to focus attention on mental
health parity enforcement.
Finally, network deficiencies cannot be discussed without
highlighting the growing physician shortage and the need for investment
in our workforce. Lawmakers have a clear opportunity to help increase
the total number of physicians by enacting S. 1302/H.R. 2389, the
``Resident Physician Shortage Reduction Act,'' which will increase the
number of Medicare-supported residency slots by 14,000 over 7 years,
build upon the investment Congress has made over the last few years to
improve Graduate Medical Education, including the 1,000 new Medicare-
supported residency slots included in the Consolidated Appropriations
Act of 2021, and the 200 new physician residency positions funded by
Medicare to teaching hospitals for training new physicians in
psychiatry and psychiatry subspecialties included in the Consolidated
Appropriations Act, 2023.
Thank you for considering my comments. My goal, and the goal of the
AMA, is to improve patient access to timely, affordable, and convenient
care. Addressing the ability of patients to locate such care through
accurate provider directories is a critical component of this goal and
of great importance to physicians and the patients we serve.
______
Questions Submitted for the Record to Jack Resneck, Jr., M.D.
Questions Submitted by Hon. Maria Cantwell
workforce
Question. Our country is currently facing a shortage of health-care
workers, especially as we work to recover from the COVID-19 pandemic. A
2021 Washington Post-Kaiser Family Foundation survey found that about
30 percent of health-care workers are considering leaving the
profession and about 60 percent reported that the pandemic impacted
their mental health. The American Hospital Association estimates that
the U.S. will face a shortage of 124,000 physicians by 2033.
The health workforce shortage is especially problematic for mental
and behavioral health. 158 million people currently live in a mental
health workforce shortage area, and the U.S. is expected to be short
about 31,000 full-time mental health practitioners by 2025.
In my State of Washington, there is just one mental health provider
for every 360 people. In rural or underserved areas, like the eastern
counties of Washington State, access barriers are even higher. Nearly
half of all counties in Washington do not have a single working
psychiatrist.
When Americans are already struggling to find adequate health care
because of workforce shortages, it is unacceptable that ghost networks
add yet another barrier to care. Someone who is in the midst of a
mental health crisis, or already overburdened with caregiving
responsibilities, or exhausted from working multiple jobs, should not
have to waste hours calling providers only to find that no one takes
their insurance or accepts new patients.
We know there's a shortage of providers in certain specialties such
as psychiatry. To what degree are challenges in accessing behavioral
health care an outcome of health-care workforce shortages versus
inaccurate provider directory information?
Answer. It is impossible to compare these two issues. Inaccurate
provider directories challenge patients' ability to access timely, in-
network care by failing to provide patients with the information they
need to pursue care. Inaccuracies can also create the impression that a
network can meet the needs of enrollees, when, in fact, the network is
insufficient. When provider directories are inaccurate, they may be
masking inadequate networks of providers. Accuracy of directories and
adequacy of network is ultimately the responsibility of the health plan
offering the network product.
Physician workforce shortages is a different issue that will also
result in decreased patient access to care because, unless action is
taken, there will simply not be enough practicing physicians to meet
patient demand. Lawmakers have a clear opportunity to help increase the
total number of physicians by enacting S. 1302/H.R. 2389, the
``Resident Physician Shortage Reduction Act,'' which will increase the
number of Medicare-supported residency slots by 14,000 over 7 years,
build upon the investment Congress has made over the last few years to
improve Graduate Medical Education, including the 1,000 new Medicare-
supported residency slots included in the Consolidated Appropriations
Act of 2021, and the 200 new physician residency positions funded by
Medicare to teaching hospitals for training new physicians in
psychiatry and psychiatry subspecialties included in the Consolidated
Appropriations Act, 2023.
Question. To expand the mental health-care workforce, Congress
created 100 new Graduate Medical Education slots specially reserved for
psychiatry and psychiatry subspecialties as part of the FY 2023
appropriations legislation.
Do policies like additional GME slots help make provider
directories more adequate and accurate?
Answer. No, policies like additional GME slots do not help make
provider directories more accurate but will ultimately increase/sustain
access to care.
Question. Is the current availability of GME slots sufficient in
addressing the growing mental health provider shortage?
Answer. No, additional GME slots are needed to sufficiently address
the growing mental health provider shortage.
Though I appreciated and welcomed the additional 200 new Medicare-
supported residency positions in psychiatry and psychiatry
subspecialties that were provided in the Consolidated Appropriations
Act, 2023, that is just the beginning of what is needed. Given the
severity of the current and projected workforce shortage, a greater
investment in this space is necessary to increase the supply of
physicians with expertise in mental health. The United States is facing
a shortage of between 37,800 and 124,000 physicians by 2034--a dearth
that is almost certain to be exacerbated by rising rates of physician
burnout and early retirement due to the COVID-19 pandemic. On top of
this, there is a current shortage of mental health providers that has
resulted in 163 million individuals living in mental health HPSAs
requiring an additional 8,200 mental health professionals to eliminate
the current shortage areas according to the Health Resources and
Services Administration (HRSA). Therefore, it is crucial that we invest
in our country's health-care infrastructure to help provide patients
with the physicians they need and improved access to care. As such, I
urge you to take this opportunity to further invest in the physician
workforce by again increasing the number of Medicare-supported GME
positions. The Resident Physician Shortage Reduction Act of 2023 (S.
1302/H.R. 2389) is bipartisan legislation that would take steps to
better alleviate the physician shortage by gradually providing 14,000
new Medicare-supported GME positions over 7 years. Additionally,
Congress could provide more funding for mental health providers through
the National Health Service Corps, provide more scholarships or loan
forgiveness programs for physicians providing mental health care
especially for those who agree to serve in underserved communities, and
increase the cap building window so that new programs have a longer
period of time to establish their cap (e.g., H.R. 4014/S. 2094, the
Physician Shortage GME Cap Flex Act). Additional legislation that
should be supported to help mitigate GME shortages in this space
include:
Medical Student Education Authorization Act of 2023 (House
and Senate).
Resident Education Deferred Interest (REDI) Act (H.R. 1202).
Restoring America's Health Care Workforce and Readiness Act.
Strengthening America's Health Care Readiness Act (S. 862).
Specialty Physicians Advancing Rural Care Act, or the
``SPARC Act'' (H.R. 2761 and S. 705).
Taskforce Recommending Improvements for Unaddressed Mental
Perinatal and Postpartum Health for New Moms Act of 2021 or the
``TRIUMPH for New Moms Act of 2021'' (H.R. 4217 and S. 2779).
Question. Our mental health workforce is already overworked and
understaffed, especially coming out of the pandemic. Do you believe it
is the provider's job to ensure that provider directories are up-to-
date, or is this the responsibility of insurance companies?
Answer. The provider directory is a critical component of the
product that a health insurer sells. As such, the accuracy of a
directory is ultimately the responsibility of the health plan.
Question. Is there a middle ground where the two sides can meet to
coordinate on this issue?
Answer. While the responsibility of accurate provider directories
lies with the insurer, there is of course a role for physician
practices to play in improving accuracy, and efforts should be made to
assist practices in doing so. Recently, the AMA published a paper with
CAQH, an alliance of health plans, providers and other health-care
stakeholders, to analyze the current state of the provider directory
problem, identify best practices and recommend practical approaches
that both health plans and physician practices can take to solve the
problem. Among the solutions considered, the paper recognizes that
health plans have a responsibility to streamline data update channels
and providing practices with a way to differentiate between locations
where a clinician is seeing patients versus one where he or she is
contracted but not regularly seeing patients. Meanwhile, efforts should
be made by practices to provide timely and accurate updates when key
directory data, such as office address and phone number, change and
associating clinicians to practice locations where they regularly see
patients as opposed to registering every clinician at all possible
practice locations in the event they are covering for colleagues.
______
Questions Submitted by Hon. Michael F. Bennet
medicare advantage provider directory requirements
Question. Senate Finance Committee staff recently conducted a
secret shopper survey of Medicare Advantage (MA) plans to understand
responsiveness and appointment availability.\1\ Their results were
similar to other studies conducted over the last decade.\2\ The staff
selected the two largest non-employer MA plans in Denver and called a
total of 20 providers posing as the adult child of a parent with the
given MA plan, seeking treatment for the parent's depression. Of the 20
calls, five went unanswered. The calls that were answered, 50 percent
of them were not successful either because the provider was out-of-
network (despite being listed in the plan's directory), the provider
was not accepting new patients, or the provider required a referral to
set an appointment. The results of this study are troubling for
Coloradans.
---------------------------------------------------------------------------
\1\ https://www.finance.senate.gov/imo/media/doc/
050323%20Ghost%20Network%20Hearing%
20-%20Secret%20Shopper%20Study%20Report.pdf.
\2\ https://pubmed.ncbi.nlm.nih.gov/25354035/.
While the Senate Finance Committee's secret shopper study targeted
major cities, the results are also concerning for access to mental and
behavioral health services in rural areas. In my State, 22 of the 64
counties do not even have a psychologist or psychiatrist.\3\
---------------------------------------------------------------------------
\3\ https://coruralhealth.org/wp-content/uploads/2013/10/2022-
Snapshot-of-Rural-Health-February-final-release.pdf.
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Could you describe how ghost networks affect rural America?
Answer. Inaccurate provider directories leave patients scrambling
to find a physician and oftentimes with expensive out-of-network care.
This phenomenon is demoralizing to patients and can lead to serious
adverse health outcomes for vulnerable patients in need of mental
health-care services, patients with serious health conditions, and
patients living in rural and underserved areas. Patients who live in
rural areas might be left traveling hundreds of miles to find a
physician who accepts their insurance and is taking new patients,
leading to unreasonable delays in care, despite the directory showing
more accessible options. Patients who do not have the means to travel
will often forgo needed care leading to much more dire and in some
cases deadly health-care consequences.
mental and behavioral health integration
Question. In order to access care, a patient first needs to be able
to find a provider. In 2020, a third of adults aged 18 or older
reported having a mental illness but not receiving care because they
did not know where to go for services.\4\ Primary care providers are
often more accessible for patients, and studies have shown that
patients with mental health illnesses are more likely to discuss them
with a primary care doctor than with psychiatrists or other health
professionals.\5\ But our current system is not designed for
collaboration to coordinate a patient's care. Mental health illnesses
are often diagnosed and treated separately from physical health
services.
---------------------------------------------------------------------------
\4\ https://www.aamc.org/advocacy-policy/aamc-research-and-action-
institute/barriers-mental-health-care.
\5\ https://www.aamc.org/media/62886/download.
Given how frequently individuals bring up mental health concerns in
primary care settings, could a behavioral health integration model work
---------------------------------------------------------------------------
to increase services in rural areas?
Answer. Yes, the AMA is a strong supporter of the Collaborative
Care Model where a primary care physician serves at the head of the
care team, coordinating with mental health professionals to treat both
mental and behavioral health-care problems in the same setting. This is
a model that has been proven to work and is one effective approach to
treating access issues in rural and underserved areas.
The AMA and seven leading medical associations have established the
Behavioral Health Integration (BHI) Collaborative, a group dedicated to
catalyzing effective and sustainable integration of behavioral and
mental health care into physician practices. As part of this
initiative, the BHI Collaborative has created a Compendium that serves
as a tool for clinicians to learn about integrating behavioral health
care, which includes mental health and substance use disorders, and how
to make it effective for the practice and patients.\6\ The AMA offers
additional resources to support practices in integrating behavioral
health services.\7\
---------------------------------------------------------------------------
\6\ https://www.ama-assn.org/delivering-care/public-health/
compendium-behavioral-health-integration-resources-physician.
\7\ https://www.ama-assn.org/delivering-care/public-health/
behavioral-health-integration-physician-practices.
Question. Are there other models that could increase access to
---------------------------------------------------------------------------
mental and behavioral health services?
Answer. Yes, the COVID-19 Public Health Emergency saw the emergence
of many new hybrid models of care combining telehealth, in-person, and
remote monitoring services that have been extremely helpful in
improving access to mental and behavioral health services. Even before
COVID, Project Echo was a successful telehealth model, started in New
Mexico, that utilizes telehealth to connect specialists in cities to
primary care physicians in rural and underserved areas. Specialists
collaborate and train primary care physicians to treat patients with
conditions traditionally treated by the specialist. This model was
initially founded to help treat hepatitis C, a treatable condition with
high survival rate when caught early. A patient in New Mexico who was
unable to access the specialized treatment in their rural town
eventually saw a specialist when it was too late. The patient ended up
needlessly dying from hepatitis C. This and other models that combine
virtual and in-person services based on the patient's needs could be
applied to help address the mental health professional shortage in
rural and other underserved areas.
______
Questions Submitted by Hon. Sheldon Whitehouse
Question. What is the impact of prior authorization requirements on
access to mental health care?
Answer. Prior authorization (PA) has been used by insurers as
another tool to delay provision of and payment for necessary health
care to patients. The 2022 AMA Prior Authorization Physician Survey
quantifies the patient harms associated with PA.\8\ An overwhelming
majority (94 percent) of surveyed physicians reported that PA delays
access to necessary medical care, and 80 percent of physicians
indicated that PA can lead to treatment abandonment. The downstream
consequences can be devastating: 89 percent of physicians reported that
PA has a negative impact on clinical outcomes, and 33 percent said that
PA has led to a serious adverse event (hospitalization, life-
threatening event, or even death) for a patient in their care.
---------------------------------------------------------------------------
\8\ https://www.ama-assn.org/system/files/prior-authorization-
survey.pdf.
The impact of PA on access to mental health care aligns with the
AMA's physician survey data. There is a finite number of medications
that are proven to treat opioid addiction and other substance use
disorders, yet insurers continue to apply PA to these treatments. When
it comes to behavioral health care, delaying care for a person in a
mental health crisis can have deadly consequences. That is why the VA
in response to their suicide epidemic is allowing veterans to receive
mental health care at any facility where they seek care. The VA is
taking access to mental health care seriously, the private sector needs
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to follow suit.
Several recent Federal studies have also identified a lack of
parity between health plans' PA programs for behavioral health services
and traditional medical care. For example, a March 2022 Government
Accountability Office study found that private health plans and
Medicaid were less likely to grant PA for mental health hospital stays
compared with medical and surgical hospital stays, with this delaying
access to initial mental health treatments.\9\ Concerningly, the 2022
Mental Health Parity and Addiction Equity Act Report to Congress found
that many health plans were unprepared to respond to requests for
comparative analyses of non-quantitative treatment limitations for
behavior health services vs. medical/surgical care (as legislatively
required), and none of the analyses initially reviewed contained
sufficient information.\10\ These data indicate that PA-related
barriers to care may be particularly significant for patients seeking
mental health care.
---------------------------------------------------------------------------
\9\ https://www.gao.gov/assets/gao-22-104597.pdf.
\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.
Question. What are the largest sources administrative and payment-
recovery costs for mental health providers, and how do these affect
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their ability to serve patients and communities?
Answer. My colleague from the American Psychiatric Association will
be able to provide information more specific to the impact and costs of
administrative burdens such as PA on mental health-care professionals.
Speaking broadly across medical specialties, I can confidently say that
PA is the most significant and costly administrative requirement facing
physicians today. That's why fixing PA is one of the pillars of the AMA
Recovery Plan for America's Physicians.\11\ The AMA's 2022 physician
survey found that practices complete an average of 45 PAs per
physician, per week, and that this PA workload for a single physician
consumes nearly 2 business days of physician and staff time.\12\ Over
one-third (35 percent) of physicians report having staff who work
exclusively on PA. This represents an enormous amount of administrative
waste in our health-care system--resources and time that could be much
better spent on taking care of patients and improving health outcomes.
---------------------------------------------------------------------------
\11\ https://www.ama-assn.org/amaone/ama-recovery-plan-america-s-
physicians.
\12\ https://www.ama-assn.org/system/files/prior-authorization-
survey.pdf.
Administrative tasks such as PA can be particularly burdensome for
physicians in smaller practices. Data from the AMA's 2022 Physician
Practice Benchmark Survey show that many more psychiatrists work in
smaller practices compared with other medical specialties: 45 percent
of psychiatrists work in practices that include between one and four
physicians, compared with 33 percent for all specialties combined.\13\
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\13\ https://www.ama-assn.org/about/research/physician-practice-
benchmark-survey.
Question. What payment reforms have reduced these administrative
costs, and which models hold the greatest promise to reduce the
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administrative burden on mental health providers?
Answer. Any meaningful PA reform must involve a reduction in the
overall volume of requirements. Physicians consistently report that the
number of both medical services and prescription drugs that require PA
has increased in recent years,\14\ despite the fact that health plans
agreed to reduce PA volume over 5 years ago in the Consensus Statement
on Improving the Prior Authorization Process.\15\ The AMA urges health
plans to eliminate requirements on treatments that are routinely
approved, as these low-value requirements merely add cost to the
health-care system and delay patient care. In addition, our Prior
Authorization and Utilization Management Reform Principles--which are
supported by over 100 organizations representing health-care
professionals and patients--state that health plans should offer at
least one physician-driven, clinically based alternative to PA, such as
but not limited to ``gold-card'' or ``preferred provider'' programs or
attestation of use of appropriate use criteria, clinical decision
support systems, or clinical pathways.\16\
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\14\ https://www.ama-assn.org/system/files/prior-authorization-
reform-progress-update.pdf.
\15\ https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-
browser/public/arc-public/prior-authorization-consensus-statement.pdf.
\16\ https://www.ama-assn.org/system/files/principles-with-
signatory-page-for-slsc.pdf.
One of the great promises of alternative payment modes (APMs) that
accept two-sided financial risk is the ability to be subjected to
fewer, if any, utilization management policies, such as PA. Indeed, our
PA Principles state that a physician who contracts with a health plan
to participate in a financial risk-sharing payment plan should be
exempt from PA and step-therapy requirements for services covered under
the plan's benefits.\17\ With most two-sided risk models, physicians
are permitted to receive a portion of associated savings when the cost
of the care delivered does not exceed certain spending benchmarks and
quality assurance standards are met. The quality assurance standards
are crucial to ensuring that value-based care does not inadvertently
lead to rationing of care. Conversely, physicians are responsible for
the cost of care when the services delivered within a model eclipse
spending benchmarks or quality assurance standards are not met. Not
only can two-sided APMs incentivize better care by linking payments to
quality, care coordination, and more health-care outcomes, but the
models can also help alleviate administrative burdens on physicians,
including those treating mental health conditions. By incentivizing
physicians to have a greater financial stake in the ultimate patient
outcomes, PA requirements, which are a huge source of administrative
burden, can be lessened or even completely eliminated within an APM.
However, I must stress that APMs alone will not solve the PA problem,
as fee-for-service (FFS) remains the most prevalent payment method. In
2020, 88.1 percent of physicians reported at least some payment from
FFS; moreover, an average of 70 percent of practice revenue came from
FFS and 30 percent from APMs.\18\ In addition, CMS has not designed
APMs in ways that alleviate the burdens physicians face from PA.
Common-sense PA reforms must be enacted in regular FFS payment systems
as well as in APMs to prevent delays in patient care, alleviate the
crushing administrative burdens, and reduce costs to the system.
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\17\ https://www.ama-assn.org/system/files/principles-with-
signatory-page-for-slsc.pdf.
\18\ https://www.ama-assn.org/system/files/2020-prp-payment-and-
delivery.pdf.
To help physicians accelerate the implementation of coordinated
care within the mental health arena, in 2021 the AMA released the
Behavioral Health Integration Compendium. Created by several of the
Nation's leading physician organizations, the Compendium is a tool for
physicians and their practices to learn about and implement behavioral
health integration (BHI) in order to achieve the goal of optimal,
whole-person care. There are many ways to approach BHI and practices
have a number of models to choose from. Yet, the integrated care
spectrum typically covers six defined levels: minimal collaboration;
basic collaboration at a distance; basic collaboration on-site; close
collaboration on-site; close collaboration; and full collaboration.
Minimal collaboration, which features care delivered in separate
facilities with separate systems and infrequent communication typically
initiated under compelling circumstances and driven by the physician,
marks the least integrated level of the overarching spectrum. Full
collaboration, or physicians and other clinicians being in the same
facility, sharing all practice space, and functioning as one team,
marks the most integrated option. The Primary Care Behavioral Health
(PCBH) and Collaborative Care Model (CoCM) are two examples of these
innovative care structures that fall within the larger integrated care
---------------------------------------------------------------------------
spectrum.
Despite their strong potential, APMs are still not widely available
for all physicians, especially specialists. In addition, payment
reforms need to support redesigning care delivery to improve access to
mental and behavioral health services and collaboration and teamwork
between primary care physicians, psychiatrists, and other mental and
behavioral health professionals. As outlined in my written testimony
and responses to other questions for the record, the CoCM is an
evidence-based approach to improving patient care for mental health
conditions but payment reforms, especially ones geared towards primary
care physicians, are needed to support it. This reality is one reason
behind AMA's longstanding concern about multiple Centers for Medicare
and Medicaid Innovation (CMMI) primary care medical home models being
terminated. Unfortunately, Medicare still lacks a nationwide, voluntary
primary care medical home model more than a decade after the creation
of CMMI. This is also one reason why AMA supports strengthening the
ability of Accountable Care Organizations (ACOs) and other APMs to
engage specialists through approaches such as the Payments for
Accountable Specialty Care framework, which would significantly improve
collaboration between primary care physicians participating in ACOs and
specialists to whom they refer patients with certain conditions who
require enhanced specialty care. The AMA also recently provided
information to the PTAC on this topic.
______
Questions Submitted by Hon. Chuck Grassley
Question. Are government regulations or policies preventing the
private sector from solving the problem of inaccurate provider
directories?
Answer. I would not go so far as to say government policies are
preventing resolution of this issue, but some policies may cause health
plans to focus on the completion of regulatory/statutory requirements
rather than the goal of directory accuracy. For example, regulation may
require twice yearly outreach to practices. Completing such outreach
could be accomplished without any improvements in the accuracy of
directory information. There are also policy gaps. For example, when
outreach does occur, each health plans' directory requires that
physicians provide different types of data in different formats. Our
experience also shows that this lack of uniformity is a major driver in
physician burden.
Additionally, CMS is currently considering the development of a
National Directory of Healthcare Providers and Services (NDH). While we
support the goals of advancing public health, improving data exchange,
streamlining administrative processes, and promoting interoperability,
CMS's authority only extends to its regulated programs, and not to
other payers and providers. As such, it could be difficult for an NDH
to have meaningful impact. In comments on the recent RFI exploring such
an initiative, the AMA stated that CMS should avoid creating another
place for physicians and practices to submit and update data by working
with physicians, and those experienced in managing physician data, to
identify and solve for directory inaccuracy root causes, starting with
standardization.
Question. In your written testimony, you mentioned how separate
systems of credentialing and contracting can result in siloed
information. What responsibility do providers have in communicating
their in-network status to patients? What role do providers have in
communicating their appointment availability information in real-time?
Answer. To address unexpected out-of-pocket expenses for patients,
health plans must provide more usable plan and product information to
practices and ensure it is correct in directories. While practices and
health plans agree that their contract is the ``source of truth'' on
whether a clinician is participating, the question of whether a
clinician is accepting insurance for a particular patient or accepting
new patients is more dynamic. These agreements can contain many
nuances: providers participating in multiple plan-products, contracts
including a subset of locations and specialties and ``accepting new
patients'' being a function of both the contract and whether the
clinician's panel is full. Practices and health plans should agree,
based on how a contract is structured and the practice's current
situation, how information about whether a clinician is accepting
insurance and is accepting new patients should be presented.
Links:
https://www.aamc.org/news/press-releases/aamc-report-reinforces-
mounting-physician-shortage
https://data.hrsa.gov/topics/health-workforce/shortage-areas
https://searchlf.ama-assn.org/letter/
documentDownload?uri=%2Funstructured%2F
binary%2Fletter%2FLETTERS%2Flfcmps.zip%2F2023-5-9-Letter-to-Menendez-
Boozman-Schumer-and-Collins-re-S-1302-Resident-Physician-Shortage-
Reduction-Act-v2.pdf
https://searchlf.ama-assn.org/letter/
documentDownload?uri=%2Funstructured%2F
binary%2Fletter%2FLETTERS%2Flfcmps.zip%2F2023-5-9-Letter-to-Sewell-and-
Fitzpatrick-re-HR-2389-Resident-Physician-Shortage-Reduction-Act.pdf
https://nhsc.hrsa.gov/about-us
https://searchlf.ama-assn.org/letter/
documentDownload?uri=%2Funstructured%2F
binary%2Fletter%2FLETTERS%2F2021-6-23-Letter-to-Barrasso-and-Cortez-
Masto-re-Physician-Shortage-GME-Cap-Flex-Act-Senate-v3.pdf
https://searchlf.ama-assn.org/letter/
documentDownload?uri=%2Funstructured%2F
binary%2Fletter%2FLETTERS%2F2021-6-23-Letter-to-Ruiz-et-al-re-
Physician-Shortage-GME-Cap-Flex-Act-House-v3.pdf
https://searchlf.ama-assn.org/letter/
documentDownload?uri=%2Funstructured%2F
binary%2Fletter%2FLETTERS%2F2021-6-23-Letter-to-Barrasso-and-Cortez-
Masto-re-Physician-Shortage-GME-Cap-Flex-Act-Senate-v3.pdf
https://searchlf.ama-assn.org/letter/
documentDownload?uri=%2Funstructured%2F
binary%2Fletter%2FLETTERS%2Fmlfd.zip%2F2023-3-22-Letter-to-House-re-
Medical-Student-Education-Authorization-Act-of-2023.pdf
https://searchlf.ama-assn.org/letter/
documentDownload?uri=%2Funstructured%2F
binary%2Fletter%2FLETTERS%2Flfcmt.zip%2F2023-5-9-Letter-to-Senate-re-
Medical-Student-Education-Authorization-Act-of-2023.pdf
https://searchlf.ama-assn.org/letter/
documentDownload?uri=%2Funstructured%2F
binary%2Fletter%2FLETTERS%2Flf.zip%2F2022-3-1-Signed-On-Letter-re-
Physician-Dentist-Coalition-letter-to-House-REDI-Act-Sponsors.pdf
https://searchlf.ama-assn.org/letter/
documentDownload?uri=%2Funstructured%2F
binary%2Fletter%2FLETTERS%2Fmlfd.zip%2F2023-5-5-Letter-to-Joyce-and-
Ross-re-HR-2761-SPARC-Act-Support-v2.pdf
https://searchlf.ama-assn.org/letter/
documentDownload?uri=%2Funstructured%2F
binary%2Fletter%2FLETTERS%2Fmlfd.zip%2F2023-5-5-Letter-to-Rosen-and-
Wicker-re-S-705-SPARC-Act-Support-v2.pdf
https://searchlf.ama-assn.org/letter/
documentDownload?uri=%2Funstructured%2F
binary%2Fletter%2FLETTERS%2F2021-10-15-Letter-to-House-re-TRIUMPH-Act-
v2.pdf
https://searchlf.ama-assn.org/letter/
documentDownload?uri=%2Funstructured%2F
binary%2Fletter%2FLETTERS%2F2021-10-15-Letter-to-Senate-re-TRIUMPH-Act-
v2.pdf
https://www.ama-assn.org/system/files/improving-health-plan-provider-
directories.
pdf
https://www.ama-assn.org/system/files/bhi-compendium.pdf
https://www.ama-assn.org/system/files/apm-payments-accountable-
specialty-care-pasc.pdf
https://searchlf.ama-assn.org/letter/
documentDownload?uri=%2Funstructured%2F
binary%2Fletter%2FLETTERS%2Flfcm.zip%2F2023-5-5-Letter-to-Hardin-and-
Sinopoli-re-PTAC-RFI-Specialty-Care-In-Population-Based-Models-v2.pdf
https://www.federalregister.gov/documents/2022/10/07/2022-21904/
request-for-information-national-directory-of-healthcare-providers-and-
services
https://searchlf.ama-assn.org/letter/
documentDownload?uri=%2Funstructured%2F
binary%2Fletter%2FLETTERS%2Flfdr.zip%2F2022-12-6-Letter-to-Brooks-
LaSure-re-CMS-Provider-Directories-v2-combined.pdf
______
Prepared Statement of Jeff Rideout, M.D., MA, FACP,
President and CEO, Integrated Healthcare Association
executive summary
The Integrated Healthcare Association (IHA) is a California
leadership group whose members include physician groups, health plans,
hospital systems, regulatory agencies, and other health-care
stakeholders. One of IHA's key programs is a
California-wide Provider Data Management program called Symphony, with
a goal to simplify and unify how providers and health plans share,
reconcile, and validate provider data. With our technology partner
Availity,\1\ we are creating a single utility to increase accuracy and
reduce administrative burden, designed to be the primary source of data
and to replace non-aligned existing processes between health plans and
providers.
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\1\ As one of the Nation's largest health information networks,
Availity facilitates billions of clinical, administrative, and
financial transactions annually. Our suite of dynamic products, built
on a powerful, intelligent platform, enables real-time collaboration
for success in a competitive, value-based care environment. For more
information visit www.availity.com.
As an output of the process, Symphony creates a ``golden record''
by applying a strict set of agreed upon rules that determine what the
best information is when information from multiple organizations is
conflicting. The more organizations, the greater likelihood to finding
and correcting errors before this information goes back to plans and
providers for inclusion in their directories. Ultimately, sustainable
provider data improvement requires an industry solution. As the Centers
for Medicare and Medicaid Services noted in a 2018 report,\2\ ``it has
become clear that a centralized repository for provider data is a key
component missing from the accurate provider directory equation.''
Symphony is exactly that type of centralized repository.
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\2\ ``Online Provider Directory Review Report,'' CMS, November 28,
2018, https://www.cms.
gov/Medicare/Health-Plans/ManagedCareMarketing/Downloads/
Provider_Directory_Review_
Industry_Report_Round_3_11-28-2018.pdf.
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Some key findings from our work:
Provider data encompasses literally hundreds of specific
data elements. Some are critical for consumers, such as license
verification or accepting new patients. Others may be less
critical, but all need to be verified on a very frequent basis,
some as frequently as weekly. In addition, providers need to
attest to the accuracy of the information on a very frequent
basis and are much more willing to do so if they can attest
once for multiple plans.
In order to function, Symphony has created data quality
standards centered around: (1) timeliness; (2) data quality and
completeness; and (3) data accuracy that conform with
regulatory requirements and are standardized across multiple
plans and provider organizations. Symphony also has created a
standardized data validation and mastering processes to
identify inconsistencies or errors and resolve them. This is
what creates a ``golden record'' that uses the most accurate
information available from all participant organizations--both
plans and providers.
Identifying inaccuracies and correcting them is necessary
and feasible. In the last 30 days, review of provider data from
three plans representing 169,731 unique providers, with up to
300 data attributes each (which translates to over 50 million
data elements), Symphony's data mastering identified 138,124
inconsistent data elements (``updates'' or ``corrections'')
that required health plan and provider changes based on
validation and survivorship rules adopted by all parties. Of
these, over 5,000 were errors in the physical office address,
while nearly 2,127 were related to license issues.
Of the 300 data elements that IHA tracks, all stakeholders
have agreed to a standard tiering process for data elements
most important to consumers--such as accepting new patients.
Provider data accuracy should be measured with robust and
agreed-upon metrics including (but not limited to) timeliness,
completeness, and benchmarks against peers. Currently accuracy
is measured through phone surveys of provider's offices, which
have been shown to be an inaccurate and inconsistent way to
measure. Audits of individual plans may actually increase the
burden on providers unless the audits are coordinated across
multiple plans.
A Council for Affordable Quality Healthcare (CAQH) survey of
1,240 physician practices, conducted in September 2019,
determined that updating directory information costs each
practice $998.84 on average every month, the equivalent of one
staff day per week.\3\ For independent providers--of which
mental health providers are more likely to be--this can be cost
prohibitive to network participation.
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\3\ CAQH Survey: Maintaining Provider Directories Costs U.S.
Physician Practices $2.76 Billion Annually, November 13, 2019, https://
www.caqh.org/about/press-release/caqh-survey-maintaining-provider-
directories-costs-us-physician-practices-276.
Symphony market research and customer feedback suggests that
without a centralized data repository that supports a multi-
plan provider directory, health plans and providers will be
unable to maintain accurate provider data and directories
individually, even with the best of intentions. This is
particularly true in states with delegated entities such as
Independent Physician Associations (IPAs) and Provider
Organizations that are also responsible for provider data
accuracy creating additional contractual and relationship
complexities. It is even more important for mental and
behavioral health providers who are increasingly less likely to
be in health plan networks,\4\ making it even more critical for
them to be able to update their data in a convenient, single,
centralized repository.
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\4\ Susan Busch and Kelly Kyanko, ``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.
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I. Background
Provider directory inaccuracy has been a challenge for decades.
These challenges were magnified with the implementation of the
Affordable Care Act (ACA). There was an influx of consumers entering
the marketplace looking to confirm that their provider of choice was
part of their new health plan. This coupled with a rise in ``narrow
network'' plans and consumers moving between health plans more
frequently made provider directory accuracy critically important for
consumers.
Many of the plan provider directories they were searching had
inaccurate data, causing confusion and frustration for patients,
providers, and plans. Health plans expressed frustration that they were
unable to keep their directories up to date without providers updating
their information. Providers were frustrated that they had to update
their information with each health plan and for each contract they
participate under. It was difficult for everyone, and made it more
urgent for plans, providers, and regulators to come up with a solution.
In November 2015, California's Department of Managed Health Care
fined its two largest network plans, Anthem Blue Cross and Blue Shield
of California, for their inaccurate directories.\5\ Additionally, Blue
Shield of California committed $50 million to addressing provider data
inaccuracy as part of its acquisition of Care1st.\6\
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\5\ Joanne Finnegan, Blue Shield of California, ``Anthem Blue Cross
Fined for Inaccurate Provider Directories,'' November 4, 2015, https://
www.fiercehealthcare.com/payer/blue-shield-california-anthem-blue-
cross-fined-for-inaccurate-provider-directories.
\6\ DMHC Approves Blue Shield's Acquisition of Care1st Health Plan,
https://californiahealthline.org/morning-breakout/dmhc-approves-blue-
shields-acquisition-of-care1st-health-plan/.
II. The Need for a Multi-Plan Directory
In early 2016, the industry began to coalesce around the same basic
idea--the need to create one location for plans and providers to go and
update information.\7\ The problem was providers, plans and even
Covered California were all working with different vendors to pilot
different solutions.
---------------------------------------------------------------------------
\7\ CAQH Survey: Maintaining Provider Directories Costs U.S.
Physician Practices $2.76 Billion Annually, November 13, 2019, https://
www.caqh.org/about/press-release/caqh-survey-maintaining-provider-
directories-costs-us-physician-practices-276. (Practices that use one
channel for all plans spend 39.6 percent less per month than those who
use multiple approaches. Assuming similar efficiencies, using a single
channel to update directory information could save the average
physician practice $4,746 annually. Nationwide, streamlining directory
maintenance through a single platform could save physician practices at
least $1.1 billion annually.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Around this time, California legislators passed Senate Bill
137. This bill was instrumental in bringing the industry together. It
stipulated a shared responsibility between providers and plans to make
---------------------------------------------------------------------------
sure directories were accurate.
In August 2016, California held the California Provider Directory
Summit to inform and align key stakeholders. The result was the
formation of three working groups made up of representatives from
plans, hospitals, provider groups, health information exchanges,
consumer groups and regulators to drive towards creating a single,
statewide provider directory utility/repository:
Data definitions and standards group--this group defined
each data element, who was responsible for submitting it and
what, if any, the authoritative data source would be. What we
learned was that even something as straightforward as ``name''
could vary based on who was asking and when, which demonstrated
the need for standardized and agreed upon definitions.
Business and technical requirements group--this group
defined what functions the provider directory utility/
repository had to do based on the use cases developed during
the summit.
Governance group--this group decided who would own the
database and created criteria that any governance body would
have to meet--a nonprofit with a history of successfully
working with diverse stakeholders that was financially sound
and agile enough to act quickly.
There was some urgency to find a solution because of SB 137
requirements, but also, the more time people spent on the pilots
already in flight, the less likely they would be to pivot to this new
solution.
The Governance group chose Integrated Healthcare Association as the
governance body for the statewide provider directory in September 2017.
The statewide directory was piloted in January 2018 and the utility was
fully launched in January 2019 with the name Symphony Provider
Directory.
III. IHA's Market Research
As part of its planning, IHA did market research and targeted
interviews with 27 plans, providers, and purchasers to assess current
directory management processes and desired features for a statewide
utility. IHA confirmed the current challenges:
Directory update processes are manual and labor-intensive,
with reporting requirements, data definitions and templates
varying across health plans.
Data quality is inconsistent, specifically regarding data
accuracy, completeness, and timeliness.
Data validation requires significant time and resources, and
often must be done manually across each individual health
plan's network.
Most plans are unable to accurately estimate resources
devoted to directory management activities, as many of the
resources support other plan activities (e.g., labor, IT
infrastructure).
Providers vary in the level of resources dedicated to
directory management activities, ranging from 0.5 to 7 full-
time equivalents (FTEs) to support directory updates, manual
data validation and IT infrastructure. In fact, a CAQH survey
of 1,240 physician practices, conducted in September 2019,
determined that directory maintenance costs practices
nationwide $2.76 billion annually. Updating directory
information costs each practice $998.84 on average every month,
the equivalent of one staff day per week.\8\
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\8\ CAQH Survey: Maintaining Provider Directories Costs U.S.
Physician Practices $2.76 Billion Annually, November 13, 2019, https://
www.caqh.org/about/press-release/caqh-survey-maintaining-provider-
directories-costs-us-physician-practices-276.
IHA's market research also showed what features and functionality
---------------------------------------------------------------------------
the provider utility had to have to meet its customer's needs.
It called for the industry to come together and collaborate to
ensure a fully functioning utility that provides value and drives the
outcomes needed.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
IV. Symphony's Progress To Date
The Symphony Provider Directory, enabled by IHA's technology
partner Availity, is an advanced cloud-based platform, uniting
California health plans and providers around a centralized solution to
improve the efficiency, quality, and ease of provider directory data.
The Symphony solution is complex and outlines the various inputs,
processes, validations, and outputs needed to facilitate an end-to-end
solution.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Symphony commitments:
Support compliance by ensuring highest-level data accuracy
for complex regulatory mandates, while streamlining cumbersome
data exchange between providers and health plans. It ensures
frequent, routine updates and automated attestation outreach on
behalf of contracted health plans.
Ensure provider data is high-quality by validating data from
numerous primary and secondary resources, while simplifying
provider data updates via routine, automated outreach. This
enables health plans to quickly act on provider data
inaccuracies.
Leverage industry experts, including California's Department
of Managed Healthcare, to maximize industry alignment. The
Symphony Data Governance Committee is broadly represented
across client organizations who advise on provider directory
data standards, develop recommendations, and consult on
interpretation and application of compliance requirements.
To date Symphony includes:
17 contracted health plans.
100+ contracted provider organizations.
550,000+ total provider records in production.
300+ supported data elements.
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
V. Symphony's Approach to Accuracy
Symphony supports complex contractual relationships in California,
it does so at the granularity needed to comply with regulatory
requirements. Each data attribute in Symphony has a specific data
policy that helps determine how data is validated and which value
survives as the recommended ``golden master record.'' In addition to
primary reference sources, Symphony leverages provider attestation, as
well as the democratic opinion of other participants, offering a more
complete view of data quality.
Symphony's data accuracy is structured around three pillars: (1)
timeliness; (2) validity and completeness; and (3) accuracy. A recent
review of provider data from the three largest network plans in
California surfaced over 138,124 data events requiring data validation,
mastering and corrections. Participants show confidence that Symphony
reduces suppressed providers by nearly 25 percentage points.
______
Questions Submitted for the Record to Jeff Rideout, M.D., MA, FACP
Questions Submitted by Hon. Maria Cantwell
technological solutions
Question. There is currently no national database of health-care
providers, resulting in an unreliable patchwork system. Instead of
being able to go to a one-stop-shop website and find a health-care
provider, patients have to waste hours and hours calling around. The
directories that insurers provide are often out-of-date, inaccurate, or
list providers who are not taking new patients.
A centralized directory of providers could reduce inconvenience for
patients, but we lack the nationwide technology and funding to
establish one. In addition, provider data contains multitudes of
specific data points, and each insurance company may have different
requirements on data collection, data format, or other specifications.
This complexity calls for creative solutions and cooperation between
the government and the private sector.
Your organization created a centralized platform at the request of
the California Government called the Symphony Provider Directory to
help consumers in California find providers. The platform houses
provider directory data for 18 health plans and purchasers and over 100
provider organizations. It's a public-private partnership, which has
streamlined the complex collection of information and successfully
reduced barriers to care for patients.
What metrics are you using to evaluate the effectiveness of the
program you created? How does that differ from the traditional way that
provider networks evaluate adequacy and accuracy?
Answer. IHA has followed a traditional ``structure, process,
outcomes'' model in assessing effectiveness. Given our program is in
its early stages and is just now becoming operational, our focus to
date has been on:
Structural effectiveness--Do we have a significant majority
of health plans, providers and health systems under contract so
that a consumer is looking at accurate information for the full
range of licensed providers? Here we have all the major health
plans and over 100 provider groups, which constitute nearly 1
million unique providers under contract. However, we have
focused initially on physician, NP, PA and facility providers;
our next wave will be ancillary, including dental, and
behavioral health providers.
Process effectiveness--Beyond measuring the basic ``live on
the system'' effectiveness, we have focused on the core data
elements being tracked and have prioritized those most
meaningful to consumers, including license in good standing,
correct address and phone number, and accepting new patients,
as I outline in the testimony.
Outcome effectiveness--This is down the road for Symphony,
but ideally, we would test the accuracy of the data against the
consumer's actual experience through surveys or other consumer
direct information. Ultimately even if we correct thousands of
errors, it only matters if that has a positive impact on
consumers.
Question. Could the Symphony Provider Directory be scaled
nationwide? What type of resources and coordination would be needed to
effectively create a nationwide database?
Answer. Either the Symphony directory or a similar platform could
be scaled nationwide. The major challenge is regional market and
regulatory considerations that impact the data collected and the
frequency of updating required. As California is probably the largest
and most complex provider market given the degree of capitation and the
presence of large provider organizations, Symphony has likely
considered most of the issues a nationwide utility would encounter,
especially as California State regulations in this area are
sophisticated and well established. However, there would ultimately be
important new issues to consider that are specific to individual
regions. Probably an undesirable outcome would be for a nationwide
provider directory to not consider the more complex needs of larger
markets or to focus only on third-party information verification (such
as licensing).
______
Questions Submitted by Hon. Sheldon Whitehouse
Question. What is the impact of prior authorization requirements on
access to mental health care?
Answer. Symphony only addresses provider accuracy using a utility
model that ``masters'' data from multiple sources, so my current
experience does not extend to prior authorization requirements.
However, in my past experience, I can offer that prior authorization is
not generally effective as a care coordination/navigation process
unless the intake is done by a clinical professional that is familiar
with the consumer's condition and the plan's network.
Question. What are the largest sources administrative and payment-
recovery costs for mental health providers, and how do these affect
their ability to serve patients and communities?
Answer. My experience does not include any knowledge of this topic.
Question. What payment reforms have reduced these administrative
costs, and which models hold the greatest promise to reduce the
administrative burden on mental health providers?
Answer. Specific to a provider directory utility, mental health
providers would theoretically reduce their own administrative burden
significantly by only needing to complete a single, uniform process.
According to a Council for Affordable Quality Healthcare (CAQH) survey
of 1,240 physician practices, conducted in September 2019, updating
directory information costs each practice $998.84 on average every
month, the equivalent of one staff day per week.
______
Questions Submitted by Hon. Chuck Grassley
Question. Are government regulations or policies preventing the
private sector from solving the problem of inaccurate provider
directories?
Answer. It may be the lack of regulations and the lack of
specificity in what is expected from providers that prevent the private
sector from solving the problem. A huge first step in any
standardization process is for the multiple organizations to choose to
get together voluntarily and agreeing on a single standard approach
(data, format, submission timing, process, mastering), when there is no
requirement to do so. In a market-oriented health-care environment,
this may feel unnatural or a ``nice to do.'' Doing some will invariably
require individual organizations to migrate to processes they do not
fully own, additional costs, IT and operational changes, etc.
Question. In your written testimony, you shared how California has
worked to address the problem of inaccurate provider directories. How
has California worked to ensure provider directories are user-friendly?
Does California's efforts account for rural patient needs?
Answer. The Symphony Provider Directory created was a direct
response by plans, providers and purchasers in California to new State
requirements for provider data accuracy under SB 137. These
requirements were actually more stringent than both Medicare and
Medicaid expectations and Symphony was designed to cover all programs
regulated by the State of California or CMS. For better or worse, SB
137 specified that provider directory production would be the purvey of
plans, so Symphony is precluded from producing an independent, consumer
facing directory. Fortunately, the State insurance exchange, Covered
California, has created a cross plan provider directory that will be
supported by Symphony information. Currently any consumer can use the
website provider look up function, but the plan networks are limited to
those plans offered through the exchange.
______
Prepared Statement of Robert L. Trestman, Ph.D., M.D., Chair and
Professor, Department of Psychiatry and Behavioral Medicine, Carilion
Clinic, Virginia Tech Carilion School of Medicine, on Behalf of the
American Psychiatric Association
Chairman Wyden and Ranking Member Crapo, on behalf of the American
Psychiatric Association (APA), the national medical specialty
association representing more than 38,000 psychiatric physicians, I
want to thank you for conducting the hearing today entitled ``Barriers
to Mental Health Care: Improving Provider Directory Accuracy to Reduce
the Prevalence of Ghost Networks.'' The APA appreciates your bipartisan
efforts to examine and address the mental health crisis in our country.
My name is Robert Trestman, Ph.D., M.D., and I am professor and
chair of psychiatry and behavioral medicine at the Carilion Clinic and
the Virginia Tech Carilion School of Medicine. I also chair the APA
Council on Healthcare Systems and Financing, serve as the liaison
between the American Hospital Association and the APA, and am chair of
the American Association of Chairs of Departments of Psychiatry's
Clinical Enterprise Committee. In addition, I personally provide
clinical care for general psychiatry patients and those living with
Huntington's Disease at Carilion Clinic in Roanoke, VA. My department
has 35 psychiatrists, 36 resident and fellow-level psychiatrist
trainees, a dozen nurse practitioners, and a range of psychologists,
therapists, and nursing staff. We are located in rural Virginia. We
deliver more than 90,000 care visits per year for individuals living
with a broad range of complex mental health and substance use disorder
(MH/SUD) challenges. Our system provides care across all ages and
delivers ambulatory, emergency, and acute inpatient treatment.
Ghost networks are false promises by insurers to provide access to
care that shift the expense to the patient. They affect private sector
health plans purchased by individuals and employers and public sector
plans like Medicaid and Medicare Advantage. More than that, they can
have negative health consequences for patients who forego or delay
treatment because they cannot find a clinician able to provide the
mental health care they need.
data on ghost networks
Psychiatric Services will soon publish a study where investigators
called 322 psychiatrists listed in a major insurer's database in three
cities to seek an appointment for a child using three payer types.
Those calling psychiatrist offices as part of the study were able to
schedule 34 appointments--10.6 percent of calls made--and it was
significantly more difficult to obtain an appointment when utilizing
Medicaid. In addition, 18.6 percent of the phone numbers were wrong and
25.5 percent of psychiatrists were not accepting new patients. These
results are particularly concerning given the current mental health
crisis among youth.
A 2017-18 CMS review of Medicare Advantage provider directories
found that 48.7 percent of the provider directory locations listed had
at least one inaccuracy, such as the provider not being at the listed
location, at an incorrect phone number, or no longer accepting new
patients.\1\ A January 2023 study of directory information for more
than 40 percent of U.S. physicians found inconsistencies in 81 percent
of entries when comparing the listed networks of five large national
health insurers.\2\
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\1\ https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/
Downloads/Provider_Directory_Review_Industry_Report_Round_3_11-28-
2018.pdf.
\2\ Butala N.M., BTech K.J., Bucholz E.M. ``Consistency of
Physician Data Across Health Insurer Directories.'' Journal of the
American Medical Association. 2023. 329 (10): 841-41.
In a 2020 study, 53 percent of participants who had used a mental
health directory reported encountering at least one inaccuracy, the
most common being that the provider was incorrectly listed as taking
new patients (36 percent).\3\ Twenty-six percent of participants found
that a provider listed in the directory did not accept their insurance.
Twenty-four percent encountered incorrect contact information, and 20
percent reported being told that a provider listed as taking new
patients was not taking patients with their problem or condition.
---------------------------------------------------------------------------
\3\ Incorrect Provider Directories Associated With Out-Of-Network
Mental Health Care And Outpatient Surprise Bills, https://
www.healthaffairs.org/doi/epdf/10.1377/hlthaff.2019.01501.
A 2022 study of phantom networks among mental health services using
claims data from Medicaid, the largest payer serving marginalized
populations with serious mental illness, found 51.8 percent of
providers listed in Medicaid directories had no evidence in claims data
of having seen patients over the study period.\4\ Phantom providers
represented up to 90.3 percent of some provider lists, constituted 67.4
percent of the mental health prescribers, 59 percent of the non-
prescribing mental health clinicians, and 54 percent of the primary
care providers listed in the provider directories.
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\4\ Zhu J., Charlesworth C.J., Polsky D., McConnell K.J. ``Phantom
networks: Discrepancies between reported and realized mental health
access in Medicaid.'' Health Aff (Millwood). 2022;41(7):1013-22,
https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2022.00052.
These findings are consistent with data APA gathered in our own
``secret shopper'' surveys of many States' insurance markets back in
2016. Our study of the DC market found that almost 25 percent of the
phone numbers for the listed psychiatrists were nonresponsive or were
nonworking numbers. Only 15 percent of psychiatrists listed in the
directory were able to schedule an appointment for callers; under one
plan, only four percent were able to schedule an outpatient
appointment. Unfortunately, not much seems to have changed since 2016.
patient and clinician impact
What these studies do not show is the impact of ghost networks on
patients and clinicians. For those who are healthy and well educated,
going through an inaccurate provider list and being told repeatedly
that ``we are not taking new patients,'' ``this provider has retired,''
``we no longer accept your insurance,'' or leaving a message with no
one returning the call is at best frustrating. For people who are
experiencing significant mental illness or substance use disorders, the
process of going through an inaccurate provider directory to find an
appointment with someone who can help them is at best demoralizing and
at worst set up to precipitate clinical deterioration and a preventable
crisis. Many are already experiencing profound feelings of
worthlessness, fear, grief from loss and trauma, and/or the impact of
substance use; some are in crisis and suicidal. Patients have told me
that they felt rejected repeatedly or that somehow they themselves were
at fault. Even when they make the effort to reach out to find help,
something that can be very difficult anyway, their efforts to cull
through an inaccurate provider list results in more rejection and
failure, exacerbating these feelings. Some give up looking for care.
Others delay care.
I was a ghost physician in Connecticut after I moved to Virginia
Tech 6 years ago. My former colleagues at the University of Connecticut
Health Center told me that patients were calling for 2 years after my
departure to request appointments with me because I was still listed in
multiple commercial insurance plans. More recently, many patients,
especially those with commercial insurance, have told me about their
frustration that they could not find anyone who would answer the phone,
call them back, or offer available appointment times. If the office had
openings, the waiting time was 8 to 10 months, as opposed to days or
weeks.
These patients typically run through the entire provider list and
find nobody to care for them. Others give up and go to the emergency
room (ER) for crisis stabilization. However, few psychiatric beds are
available because insurance payment for those beds is below the cost of
care, so patients are boarded in the hallways of the ER. Upon release,
they are told to work with their insurance company to find outpatient
care, which is inaccessible, and the cycle continuously repeats itself.
This cycle is devastating for a person with a mental illness. Many
plans do not cover ER visits for mental health as a substitute for
outpatient care and the patients are left to pay the bill themselves,
or complete payment of their annual deductible before their insurance
applies. Even when the visit is covered, insurance copayments are
higher for the ER than for an office visit.
Access to care in rural settings, like mine, is particularly
challenging. These areas are generally physician shortage areas to
begin with, and patients can be required to drive 2 hours or more to
find psychiatric care, whether from a psychiatrist, nurse practitioner,
or commonly from a primary care physician. Prior to March 2020, my team
was delivering about 5 percent of our ambulatory psychiatric care via
video telehealth. By the end of March 2020, we were delivering 95
percent of our ambulatory care by telehealth: video and audio-only.
Even after resolving the technical issues of video connectivity with
our patients, many lived in areas without broadband access. Many others
could not afford the data plans to allow for video interviews. We
therefore delivered about 50 percent of our care by audio-only. Was it
perfect, no. Was it better than not providing the care, absolutely. But
it takes just as much provider time to deliver care, whether in person,
by video, or by audio-only. And for the many people who do not have
paid sick days, having access to telehealth visits, video or audio-
only, means they don't have to lose a day of pay for a 30-minute visit
to us. For those who rely on public transportation in rural areas, that
means they don't have to take multiple buses over several hours to get
to us--assuming they have the capability to do so without assistance.
Finding anyone accepting new patients can be nearly impossible.
Carilion is the only tertiary referral center for 150 miles, and we
function as the public health point of access for many people. My
clinic is in almost all networks and our adult waiting list has more
than 800 people in line.
Challenges are especially acute for children. School teachers tell
us kids are in significant need due to the pandemic and overall current
trends. Most are on Medicaid and teachers just refer them to the ER.
The ER is typically the first point of contact when referred by
teachers because kids cannot get help any other way.
financial and administrative burden
Insurers intentionally make it difficult for psychiatrists and
other mental health professionals to participate in their networks,
which frequently enables them to avoid paying for mental health care.
For example, at Carilion, keeping our credentialing updated with
insurance plans is time-consuming and expensive. We have three full-
time employees (FTE) doing nothing but maintaining our credentialing
with insurance companies and public payers, including Medicaid and
Medicare Advantage. My team of 35 psychiatrists and a dozen
psychologists and nurse practitioners requires close to one-half FTE
just to work with payers to be sure someone is in-network. The
administrative burden of sending directory updates to insurers via
disparate technologies, schedules, and formats costs physician
practices a collective $2.76 billion annually.\5\
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\5\ Council for Affordable Quality Healthcare. The Hidden Causes of
Inaccurate Provider Directories. Published 2019, https://www.caqh.org/
sites/default/files/explorations/CAQH-hidden-causes-provider-
directories-whitepaper.pdf.
Not all mental health clinicians practice in settings like mine
that are willing and able to invest the resources needed to participate
in the networks. Private practitioners make up a significant portion of
the psychiatric workforce and many do not participate in the networks
because of the burdensome requirements imposed by the plans. The burden
should be on the plans, whose profits appear sufficiently healthy, to
maintain accurate directories, not on the clinicians who are in short
supply and should be spending their time treating patients.
burden on employers
When employers purchase health coverage for their employees, they
rely on representations about the breadth and depth of the mental
health panel reflected in the network directory. Employers have a
significant interest in ensuring that their mental health network is
robust and available because connecting employees to treatment
increases productivity, lowers absenteeism and presenteeism, and
decreases overall health-care costs--boosting employer bottom lines and
improving quality of life for all employees.
Despite their care in selecting insurers who purport to have robust
psychiatric networks, employers generally see that more mental health
care is provided on an out-of-network basis than on an in-network
basis: demonstrating that employees cannot find mental health care in
their plan. One study by Milliman found that 17.2 percent of behavioral
health visits in 2017 were to an out-of-network provider compared with
3.2 percent for primary care providers and 4.3 percent for medical/
surgical providers. The out-of-network rate for behavioral health
residential facilities was more than 50 percent in 2017.\6\ Forcing
employees to seek out-of-network care shifts the expense from the
insurer to the patient. Mental health care then becomes available only
to those who can most afford it; many others go without treatment.
Employers pay insurers to have mental health care available to their
staff, and by not delivering the promised network, insurers often avoid
the cost of mental health care altogether.
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\6\ Addiction and mental health vs. physical health: Widening
disparities in network use and provider reimbursement, https://
www.milliman.com/en/insight/addiction-and-mental-health-vs-physical-
health-widening-disparities-in-network-use-and-p.
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solutions
Ghost networks are both a cause and a symptom of a system that has
inadequately addressed mental health care for decades. Consequently,
APA recommends that the committee confront the root causes of ghost
networks in addition to holding insurance plans accountable to their
network representations:
Hold plans accountable for the accuracy of their
directories. Plans should be required to maintain and regularly
update their directories. They should have to demonstrate that
the clinicians listed in their directories are actually seeing
patients covered by the plan and are accepting new patients;
there should be real enforcement for misrepresentations. To
date, enforcement has largely fallen on States, efforts that
have been weak at best.\7\ The Behavioral Health Network and
Directory Improvement Act (S. 5093), introduced last Congress
by Senator Smith and Chairman Wyden, would require audits of
plans' provider directories to determine if they are accurate
and if the listed providers are serving patients in-network.
Importantly, it allows the Department of Labor to levy civil
monetary penalties on plans and third-party administrators
whose directories are inaccurate or are filled with providers
not seeing in-network patients.
---------------------------------------------------------------------------
\7\ ``Laying Ghost Networks to Rest: Combatting Deceptive Health
Plan Provider Directories,'' Yale Law & Policy Review, https://
ylpr.yale.edu/sites/default/files/YLPR/2_burman_pe.12.2_
78-148.pdf.
Require Medicare Advantage plans to maintain accurate
directories. The Better Mental Health Care for Americans Act
(S. 923), introduced this Congress by Senator Bennet and
Chairman Wyden, would require Medicare Advantage plans to
maintain accurate provider directories. Additionally, it would
require Medicare Advantage plans and Medicaid managed care
organizations to provide information on the performance of
their behavioral health networks, including average wait times
to see providers and the percentage of behavioral health
---------------------------------------------------------------------------
providers accepting new patients.
Remove disincentives to clinicians joining networks. In a
survey of psychiatry fellows and early career psychiatrists APA
conducted last summer, the majority reported they wanted to
join a network but were concerned about the high level of
administrative tasks and low reimbursement rates. APA members
recognize their administrative responsibilities in
participating in plan networks, however, the requirements have
grown exponentially This results in psychiatrists, particularly
those in solo or small practices, spending an inordinate amount
of time on non-clinical work, often to an extent that far
exceeds what their medical/surgical counterparts encounter--a
practice that violates the Mental Health Parity and Addiction
Equity Act (MHPAEA). APA members also indicate that the
credentialing process to join a network panel takes many
months, often a lengthier delay than what other physicians
experience, which again violates MHPAEA. These practices,
seemingly by design, discourage physicians from providing
necessary treatments, reduce the time psychiatrists are
available to treat patients, and violate a landmark
antidiscrimination law.
Improve access by providing reasonable reimbursement rates.
Plans' reimbursement rates for psychiatric care have not been
raised in decades. Meanwhile, unreimbursed time spent on
administrative tasks has risen dramatically. When psychiatrists
attempt to negotiate contract provisions, including their
rates, plans respond ``take it or leave it'' even when there is
a known and obvious shortage of mental health providers in the
network. This is not how insurers behave when they face
shortages of other physicians. They raise rates and loosen
credentialing standards to ensure that they don't have a dire
shortage of important specialists. This too is a violation of
MHPAEA. Insurers must design and maintain their MH/SUD networks
in a manner that is comparable to their medical/surgical
network. This includes how they set reimbursement rates and how
they adjust rates in response to market forces. Demand for care
is skyrocketing. In-network provider availability is scarce,
yet public and private plans do not provide adequate
reimbursement rates for psychiatrists or other mental health
clinicians. The basic economics of supply and demand suggest
the predictable result that is desired by the plans--lack of
access to care and violation of the law.
Extend MHPAEA to Medicare. While regulators already can
enforce the MHPAEA violations described above for private
insurance plans and Medicaid managed care, they have no
recourse when it comes to Medicare because the law does not
apply. The Better Mental Health Care for Americans Act (S.
923), introduced by Senator Bennet and Chairman Wyden, takes an
important step by applying MHPAEA to Medicare Parts C and D.
Extending MHPAEA to Medicare Advantage would help to ensure
that those plans respond to shortages and deficiencies in their
MH/SUD treatment networks in a way that is comparable to how
they respond to shortages and deficiencies in their medical/
surgical provider networks.
Invest in the Physician Workforce. With more than half of
U.S. counties lacking a single psychiatrist, underlying
workforce shortages will continue to impede patient access to
behavioral health care even if ghost networks are adequately
addressed. Last year, Senators Stabenow and Daines introduced
legislation to increase Medicare funded graduate medical
education (GME) slots specifically for psychiatry. The Fiscal
Year 2023 Consolidated Appropriations Act (FY23 Omnibus) made a
downpayment on this effort by adding 200 new GME residency
slots with 100 going directly to psychiatry or psychiatric
subspecialties beginning in 2026. With projections showing that
the country will still be short between 14,280 and 31,109
psychiatrists by 2025,\8\ it is imperative that we invest in
additional GME slots for psychiatry and psychiatric
subspecialties with residencies spread geographically in rural
and urban areas alike. Such an investment would supplement
efforts to address network adequacy and better position us to
address the growing crisis of access to MH/SUD care and
treatment. Additional incentives tied to practicing in shortage
areas, like loan deferment or forgiveness, can also help to
better distribute physicians and other practitioners where they
are needed most.
---------------------------------------------------------------------------
\8\ Projected Workforce of Psychiatrists in the United States: A
Population Analysis--PubMed, https://pubmed.ncbi.nlm.nih.gov/29540118/.
Support Evidence-Based Integrated Care Models. Despite
ongoing network adequacy challenges, the integration of primary
care and behavioral health has proven effective in expanding
the footprint of our existing behavioral health workforce and
is essential to improving patient access. The Collaborative
Care Model (CoCM) is a behavioral health integration model that
enhances primary care by including behavioral care management
support, regular psychiatric inter-specialty consultation, and
the use of a team that includes the Behavioral Health Care
Manager, the Psychiatric Consultant, and the Treating (Billing)
Practitioner. The evidence- and population-based CoCM can help
improve outcomes and alleviate existing workforce shortages by
enabling a primary care provider (PCP) to leverage the
expertise of a psychiatric consultant to provide treatment
recommendations for a panel of 50-60 patients in as little as
1-2 hours per week. By treating more people and getting them
better faster, the CoCM is a proven strategy that enhances the
efficient use of existing clinicians and in turn helps address
the behavioral health workforce crisis in real time. The
Connecting Our Medical Providers with Links to Expand Tailored
and Effective (COMPLETE) Care Act (S. 1378), recently
introduced by Senators Cortez Masto and Cornyn, would expand
access to the CoCM and other evidence-based models by helping
providers with the cost of implementing integrated care models.
One advantage of the CoCM is the psychiatric consultant need
---------------------------------------------------------------------------
not be in-network since reimbursement goes directly to the PCP.
Expand Access to Tele-Behavioral Health Services. For
individuals residing in rural areas, even when they can find an
in-network physician, the reality of potentially having to
travel long distances for behavioral health services is often a
deterrent to receiving care. Telehealth access has helped
alleviate the gaps exposed by workforce maldistribution,
including in urban underserved areas, by providing a linkage
between clients in their home communities and behavioral health
providers in other locations. The FY23 Omnibus temporarily
extended multiple telehealth flexibilities implemented in
response to the public health emergency (PHE) and critically
delayed implementation of the 6-month in-person requirement for
mental telehealth services until December 31, 2024. At a time
of unprecedented demand, it is imperative that we continue work
to remove unnecessary barriers and ensure the continuity of
care for those seeking MH/SUD services by permanently removing
this arbitrary in-person requirement.
In closing, thank you for your attention to the mental health needs
of our patients across the country and for extending me the opportunity
to testify on behalf of the American Psychiatric Association. I look
forward to answering any questions you may have.
______
Questions Submitted for the Record to Robert L. Trestman, Ph.D., M.D.
Questions Submitted by Hon. Maria Cantwell
substance use disorder
Question. Mental health and substance use disorders are closely
linked. According to the Substance Abuse and Mental Health Services
Administration, over one in four adults with serious mental health
problems also has a substance use problem. In addition, American
Medical Association research shows that 37 percent of alcohol abusers
and 53 percent of drug abusers also have at least one serious mental
illness.
My home State of Washington reported a shocking 1,623 opioid
overdose deaths during the second year of the COVID-19 pandemic, which
to no surprise coincided with higher-than-normal rates of anxiety and
depression in all population groups. That is why an adequate and
accurate provider directory is so critical.
Oftentimes, people who are seeking mental and behavioral health
care are already emotionally distressed, and may not have the capacity
to call multiple providers only to find that no one is available, or
their insurance is not actually accepted. One single call could be all
they have before they resort to self-medicating or other means.
Ghost networks create an enormous barrier to care, but more
importantly, they take away the opportunity for someone to help the
patient in need. As a result, the patient sinks deeper into their
mental health issues and could end up in tragic situations such as
overdose or death.
If a patient is already suffering from mental health issues, are
they more likely to spend hours looking through an inaccurate provider
directory to look for help or resort to other means such as self-
medicating?
Answer. Patients already suffering from behavioral health issues
are not likely to continue to search through provider directories that
are inaccurate to seek treatment. For those who are healthy and well
educated, going through an inaccurate provider list can be frustrating
at best. However, for people who are experiencing significant mental
illness or substance use disorders, the process is at best demoralizing
and at worst a set up for clinical deterioration and a preventable
crisis. Many are already experiencing profound feelings of
worthlessness, grief from loss and trauma, and/or the impact of
substance use. Patients have shared with me that they felt repeatedly
rejected and that somehow, it was their fault. Many patients will
simply give up looking for care and may resort to self-medicating as
their illness deteriorates.
Question. In your testimony, you said that patients who cannot find
help through the provider directories often end up in the emergency
department with little to no access to follow-up care. Do you agree
that inaccurate provider directories directly contribute to decreasing
quality of care and increased cost for patients and the government?
Answer. Yes. Inaccurate directories contribute to patients seeking
treatment in emergency departments and can decrease quality of care as
well as increase costs to the patient, the government, and the overall
health-care system. Inaccurate directories are extremely demoralizing
for patients seeking treatment that can lead to a deterioration of
their illness. Clinically, it is imperative for patients with mental
illness and/or SUD to start treatment protocols as soon as possible or
risk a deterioration of their illness. Having inaccurate directories
delays care for patients who may end up in the emergency room requiring
more intensive and costly services.
Moreover, inaccurate directories increase the cost and burden for
clinicians and practices that can also divert time and resources from
patients. At Carilion, keeping our credentialing updated with insurance
plans is time-consuming and expensive. We have multiple full-time
employees doing nothing but maintaining our credentialing with
insurance companies and public payers, including Medicaid and Medicare
Advantage. The national administrative burden for physician practices
to send directory updates to insurers via disparate technologies,
schedules, and formats costs $2.76 billion annually.
Question. Is the issue of inaccurate provider directories more
significant for the youth and young adult population, who may have
limited resources and knowledge of accessing care?
Answer. Inaccurate provider directories delay treatment for both
adult and youth populations, with serious implications. The impacts on
our youth and most vulnerable populations are magnified as patients
struggle to find treatment and often with limited resources. The
workforce shortage in behavioral health is projected to grow and for
children, the shortage is even worse. This is also the case for rural
and vulnerable populations where access is limited and there is a lack
of culturally competent clinicians. Therefore, it is critical that
provider directories be accurate especially for our youth and
vulnerable populations, to ensure timely access to behavioral health
care.
In addition, we recommend that Congress consider enacting policies
that increase the effective behavioral health workforce. This includes
incentivizing primary care to adopt and implement the Collaborative
Care Model (CoCM) and integrate behavioral health into their practices,
which is why APA strongly supports S. 1378, the COMPLETE Care Act
introduced by Senators Cortez Masto and Cornyn. The CoCM is an
evidence-based model, developed at the University of Washington's AIMs
Center, which provides early identification and treatment for mental
health and substance use disorders in the primary care setting while
saving our health-care system money and measuring patient improvement.
The APA also strongly encourages the committee to take further action
to fund additional GME slots for psychiatry and support loan repayment
for behavioral health clinicians practicing in rural and underserved
areas.
______
Questions Submitted by Hon. Michael F. Bennet
medicare advantage provider directory requirements
Question. Senate Finance Committee staff recently conducted a
secret shopper survey of Medicare Advantage (MA) plans to understand
responsiveness and appointment availability.\1\ Their results were
similar to other studies conducted over the last decade.\2\ The staff
selected the two largest non-employer MA plans in Denver and called a
total of 20 providers posing as the adult child of a parent with the
given MA plan, seeking treatment for the parent's depression. Of the 20
calls, five went unanswered. The calls that were answered, 50 percent
of them were not successful either because the provider was out-of-
network (despite being listed in the plan's directory), the provider
was not accepting new patients, or the provider required a referral to
set an appointment. The results of this study are troubling for
Coloradans.
---------------------------------------------------------------------------
\1\ https://www.finance.senate.gov/imo/media/doc/
050323%20Ghost%20Network%20Hearing%
20-%20Secret%20Shopper%20Study%20Report.pdf.
\2\ https://pubmed.ncbi.nlm.nih.gov/25354035/.
While the Senate Finance Committee's secret shopper study targeted
major cities, the results are also concerning for access to mental and
behavioral health services in rural areas. In my State, 22 of the 64
counties don't even have a psychologist or psychiatrist.\3\
---------------------------------------------------------------------------
\3\ https://coruralhealth.org/wp-content/uploads/2013/10/2022-
Snapshot-of-Rural-Health-February-final-release.pdf.
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Could you describe how ghost networks affect rural America?
Answer. Ghost networks exacerbate the challenges patients have
accessing care in rural and underserved areas. My department is in
rural Virginia and delivers over 90,000 care visits per year for
individuals living with a broad range of complex mental illnesses and
substance use disorders. Rural areas are generally physician shortage
areas to begin with, and patients can be required to travel 2 hours or
more to find psychiatric care. Finding anyone who is accepting new
patients can be nearly impossible. Furthermore, ghost networks
exacerbate health disparities by providing false or outdated provider
information and often lack culturally competent clinicians to provide
care to patients. The Carilion Clinic is our region's only tertiary
referral center, and we function as the public health point of access
for many people. My clinic is in almost all networks and our waiting
list currently includes over 800 people.
mental and behavioral health integration
Question. In order to access care, a patient first needs to be able
to find a provider. In 2020, a third of adults aged 18 or older
reported having a mental illness but not receiving care because they
did not know where to go for services.\4\ Primary care providers are
often more accessible for patients, and studies have shown that
patients with mental health illnesses are more likely to discuss them
with a primary care doctor than with psychiatrists or other health
professionals.\5\ But our current system is not designed for
collaboration to coordinate a patient's care. Mental health illnesses
are often diagnosed and treated separately from physical health
services. other health professionals.
---------------------------------------------------------------------------
\4\ https://www.aamc.org/advocacy-policy/aamc-research-and-action-
institute/barriers-mental-health-care.
\5\ https://www.aamc.org/media/62886/download.
Given how frequently individuals bring up mental health concerns in
primary care settings, could a behavioral health integration model work
---------------------------------------------------------------------------
to increase services in rural areas?
Are there other models that could increase access to mental and
behavioral health services?
Answer. Yes. The integration of behavioral health with primary care
can increase access to timely treatment of mental health and SUD in
rural and underserved areas. The first time many patients demonstrate a
MH/SUD need is in the primary care setting, and primary care practices
may not have the clinical training or resources to treat patients with
MH/SUD needs. Some patients may prefer the convenience and privacy of
treatment from their primary care physician instead of a behavioral
health specialist. It may be incredibly difficult, especially for
patients in rural and underserved areas, to access specialty care due
to lack of clinicians or the time it takes to travel.
Specifically for the integration of behavioral health, we recommend
the Collaborative Care Model (CoCM) that provides early identification
and treatment of mental health and SUD needs in the primary care
setting. The evidence- and population-based CoCM can help improve
outcomes and alleviate existing workforce shortages by enabling a
primary care provider (PCP) to leverage the expertise of a psychiatric
consultant to provide treatment recommendations for a panel of 50-60
patients in as little as 1-2 hours per week. CoCM reduces health
inequities, is proven to substantially improve MH/SUD clinical outcomes
in a primary care setting and allows a psychiatrist to positively
impact care of three times as many patients, in comparison to
traditional ``one-on-one'' sessions between a psychiatrist and a
patient (Fortney et al., 2021). By treating more people and getting
them better faster, the CoCM is a proven strategy that enhances the
efficient use of existing clinicians and in turn helps address the
behavioral health workforce crisis in real time. The CoCM also utilizes
psychiatric services via telehealth and does not necessarily require
the psychiatric consultant to be in network when primary care is
billing for the services, which is important for those living in rural
and underserved areas.
The APA thanks you for your leadership in introducing S. 923, the
Better Mental Health Care for Americans Act, which proposes waiving the
cost sharing for patients within integrated care models, and other
strategies to increase access to mental health and SUD treatment. We
recommend that the committee advance this legislation expeditiously. We
also recommend that the committee incentivize primary care to adopt and
implement the Collaborative Care Model (CoCM) by passing S. 1378, the
COMPLETE Care Act introduced by Senator Cortez Masto and Senator
Cornyn. S. 1378 would facilitate adoption of the model by temporarily
increasing payment under the Medicare codes for CoCM and general
integration for 3 years and facilitating technical assistance to help
primary care practices adopt the CoCM.
______
Questions Submitted by Hon. Sheldon Whitehouse
Question. What is the impact of prior authorization requirements on
access to mental health care?
Answer. As more Americans seek help for mental health challenges,
widespread discriminatory practices, such as frequent and more arduous
prior authorization practices, more interference in medical decision
making, and improper denials of claims, have resulted in psychiatrists,
particularly those in solo or small practices, spending an inordinate
amount of time on uncompensated tasks, leaving far less time for
treating patients. APA members routinely report burdens such as having
to use a fax machine (when fax machines have not been in use in most
systems for years) to secure prior approval for a patient's medication,
the plan providing them with incorrect phone numbers for seeking
approval and waiting on hold for up to 40 minutes when trying to get
approval for patient care.
These practices are designed to discourage physicians from
providing necessary treatments and reduce the time psychiatrists are
available to treat patients. The result is less time to engage in
appropriate treatment activities which reduces patient access and
psychiatrist participation in networks. Notably, the impact of prior
authorization on patients can be life-threatening. According to a
recent American Medical Association survey, over 90 percent of doctors
report that prior authorization delayed access to care and negatively
impacted patient outcomes. Four in five doctors report that it can lead
patients to abandon their recommended course of treatment entirely. For
individuals living with mental health conditions, gaps in treatment due
to denials can lead to relapse and devastating effects for them and
their families.
Question. What are the largest sources administrative and payment-
recovery costs for mental health providers, and how do these affect
their ability to serve patients and communities?
Answer. As I detailed in my written testimony, insurers frequently
and purposefully make it difficult for psychiatrists and other mental
health professionals to participate in their networks, which enables
them to avoid paying for mental health care. At Carilion, keeping our
credentialing updated with insurance plans is time-consuming and
expensive. We have multiple full-time employees (FTE) doing nothing but
maintaining our credentialing with insurance companies and public
payers, including Medicaid and Medicare Advantage. My team of 35
psychiatrists and a dozen psychologists and nurse practitioners
requires close to one-half FTE just to work with payers to be sure
someone is in-network. The administrative burden of sending directory
updates to insurers via disparate technologies, schedules, and formats
costs physician practices a collective $2.76 billion annually. Not all
mental health clinicians practice in settings like mine that are
willing and able to invest the resources needed to participate in the
networks. Private practitioners make up a significant portion of the
psychiatric workforce and many do not participate in the networks
because of the burdensome requirements imposed by the plans.
Further, the frequency of health plan audits has risen, as have
fears around ``clawbacks,'' in which plans demand the return of
reimbursement for previously approved and paid claims, often amounting
to tens of thousands of dollars paid for care provided years earlier.
These audits are disruptive to patient care and often require
production of large quantities of documents. Psychiatrists want to
serve and help patients. We want to join insurance networks and ensure
that all people, regardless of income, will have access to quality care
for MH/SUD. These administrative practices, many of which violate
Mental Health Parity and Addiction Equity Act (MHPAEA), preclude them
from doing so. As a result, as the demand for mental health-care
increases, the supply of accessible psychiatric care for insured
populations decreases.
Question. What payment reforms have reduced these administrative
costs, and which models hold the greatest promise to reduce the
administrative burden on mental health providers?
Answer. To date, payment reforms have done little to address the
increased administrative burden faced by psychiatrists. Plans'
reimbursement rates for psychiatric care have not been raised for
decades. Meanwhile, unreimbursed time spent on administrative tasks has
risen exponentially. When psychiatric doctors attempt to negotiate
contract provisions, including their rates, plans typically respond
``take it or leave it.'' Demand for care is skyrocketing. In-network
provider availability is scarce yet plans refuse to raise reimbursement
rates for psychiatrists. The basic economics of supply and demand
suggest the predictable result that is desired by the plans: lack of
access to care. Low reimbursement rates, burdensome credentialing, and
excessive documentation requirements, all work collaboratively to
discourage psychiatrists from contracting with health plans. Increasing
reimbursement for psychiatrists, especially those in shortage areas,
could help to address these barriers and to improve networks.
The Collaborative Care Model (CoCM) is a behavioral health
integration model that enhances primary care by including behavioral
care management support, regular psychiatric inter-specialty
consultation, and the use of a team that includes the Behavioral Health
Care Manager, the Psychiatric Consultant, and the Treating (Billing)
Practitioner. The evidence- and population-based CoCM can help improve
outcomes and alleviate existing workforce shortages by enabling a
primary care provider (PCP) to leverage the expertise of a psychiatric
consultant to provide treatment recommendations for a panel of 50-60
patients in as little as 1-2 hours per week. By treating more people
and getting them better faster, the CoCM is a proven strategy that
enhances the efficient use of existing clinicians and in turn helps
address the behavioral health workforce crisis in real time. One
advantage of the CoCM is the psychiatric consultant typically need not
be in-network since reimbursement goes directly to the PCP, reducing
some of the existing administrative burdens associated with network
adequacy and described above.
______
Questions Submitted by Hon. Chuck Grassley
Question. Are government regulations or policies preventing the
private sector from solving the problem of inaccurate provider
directories?
Answer. We are not aware of any government regulations that prevent
the private sector from improving the accuracy of provider directories.
Question. In your written testimony, you stated the financial and
administrative burdens as a result of inaccurate provider directories.
Do you know the cost of inaccurate provider directories to the patient?
What's the total out-of-pocket costs patients pay for delayed care or
for costly out-of-network care?
Answer. The costs of inaccurate providers to patients manifest
themselves in two ways: impacts to their health and their pocketbooks.
As I described in my testimony, the process of going through an
inaccurate provider directory to find an appointment with someone who
can help them is at best demoralizing and at worst set up to
precipitate clinical deterioration and a preventable crisis. When this
process results in further deterioration of a patient's condition, the
treatment required as a result can be more lengthy and costly
regardless, even before considering the added costs of having to seek
care out of network. Patients who have delayed or foregone needed care
because they could not find clinician through the provider directory
often experience acute mental health crises that are treated in an
emergency room.
I am not aware of any studies that have looked at the cost of
inaccurate provider directories to patients. When patients cannot find
an in-network provider, they have two choices: go out of network or go
without care. Patients are five times more likely to go out of network
for MH/SUD care than for other types of medical care.\6\ Out-of-pocket
costs for out-of-network MH/SUD care are higher than for other medical
services.\7\ These costs increase when needed treatment is delayed and
symptoms worsen.\8\
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\6\ Kyanko K.A., Curry L.A., Busch S.H. ``Out-of-network provider
use more likely in mental health than general health care among
privately insured.'' Med Care. 2013;51(8):699-705, https://
www.milliman.com/-/media/milliman/importedfiles/ektron/
addictionandmentalhealth
vsphysicalhealthwideningdisparitiesinnetworkuseandproviderreimbursement.
ashx.
\7\ Pelech D., Hayford T. ``Medicare Advantage and commercial
prices for mental health services.'' Health Affairs (Millwood).
2019;38(2):262-7, https://doi.org/10.1377/hlthaff.2018.05226.
\8\ Drake R.J., Husain N., Marshall M., Lewis S.W., Tomenson B.,
Chaudhry I.B., Everard L., Singh S., Freemantle N., Fowler D., Jones
P.B., Amos T., Sharma V., Green C.D., Fisher H., Murray R.M., Wykes T.,
Buchan I., Birchwood M. ``Effect of delaying treatment of first-episode
psychosis on symptoms and social outcomes: A longitudinal analysis and
modeling study.'' Lancet Psychiatry. 2020 Jul;7(7):602-610. doi:
10.1016/S2215-0366(20)30147-4. PMID: 32563307; PMCID: PMC7606908,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7606908/.
______
Submitted by Hon. Elizabeth Warren,
a U.S. Senator From Massachusetts
May 3, 2023 Senate Committee on
Finance
Majority Study Findings:
Medicare Advantage Plan Directories
Haunted by Ghost Networks
Executive Summary
Ghost networks occur when a health plan's provider directory is filled
with inaccurate provider listings or unavailable providers. Academic
research has examined ghost networks across many provider specialty
types within group and nongroup health plans and Medicare Advantage
(MA). However, it is not known how pervasive ghost networks are for
mental health-care providers within the MA program. Senate Committee on
Finance's Majority staff conducted a brief secret shopper study to
examine the extent of mental health provider ghost networks in the MA
program.
Staff reviewed directories from 12 different plans in a total of 6
States, calling 10 systematically selected providers from each plan,
for a total of 120 calls. Of the total 120 provider listings contacted
by phone, 33 percent were inaccurate, nonworking numbers, or unreturned
calls. Staff could only make appointments 18 percent of the time.
Appointment rates varied by plan and State, ranging from 0 percent in
Oregon to 50 percent in Colorado. More than 80 percent of the listed,
in-network, mental health providers staff attempted to contact were
therefore ``ghosts,'' as they were either unreachable, not accepting
new patients, or not in-network.
It is particularly troubling to consider how this report's findings may
acutely affect an individual struggling with a mental health condition
and attempting to navigate the process of identifying an in-network
provider in a directory where 80 percent of the listed providers are
inaccurate or unavailable. CMS should increase its oversight efforts to
audit health plan directories to ensure they hold MA plans accountable
for these directories and for accurately documenting their networks.
Congress can also require additional steps to ensure provider directory
accuracy including regular audits, transparency, and financial
penalties for non-compliance.
Introduction
In the United States, approximately one in five adults suffer from a
diagnosable mental health illness. In 2021, it was estimated that less
than half of the 57.8 million adults living with a mental illness
received mental health services in the past year.\1\ Delayed access to
mental health care and inadequate treatment results in suffering, lost
productivity, worsening of other health conditions, and even death.
Therefore, access to timely and quality mental health care is
imperative and lifesaving. Tragically, many Americans experience the
complete opposite.
---------------------------------------------------------------------------
\1\ National Institute of Mental Health. ``Mental Illness.''
National Institute of Mental Health Office of Science Policy, Planning,
and Communications, https://www.nimh.nih.gov/health/statistics/mental-
illness. Accessed April 24, 2023.
To ensure that consumers are aware of and able to seek care from in-
network providers, health plans publish ``provider directories.'' These
documents list the health plan's in-network providers, usually by
specialty, and their contact information. Health insurers typically
also provide online searchable versions of this information. These
directories are supposed to help consumers both understand a plan's
network when shopping for a plan--that is, prior to enrolling--as well
as help enrollees find in-network providers when seeking care. However,
consumers experience many challenges when using these provider
directories, including providers not accepting new patients, long wait
times to see providers, and/or plans having inaccurate or out-of-date
provider information.\2\
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\2\ Government Accountability Office, ``Mental Health Care; Access
Challenges for Covered Consumers and Relevant Federal Efforts'' (2022),
https://www.gao.gov/assets/gao-22-104597.pdf.
Previous government audits \3\ and academic reports \4\,
\5\, \6\, \7\, \8\ have identified
widespread provider directory inaccuracies, referred to as ``ghost
networks.'' Ghost networks occur when a health plan's provider
directory is replete with inaccurate information or unusable provider
listings, such as when the provider is either (i) not taking new
patients or (ii) not in a plan's network.\9\
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\3\ Government Accountability Office, Report to the Chairman,
Committee on Finance, U.S. Senate, ``Mental Health Care: Access
Challenges for Covered Consumers and Relevant Federal Efforts,'' March
2022. Available at: https://www.gao.gov/assets/gao-22-104597.pdf.
\4\ Cama, S., Malowney, M., Smith, A.J.B., Spottswood, M., Cheng,
E., Ostrowsky, L., Rengifo, J., Boyd, J.W. ``Availability of Outpatient
Mental Health Care by Pediatricians and Child Psychiatrists in Five
U.S. Cities.'' Int J Health Serv. 2017 Oct;47(4):621-635. doi: 10.1177/
0020731417707492. Epub 2017 May 5. PMID: 28474997.
\5\ Malowney, M., Keltz, S., Fischer, D., Boyd, J.W. ``Availability
of outpatient care from psychiatrists: A simulated-patient study in
three U.S. cities.'' Psychiatr Serv. 2015 Jan 1;66(1):94-6. doi:
10.1176/appi.ps.201400051. Epub 2014Oct 31. PMID: 25322445.
\6\ Butala, N.M., Jiwani, K., Bucholz, E.M. ``Consistency of
Physician Data Across Health Insurer Directories.'' JAMA. 2023 Mar
14;329(10):841-842. doi: 10.1001/jama.2023.0296. PMID: 36917060; PMCID:
PMC10015301.
\7\ Resneck, J.S., Jr., Quiggle, A., Liu, M., Brewster, D.W. ``The
accuracy of dermatology network physician directories posted by
Medicare Advantage health plans in an era of narrow networks.'' JAMA
Dermatol. 2014 Dec;150(12):1290-7. doi: 10.1001/jamadermatol.2014.3902.
PMID: 25354035.
\8\ Zhu, J.M., Charlesworth, C.J., Polsky, D., McConnell, K.J.
``Phantom Networks: Discrepancies Between Reported and Realized Mental
Health Care Access in Oregon Medicaid.'' Health Aff (Millwood). 2022
Jul;41(7):1013-1022. doi: 10.1377/hlthaff.2022.00052. PMID: 35787079;
PMCID: PMC9876384.
\9\ Government Accountability Office, ``Mental Health Care: Access
Challenges for Covered Consumers and Relevant Federal Efforts,'' GAO-
22-104597, March 2022. Available at: https://www.gao.gov/assets/gao-22-
104597.pdf.
Academic research has examined the presence of ghost networks across
many provider specialty types within group, non group, and Medicare
Advantage (MA) plans. A March 2022 Government Accountability Office
(GAO) report to the Senate Committee on Finance, described the
prevalence of ghost networks for mental health providers in Medicaid
---------------------------------------------------------------------------
and employer group health plans.
However, it is unclear how pervasive ghost networks are for mental
health providers within the MA program. Additionally, although the
Centers for Medicare and Medicaid Services (CMS) requires MA plans to
keep provider directories up to date,\10\ CMS does not currently audit
these directories on a regular basis. This suggests that provider
directory inaccuracies go unnoticed by regulators and therefore
unaddressed.
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\10\ 42 CFR 422.2267(e)(11).
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Approach
Building on Chairman Wyden's existing work to crack down on ghost
networks,\11\ the United States Senate Committee on Finance's Majority
staff conducted a brief secret shopper study to examine the extent of
mental health provider ghost networks in the MA program. Staff
contacted in-network providers with the goal of securing an appointment
for an older adult family member with depression who moved to the area.
Staff used a secret shopper methodology commonly used in academic
studies. Staff reviewed directories from 12 different plans in 6
States, calling 10 systematically selected providers from each plan,
for a total of 120 calls (see Appendix for additional details).
---------------------------------------------------------------------------
\11\ S. 5093, ``Behavioral Health Network and Directory Improvement
Act,'' 117th Congress (2021-2022); S. 923, ``Better Mental Health Care
for America Act,'' 118th Congress (2023-2024).
---------------------------------------------------------------------------
Findings
In total, more than 80 percent of the identified listings for mental
health providers were inaccurate or unavailable. Of the total 120
provider listings contacted: 39 (33 percent) were nonworking numbers,
incorrect numbers, or unreturned calls (Figure 1). Staff could only
make appointments if the provider was in-network and accepting new
patients for 22 (18 percent) of the listings (Figure 1). Appointment
rates varied by plan and State (see Appendix for additional details).
More than 80 percent of the listed providers staff attempted to contact
were therefore ``ghosts,'' as they were either unreachable, not
accepting new patients or not in-network. In other words, for every 10
calls where staff attempted to make an appointment to a listed, in-
network mental health provider, only two calls resulted in an possible
appointment.
When staff were able to connect with a working telephone number, on
multiple occasions the number listed was for an entirely different
entity. Using one plan's directory, mental health specialists listings
led staff to a high school student health center, the nursing station
at an in-patient psychiatric facility, and a nonprofit organization
that manages logistics for peer support groups. A different plan
directory mental health specialist listing led to a mental health
specialist located in a different State. In this instance, the
receptionist at the facility explained that the providers have notified
the health plan on multiple occasions that they are not located in the
health plan's contracted State and do not have licensed providers
there. These are examples of the types of challenges staff ran into
while attempting to secure appointments.
In six instances, calls were routed to a national third-party provider
matching service. In these cases, the services indicated that there
were providers available, but staff were asked to submit additional
information about the patient's health needs (e.g., date of birth,
condition to be treated, modality of treatment--therapy or medications)
and insurance information in order to receive an appointment date,
time, and provider name. In these instances, we counted these calls as
successful appointments under the assumption that an appointment would
be secured if the required additional information was submitted. If
this was not true, our overall success in obtaining appointments would
have been reduced to 16/120 (13 percent).
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Reasons for not being able to secure an appointment included: not
accepting that insurance (even though a provider was listed on that
plan's directory indicating that they are in-network); not accepting
new patients; or requiring a referral to see a mental health provider
(sometimes requiring a primary care provider referral from within the
same system).
Furthermore, time required for staff to reach providers varied widely
across plans. Call times ranged from 1-3 hours to contact 10 listings
per plan. Of the appointments committee staff were ultimately able to
make, some were offered within a month. However, several providers
offered an appointment months in the future. In one instance, the
earliest available appointment was in 10 months.
Limitations
The goal of this study was to replicate a family member's experience in
seeking care for a loved one with depression. This was a brief secret
shopper survey and, as a result, our findings are subject to
limitations. Staff surveyed a sample of mental health specialists
listed by two plans each in six urban counties, but did not survey all
mental health providers in the plan's network or all plans. The sample
was limited per plan to examine a number of plans and areas.
Furthermore, the analysis included certain mental health specialists
(psychiatrists, social workers, nurse practitioners, and psychologists)
and may not generalize to other specialties.
Discussion
In this secret shopper study, majority staff found it challenging to
secure mental health care for an older adult with depression who is
enrolled in an MA plan. These results are consistent with previous
studies of provider directory accuracy for psychiatrists: 26 percent in
Malowney et al and 17 percent in Cama et al.\12\, \13\ While
health plans are responsible for building and maintaining a network of
providers, these findings suggest that plans are not accurately
representing who is actually in their network and/or able to deliver
care and/or available to deliver care.
---------------------------------------------------------------------------
\12\ Malowney, M., Keltz, S., Fischer, D., Boyd, J.W.
``Availability of outpatient care from psychiatrists: A simulated-
patient study in three U.S. cities.'' Psychiatr Serv. 2015 Jan
1;66(1):94-6. doi: 10.1176/appi.ps.201400051. Epub 2014Oct 31. PMID:
25322445.
\13\ Cama, S., Malowney, M., Smith, A.J.B., Spottswood, M., Cheng,
E., Ostrowsky L., Rengifo, J., Boyd, J.W. ``Availability of Outpatient
Mental Health Care by Pediatricians and Child Psychiatrists in Five
U.S. Cities.'' Int J Health Serv. 2017 Oct;47(4):621-635. doi: 10.1177/
0020731417707492. Epub 2017 May 5. PMID: 28474997.
To the extent that consumers are relying on health plan provider
directories when selecting a plan to enroll in, either as a measure of
network breadth or to confirm participation by a particular provider,
these findings suggest that relying on provider directories would be
misleading. Because of this, some experts have suggested that consumers
should not rely on health plan provider directories and should call
their providers prior to enrolling in a plan to confirm their
participation.\14\ However, this suggested workaround puts the burden
on beneficiaries. It requires seniors to invest significant time in
calling all of their providers who they currently see and anticipating
any health needs they may have in the future.
---------------------------------------------------------------------------
\14\ Based on majority staff conversations with an independent
broker and consumer advocates.
If a health plan does not have accurate providers listed in their
directories, patients seeking care will struggle to find a provider. It
is particularly troubling to consider how this report's findings may
acutely affect an individual struggling with a mental health condition
and attempting to navigate the process of identifying an in-network
provider in a directory where 80 percent of the listed providers are
---------------------------------------------------------------------------
inaccurate or unavailable.
CMS is responsible for overseeing the implementation of MA program
requirements. However, it is clear that more needs to be done to ensure
MA plan provider directories are accurate and usable for getting care.
MA plan directories have not been audited since 2018. CMS should
increase its oversight efforts to regularly audit health plan
directories to ensure they hold MA plans accountable for these
directories and for accurately documenting their networks. Congress can
also require additional steps to ensure provider directory accuracy
including regular audits, transparency, and financial penalties for
non-compliance.
Appendices
Study Methods
To assess provider directory accuracy for mental health care across
Medicare Advantage (MA) plans, we conducted a ``simulated patient''
secret shopper study. We selected six counties with major U.S. cities
across six States to ensure geographic diversity. Using State County
Plan enrollment public use files provided by the Centers for Medicare
and Medicaid Services (CMS), we selected the two largest non-employer
Medicare Advantage plans in each county from different parent
organizations.
Using the online provider directories for each plan available as of
April 2023, we selected a sample of 10 mental health providers for each
plan by selecting a ZIP code for the city center then sorting by
distance. We selected the first five providers listed at unique office
locations and then selected the next five providers of professional
background not represented in the first five, again at unique offices
to ensure representation of the mental health workforce (e.g.,
psychiatrist, psychologist, nurse practitioner, and social worker).
This approach did not appear to sort providers alphabetically.
Two staff members, one physician and one with a master's degree, called
the phone number listed in the provider directory, posing as the adult
child of a parent with the given MA plan, seeking treatment for the
parent's depression. Staff used the following script: ``My mom recently
moved to the area and has [XXX] MA plan. She used to see a mental
health specialist for her depression. I reviewed the online directory
for the plan which says you are an in-network provider for mental
health. Do you accept this insurance and if so, when is the earliest my
mom would be able to get an appointment?''
When appropriate, staff members left voicemails with the relevant
questions and a request for a call back or to leave a message
addressing those questions. Staff members tried to contact each listed
provider a second time if the voicemail was not returned. Unreturned
voicemails were defined as an unsuccessful contact. When put on hold,
we defined hold times greater than 60 minutes as an unsuccessful
contact.
We defined a successful appointment as being told there was an
appointment available to schedule for the simulated patient. Staff
members did not actually make an appointment.
Appendix Table 1. Overall and By State Call Results
----------------------------------------------------------------------------------------------------------------
Successful
State No Contact Yes Contact Appointments Ghost Listings
----------------------------------------------------------------------------------------------------------------
OH 35% 65% 25% 75%
----------------------------------------------------------------------------------------------------------------
PA 10% 90% 15% 85%
----------------------------------------------------------------------------------------------------------------
OR 30% 70% 0% 100%
----------------------------------------------------------------------------------------------------------------
MA 45% 55% 10% 90%
----------------------------------------------------------------------------------------------------------------
CO 25% 75% 50% 50%
----------------------------------------------------------------------------------------------------------------
WA 50% 50% 10% 90%
----------------------------------------------------------------------------------------------------------------
Total 33% 68% 18% 82%
----------------------------------------------------------------------------------------------------------------
Appendix Table 2. Overall and By Plan and State Call Results
----------------------------------------------------------------------------------------------------------------
Listings No Contact (# Successful
Plan State Contacted Not Functional) Yes Contact Appointments
----------------------------------------------------------------------------------------------------------------
Plan A OH 10 5 5 2
----------------------------------------------------------------------------------------------------------------
Plan B OH 10 2 8 3
----------------------------------------------------------------------------------------------------------------
Plan C PA 10 0 10 2
----------------------------------------------------------------------------------------------------------------
Plan D PA 10 2 8 1
----------------------------------------------------------------------------------------------------------------
Plan E OR 10 0 10 0
----------------------------------------------------------------------------------------------------------------
Plan F OR 10 6 4 0
----------------------------------------------------------------------------------------------------------------
Plan G MA 10 5 5 1
----------------------------------------------------------------------------------------------------------------
Plan H MA 10 4 6 1
----------------------------------------------------------------------------------------------------------------
Plan I CO 10 1 9 6
----------------------------------------------------------------------------------------------------------------
Plan J CO 10 4 6 4
----------------------------------------------------------------------------------------------------------------
Plan K WA 10 2 8 1
----------------------------------------------------------------------------------------------------------------
Plan L WA 10 8 2 1
----------------------------------------------------------------------------------------------------------------
Totals 120 39/120 (33%) 81/120 (68%) 22/120 (18%)
----------------------------------------------------------------------------------------------------------------
* Totals may not add up to 100% due to rounding.
______
Prepared Statement of Hon. Ron Wyden,
a U.S. Senator From Oregon
This morning the Finance Committee gathers to discuss ghost
networks, which are provider directories maintained by insurance
companies that are often inaccurate and unusable by American families
who need mental health care.
I want to be clear from the outset what I mean: when insurance
companies host ghost networks, they are selling health coverage under
false pretenses, because the mental health providers advertised in
their plan directories aren't picking up the phone or taking new
patients. In any other business, if a product or service doesn't meet
expectations, consumers can ask for a refund.
In my view, it's a breach of contract for insurance companies to
sell their plans for thousands of dollars each month while their
product is unusable due to a ghost network. I'm going to use all
resources at my disposal as chairman of the Senate Finance Committee to
get some real accountability.
In a moment of national crisis about mental health, with the
problem growing exponentially during the pandemic, the widespread
existence of ghost networks is unacceptable. When someone who's worried
about their mental health or the mental health of a loved one finally
works up the courage to pick up the phone and try to get help, the last
thing they need is a symphony of ``please hold'' music, non-working
numbers, and rejection.
Just take a moment and think about the impact that might have on an
individual who's already in a challenging situation. It's not hard to
imagine how many Americans simply give up and go on struggling without
the help they need.
This is not a hypothetical matter. Just last month, my staff
conducted a secret shopper study: they made over 100 phone calls to
make an appointment with a mental health-care provider for a family
member with depression across 12 Medicare Advantage insurance plans in
six States.
The results were clear. Our secret shoppers were only able to get
an appointment 18 percent of the time. That means more than 8 in 10
mental health-care providers listed in the insurance companies'
directories were inaccurate or not taking new appointments. A third of
the time the phone number was a dead end altogether. In one instance,
staff trying to reach a mental health provider were instead connected
to a high school student health center. In another, they were connected
to a mental health specialist in another State. And in my State of
Oregon, the results are especially troubling--my staff could not make
one successful appointment.
Other secret shopper studies looking at commercial health insurance
found similar results. In 2017, researchers posing as parents seeking
care for a child with depression were only able to obtain an
appointment 17 percent of the time. Another from 2015 resulted in an
appointment only 26 percent of the time after 360 calls. It is clear
that ghost networks are a persistent, widespread problem in the health-
care system.
The Finance Committee has been looking closely at this issue, and
in my view there are reasons to be optimistic that Congress can take
action. A little over a year ago the committee first heard the term
``ghost networks'' used in this room when the Government Accountability
Office shared their findings about the prevalence of inaccurate
provider directories.
Since then, the committee has put a lot of sweat equity into
developing legislation to improve mental health care for all Americans,
from telehealth, to youth mental health, to workforce, to care
integration and parity. Some of our policies were passed into law in
the last Congress, including a policy to strengthen provider directory
standards in Medicaid, but there is still more to be done. I look
forward to working with Ranking Member Crapo and every member of the
committee to get more of our hard work across the finish line so more
families can get mental health care when they need it.
In my view, eliminating ghost networks is going to require a three-
legged approach: more audits, greater transparency, and stronger
consequences for insurance companies that don't keep their directories
up to date.
Today, Medicare performs regular audits of plans offering coverage
to seniors to ensure they meet minimum standards. However, CMS does not
regularly audit Medicare Advantage provider directories, and the
results speak for themselves. It's time for that to change.
I'm always an advocate for greater transparency that allows
consumers and advocates to compare plans. That's why last year the
committee put forward a bipartisan proposal to improve the accuracy of
provider directors in Medicaid and to require Medicare to publish plan
provider directories on a central website. That will help consumers,
advocates, and researchers dig into this information and make informed
choices about their care.
We got started by passing the Medicaid ghost network provision into
black letter law last year. This year I want consensus on how to
address ghost networks in Medicare.
I want to conclude by talking about accountability. My view is that
insurance companies have gotten a free pass for too long letting ghost
networks run rampant. If a student were writing an essay and 80 percent
of their citations were incorrect or made up, they'd receive an ``F.''
If a business gave the SEC false or incorrect information, it would
face extremely severe consequences. So in my view, insurance companies
should face strict consequences if their products don't live up to the
billing. That's the least that should be done, and I'll keep pushing
for the necessary accountability so families across the country aren't
getting lost in these ghost networks.
This issue needs to be addressed across the board, not just in
Medicare and Medicaid. Many of my colleagues have expressed interest in
applying these policies to commercial insurance like employer-sponsored
plans. I look forward to working with this committee and the entire
Senate to find consensus that will consign ghost networks to the
dustbin of history.
There's a lot for us to talk about today. I want to thank our
witnesses for joining the committee. I look forward to our discussion.
______
Communications
----------
AHIP
601 Pennsylvania Avenue, NW
South Building, Suite 500
Washington, DC 20004
T 202-778-3200
F 202-331-7487
https://www.ahip.org/ahip.org
Every American deserves access to effective, affordable, and equitable
mental health support and counseling. Health insurance providers are
committed to lowering barriers to care for mental health and substance
abuse disorders (SUD). That commitment includes ensuring provider
networks of mental health professionals are as robust as possible.
As the national association whose members provide health care coverage,
services, and solutions to hundreds of millions of Americans every day,
our member plans work consistently with care professionals, and
government agencies to make certain that provider directories are up-
to-date and accurate as possible, so patients can get the mental health
care services, care, and support they need at a price they can afford.
AHIP appreciates the Committee's focus on these important issues.
Maintaining accurate provider directories is a shared responsibility
that requires a joint commitment from health plans and providers to
ensure patients have the information they need, and that the
information is updated in a timely and accurate fashion. We look
forward to working with providers and policymakers to address the
current provider directory challenges, particularly for patients
seeking mental health support.
Ensuring Accurate Provider Directory Information: A Shared
Responsibility
Since the COVID-19 pandemic, more Americans of all ages are seeking
mental health care--stretching capacity to its limits. While more
people are receiving the treatment they need, still more work needs to
be done. If an individual seeks help and can't answer key questions
about their mental health care, such as which providers to see or
whether a specialist is in their plan's network, no one benefits.
It is more critical than ever that patients are able to access the
mental health care they need. One in five adults in the United States
lived with mental illness, according to the National Institute of
Mental Health.\1\ To that end, it is essential that all stakeholders
work together, including care professionals, federal and state
policymakers, community organizations, health insurance providers, and
other health leaders.
---------------------------------------------------------------------------
\1\ https://www.nimh.nih.gov/health/statistics/mental-illness.
Late last year, the AHIP Board of Directors noted the crucial role of
collaboration in their commitment and vision to improve access to
mental health care.\2\ As such, maintaining accurate provider
directories is a shared responsibility that requires a joint commitment
from health plans and providers to ensure patients have the information
they need, and it is updated in a timely and accurate fashion.
---------------------------------------------------------------------------
\2\ https://www.ahip.org/news/press-releases/ahip-board-reinforces-
commitment-to-improved-access-to-mental-health-care-with-new-
principles-and-advocacy-priorities.
---------------------------------------------------------------------------
Health Plans Work to Provide Patients with Essential Information
Every American should be able to easily find a clinician or facility
skilled in the type of care they seek, that is convenient to access,
and with whom they are comfortable. Health plans are committed to
ensuring provider directories reflect the most current and accurate
information, so that individuals can maximize the value of their
coverage for both physical and mental health.
Provider directories offer essential information for patients on
providers in-network, such as their contact information, practicing
specialties, board certifications, hospital affiliations, and ability
to speak languages other than English. Provider directories also
usually include information on hospitals, and non-hospital facilities.
In addition to our commitment to ensure that Americans have accurate
information, federal laws have imposed provider directory requirements
across various types of coverage (e.g., Medicare, Medicaid, and the
commercial health insurance markets). To supplement those requirements,
at least 39 states impose their own state-specific provider directory
requirements. Regulations implementing provider directory provisions
under the Consolidated Appropriations Act of 2021 are also forthcoming
from the Administration.
Health plans use a variety of approaches to maintain and update
provider directory information, including regular phone calls, emails,
online reminders, and in-person visits. This multi-faceted outreach
effort is reinforced by contractual requirements between health plans
and providers to ensure provider directory information is accurate and
up to date.
Provider Engagement and Accountability
Given the breadth and diversity of providers in health plans' networks
and the frequency of changes, information can quickly become out of
date. Moreover, not all providers rely on the same method of
communicating information to health plans. This often leads to delays
in updating pertinent provider information. These challenges are
further complicated by the fact that providers contract with multiple
health plans and may be part of multiple medical groups or independent
physician associations.
Maintaining accurate and up-to-date provider directory information has
been a longstanding issue for the health care industry. In 2016, AHIP
launched a Provider Directory Initiative to identify opportunities to
improve the process of developing and maintaining accurate and timely
provider directory information.\3\ During the project, AHIP worked with
two vendors to contact over 160,000 providers, testing different ways
to coordinate with them to update key directory data.
---------------------------------------------------------------------------
\3\ https://www.ahip.org/resources/provider-directory-initiative-
key-findings.
The results of the project found that while providers indicated that
they were familiar with directories and were aware that they are used
to help consumers find clinicians who are in-network, and accepting new
---------------------------------------------------------------------------
patients, they and/or their staff:
Expressed a general lack of awareness regarding the need to
proactively alert plans of changes to their information.
Did not understand the purpose of, or need for, responding to
plan requests to validate or update their information.
Felt overwhelmed with responsibility and therefore prioritized
activities that were required of them by regulation or to secure
payment for the provider.
Were not necessarily aware of state and federal regulations
requiring health plans to have accurate, up-to-date provider directory
information.
Health plans have worked with their provider partners for many years to
improve the accuracy of directory data for patients. These efforts
include regular outreach to clinicians to ensure their information is
accurate; collaborating to streamline information updates; using
advanced analytics and artificial intelligence methods to identify
information that should be updated; and validating directories to
ensure they are correct. Further, third-party vendors have developed
innovative products to improve provider directories, and health
insurance providers are contracting with those companies as valuable
partners.
While health plans are committed to making accurate and up-to-date
provider directory information available to consumers, a strong
partnership and active participation with health care providers is
essential to achieving this goal. Enhancing provider responsibility for
ensuring accurate directory information would also lead to a more
collaborative process and a more useful tool for patients, avoiding the
inconvenience of inaccurate office locations, incorrect phone numbers,
and non-acceptance of new patients.
Greater Standardization to Reduce Provider and Plan Burden
Despite private-sector initiatives and government actions, provider
directory data challenges remain. One key barrier to ensuring accurate
provider directory information is that there is no single source-of-
truth for provider information that can be leveraged to verify provider
directory submissions without direct engagement of the clinician
themselves.
To address these challenges, Americans would benefit from a public-
private partnership between the federal government, clinicians, payers,
and vendors to streamline and simplify collection of this information
and improve its accuracy and completeness. Greater standardization and
harmonization in the technical aspects of the information validation
process would reduce provider and plan burden and make it easier to
update directory information.
To that end, the Centers for Medicare and Medicaid Services (CMS)
sought feedback in an October 2022 request for information (RFI) on
developing a cohesive, national approach to building a technology-
enabled infrastructure, such as the National Directory of Healthcare
Providers and Services (NDH).\4\ This approach could serve to promote
better accuracy of directories, reduce provider burden, and improve
efficiency. It also could serve as a source of truth that health
insurance providers could leverage to inform more accurate directories,
as AHIP noted in our response to the RFI.\5\
---------------------------------------------------------------------------
\4\ https://www.govinfo.gov/content/pkg/FR-2022-10-07/pdf/2022-
21904.pdf.
\5\ https://www.ahip.org/resources/directory-ahips-response-to-
cmss-request-for-information-on-the-creation-of-a-national-directory-
of-health-care-providers-and-services-2.
Especially as digital technologies become a more essential part of
health care delivery, improved provider directory accuracy that could
be developed through a national streamlined infrastructure would reduce
the burden on patients and would allow them to access the most up-to-
date and accurate information about providers and identify an
appropriate in-network provider and is a good fit for their specific
---------------------------------------------------------------------------
needs.
Multi-stakeholder engagement is critical to the success of such an
effort. AHIP urges the Committee to explore ways to leverage existing
initiatives and support additional ways to standardize data elements to
build on what is currently working. AHIP also encourages the Committee
to work towards solutions that increase the efficiency and adoption of
scalable technological solutions for improving the accuracy of provider
directories. For example, we recommend that Congress provide adequate
funding to support CMS' approach to building the NDH through a public-
private partnership.
Addressing Systemic Challenges to Meet Growing Mental Health Care
Demands
AHIP acknowledges and recognizes the important role health plans play
in provider networks; effective mental health support depends upon
accessible and affordable robust networks. Unfortunately, systemic
barriers, such as workforce shortages and growing treatment demands,
have also contributed to challenges with mental health access.
Health plans are working to address these challenges, such as
integrating mental health care with primary care, providing access to
telehealth, and broadening access to a wider range of mental health
professionals in order to better meet the needs of patients where they
are and offer care that is more coordinated, holistic, and effective.
Workforce Shortages
Health insurance providers recognize the need to address widely
acknowledged workforce shortages and a growing demand for treatment
where the supply of providers is insufficient to serve local needs. A
recent analysis found that 47% of the U.S. population--158 million
people--live in an area where there is a mental health workforce
shortage.\6\ But addressing this ongoing issue can only be accomplished
by all health care stakeholders working together.
---------------------------------------------------------------------------
\6\ https://www.kff.org/medicaid/issue-brief/a-look-at-strategies-
to-address-behavioral-health-workforce-shortages-findings-from-a-
survey-of-state-medicaid-programs/.
Health insurance providers are working to improve mental health
workforce issues by bringing more high-quality clinicians into their
networks, training and supporting primary care physicians (PCPs) to
care for patients with mild to moderate mental health conditions,
expanding tele-behavioral health, and helping patients find available
mental health appointments. In fact, among commercial health plans, the
number of in-network mental health providers has grown by an average of
48% in 3 years.\7\ Nonetheless, longstanding mental health provider
shortages persist and are exacerbated by many providers choosing not to
participate in health plan networks.
---------------------------------------------------------------------------
\7\ https://www.ahip.org/news/press-releases/new-survey-shows-
strong-action-by-health-insurance-providers-to-growing-mental-health-
care-demands.
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Strengthening the Mental Health Workforce
Action is urgently needed to expand the number of mental health
providers of all types--from psychiatrists and psychologists to social
workers and mental health professionals.
AHIP supports legislative policies that provide incentives for
individuals to enter the mental health field. These could include:
Increasing funding for loan repayment programs for providers who
enter the mental health field. If government resources are used to
encourage people to enter the mental health field, AHIP supports
requirements that those providers participate in health plan networks,
particularly in public programs such as Medicare and Medicaid.
Expanding the eligible provider types for National Health
Service Corp (NHSC) scholarships to include mental health care
professions with an additional emphasis on promoting workforce
diversity.
In addition to expanding the number of providers, AHIP member
organizations 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 people can find
providers who meet their needs and preferences. This includes provider
and practitioner demographic diversity as well as diversity of staff
and care team members. Improved directories where providers can more
easily disclose demographics--such as race/ethnicity and languages
spoken--would also help patients seek the type of provider that best
meets their needs. Furthermore, a public-private partnership for a
national directory infrastructure that could be leveraged to collect
both provider and payer digital addresses to advance health data
interoperability would also help improve the patient experience related
to quality, equity, and affordability of care.
Mental Health Integration
Because the front door to health care for most individuals is their
PCP, making that primary care practice a one-stop shop for people's
physical and mental health needs can help with early identification of
mental health issues, reduce the wait time to treatment, and improve
access to mental health services for everyone.
That's why health insurance providers are exploring multiple ways to
integrate mental health care with primary care--leveraging
collaborations with PCPs as an effective way to enhance access to
mental health support and improve overall health results. Integrated
mental health care blends care for physical conditions and mental
health, including 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.\8\
---------------------------------------------------------------------------
\8\ https://www.integrationacademy.ahrq.gov/about/integrated-
behavioral-health.
Because many patients already have existing relationships with PCPs,
integration of physical and mental health can provide multiple benefits
to patients, including earlier diagnosis and treatment, better care
coordination, timely information sharing, improved results, and
improved patient and provider satisfaction. Many people with mental
health conditions also have other chronic medical conditions.
Integrating mental health with primary care can allow for earlier
diagnosis and better coordination of care for patients with multiple
complex physical and mental health conditions. This approach has also
been identified by many stakeholders as a strategy not only to improve
access and quality, but also to reduce disparities and promote
equity.\9\, \10\
---------------------------------------------------------------------------
\9\ https://www.chcs.org/media/PCI-Toolkit-BHI-Tool_090319.pdf.
\10\ https://www.ama-assn.org/delivering-care/public-health/
behavioral-health-integration-physician-practices.
The Collaborative Care Model (CoCM) is one such model.\11\ This model
of integration includes care management support for patients receiving
mental health treatment and psychiatric consultation. 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 mental health
conditions, and value-based arrangements.
---------------------------------------------------------------------------
\11\ https://www.chcs.org/media/
HH_IRC_Collaborative_Care_Model__052113_2.pdf.
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 mental health care. Health insurance providers see
firsthand the vital role that mental health plays in overall health
care and are committed to working with their provider partners to
promote whole-person care through mental health integration.
The Role of Telehealth
Patients, health care professionals, and health insurance providers all
appreciate the value of telehealth. Many patients can access telehealth
from wherever they are, making it a vital tool to bridge health care
gaps nationwide. Patients now accept--and often prefer--digital
technologies as an essential part of health care delivery, including
the delivery of mental health and substance use disorder services.
Those accessing mental health services via telehealth can do so from
the privacy of their own homes and free from concerns about the
potential 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 mental 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 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 is why they
embrace telehealth solutions that help increase access to care. The
telehealth flexibilities put in place during the 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.
The collective 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 mental health services. Data show that over 60% of telehealth
use is for mental health care.\12\
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\12\ 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 support legislative action and
encourage Congress to act to permanently 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 mental health
services in an equitable manner across all populations and communities.
Conclusion
Mental health is an essential part of a person's overall health and
well-being. Health insurance providers are working everyday with
patients, providers, and communities to ensure access to mental health
care and support--including making accurate and up-to-date provider
directory information available to patients.
We are making progress, but we must recognize the multi-faceted nature
of the challenges facing our nation's mental health care system and
acknowledge the need for all stakeholders to do much more. AHIP
believes that a strong partnership and active participation among both
health plans and providers is essential to achieving the goal of
maintaining timely, accurate provider directories so patients have the
information they need and the information is up to date.
AHIP and its members are committed to working with the Committee to
improve provider directory information and therein help patients access
care more quickly and reduce administrative burden and costs for
everyone, helping make coverage and care more affordable while also
permitting clinicians to spend more of their time caring for patients.
AHIP appreciates the Committee's increased focus on these important
issues. We look forward to working with you to further develop
solutions to improve longstanding provider directory issues and enhance
mental health care access and affordability.
______
American Association of Payers Administrators and Networks
3774 LaVista Road, Suite 101
Tucker, GA 30084
502-403-1122
502-403-1129 (fax)
https://aapan.org/
May 12, 2023
The Honorable Ron Wyden The Honorable Mike Crapo
Chairman Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
Washington, DC 20510 Washington, DC 20510
Dear Chairman Wyden and Ranking Member Crapo:
On behalf of the 100 members of the American Association of Payers
Administrators and Networks (AAPAN), we would like to share our
thoughts on ways to improve the accuracy of provider directories. AAPAN
members strive to provide our beneficiaries with the most up-to-date
and accurate information on the providers in our networks. We
understand the frustrations people face when their ability to seek care
is hampered by incorrect provider information. However, the
responsibility of ensuring this information is accurate lies with both
the plans as well as the providers. While your recent hearing on
``ghost networks'' focused on the deficiencies with respect to mental
health care, AAPAN believes these issues are not limited to mental
health care.
AAPAN provides a unified, integrated voice for payers, third-party
administrators, networks, and care management in the group/government
health and workers' compensation markets. The association serves as an
advocate that respects and balances the unique business needs of its
members so that both may more effectively provide patient access to
appropriate, quality health care.
Provider directories are an important resource and tool given to
enrollees to help them determine which providers are in-network. The
directories provide market opportunities for both plans and providers.
However, inaccurate directories could potentially result in unforeseen
costs for enrollees as well as frustrations finding care. While the
hearing highlighted the challenges faced by patients and the burdens
and costs borne by providers, the costs to plans and payers were
overlooked and are significant. Plans need to comply with both federal
and state provider directory laws and invest significant amounts of
money to do so. The costs associated with ensuring provider directory
accuracy include data acquisition which can be in the millions of
dollars, the costs of engaging a third-party vendor to scrub the data
which can cost hundreds of thousands of dollars, and the costs of
hiring employees to work on the internal processes necessary to ensure
the data are current. However, at the end of the day plans are
hamstrung by the information, or lack of information, from the
providers.
Our members have found that providers often omit or neglect to include
certain data when submitting this information to plans, such as whether
they are accepting new patients, their hours of operation, or the
accessibility of their office setting (i.e., handicap accessibility,
languages spoken, etc). While it is incumbent on the plan to verify and
ensure this information, AAPAN believes that providers need to be a
willing partner. Anecdotally, our members have reported that some
providers are less forthcoming and responsive if they believe they have
a less favorable reimbursement rate as compared to other networks/
plans.
One example that was raised in the hearing was of a patient with
schizophrenia being unable to find a provider. Our members were
particularly concerned about this example because when providers are
credentialed plans determine that providers have the proper
qualifications and licensing to perform their jobs. While specialty is
often part of the data included in a provider directory, plans would
not know a provider's preference for treating certain conditions within
their scope of practice. There are health equity issues that this
example raised that are not confined to just the mental health care
field. Patients with disabilities face similar challenges, according to
a report published in Health Affairs in October 2022.\1\ These
attitudes and biases would not be captured in a directory.
---------------------------------------------------------------------------
\1\ ``I Am Not the Doctor for You'': Physicians' Attitudes About
Caring for People With Disabilities; Tara Lagu, Carol Haywood, Kimberly
Reimold, Christene DeJong, Robin Walker Sterling, and Lisa I. Iezzoni;
Health Affairs 2022 41:10, 1387-1395.
AAPAN supports efforts to alleviate this burden. We believe that having
standardized data elements and definitions around those elements could
go a long way in ensuring that provider directories are accurate.
Having a common language and expectations around the elements included
in the directory will not only help plans and providers, but will help
patients. AAPAN believes that some ideas that have been proposed, such
as a National Directory, may create their own issues and additional
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burdens.
Under such a National Directory model, the directory information could
be maintained in a standardized and interoperable way which could serve
as an important resource for plans. This would allow all plans to
update their own directories without requiring providers to submit
multiple data collections from their plans, reducing burdens for both
plans and providers. However, AAPAN members have raised concerns about
how such a model would account for directory requirements imposed at
the state level. A majority of states have legislated the items plans
are required to collect and include on directories. AAPAN also believes
for a National Directory to be successful all states must agree to the
data elements being collected. If plans have to submit to 50 different
state requirements because states continue to mandate their own data
elements for provider directories, then it would ultimately be an
additional burden on plans and providers.
While it is incumbent on plans to ensure the accuracy of their provider
directories, AAPAN believes that accurate directories are a shared
responsibility between plans and their in-network providers. Plans can
establish processes to update provider data but providers themselves
need to inform plans when they have changes to their practices. AAPAN
believes that a National Directory would have similar difficulties
ensuring accurate information unless providers are willing and active
participants. The Committee should consider opportunities to increase
provider accountability, including consequences for failure to update
data changes in a timely manner. As part of California's law on
provider directories plans are permitted to delay payments to providers
who fail to respond to the plans' attempt to verify their information.
While plans are also able to terminate provider contracts for failure
to inform plans of changes in the directory information, AAPAN believes
this course of action could ultimately harm patients by leaving
existing patients of that provider vulnerable and searching for a new
provider.
As the Committee considers its next steps it should keep in mind that
the No Surprises Act (NSA) included provisions that require health
plans and issuers to verify and update provider directory information
at least once every 90 days, process updates within two business days
of receiving updated information, and remove providers from the
directory if their information has not been verified during a period
specified by the health plan. It also requires certain elements to be
included such as the name of the provider, address, phone number,
specialty, and digital contact information. However, to date, the
Administration has not yet issued any rulemaking to implement these
requirements of the NSA, despite these provisions going into effect on
January 1, 2022. AAPAN members are making good faith efforts to comply,
but further guidance is needed to ensure providers fulfill their
requirements.
While there are requirements and enforcement mechanisms imposed on
plans to ensure the accuracy of directories, these mechanisms are not
imposed on providers. Congress should consider both incentives and
penalties to ensure providers participate and they do so with the
frequency needed to keep their information current. Earlier versions of
the NSA included penalties for both providers and plans, but this
language did not make it into the enacted version.
As the Committee looks for ways to improve the accuracy of directories,
it should consider convening listening sessions with all stakeholders
included to develop a meaningful solution that works for all parties.
AAPAN believes the unique perspectives of all these types of payers
within its membership should be included in the debate. However, before
undertaking any new legislation, Congress should allow for time to
ensure the NSA provisions are fully implemented. The Committee could
encourage CMS to move forward with guidance or rulemaking.
AAPAN supports your effort to reduce the compliance burden for
providers and payers with respect to the accuracy of provider
directories. We would like to be a resource to the Committee as your
work on this vital issue continues. If you have any questions regarding
our comments, please contact Julian Roberts at jroberts@
aapan.org or 404-634-8911.
Sincerely,
Julian Roberts
President and CEO
______
American Medical Association
The American Medical Association (AMA) appreciates the opportunity to
provide testimony to the U.S. Senate Committee on Finance as part of
the hearing entitled, ``Barriers to Mental Health Care: Improving
Provider Directory Accuracy to Reduce the Prevalence of Ghost
Networks.''
As the largest professional association for physicians and the umbrella
organization for state and national specialty medical societies, the
AMA understands that provider directories are critically important
tools to help patients find a physician when they need one. Directories
allow patients to search and view information about in-network
providers, including the practice location, phone number, specialty,
hospital affiliations, whether they are accepting new patients, and
other details. Some directories also provide information on health
equity and accessibility issues, such as public transportation options,
languages spoken, experience with specific patient populations, and the
ability to provide specific services.
Directories can help physicians make referrals for their patients,
serving as a primary source of network information for patients' health
plans. Directories also serve as a representation of a plan network and
the network's adequacy for regulators.
Importantly, directories can help patients purchase the health
insurance product that is right for them. A patient with psoriatic
arthritis may select a product that appears to have their
rheumatologist and dermatologist in the network. A family without a car
may select a product because the pediatrician down the street is in-
network. A 26-year-old may not choose to put money in her flexible
savings account this year because all of her physicians appear to be
contracted under her new plan. And patients being treated for opioid
use disorder may pick a product because it appears that the mental and
behavioral health care services they require are available through the
plan's network providers.
Therefore, when directory information is incorrect, the results can be
complicated, irritating, expensive, and potentially devastating,
especially to patients. Inaccurate directories shift the responsibility
onto patients to locate a plan's network or pay for out-of-network
care. Patients are financially impacted and may be prevented from
receiving timely care.
Moreover, in the long run, continuing to allow inaccuracies makes it
easier for plans to fail to build networks that are adequate and
responsive to enrollees' needs. Accurate directories are a basic
function and responsibility of health plans offering network products.
It should be noted that directory accuracy seems of particular
importance in the immediate term, as we face the end of the Medicaid
continuous enrollment provision, and many Medicaid recipients begin to
transition off Medicaid and onto private health insurance plans. It is
critical that directories provide accurate information for individuals
who are entering the private market, especially those who may have
chronic conditions or significant health care needs and are looking to
ensure that their physicians and other health care providers are in-
network.
I. Scope of the Problem
There have been dozens of studies over the last 10 years looking at the
scope of the provider directory problem and nearly all of them point to
serious inaccuracies with physicians' locations, as well as inaccurate
physicians' network status, physicians' availability to accept new
enrollees, physicians' specialties, or all of the above.
In October 2014, Jack Resneck, MD (the AMA's current President and
witness for this hearing) published a study with several colleagues in
the Journal of the American Medical Association Dermatology.\1\ He and
his colleagues specifically studied Medicare Advantage (MA) plan
directories of participating dermatologists and the appointment
availability of those dermatologists listed. Their ``secret-shopper''
research first found that about 45 percent of the listings included
duplicates--multiple office listings at different addresses for the
same physician, or the same physicians at the same addresses with
slightly different versions of their names. This, of course, created
the appearance of more robust networks than were in place.
---------------------------------------------------------------------------
\1\ J. Resneck, A. Quiggle, M. Liu, D. Brewster, ``The Accuracy of
Dermatology Network Physician Directories Posted by Medicare Advantage
Health Plans in an Era of Narrow Networks,'' JAMA Dermatology (October
24, 2014).
After accounting for those duplicates, they found that they were unable
to contact nearly 18 percent of physicians either because the numbers
were wrong, or the office had never heard of that physician.
Furthermore, 8.5 percent reported that the listed physicians had died,
---------------------------------------------------------------------------
retired, or moved out of the area.
After that, it was found that 8.5 percent of those physicians were not
accepting new patients, and more than 10 percent were not the right
type of physician to address the condition for which they were seeking
care (e.g., an itchy rash), they were subspecialists, dermatologic
surgeons, pediatric dermatologists, etc. In the end, it was found that
about 26.6 percent of the individual directory listings were unique,
accepting the patient's insurance, and offering a medical dermatology
appointment. However, the average wait time to get that appointment was
45.5 days.
Since that study was published, the situation has, unfortunately, not
improved. In 2018, the Centers for Medicare & Medicaid Services (CMS),
in a review of 52 MA organizations (MAOs) (approximately one-third of
MAOs at the time), found that nearly 49 percent of the provider
directory locations listed had at least one inaccuracy.\2\
Specifically, providers should not have been listed at 33 percent of
the locations because the provider did not work at the location or
because the provider did not accept the plan at the location. CMS also
found a high number of instances where phone numbers were wrong or
disconnected and incorrect addresses were listed. Similarly, CMS
reported cases where the provider was found not to be accepting new
patients, although the directory indicated that the provider was
accepting new patients.
---------------------------------------------------------------------------
\2\ ``Online Provider Directory Review Report,'' CMS, November 28,
2018, https://www.cms.
gov/Medicare/Health-Plans/ManagedCareMarketing/Downloads/
Provider_Directory_Review_
Industry_Report_Round_3_11-28-2018.pdf.
Errors in location and contact information can lead to patient
frustration and, in many cases, delays in accessing care. It can also
result in higher costs for patients. The AMA fielded a survey between
2017 and 2018 where 52 percent of physicians reported that their
patients encountered coverage issues due to inaccurate information in
provider directories at least once per month.\3\ And a 2020 study in
the Journal of General Internal Medicine found that, of patients
receiving unexpected bills, 30 percent noted errors in their health
plan's provider directory.\4\
---------------------------------------------------------------------------
\3\ ``What Physicians are Saying About Directories,'' Power Point
summary, American Medical Association, 2018.
\4\ K.A. Kyanko, S.H Busch, ``Surprise Bills from Outpatient
Providers: A National Survey,'' Journal of General Internal Medicine
36, 846-848 (2021), https://doi.org/10.1007/s11606-020-06024-5.
Imagine selecting a health plan and paying health insurance premiums
only to find out that you relied on erroneous information. Imagine the
sense of helplessness and frustration amongst patients when they cannot
---------------------------------------------------------------------------
access the care on which they were counting.
Directory inaccuracy issues do not seem to be specific to any type of
physician specialist or patient care, but in a moment where we are
facing a mental health crisis, it is imperative that health plans offer
adequate networks that are accurately reflected in their directories so
that patients can access timely mental and behavioral health care.
Unfortunately, this does not seem to be happening. For example, a March
2022 Government Accountability Office (GAO) report to this Committee
\5\ highlighted patient challenges with accessing mental health care.
Stakeholders reported inaccurate or out-of-date information; these
inaccuracies where mental health providers appear to be in a health
plan's network contributes to ongoing access issues for consumers and
may lead consumers to obtain out-of-
network care at higher prices.
---------------------------------------------------------------------------
\5\ Mental health care: Access Challenges for Covered Consumers and
Relevant Federal Efforts, GAO, March 2022, https://www.gao.gov/assets/
gao-22-104597.pdf.
Similarly, a 2020 Health Affairs study found that 44 percent of the
patients surveyed had used a mental health provider directory and 53
percent of those had encountered directory inaccuracies.\6\ Those who
encountered at least one directory inaccuracy were four times more
likely to have an out-of-network bill for the care.
---------------------------------------------------------------------------
\6\ S.H. Busch, K.A. Kyanko, ``Incorrect Provider Directories
Associated with Out-of-Network Mental Health Care and Outpatient
Surprise Bills,'' Health Affairs Vol. 39 No. 6, June 2020, https://
www.healthaffairs.org/doi/10.1377/hlthaff.2019.01501.
In 2022, another study published in Health Affairs looked at mental
health care directories in Oregon Medicaid managed care
organizations.\7\ The study found that 58.2 percent of network
directory listings were ``phantom'' providers who did not see Medicaid
patients, including 67.4 percent of mental health prescribers, 59.0
percent of mental health non-prescribers, and 54.0 percent of primary
care providers.
---------------------------------------------------------------------------
\7\ J.M. Zhu; C. Charlesworth; D. Polsky, K.J. McConnell, ``Phantom
Networks: Discrepancies Between Reported and Realized Mental Health
Care Access in Oregon Medicaid,'' Health Affairs, Vol. 41 No. 7, July
2022, https://www.healthaffairs.org/doi/10.1377/hlthaff.2022.00052.
---------------------------------------------------------------------------
II. Identifying the problems without pointing fingers
Achieving provider directory accuracy is not easy and we acknowledge
that physicians and practices have a role to play in achieving
accuracy. That is why in 2021 the AMA collaborated with CAQH to examine
the pain points for both physicians and health plans in achieving
directory accuracy and published a white paper \8\ with the hopes of
identifying how insurers and physicians can work together to improve
the data collection and directory updating processes.
---------------------------------------------------------------------------
\8\ ``Improving Health Plan Provider Directories and the Need for
Health Plan-Practice Alignment, Automation and Streamlined Workflows,''
AMA, CAQH; https://www.ama-assn.org/system/files/improving-health-plan-
provider-directories.pdf (2021).
Physicians have a responsibility to notify health plans when a
physician leaves a group, is no longer practicing at a certain
location, and when contact information changes. However, it is
important to recognize the burden on practices that comes with these
obligations. Practices on average contract with more than 20 plans, and
even more products per plan, and can be inundated with requests for
updates through phone calls, emails, or health plan-specific portals.
And even when new information is provided, practices report that the
---------------------------------------------------------------------------
updates do not always appear in the directories.
Additionally, many practices separate their credentialing information
(about the clinician) from contracting information (about practice
locations and health plan participation) and appointment scheduling
data (on availability). When information is siloed, a practice may
struggle to bring the disparate data together accurately and make it
available to health plans and other parties.
Finally, because the relationship between a plan and a physician
practice is a financial one, and because some plans contract and
adjudicate claims by location, practices may list all clinicians at
every location when, in fact, each clinician primarily practices at
only one or two. Practices may do this in the event a clinician
provides care or coverage at a location other than his or her primary
site(s). While this approach may help avoid claim denials and payment
delays, it has the unintended consequence of contributing to directory
inaccuracy. With ever decreasing reimbursement rates plaguing
practices, a reality exacerbated by the COVID-19 pandemic, physicians
are often forced to take certain actions to ensure timely payment.
For health plans, the provider directory is the most public-facing data
that health plans provide, and patients are dependent on accurate
directories to access care. Likewise, being listed correctly in a
directory is a fundamental component of a
practice-health plan contract. As a result, most directory regulation
and legislation appropriately identify health plans as the party
accountable for provider directory accuracy. Consequently, many plans
have devoted resources to comply.
While the contract between the health plan and practice is the
authoritative source on which clinicians may see patients in certain
plans and products, plans also maintain claims data that provide a
variety of other insights into the practice, care provided to patients,
and billing activities. While pockets of high-quality data exist, the
industry has yet to converge upon a widely recognized ``source-of-
truth'' and the proliferation of data collection channels and
correction methods has made it more difficult for an authoritative
source to emerge.
Similarly, while some health plans have worked towards establishing an
internal source of truth, many face their own internal data silos that
result in delayed updates and inaccurate data overwriting good data.
This internal misalignment of data requires health plans to take
additional steps to re-validate information, which places an additional
burden on physician practices and can dilute the effect of data quality
improvements.
In addition to siloed data sources, adjacent regulatory requirements
also affect improvement efforts. Regulators like CMS have established
requirements for both network adequacy and directory accuracy for
health plans. While these requirements go hand-in-hand, efforts to
improve directory accuracy and network adequacy can impact each other.
The confluence of industry data silos and misalignment between health
plans and practices on roles, responsibilities, and compliance with
regulatory requirements has created barriers to improvements in
provider directory accuracy.
III. Working toward solutions
In our research with CAQH, we identified a number of solutions aimed at
simplifying and standardizing the data, the data requests, and the data
systems with the goal of a solid foundation of basic provider directory
information. For example, we suggest that practices should identify the
best sources for directory data, make timely and accurate updates when
offices move or physicians leave the practice, and establish the right
processes so that their teams and vendors can deliver the best data
possible for provider directories. Likewise, health plans should
similarly make timely updates, streamline processes for practices to
submit the data, permit practices to report all locations associated
with a physician to enable coverage when necessary while accurately
indicating the practice locations that should appear in the
directories, and leverage interoperability and automation where
possible so that updates are made as quickly as possible.
In a recent response to a CMS Request for Information (RFI) seeking
public input on the concept of CMS creating a directory with
information on health care providers and services or a ``National
Directory of Healthcare Providers and Services'' (NDH), the AMA doubled
down on our call for increased data standardization and highlighted a
lack of data reporting standards as a barrier to accuracy. For example,
each payer's directory requires that physicians provide different types
of data, similar data but named differently, or requires that
physicians report their information using different data formats.
Policymakers, including CMS and state regulators, should consider
standardizing physician data elements with the most impact on accuracy
and standardizing reporting formats in all common business
transactions.
It is also critical that policymakers and health plans take meaningful
steps to reduce other administrative burdens on physician practices,
especially those that directly impact patient care and coverage and,
thus, are likely prioritized over the directory burden by practices.
The clearest example of such a burden is prior authorization. Practices
are completing 45 prior authorizations per week per physician, adding
up to two business days per week spent on prior authorization alone.\9\
With hours spent on the phone with insurance companies, endless
paperwork for initial reviews and appeals, and constant updating of
requirements and repeat submissions just to get patients the care they
need, is it any wonder that added administrative burdens on practices
may not be getting the attention they should?
---------------------------------------------------------------------------
\9\ 2022 AMA prior authorization (PA) physician survey, https://
www.ama-assn.org/system/files/prior-authorization-survey.pdf.
Last Congress, the House of Representatives sought to address the
burden of prior authorization with the passage of the ``Improving
Seniors' Timely Access to Care Act.'' In fact, key members of the
Finance Committee, including Senator Sherrod Brown (D-OH) and Senator
John Thune (R-SD), worked together to introduce this important
legislation in the Senate. While the bill ultimately failed to pass
both chambers, this legislation sought to simplify, streamline, and
standardize prior authorization processes in the MA program to help
ease the burden on physicians and ensure no patient is inappropriately
denied medically appropriate services. CMS has subsequently taken
action toward ensuring timely access to health care by proposing rules
similar to the aforementioned legislation to streamline prior
authorization protocols for individuals enrolled in federally sponsored
health insurance programs, including MA plans. The AMA urges CMS to
promptly finalize and implement these changes to increase transparency
and improve the prior authorization process for patients, providers,
and health plans. We also urge CMS to expand on these proposed rules
by: (1) establishing a mechanism for real-time electronic prior
authorization (e-PA) decisions for routinely approved items and
services; (2) requiring that plans respond to prior authorization
requests within 24 hours for urgently needed care; and (3) requiring
detailed transparency metrics. We applaud CMS' recent finalization of
regulations that will ensure a sound clinical basis and improved
transparency for criteria used in MA prior authorization programs, as
well as protect continuity of ongoing care for patients changing
---------------------------------------------------------------------------
between plans.
Finally, a new approach to regulation and enforcement that includes
proactive solutions is needed. Most enforcement currently is reliant on
patient reporting, which is inconsistent and likely underestimates the
scope of the issue. For example, the 2020 study in Health Affairs
mentioned above found that, among those patients who encountered
inaccuracies in the mental health directories, only three percent
reported that they had filed a complaint with a government agency and
only nine percent said that they had submitted a grievance or complaint
form to their insurer. Sixteen percent said they had complained to
their insurer by phone. Ultimately, we have no way of knowing how
frequently a plan is contacted by a patient who is unable to find the
right physician using the directory, or how often a physician refers a
patient to another physician who appeared in-network under the
directory but was ultimately not, or how often a patient pays the out-
of-network rate because they relied on erroneous directory information.
Secret shopper studies and CMS reports published on the scope of the
problem are important, but they are not fixing the deficiency for any
individual patient who is in need of in-network care.
Given the limitations of the current complaint-based system, the AMA
urges all organizations charged with regulating health plans--whether
it be CMS, state departments of insurance, or the Department of Labor--
to take a more active role in regularly reviewing and assessing the
accuracy of directories. For example, regulators should: require health
plans to submit accurate network directories every year prior to the
open enrollment period and whenever there is a significant change to
the status of the physicians included in the network; audit directory
accuracy more frequently for plans that have had deficiencies; take
enforcement action against plans that fail to either maintain complete
and accurate directories or have a sufficient number of in-network
physician practices open and accepting new patients; encourage
stakeholders to develop a common system to update physician information
in their directories; and require plans to immediately remove from
network directories physicians who no longer participate in their
network. This enhanced oversight will drive the needed improvement in
directories to ensure that patients have access to current, accurate
information about in-network physicians.
IV. Conclusion
Implementing solutions to provider directory inaccuracies is a critical
component of improving patient access to timely, convenient, and
affordable care. Policymakers and other stakeholders must take action
to improve the data, standardize the data collection and maintenance,
reduce burden on physician practices, and protect patients from errors
in real time.
However, in order to truly address the real harms, it is also critical
that we address the network and access issues that directory
inaccuracies may mask. For example, a bloated provider directory may be
hiding a network that is wholly inadequate to serve the needs of the
plan's enrollees. Requiring and enforcing adherence to quantitative
network adequacy standards, including wait-time requirements, is
critical. Additionally, updating directories when there is a change to
the network is essential, but that should be followed by a notification
to regulators if the change is material, continuity of care protections
for patients to continue with the provider if they wish, and a
reevaluation of the network's ability to continue providing timely and
convenient access to care. We are glad to see that CMS, generally, is
more recently making progress on network adequacy requirements for MA
plans, as well as Qualified Health Plans (QHPs). For example, just
recently CMS finalized stronger behavioral health network requirements
in MA plans and codified standards for appointment wait times for
primary care and behavioral health services in these plans. And for the
2024 plan year, CMS will begin evaluating QHPs for compliance with
appointment wait time standards, in addition to time and distance
standards. However, these requirements are only as good as their
enforcement, and right now there is simply not enough. States and
federal regulators should work together to ensure that health plans are
meeting minimum quantitative requirements before they go to market and
tough penalties are assessed when violations are found. Patients must
be getting value for their premiums paid by being able to access the
care they need--when they need it--within their networks.
Given recent reports of ghost mental health networks in provider
directories, network evaluation is also important in the context of
mental health parity compliance. Behind these misleading mental and
behavioral health directories are potential plan processes that have
more restrictive strategies and standards, or lower payment for
behavioral health providers in their networks compared with physical
health providers. The AMA is gravely concerned by the findings of the
2022 Mental Health Parity and Addiction Equity Act (MHPAEA) Report to
Congress, which found that insurers' parity violations have continued
and become worse since the MHPAEA was enacted in 2008, and it is
important that policymakers continue to focus attention on mental
health parity enforcement.
Finally, network deficiencies cannot be discussed without highlighting
the growing physician shortage and the need for investment in our
workforce. Lawmakers have a clear opportunity to help increase the
total number of physicians by enacting S. 1302/H.R. 2389, the
``Resident Physician Shortage Reduction Act,'' which will increase the
number of Medicare-supported residency slots by 14,000 over seven
years, build upon the investment Congress has made over the last few
years to improve Graduate Medical Education, including the 1,000 new
Medicare-supported residency slots included in the Consolidated
Appropriations Act of 2021, and the 200 new physician residency
positions funded by Medicare to teaching hospitals for training new
physicians in psychiatry and psychiatry subspecialties included in the
Consolidated Appropriations Act, 2023.
In conclusion, the AMA stands ready to work with Congress to improve
patient access to timely, affordable, and convenient care. Addressing
the ability of patients to locate such care through accurate provider
directories is a critical component of this goal and of great
importance to physicians and the patients we serve.
______
Association for Behavioral Health and Wellness
700 12th Street, NW, Suite 700
Washington, DC 20005
202-499-2280
https://abhw.org/
Chair Wyden and Ranking Member Crapo,
The Association for Behavioral Health and Wellness (ABHW) appreciates
the Committee's support and leadership in 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. In administering these benefits, ABHW
members maintain extensive networks and associated provider directories
on behalf of their members, providers, and health benefit plan
sponsors.
We appreciate the opportunity to submit a statement for the record
supporting the Committee's efforts to identify solutions and
opportunities to improve provider directories. Our plans have heavily
invested in ensuring complete and accurate provider directories of
available in-network provider resources. We agree that discrepancies in
provider directories can be frustrating for consumers and are an issue
that directly impacts accessing care in a timely manner.
Over the past several years, ABHW member plans have dedicated
significant resources to ensuring that their directories are accurate.
They have taken several steps to validate the external data and
information used to populate these directories, improving outreach to
providers, and simplifying the processes for providers to update their
information with plans. These activities include monthly provider
communications, direct provider outreach programs, streamlining updates
based on provider-initiated correspondence, and claims submission
reviews to identify provider changes. Despite these efforts, some of
our member plans report a less than 50 percent response rate from
providers, and one plan indicates that only 11 percent of providers
responded to their requests to update information. For provider
directories to be the most accurate, health plans and providers have a
role to play. There must be appropriately aligned incentives for
providers to fulfill their obligations to plans and patients by
maintaining timely, accurate information updates.
We are dedicated to finding solutions to provider directory
inaccuracies that work for plans, providers, and consumers. ABHW
members are working to comply with the more recently developed provider
directory standards and requirements set forth by Congress in the
Consolidated Appropriations Act (CAA) of 2021; however, we note that
the required rulemaking and guidance have yet to be issued on this
portion of the CAA. We highlight this because the CAA provisions
establish a solid model for improving provider directories that has yet
to be tested due to the delay in rulemaking and implementation of to-
be-issued guidance. In addition, Congress should ensure that the
standards for provider directories, and by extension, network adequacy
and access, should not vary by payer or program to ensure health equity
and avoid disparities in access. Accordingly, we urge the Committee to
work with the Centers for Medicare and Medicaid Services (CMS) to
release the guidance.
In addition, as you are aware, in December 2022, CMS issued a request
for information (RFI) on establishing a centralized repository for
healthcare providers and services data. ABHW and many of our members
responded to this RFI, sharing that a national directory could help
enhance accuracy and access provided it is designed, established, and
operated thoughtfully, and addresses the points above about the need
for aligned incentives and responsible participation by both plans and
providers. While there are many details to examine before implementing
a national directory, we urge the Committee to explore solutions that
engage health plans and providers to ensure accurate provider
directories.
To further help alleviate provider directory issues, we urge the Senate
Finance Committee to continue addressing behavioral health workforce
shortages and ensuring access to services via telehealth. Provider
directory issues are a symptom, not the disease. The real challenge,
the workforce, is one of the most pressing issues facing the behavioral
health industry. We urge Congress to consider approaches to help
mitigate existing shortages to utilize our existing workforce and
expand it simultaneously. ABHW recommends the Committee work to:
Increase psychiatry residency positions,
Allow advanced psychologist trainees to practice without direct
supervision,
Cover peers in all Medicare settings, not limited to integrated
care,
Examine proposals that increase loan repayment incentives, such
as S. 462, Mental Health Professionals Workforce Shortage Loan
Repayment Act of 2023, and
Identify opportunities to advance integrated care solutions,
such as the Collaborative Care model.
We also urge the Committee to focus on making the COVID-19 telehealth
flexibilities permanent. Telehealth is an emerging strategy to help
fill in gaps in the workforce.\1\ We recommend that the Committee make
permanent the COVID-19 telehealth flexibilities that are currently
extended until December 2024. The Drug Enforcement Agency (DEA)
recently extended controlled substances telehealth prescribing
flexibilities available during the COVID-19 pandemic until November 11,
2023. It gave an additional year of safe harbor until November 11,
2024, for an established telemedicine relationship. Continued access
via telehealth is vital to maintaining care, particularly considering
the opioid and fentanyl crisis our nation is grappling with, and we
encourage the Committee to work with the DEA to release the special
registration rule, as previously mandated by Congress, before these
flexibilities expire. We also recommend the following:
---------------------------------------------------------------------------
\1\ https://www.healthcareitnews.com/news/staffing-expert-shows-
how-telehealth-stepping-fill-staffing-shortage.
Repealing the 6-month in-person Medicare requirement for
telemental health visits,
Fostering cross-state licensure, and
Covering telehealth in high deductible plans.
We look forward to working with the Committee and other stakeholders to
identify solutions to improve the accuracy of provider directories. We
thank the Committee for the opportunity to submit ABHW's comments for
the record. If you have any questions, please contact Maeghan Gilmore,
Vice President of Government Affairs, at [email protected] or 202-449-
2278.
Sincerely,
Pamela Greenberg, MPP
President and CEO
______
Blue Cross Blue Shield Association
1310 G Street, NW
Washington, DC 20005
202-626-4800
https://www.bcbs.com/
Statement of David Merritt, Senior Vice President of Policy and
Advocacy
Every American deserves access to accurate and up-to-date information
about in-network providers so they can easily find the health care
professionals that best meet their needs. The Blue Cross Blue Shield
Association (BCBSA) commends Chairman Wyden, Ranking Member Crapo, and
members of the Senate Finance Committee for holding this important
hearing on how to improve the accuracy of provider directories to
achieve this critical, shared goal.
BCBSA is a national federation of 34 independent, community-based and
locally operated Blue Cross and Blue Shield (BCBS) companies that
collectively cover, serve, and support 1 in 3 Americans in every ZIP
code across all 50 states and Puerto Rico. BCBS companies serve those
who purchase coverage on their own as well as those who obtain coverage
through an employer, Medicare and Medicaid and contract with 96% of
providers nationally. We are committed to delivering affordable access
to high-quality care for every American.
BCBS companies are working aggressively to improve the accuracy of
provider directories to provide those we serve with the most current
provider information when they are seeking medical care. However, we
know that improving provider directories alone will not resolve the
challenges many Americans face in accessing timely, quality health
care. That is a particular challenge for patients to find support for
mental and behavioral health services. In fact, studies show more than
one third of Americans live in areas with far fewer mental health
providers than the minimum needed to meet the need.1 We thank the
Committee for its ongoing bipartisan work to improve patients' access
to mental health services.
Specifically, we applaud the Committee for its part in securing passage
of key provisions within the Consolidated Appropriations Act (CAA 2023)
to help improve access to behavioral health services. This includes
meaningful steps to expand access to professional counselors and
marriage and family therapists in Medicare, creating additional
Graduate Medical Education slots for mental health providers, and
extending current telehealth flexibilities. Those flexibilities to
expand telehealth has been critical for millions of Americans to access
the mental health support they need, especially during the COVID-19
pandemic. We look forward to working further with the Committee on ways
to bolster the mental and behavioral health workforce to support robust
access across the country.
Improving Access to Providers
We applaud the Committee's interest in evaluating all avenues for
improving mental health access but encourage Congress to consider
approaches that will help mitigate existing significant workforce
capacity challenges in the mental and behavioral health fields.
Addressing these issues will have the most meaningful impact in
improving access for patients. To expand existing capacity as we work
to address the longer-term workforce challenges, we encourage
policymakers to consider actions such as:
Work to promote the use of care integration and non-clinical
support personnel by investing in providers who are seeking to
integrate care and supporting payment models that promote care
integration.
Expand the use of telehealth to help expand access to care and
augment local practitioners.
Address underlying workforce pipeline challenges by increasing
the number of residency spots in medical programs and expanding
incentives to encourage students to enter the behavioral health
workforce.
BCBS Companies' Commitment to Improving Provider Directory Accuracy
We understand the impact outdated provider information has on patients.
Inaccurate information is frustrating, confusing, and inefficient. That
is why we continue to commit significant resources and conduct regular
outreach to make it easier for providers to submit and update their
information to be displayed in provider directories. We also understand
that challenges remain for both providers and health plans in keeping
directory information accurate on a timely and consistent basis, and we
have committed to serving as an industry partner in working to build a
common repository for directory information.
Challenges in Verifying Provider Directory Information
For provider directories to be most accurate, health plans and
providers must work together to keep information current and accurate
for patients. Based on a BCBSA survey of Plans, provider response rates
to Plan requests for information are well below 50%. We understand that
providers regularly receive requests from all their contracted health
plans, so it is understandable that many providers--especially smaller
practices--struggle to keep up with these requests, and often fail to
respond on a timely basis. Unfortunately, ignoring consistent outreach
and regular requests is not a solution to deliver timely, accurate, and
updated information to patients.
While the Consolidated Appropriations Act of 2021 (CAA 2021) requires
commercial health plans to verify provider directory information every
90 days, no corresponding legislative or regulatory requirement is
placed on providers to confirm or update this demographic information
when plans request it. As a result, for the many providers who do not
consistently update their information, they will end up being removed
from health plan directories as required by the CAA 2021. BCBSA
continues to recommend that states and HHS consider this challenge when
issuing regulations and enforcing these provider directory
requirements.
Moving Forward
Plans are still awaiting regulations from HHS implementing the provider
directory requirements included in CAA 2021. Being overly aggressive on
provider directory standards could impair patients' access to needed
care, particularly in the behavioral health space where the supply of
providers is not able to meet the demand for services. While accuracy
of the directories is critical, we urge caution in considering any
policies that would further require removing providers from directories
if they are delayed in responding to data requests--but who are still
practicing, in-network and accepting patients. BCBS Plans comply with
both state and CMS network adequacy standards and Plans continue to
engage with regulators to ensure networks meet the needs of their
customers.
Additionally, we urge the Committee to require additional oversight of
providers to improve the timeliness and accuracy of the information
they provide to Medicare Advantage (MA) plans and to CMS in the
National Plan and Provider Enumeration System (NPPES). MA plans are
making a good faith effort to obtain accurate and timely provider
information and should not be held solely accountable when providers do
not send timely information to their requests or give inaccurate
information. Updated, accurate information is the responsibility of
both plans and providers.
Lastly, CMS, health plans, providers, technology vendors, and other
stakeholders are currently in the process of standardizing the data and
transactions to make it possible for providers and health plans to
transmit more real-time information about their availability and
network participation. BCBSA and stakeholders agree, as evidenced by
shared comments on CMS' proposed National Directory of Health, that the
more that manual processes can be streamlined and standardized, the
more accurate and patient-friendly provider directories will be. We
urge members of Congress to avoid any legislative measures that would
set back this important work.
Conclusion
Ensuring accurate provider directories is a shared responsibility
between health plans and health care clinicians. We look forward to
continuing to work with Congress, the Administration and our provider
partners to identify and implement meaningful solutions that will
improve provider directory accuracy while reducing burden on all
stakeholders.
______
Center for Fiscal Equity
14448 Parkvale Road, Suite 6
Rockville, MD 20853
[email protected]
Statement of Michael G. Bindner
Chairman Wyden and Ranking Member Crapo, thank you for the opportunity
to submit these comments on the problem of ghost networks. We thank
Senator Smith for bringing attention to this issue.
The problem of ghost networks varies, depending upon one's health plan.
If one enters mental health care through Medicaid, state departments of
health generally have up-to-date listings for programs that provide
both psychiatric and social worker services. This was my experience as
a patient in the District of Columbia. I did not choose a health plan
when I was in the DC system, which made finding a primary care
physician interesting. After moving to Maryland, I chose Kaiser for
medical care, but could not do so for mental health services.
Participants in a Psychiatric Rehabilitation Program include access to
a nurse practitioner (which is usually what Medicaid pays for). PRPs
have case managers who will do the searching for you when a therapist
is needed--although this may take some time, precisely because of the
problem of ghost networks. Medicaid patients have access to certified
counselors and licensed marriage and family therapists, but not to
Licensed Clinical Social Workers. LCSWs were only covered by Medicare,
while the other therapists were not.
Starting in 2024, the counselors available with Medicaid are added to
Part B coverage. This makes ghost networks a problem for more people--
although wider availability may help individuals find care.
In my case, my relationship with my nurse practitioner in my PRP proved
toxic, so I had to find a new provider. In reality, there was not much
choice--only one was open--even though more were listed.
Before moving to Medicare after two years of Medicaid after my SSDI
began, I could no longer meet the asset test of Medicaid when I
received assets from my divorce (although I probably did not have to
take this step). At this time, I signed up for the Affordable Care Act
Silver Plan. The coverage was too expensive and the copays too high for
care when I fell and broke a rib. Luckily, at the two-year mark, I
moved to Medicare Parts B/D and a Psychiatrist and LCSW. A year later,
I signed up for Part C.
Shifting from Medicaid to the Affordable Care Act to Medicare was
seamless with my Primary Care Physician, unlike my mental health
services. Of late, I was offered the ability to go out of the HMO for
services due to regulatory changes. None were as convenient as what
Kaiser provided.
I had previously been a Kaiser member fifteen years prior to this as a
government contract employee. During this time, I noted that the DC
Government, where I had been working a few years earlier, had shifted
to Kaiser as well for their employees.
The point of my tale of coverage is that, once I chose Kaiser, my
relationship with my PCP was unchanged, although details of copayments
and prescription coverage did vary, especially regarding the
pharmaceuticals.
For those who sign up for managed care, we have achieved fusion in some
aspects, but not in others--although this will change in 2024 as far as
therapists are concerned. One can work for a company, get an individual
policy under the ACA at a later time, get Medicaid when disabled and
full Medicare without changing doctors. What is complicated is what is
covered and what is not with the same provider network.
The real antidote to ghost networks is the kind of network care that is
provided through community healthcare in Medicaid and to managed care
participants (regardless of funding). Getting to single payer funding
is not an issue as much as is seamless coverage within the same
provider network regardless of which government or employer plan one
uses.
Professional employees always get good coverage, as do unionized
employees. Others need to rely on some sort of governmentally funded
care. For those in this situation, the care package should be the same,
with providers getting the same level of support in each setting.
If this sounds like an endorsement of Medicare for All, which is
essentially Dual Eligibility for all (meaning Medicare reimbursement
with Medicaid copays) for all seniors, then you have been listening.
There are other options, however, like Medicare Part E coverage
replacing dual eligibility for seniors in long-term care (taking these
patients off of state Medicaid rolls) and a public option added to
Affordable Care Act coverage (which could replace Medicaid--at least
for non-retirees--and be more heavily subsidized than current
coverage). The other option is to have employers offer direct care.
I have addressed these options in more detail previously in comments
regarding Single Payer coverage, which I have attached.
Thank you for the opportunity to address the committee. We are, of
course, available for direct testimony or to answer questions by
members and staff.
Attachment--Single-Payer, June 12, 2019
There is no logic in rewarding people with good genes and punishing
those who were not so lucky (which, I suspect, is most of us). Nor is
there logic in giving health insurance companies a subsidy in finding
the healthy and denying coverage for the sick, except the logic of the
bottom line. Another term for this is piracy. Insurance companies, on
their own, resist community rating and voters resist mandates--
especially the young and the lucky. As recent reforms are inadequate
(aside from the fact of higher deductibles and the exclusion of
undocumented workers), some form of single-payer is inevitable. There
are three methods to get to single-payer.
The first is to set up a public option and end protections for pre-
existing conditions and mandates. The public option would then cover
all families who are rejected for either pre-existing conditions or the
inability to pay. In essence, this is an expansion of Medicaid to
everyone with a pre-existing condition. As such, it would be funded
through increased taxation, which will be addressed below. A variation
is the expansion of the Uniformed Public Health Service to treat such
individuals and their families.
The public option is inherently unstable over the long term. The profit
motive will ultimately make the exclusion pool grow until private
insurance would no longer be justified, leading again to Single Payer
if the race to cut customers leads to no one left in private insurance
who is actually sick. This eventually becomes Medicare for All, but
with easier passage and sudden adoption as private health plans are
either banned or become bankrupt. Single-payer would then be what
occurs when
The second option is Medicare for All, which I described in an
attachment to yesterday's testimony and previously in hearings held May
8, 2019 (Finance) and May 8, 2018 (Ways and Means). Medicare for All is
essentially Medicaid for All without the smell of welfare and with
providers reimbursed at Medicare levels, with the difference funded by
tax revenue.
Medicare for All is a really good slogan, at least to mobilize the
base. One would think it would attract the support of even the Tea
Partiers who held up signs saying ``Don't let the government touch my
Medicare!'' Alas, it has not. This has been a conversation on the left
and it has not gotten beyond shouting slogans either. We need to decide
what we want and whether it really is Medicare for All. If we want to
go to any doctor we wish, pay nothing and have no premiums, then that
is not Medicare.
There are essentially two Medicares, a high option and a low one. One
option has Part A at no cost (funded by the Hospital Insurance Payroll
Tax and part of Obamacare's high unearned income tax as well as the
general fund), Medicare Part B, with a 20% copay and a $135 per month
premium and Medicare Part D, which has both premiums and copays and is
run through private providers. Parts A and B also are contracted out to
insurance companies for case management. Much of this is now managed
care, as is Medicare Advantage (Part C).
Obamacare has premiums with income-based supports and copays. It may
have a high option, like the Federal Employee Health Benefits Program
(which also covers Congress) on which it is modeled, a standard option
that puts you into an HMO. The HMO drug copays for Obamacare are higher
than for Medicare Part C, but the office visit prices are exactly the
same.
What does it mean, then, to want Medicare for All? If it means we want
everyone who can afford it to get Medicare Advantage Coverage, we
already have that. It is Obamacare. The reality is that Senator Sanders
wants to reduce Medicare copays and premiums to Medicaid levels and
then slowly reduce eligibility levels until everyone is covered. Of
course, this will still likely give us HMO coverage for everyone except
the very rich, unless he adds a high-option PPO or reimbursable plan.
Either Medicare for All or a real single payer would require a very
large payroll tax (and would eliminate the HI tax) or an employer paid
subtraction value-added tax (so it would not appear on receipts nor
would it be zero rated at the border, since there would be no evading
it), which we discuss below, because the Health Care Reform debate is
ultimately a tax reform debate. Too much money is at stake for it to be
otherwise, although we may do just as well to call Obamacare Medicare
for All.
The third option is an exclusion for employers, especially employee-
owned and cooperative firms, who provide medical care directly to their
employees without third party insurance, with the employer making HMO-
like arrangements with local hospitals and medical practices for
inpatient and specialist care.
Employer-based taxes, such as a subtraction VAT or payroll tax, will
provide an incentive to avoid these taxes by providing such care.
Employers who fund catastrophic care or operate nursing care facilities
would get an even higher benefit, with the proviso that any care so
provided be superior to the care available through Medicaid or Medicare
for All. Making employers responsible for most costs and for all cost
savings allows them to use some market power to get lower rates.
This proposal is probably the most promising way to arrest health care
costs from their current upward spiral--as employers who would be
financially responsible for this care through taxes would have a real
incentive to limit spending in a way that individual taxpayers simply
do not have the means or incentive to exercise. The employee ownership
must ultimately expand to most of the economy as an alternative to
capitalism, which is also unstable as income concentration becomes
obvious to all.
The key to any single-payer option is securing a funding stream. While
payroll taxes are the standard suggestion, there are problems with
progressivity if such taxes are capped and because profit remains
untaxed, which requires the difference be subsidized through higher
income taxes. For this reason, funding should come through some form of
value-added tax.
Timelines are also a concern. Medicare for All be done gradually by
expanding the pool of beneficiaries, regardless of condition. Relying
on a Public Option will first serve the poorest and the sickest, but
with the expectation that private insurance will enlarge the pool of
those not covered until the remainder can safely be incorporated into a
single-payer system through legislation or bankruptcy in the health
insurance marketplace.
______
First Focus on Children
1400 Eye Street, NW, Suite 450
Washington DC 20005
t. 202-657-0670
f. 202-657-0671
https://firstfocus.org/
May 9, 2023
Senator Ron Wyden
Chairman
U.S. Senate
Committee on Finance
Washington, DC 20510
Senator Michael Crapo
Ranking Member
U.S. Senate
Committee on Finance
Washington, DC 20150
Dear Chairman Wyden and Ranking Member Crapo,
Thank you for your bipartisan leadership on the Senate Finance
Committee regarding mental health issues, particularly for children,
youth and young adults. I am writing to you regarding the recent
hearing titled ``Barriers to Mental Health Care: Improving Provider
Directory Accuracy to Reduce the Prevalence of Ghost Networks.''
First Focus on Children is a bipartisan advocacy organization dedicated
to making children and families a priority in federal and budget
decisions. Since the release of the U.S. Surgeon General's report on
youth mental health in December 2021 \1\ we have been pleased to see
Congress shine a light on the array of major behavioral health system
issues that need to be addressed, including network adequacy. We
appreciate the invitation to share our thoughts on the issue of ``ghost
networks'' as it impacts children, youth and young adults.
---------------------------------------------------------------------------
\1\ U.S. Surgeon General Issues Advisory on Youth Mental Health
Crisis Further Exposed by COVID-19 Pandemic, December 7, 2021, https://
www.hhs.gov/sites/default/files/surgeon-general-youth-mental-health-
advisory.pdf.
Mr. Chairman, we agree with the comments you made in your opening
statement. ``In a moment of national crisis about mental health, with
the problems growing at such a rapid rate, the widespread existence of
ghost networks is unacceptable.'' This Committee is already familiar
with the range of issues facing our nation's youth. The February 15,
2022 hearing, ``Protecting Youth Mental Health: Part II--Identifying
and Addressing Barriers to Care'' and the subsequent white paper on
mental health and youth \2\ laid out many of the staggering statistics
of the increased demand for mental health services among children,
teens and young adults. It is widely agreed that while COVID-19
exacerbated the crisis, our teens were in crisis before the pandemic.
The current statistics are alarming. Roughly 42% of high school
students felt so sad or hopeless almost every day for at least two
weeks in a row that they stopped participating in their usual
activities.\3\ One in ten high school students attempted suicide one or
more times during the past year.\4\ A statistic that hits at the heart
of the ghost network problem, and a statistic that you have noted in
previous hearings, is that typically 11 years pass between the onset of
symptoms in our children and adolescents and when they first receive
treatment.\5\ Nationwide, more than 60% of children who experience a
severe depressive episode do not receive treatment.\6\ This is simply
unacceptable and we can do better.
---------------------------------------------------------------------------
\2\ U.S. Senate Finance Committee, Youth Mental Health Discussion
Draft. June 15, 2023, https://www.finance.senate.gov/chairmans-news/
wyden-crapo-carper-cassidy-unveil-youth-mental-health-discussion-draft.
\3\ ``Youth Risk Behavior Survey Data Summary and Trends Report,''
Centers for Disease Control and Prevention, February 2023, https://
www.cdc.gov/healthyyouth/data/yrbs/yrbs_data_
summary_and_trends.htm.
\4\ ``Youth Risk Behavior Survey Data Summary and Trends Report,''
Centers for Disease Control and Prevention, February 2023, https://
www.cdc.gov/healthyyouth/data/yrbs/yrbs_data_
summary_and_trends.htm.
\5\ U.S. Surgeon General Issues Advisory on Youth Mental Health
Crisis Further Exposed by COVID-19 Pandemic, December 7, 2021, https://
www.hhs.gov/sites/default/files/surgeon-general-youth-mental-health-
advisory.pdf.
\6\ Youth Ranking 2022. Mental Health America, https://
www.mhanational.org/issues/2022/mental-health-america-youth-data.
While Congress passed and President George W. Bush signed the Mental
Health Parity and Equity Act (MHPAEA) into law in 2008 (which addresses
the disparities between general and behavioral health care and seeks to
create equal access to behavioral health services), millions of
children and their families have not enjoyed the benefits of this
important law. Insurance companies have skirted the universal benefits
guaranteed by the MHPAEA law, and enforcement of the law is lacking,
meaning no one, including children and youth, has achieved equitable
access over the past 14 years. Even the 2010 passage of the Affordable
Care Act did not force all insurance companies to offer parity in
behavioral health services. While patients have the legal right to
equal access and coverage of behavioral health treatment services,
coverage still remains restrictive.
What a Lack of Parity Means to Children and their Families
When a child or teenager has a behavioral health crisis (mental health
issue, eating disorder, substance use disorder, etc.), a parent's first
instinct is to seek immediate and appropriate care so their child can
receive a timely, proper diagnosis and treatment. In other words, their
response is exactly the same as if their teen had just broken their arm
in a bike accident or experienced a seizure. Unfortunately, when
children and teens experience a behavioral health crisis--even if they
are covered by health insurance (private insurance or Medicaid)--help
may not be on the way.
For families with health insurance, the lack of adequate networks or
the existence of so-called ``ghost networks'' is a brick wall or a
frustrating exercise fraught with emotional turmoil for the child and
the entire family. As we heard in your hearing and from many stories in
the press, families often encounter outdated or severely limited
provider network directories. Some providers are no longer in their
network. Or parents are told that the waiting lists are weeks--or
months--long. Providers may be so overburdened that they are not
accepting new patients. In addition to barriers from ghost directories,
insurance companies may impose limits on the number of behavioral
health visits a child can have in a calendar year. Families may also
have to pay much higher co-pays for behavioral health care visits than
for traditional physical health visits.
When children cannot access home and community-based services in real
time, they go without proper care and risk experiencing a crisis. They
may contemplate suicide or harm someone else. At the point of a true
crisis, a hospital emergency room may be the only viable option for the
child or teen to receive immediate care--a route into the system that
is traumatic for the child and family, chaotic, and costly. Sometimes,
even emergency room care for behavioral health issues requires prior
authorization before hospital treatment which can result in several
days of delay--yet another barrier to care. Ideally, children and youth
should receive care in the early stages when symptoms first appear so
that they never have to experience a crisis.
Solutions
Solving the multifaceted problem of achieving parity will require
government, providers, group health plans, states, and other entities
to work better together. Congress and the relevant agencies must
strengthen and enforce the existing 2008 MHPAEA law, and must provide
states with adequate support to oversee, monitor, and enforce parity at
the state level. First Focus on Children supports lifting the voices of
children and youth and empowering parents who face barriers in finding
and paying for care for their children. Efforts to investigate consumer
complaints about denials of services and/or network adequacy issues are
important to children and families.
Our ability to address the youth mental health crisis in this country
hinges in part upon parity. Achieving parity will require: network
adequacy; a diverse and increased number of workforce professionals and
non-professionals; fair reimbursement rates; consumer empowerment and
education; and better oversight and enforcement of insurance companies.
We agree with Chairman Wyden on a three-pronged approach of oversight,
greater transparency and enforcement to ensure these network
directories are more accurate and reliable for consumers. Only when our
nation's children and youth can access affordable, high-quality
behavioral health services in a timely fashion--a standard we apply to
the rest of their health care--will we reduce their rates of anxiety,
depression, suicide, and substance use and offer them a brighter,
healthier future.
Thank you for your leadership on mental health issues and for your
commitment to ensuring the good health and well-being of all children.
First Focus on Children looks forward to working with you and your
staff. Please feel free to contact me at [email protected], or
Elaine Dalpiaz at [email protected], or Averi Pakulis at
[email protected] with any questions.
Sincerely,
Bruce Lesley
President
______
Legal Action Center et al.
810 First St., NE, Suite 200
Washington, DC 20011
[email protected]
May 17, 2023
Re: ``Barriers to Mental Health Care: Improving Provider Director
Accuracy to Reduce the Prevalence of Ghost Networks''
Chair Wyden, Ranking Member Crapo, and Members of the Senate Finance
Committee:
The Legal Action Center, Center for Medicare Advocacy, and Medicare
Rights Center commend the Senate Finance Committee for its leadership
on improving access to mental health care and for convening the May 3rd
hearing on ``Barriers to Mental Health Care: Improving Provider
Directory Accuracy to Reduce the Prevalence of Ghost Networks.''
The Legal Action Center (LAC) is a non-profit organization that uses
legal and policy strategies to fight discrimination, build health
equity, and restore opportunity for people with arrest and conviction
records, substance use disorders, and HIV or AIDS. LAC works to expand
access to substance use disorder and mental health care through
enforcement of the Mental Health Parity and Addiction Equity Act
(Parity Act) in public and private insurance, including our Medicare
Addiction Parity Project, which seeks to improve access to substance
use disorder treatment in Medicare in a comprehensive and equitable
manner.\1\ The Center for Medicare Advocacy (the Center) is a national,
non-profit, law organization that works to advance access to
comprehensive Medicare coverage, health equity, and quality health care
for older people and people with disabilities. Founded in 1986, the
Center focuses on the needs of people with longer-term and chronic
conditions. The organization's work includes legal assistance,
advocacy, education, analysis, policy initiatives, and litigation of
importance to Medicare beneficiaries nationwide. Our systemic advocacy
is based on the experiences of the real people who contact the Center
every day. Headquartered in Connecticut and Washington, DC, the Center
also has attorneys in CA and MA. The Medicare Rights Center is a
national, nonprofit consumer service organization that works to ensure
access to affordable health care for older adults and people with
disabilities through counseling and advocacy, educational programs, and
public policy initiatives. Our organizations appreciate the opportunity
to provide a statement for the record.
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\1\ ``Medicare Addiction Parity Project,'' Legal Action Center,
https://www.lac.org/major-project/mapp.
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A. Ghost Networks and Provider Directories
Our organizations strongly agree with the Chairman's remarks, that
``when insurance companies host ghost networks, they are selling health
coverage under false pretenses.'' We further agree that eliminating
ghost networks will require more audits, greater transparency, and
stronger consequences for insurance companies that are providing false
or incorrect information to their enrollees. We urge Congress to pass
Senator Wyden and Senator Bennet's ``Mental Health Care for Americans
Act,'' which would require accuracy and transparency in Medicare
Advantage provider directories and audits by the Secretary, in addition
to other critical provisions to require Parity in Medicare Advantage
and Part D plans as well as fee-for-service Medicaid.
As noted in the testimony by Mental Health America, provider directory
requirements alone are not enough. We recommend the Committee establish
strong compliance and enforcement provisions for maintaining accurate
provider directories. Respectfully, we believe incentives should not be
needed for Medicare Advantage plans for this purpose. Our government is
paying these private health plans billions of dollars to provide
medically necessary care to older adults and people with chronic
disabilities, they are failing to do so, and they should not be given
incentives to do the job they are contracted to do. As noted by each of
the witnesses, inaccurate provider directories prevent consumers from
making informed decisions about which health plan to select, lead to a
delay in care--that may result in abandoning care altogether--that is
disproportionately harmful to people with mental health conditions and
substance use disorders, and result in unnecessary additional costs to
consumers who are forced to go out-of-network because the networks are
inadequate to meet their needs. Our organizations urge Congress and the
Centers for Medicare and Medicaid Services (CMS) to hold Medicare
Advantage plans accountable through sufficient penalties when they both
fail to provide medically necessary services to their enrollees and
when they misrepresent or falsify information to individuals and the
federal government by putting forth inaccurate network directories.\2\
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\2\ See 42 U.S.C. 1395w-27(g)(1)(A) and (E).
The Senate Finance Committee majority staff and witnesses highlighted
findings from secret shopper surveys, demonstrating their usefulness in
assessing the accuracy of provider directories and determining whether
patients are truly able to get appointments in a timely manner. As
noted by Senator Menendez, CMS recently proposed a rule that would
require an independent entity to conduct annual secret shopper surveys
of Medicaid managed care organizations for provider directory accuracy
for outpatient mental health and substance use disorder providers, as
well as several other provider types.\3\ We applaud CMS for this
proposal and urge Congress to establish consistency across health plans
and financing systems and require comparable independent secret shopper
survey requirements in Medicare Advantage and commercial insurance
plans.
---------------------------------------------------------------------------
\3\ ``Medicaid Program; Medicaid and Children's Health Insurance
Program (CHIP) Managed Care Access, Finance, and Quality,'' Centers for
Medicare and Medicaid Services (CMS), 88 Fed. Reg. 28092, 28101-02
(proposed May 3, 2023).
We appreciate Ranking Member Crapo's and many of the Senators' comments
on the importance of telehealth in expanding access to mental health
and substance use disorder care. We concur that telehealth offers a
critical opportunity to bring culturally and linguistically effective
treatment to more people, especially during the ongoing workforce
crisis. We strongly urge Congress to make permanent the telehealth
flexibilities that were established during the COVID-19 pandemic,
especially where telehealth can be used to fill in gaps in mental
health professional shortage areas and counties in which consumers have
limited or no access to prescribers of medications for opioid use
disorder and other substance use disorder providers. However, we
believe telehealth should supplement in person care, not replace it.
Many individuals still prefer in-person care, a hybrid model of care,
or telehealth only when it is delivered by an in-state provider who is
familiar with all the local resources and referrals. With this in mind,
CMS has articulated in its proposed rule for Medicaid that it is
``appropriate to prohibit managed care plans from meeting appointment
wait time standards with telehealth appointments alone,'' as doing so
would mask whether the appointments being offered by providers are
``consistent with expectations and enrollees' needs.''\4\ Thus, as
Congress considers provider directory and network adequacy standards,
we recommend requiring all Medicare Advantage provider directories to
identify the delivery modality providers use and limit the counting of
telehealth visits to meet appointment wait time standards or, at a
minimum, report telehealth utilization separately, consistent with
Qualified Health Plans and with CMS's proposal for Medicaid managed
care organizations.\5\
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\4\ Id. at 28102-03.
\5\ Id.
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B. Network Adequacy
Our organizations also concur with the American Medical Association's
testimony and Senator Warren's statements that provider directory
inaccuracies often mask another significant problem: inadequate
networks that are unable to serve the needs of the plan's enrollees.
Medicare Advantage plans must be required to meet network adequacy
standards for outpatient mental health and substance use disorder
care--both geographic time and distance standards as well as
appointment wait time standards--and they must be held accountable for
failing to do so. While CMS has developed strong geographic time and
distance network adequacy standards for mental health care, it has
failed to do so for substance use disorder care.\6\ Yet, over 50,000
Medicare Part D beneficiaries experienced an overdose in 2021 at a time
when fewer than 1 in 5 of the over 1 million Medicare beneficiaries
with an opioid use disorder received medications for opioid use
disorder.\7\ Furthermore, CMS's recent final rule for Medicare
Advantage set an appointment wait time standard for routine visits at
30 business days for mental health and substance use disorder care,
even though the final standard in Marketplace plans and the proposed
standard in Medicaid managed care plans is 10 business days. Once more,
we urge Congress to establish consistent standards across payment
systems and require Medicare Advantage plans to comply with these more
appropriate wait time standards to ensure networks are adequate for
beneficiaries to access mental health and substance use disorder care.
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\6\ ``Medicare Program; Contract Year 2024 Policy and Technical
Changes to the Medicare Advantage Program,'' Centers for Medicare and
Medicaid Services (CMS), 88 Fed. Reg. 22120, 22168-71 (April 12, 2023).
\7\ U.S. Department Health and Human Services, Office of the
Inspector General, ``Opioid Overdoses and the Limited Treatment of
Opioid Use Disorder Continue to be Concerns for Medicare
Beneficiaries'' (September 2022), https://oig.hhs.gov/oei/reports/OEI-
02-22-00390.pdf.
As part of improving network adequacy, Congress must consider the
payment rates of Medicare Advantage plans and how offering low payment
rates or failing to negotiate contributes to the insufficient networks
and lack of access to mental health and substance use disorder
services. CMS's recently proposed Medicaid/CHIP rule would continue to
allow Medicaid managed care organizations to get exceptions from the
State for failing to meet timely appointment wait time standards, but
it would also add a requirement that States consider the payment rates
offered by the managed care organization when granting exceptions,
recognizing that these ``plans sometimes have difficulty building
networks that meet network adequacy standards due to low payment
rates.''\8\ The agency also proposed requiring managed care plans to
conduct and submit to the State a payment analysis including paid
claims data to assess and compare rates for critical services,
including mental health and substance use disorder services, because
``a critical component of building a managed care plan network is
payment, low payment rates can harm access to care,'' and ``provider
payment rates in managed care are inextricably linked with provider
network sufficiency and capacity.''\9\ Our organizations recommend
Congress improve data collection, transparency, and oversight of the
payment rates and credentialing processes of Medicare Advantage
organizations and ensure that these plans are not using policies and
practices that intentionally or in practice limit networks or access to
medically necessary care for enrollees.
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\8\ ``Medicaid Program; Medicaid and Children's Health Insurance
Program (CHIP) Managed Care Access, Finance, and Quality,'' Centers for
Medicare and Medicaid Services (CMS), 88 Fed. Reg. 28092, 28100
(proposed May 3, 2023).
\9\ Id. at 28104-05.
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C. Mental Health Parity and Addiction Equity
The significant access gaps for mental health and substance use
disorder care highlighted at this hearing would also be ameliorated by
another provision of the Mental Health Care for Americans Act: applying
the Parity Act to Medicare Advantage and Part D plans and to Medicaid
fee-for-service plans. Among Americans ages 65 and over in 2021,
approximately 6.5 million individuals had a mental health condition and
over 4.3 million individuals had a substance use disorder.\10\ It is
unacceptable that millions of Americans lack the anti-discrimination
protections in their insurance that are afforded to those in other
commercial insurance plans and Medicaid managed care plans. Lack of
parity protections translate to inequitable networks of mental health
and substance use disorder providers, insufficient coverage of the full
scope of needed services, and greater barriers to services including
prior authorizations and other utilization management practices. Our
organizations strongly urge Congress to use every available strategy to
address America's mental health crisis and the opioid public health
emergency by applying the Parity Act to all parts of Medicare and to
fee-for-service Medicaid.
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\10\ Substance Abuse and Mental Health Services Administration
(SAMHSA), ``2021 National Survey on Drug Use and Health (NSDUH)
Detailed Tables,'' Table 5.4A and 6.1A (January 4, 2023), https://
www.samhsa.gov/data/report/2021-nsduh-detailed-tables.
Thank you for your work to reduce barriers to mental health and
substance use disorder care. If you have any questions about our
---------------------------------------------------------------------------
statement, please contact Deborah Steinberg at [email protected].
Sincerely,
Deborah Steinberg Kata Kertesz Julie Carter
Senior Health Policy Senior Policy Attorney Counsel for Federal
Attorney Policy
Legal Action Center Center for Medicare Medicare Rights Center
Advocacy
______
Medicare Rights Center
266 West 37th Street 1444 I Street, NW
3rd Floor Suite 1105
New York, NY 10018 Washington, DC 20005
Phone: 212-869-3850 Phone: 202-637-0961
Improving Medicare Advantage Network Accuracy and Adequacy
The Medicare Rights Center (Medicare Rights) appreciates this
opportunity to submit a statement for the record on the May 3, 2023,
Senate Finance Committee hearing, ``Barriers to Mental Health Care:
Improving Provider Directory Accuracy to Reduce the Prevalence of Ghost
Networks.'' Medicare Rights is a national, nonprofit organization that
works to ensure access to affordable and equitable health care for
older adults and people with disabilities through counseling and
advocacy, educational programs, and public policy initiatives. Each
year, Medicare Rights provides services and resources to nearly three
million people with Medicare, family caregivers, and professionals.
Based on this experience, we understand the toll inaccurate provider
directories can have on people with Medicare and the program. They
shift not only a core Medicare Advantage (MA) plan responsibility--
network identification--onto enrollees, but also expenses. Affected
plan members may have little choice but to pay higher out-of-network
rates. While this may come at a substantial personal cost, plans stand
to gain. Most policies cover such care less generously than in-network
services. Medicare's finances are also impacted, since enrollees who
forego care may need more costly interventions later, such as hospital
and acute services paid for by Medicare Part A.
From worsening health outcomes to derailing economic security,
inaccurate provider directories put enrollees at risk. For many, the
challenges begin as early as their Medicare enrollment.
On our National Consumer Help line, we frequently hear from people
struggling to navigate the complex Medicare enrollment process.
Regardless of whether they choose Original Medicare (OM) or MA, they
may need help paying for and accessing care. In our experience, these
challenges are more pronounced for MA enrollees. The MA plan landscape
is cluttered, and the stakes are high. Often, there is no quick fix if
a beneficiary finds their MA plan does not meet their needs because of
unexpected or extreme costs, inferior quality, or networks that are too
narrow or exclude their chosen providers.
To reduce these risks, MA plans must be high-quality and easy to
compare, and beneficiaries must be empowered to select the best plan
for their circumstances. We therefore recommend the following reforms
to (I) End Ghost Networks, (II) Support Beneficiary Decision-Making,
and (III) Improve MA Networks.
I. End Ghost Networks
Among MA's network accuracy and adequacy problems are so-called ``Ghost
Networks,'' in which plans tout access to providers that are not in-
network, accepting patients, clinically active, or otherwise
meaningfully available.
MA ghost networks are typically the result of inaccurate provider
directories. Though intended to be a useful decision-making resource,
directories are frequently incorrect. For example, a 2018 CMS report
found that 52% of physician listings in MA provider directories
contained at least one inaccuracy. Typical errors included wrong phone
numbers, errantly listing in-network providers as accepting new
patients when they were not, and omitting in-network providers from
directories.\1\
---------------------------------------------------------------------------
\1\ Michael S. Adelberg, et al., ``Improving the Accuracy of Health
Plan Provider Directories,'' The Commonwealth Fund (June 7, 2019),
https://www.commonwealthfund.org/publications/journal-article/2019/jun/
improving-accuracy-health-plan-provider-directories.
Provider directory inaccuracies thwart informed decision-making by
obscuring the reality of MA plan networks, undercutting beneficiaries
from the start. MA enrollees are advised to review their coverage each
year. Some use CMS's primary consumer-facing tool, Medicare Plan
Finder, to search for available plans, while others may work with
brokers or plan entities. These searches can yield a dizzying number of
options. For 2023, on average, beneficiaries had access to 43 MA plans,
more than twice as many as in 2018.\2\ Plans can vary on everything
from costs to coverage, sometimes in subtle but important ways. For
most beneficiaries, this makes close analysis both critical and
impracticable.
---------------------------------------------------------------------------
\2\ Meredith Freed, et al., ``Medicare Advantage 2023 Spotlight:
First Look'' (November 10, 2022), https://www.kff.org/medicare/issue-
brief/medicare-advantage-2023-spotlight-first-look/.
Inaccurate provider directories only compound these comparison
difficulties. As discussed during the hearing, directories may list
providers who are in-network but not accepting new patients promptly or
at all, as well as those who are not meaningfully available due to
geographic or transportation barriers. They may also make contacting
potential providers impossible due to outdated information, such as
incorrect phone numbers and addresses. Uncovering and verifying the
truth can take significant time and cause considerable stress. It also
forces providers to field time-sensitive consumer inquiries about
network participation and availability, creating additional
---------------------------------------------------------------------------
administrative burdens.
When beneficiaries make good faith coverage choices in reliance on
incorrect provider directories, the effects can be devastating. Some
enrollees discover too late that their plan's network is too small, of
low quality, or geographically distant--making care difficult to find,
access, and afford. Others may enroll in a plan thinking their
preferred provider is in-network or that needed care will be covered,
only to learn otherwise after receiving a higher-than-expected bill.
Consider a recent Medicare Rights client, Ms. P, a 32-year-old Medicare
enrollee with cardiac issues. Ms. P had a high-risk pregnancy. Since
her MA plan's network did not include the cardiac specialists she
needed, it was required to cover these services from out-of-network
providers. After confirming this and seeing the specialists, her plan
refused to pay. This caused Ms. P significant stress, leading to a
panic attack while pregnant. Further, because she was unable to afford
the excessive medical bill, it was sent to collections, saddling her
with debt.
Another client, Ms. M, is 73 and has two stage 4 cancers. Seeking a
mental health provider for assistance with end-of-life issues, she
called every provider listed in her MA plan's network directory but
could not contact many. Of those, few were accepting new patients,
willing to see her, or otherwise available. She finally found a
therapist and got the help she needed--until that doctor was suddenly
no longer in the plan's network. Unable to afford the more costly out-
of-network rates, Ms. M had to stop seeing her mental health provider.
She has not yet found a new doctor.
These problems are widespread. As Chairman Wyden highlighted during the
hearing, Senate Finance Committee staff operating as ``secret
shoppers'' could successfully make appointments only 18% of the
time.\3\ More than 80% of the listed providers ``were either
unreachable, not accepting new patients, or not in-network.''
Similarly, Dr. Robert Trestman's written testimony previews a
forthcoming Psychiatric Services investigation in which secret shoppers
could schedule appointments with psychiatrists 11% of the time.\4\
Nearly 20% of the phone numbers were wrong and over a quarter of the
doctors were not accepting new patients.
---------------------------------------------------------------------------
\3\ Senate Finance Committee, ``Medicare Advantage Plan Directories
Haunted by Ghost Networks'' (May 3, 2023), https://
www.finance.senate.gov/imo/media/doc/050323%20Ghost%20
Network%20Hearing%20-%20Secret%20Shopper%20Study%20Report.pdf.
\4\ Robert Trestman, ``Statement to the U.S. Senate Committee on
Finance Re: Barriers to Mental Health Care: Improving Provider
Directory Accuracy to Reduce the Prevalence of Ghost Networks'' (May 3,
2023), https://www.finance.senate.gov/imo/media/doc/
Robert%20Trestman%20
APA%20testimony%20050123%20FINAL.pdf.
Typically, there is little recourse available. Impacted enrollees may
be stuck with their ill-fitting plan until the next open enrollment
window. And because provider directory errors persist in the interim,
finding care may remain a struggle.
Recommendation
Make MA Provider Directories Accurate--The Medicare Rights
Center urges immediate action to address the long-standing problem of
inaccurate MA provider directories.\5\ This misinformation derails
thoughtful coverage choices and access to care. It also prevents the
Centers for Medicare and Medicaid Services (CMS) from conducting proper
oversight, as insufficient data may hide non-compliance with network
adequacy and other requirements. We recommend requiring accurate
provider directories without delay, imposing financial penalties on
plans for non-compliance, and holding beneficiaries harmless for any
enrollment decisions they may make in reliance on provider directory-
contained misinformation.
---------------------------------------------------------------------------
\5\ See, e.g., Centers for Medicare and Medicaid Services, ``Online
Provider Directory Review Report'' (March 2018), https://www.cms.gov/
Medicare/Health-Plans/ManagedCareMarketing/Downloads/
Provider_Directory_Review_Industry_Report_Round_3_11-28-2018.pdf;
Centers for Medicare and Medicaid Services, ``Online Provider Directory
Review Report (January 2018), https://www.cms.gov/Medicare/Health-
Plans/ManagedCareMarketing/Downloads/Provider_
Directory_Review_Industry_Report_Year2_Final_1-19-18.pdf.
---------------------------------------------------------------------------
II. Support Beneficiary Decision-Making
Most people new to Medicare are automatically enrolled because they are
receiving Social Security when they become eligible, but a growing
number are not.\6\ These individuals must enroll on their own,
considering specific timelines, intricate Medicare rules, and any
existing coverage. Mistakes are common and carry serious consequences,
including lifelong financial penalties, high out-of-pocket health care
costs, disruptions in care continuity, and gaps in coverage.
---------------------------------------------------------------------------
\6\ See, e.g., Medicare Payment Advisory Commission, ``Report to
the Congress: Medicare and the Health Care Delivery System'' (June
2019), http://www.medpac.gov/docs/default-source/reports/
jun19_medpac_reporttocongress_sec.pdf?sfvrsn=0.
People who choose MA face an additional hurdle: the plan selection
process. As noted above, it is recommended that enrollees review their
coverage options annually. But doing so can be complicated and
intimidating, deterring engagement. Identifying and comparing dozens of
plans and their exponential deviations, year after year, is a
challenging and time-consuming task that few people with Medicare
perform;\7\ even fewer switch plans from one year to the next.\8\ This
inertia, and any underlying sub-optimal plan choices, can have
detrimental and unanticipated results, like higher costs and problems
accessing preferred providers. Enrollees who arguably have the most at
stake--those who are older, have lower incomes, or have serious health
needs--are also the least likely to review and change their
coverage.\9\
---------------------------------------------------------------------------
\7\ See, e.g., Meredith Freed, et al., ``More Than Half of All
People on Medicare Do Not Compare Their Coverage Options Annually,''
Kaiser Family Foundation (October 29, 2020), https://www.kff.org/
medicare/issue-brief/more-than-half-of-all-people-on-medicare-do-not-
compare-their-coverage-options-annually/; Wyatt Korma, et al., ``Seven
in Ten Medicare Beneficiaries Did Not Compare Plans Past Open
Enrollment Period,'' Kaiser Family Foundation (October 13, 2021),
https://www.kff.org/medicare/issue-brief/seven-in-ten-medicare-
beneficiaries-did-not-compare-plans-during-past-open-enrollment-
period/.
\8\ https://www.kff.org/medicare/issue-brief/medicare-
beneficiaries-rarely-change-their-coverage-during-open-enrollment/.
\9\ Id.
---------------------------------------------------------------------------
Recommendations
Update Medicare Plan Finder--Beneficiaries are often confused
about the differences between plans or how to compare them and lack
sufficient tools and support for confident decision-making.\10\ CMS can
begin to address this by improving Medicare Plan Finder. Priority
upgrades should include integrating accurate plan network information
to enable beneficiaries to search by provider, individual claims
history, more realistic and predictive estimated costs, and more
information about supplemental benefits, like coverage and eligibility
limits.\11\
---------------------------------------------------------------------------
\10\ National Council on Aging, ``The Modernizing Medicare Plan
Finder Report'' (April 2018), https://www.ncoa.org/public-policy-
action/health-care/better-coverage-choices/medicare-plan-finder-
report/.
\11\ Medicare Rights Center, ``2019 Medicare Plan Finder Review''
(September 18, 2019), https://www.medicarerights.org/policy-documents/
comments-2019-medicare-plan-finder-review.
Ensure Beneficiary-Centered Materials--We also support updates
to materials explaining the differences between OM and MA, and the
trade-offs of each, to better reflect beneficiaries' primary
considerations. For example, one of the most vital decision points for
many is provider choice. Most MA plans have ever-
shifting networks that may exclude one's provider at any given time,
but this may not be well or widely understood. Even when it is, as
discussed, discovering what providers are in network can be
difficult.\12\ As a result, MA enrollees are at risk of losing--or
never even having--access to their preferred provider. Few resources
make this plain, or that post-enrollment relief is limited.
---------------------------------------------------------------------------
\12\ Centers for Medicare and Medicaid Services, ``Online Provider
Directory Review Report,'' (November 28, 2018), https://www.cms.gov/
Medicare/Health-Plans/ManagedCareMarketing/Downloads/
Provider_Directory_Review_Industry_Report_Round_3_11-28-2018.pdf.
Individually Tailor the Annual Notice of Change--CMS should
require MA plans to provide all enrollees a tailored Annual Notice of
Change (ANOC). The individualized notice should be based on claims data
and clearly describe how the enrollee's plan and costs will change, if
at all, in the coming year. This includes listing any of the
individual's providers who will no longer be in network, any
prescription drugs that will no longer be on the plan's formulary (for
---------------------------------------------------------------------------
MA-PD plans), and new applications of utilization management tools.
Support Enrollment Counselors--We urge greater investments in
State Health Insurance Assistance Programs (SHIPs). For many
beneficiaries, SHIP counselors are their sole source of objective,
highly trained, one-on-one, Medicare counseling. Despite surging
Medicare enrollment and an increasingly complex coverage landscape, the
SHIP program remains woefully underfunded. The FY 2023 level of $55.2
million is out of step with growing needs. If this investment had kept
pace with population shifts and inflation over the past decade, it
would exceed $80 million. We support increasing funding to at least
this amount ($80 million) in FY 2024.
Modernize Notification and Outreach--CMS and the Social Security
Administration (SSA) should alert people approaching Medicare
eligibility about important rules and deadlines. As documented by
MedPAC, such notice could help prevent harmful enrollment errors, like
lifetime financial penalties \13\ and harmful gaps in coverage.\14\ But
today, no such notice exists. The bipartisan BENES 2.0 Act would
correct this.\15\ In so doing, it would advance the goals of the
original BENES Act. Also bipartisan, CMS finalized its implementing
rules this year, updating Medicare enrollment for the first time in
over 50 years to end lengthy waits for coverage and align Special
Enrollment Period (SEP) flexibilities across the program.\16\ We
similarly support strengthening remedies for mistaken enrollment
delays, including through access to these SEPS and equitable relief.
---------------------------------------------------------------------------
\13\ In 2021, nearly 800,000 people were paying a Part B Late
Enrollment Penalty. The average amount increased their monthly premium
by nearly 30%. See Congressional Research Service, ``Medicare Part B:
Enrollment and Premiums'' (May 19, 2022), https://
www.everycrsreport.com/files/2022-05-
19_R40082_143a23f28239eec6ef87bac952856d5a14d0a22e.pdf.
\14\ Medicare Payment Advisory Commission, ``Report to the
Congress: Medicare and the Health Care Delivery System'' (June 2019),
http://www.medpac.gov/docs/default-source/reports/
jun19_medpac_reporttocongress_sec.pdf?sfvrsn=0.
\15\ S. 3675, https://www.congress.gov/bill/117th-congress/senate-
bill/3675?s=1&r=43.
\16\ Medicare Rights Center, ``Medicare Rights Center Welcomes
Passage of Key BENES Act Provisions'' (December 22, 2020), https://
www.medicarerights.org/media-center/medicare-rights-welcomes-passage-
of-key-benes-act-provisions.
Update Enrollment Infrastructure--Medicare Rights strongly
supports the recently proposed Medicare enrollment improvement pilot.
This initiative would also further the goals of the BENES Act, by
allowing SSA and CMS to work together to identify enrollment barriers
and solutions, including for those who are not already collecting
Social Security, and to explore opportunities to eliminate remaining
post-enrollment coverage lags, such as the requirement to wait for a
mailed Medicare card before connecting with one's earned benefits.\17\
---------------------------------------------------------------------------
\17\ See, e.g., U.S. Department of Health and Human Services,
``Fiscal Year 2024 Budget in Brief,'' page 8, https://www.hhs.gov/
sites/default/files/fy-2024-budget-in-brief.pdf; and The Office of
Management and Budget, ``Budget of the U.S. Government Fiscal Year
2024,'' page 52, https://www.whitehouse.gov/wp-content/uploads/2023/03/
budget_fy2024.pdf.
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III. Improve MA Networks
Even the best provider directory is only as effective as the network it
captures. Here too, reforms are needed. Overly narrow MA networks can
make care harder to find, access, and afford. This is especially true
for mental health and substance use disorder (SUD) treatment.\18\ On
average, MA plan networks included only 23% of psychiatrists in a
county--a smaller share than for any other physician specialty--and
nearly 40% of plans had less than 10%.\19\ By comparison, though
psychiatry has the highest opt-out rate from OM of all medical
specialties, only 7.5% of psychiatrists have done so.\20\
---------------------------------------------------------------------------
\18\ Daria Pelech, et al., ``Medicare Advantage and Commercial
Prices for Mental Health Services,'' Health Affairs (February 2019),
https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2018.05226.
\19\ Gretchen Jacobson, et al., ``Medicare Advantage: How Robust
Are Plans' Physician Networks?'', Kaiser Family Foundation (October 5,
2017), https://www.kff.org/report-section/medicare-advantage-how-
robust-are-plans-physician-networks-report/.
\20\ Nancy Ochieng, ``Most Office-Based Physicians Accept New
Patients, Including Patients With Medicare and Private Insurance,''
Kaiser Family Foundation (May 12, 2022), https://www.kff.org/medicare/
issue-brief/most-office-based-physicians-accept-new-patients-including-
patients-with-medicare-and-private-insurance/.
More broadly, a 2015 U.S. Government Accountability Office (GAO) report
found ``CMS's oversight did not ensure that MAO networks were adequate
to meet the care needs of MA enrollees.''\21\ In June 2022, GAO
testified that its recommendations to address these issues ``had not
yet been fully implemented.''\22\ Rule changes in the intervening years
further diluted this critical protection.\23\
---------------------------------------------------------------------------
\21\ U.S. Government Accountability Office, ``Medicare Advantage:
Actions Needed to Enhance CMS Oversight of Provider Network Adequacy''
(August 31, 2015), https://www.gao.gov/products/gao-15-710.
\22\ U.S. Government Accountability Office, ``Medicare Advantage:
Continued Monitoring and Implementing GAO Recommendations Could Improve
Oversight'' (June 28, 2022), https://www.gao.gov/products/gao-22-
106026.
\23\ 85 FR 33796, 33855.
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Recommendations
Strengthen Network Adequacy Rules--We support rescinding the May
2020 rule changes that weakened network adequacy requirements and
further improving consumer protections by requiring MA plans to
demonstrate they can meet enrollee care needs before they are permitted
to offer plans in the area.\24\ If a plan does not have enough
providers in network to realistically serve enrollees in a geographic
area, then CMS should not allow the plan to operate in that region. The
solution to inadequate plan networks is not for CMS to lower the bar.
---------------------------------------------------------------------------
\24\ Id.
Address Supplemental Benefits--We also recommend establishing
network adequacy requirements for supplemental benefits. Without this
basic guardrail, there is no way to measure plan capacity to deliver
---------------------------------------------------------------------------
promised benefits.
Ensure Meaningful Provider Availability--Network adequacy
standards must consider a provider's in-network status and their
meaningful availability. We specifically support the adoption of two
additional quantitative metrics: (1) the number of providers and
facilities within a given specialty that have submitted a claim over a
certain period, such as six months; and (2) the number of providers
that are accepting new patients. Plan submission and CMS verification
of these data points would better protect enrollee access to care.
Capture Timeliness-- Similarly, the existing metrics for MA
network adequacy fail to capture whether timely care is available. To
address this, we support aligning MA wait time standards with those
that will apply to Marketplace plans beginning in 2024; similar
timelines were recently proposed for Medicaid managed care plans.\25\
Accordingly, we were disappointed that in the 2024 C&D rule, CMS
instead set a wait time standard at 30 business days for routine mental
health and SUD care--well beyond the 10 business day standard for
Marketplace plans and under consideration in Medicaid.\26\ Once more,
we urge policymakers to establish consistent standards across payment
systems and to require MA plan compliance.
---------------------------------------------------------------------------
\25\ 87 FR 27208, 27329.
\26\ 88 FR 22120.
Promote Network Stability--MA enrollees must be able to count on
stability in their plan networks and the knowledge that their doctors
will be there when they need them. We urge CMS to work with plans to
minimize the practice of dropping doctors without cause in the middle
of the plan year. When such changes are necessary, affected enrollees
must receive adequate notice and relief, including access to a Special
---------------------------------------------------------------------------
Enrollment Period.
Reduce Provider Burden--As Dr. Jack Resneck noted in his
testimony, providers face significant administrative burdens, most
notably compliance with MA prior authorization requirements:
``Practices are completing 45 prior authorizations per week per
physician, adding up to two business days per week spent on prior
authorization alone.'' He further explains this requires ``hours spent
on the phone with insurance companies, endless paperwork for initial
reviews and appeals, and constant updating of requirements and repeat
submissions just to get patients the care they need.''\27\ We urge a
reduction in the services subject to prior authorization--such as
prohibiting repeated prior authorization during a course of treatment--
as well as better oversight and enforcement to ensure existing
guardrails--like the requirement to cover all OM services--are
effective. These reforms would improve enrollee access to care by
minimizing unnecessary waits for coverage and reducing provider burdens
in a way that could lead to increased network participation.
---------------------------------------------------------------------------
\27\ Jack Resneck, ``Statement to the U.S. Senate Committee on
Finance Re: Barriers to Mental Health Care: Improving Provider
Directory Accuracy to Reduce the Prevalence of Ghost Networks'' (May 3,
2023), https://www.finance.senate.gov/imo/media/doc/Jack%20Resneck%20MD
%20Statement%20to%20Finance%20Cmt%20on%20Behalf%20of%20AMA%20Re%20Provid
er%20
Directories%202023-5-3.pdf.
Thank you for your bipartisan consideration and leadership. These are
critical issues for millions of Americans. The Medicare Rights Center
looks forward to continued collaboration on improving health care
---------------------------------------------------------------------------
access and affordability.
For further information:
Lindsey Copeland
Federal Policy Director
[email protected]
______
Mental Health Association of Rhode Island
345 Blackstone Blvd.
Providence, RI 02906
Phone 401-726-2285
Fax: 401-437-6355
[email protected]
https://mhari.org/
May 1, 2023
The Honorable Ron Wyden
Chair
U.S. Senate
Committee on Finance
219 Dirksen Senate Office Bldg.
Washington, DC 20510-6200
Dear Chairman Wyden and Members of the Senate Committee on Finance:
For the first time in my life, I needed mental health treatment and
could not get it. In May of 2020, at the onset of the pandemic, I began
to lose ground in my recovery from clinical depression. Work became
more difficult. I could not taste food, feel music, sleep soundly, or
experience pleasure. Life lost its color again and returned to shades
of gray. Like most people who need healthcare, I consulted my insurer's
provider directory to find a psychiatrist. One by one, going down the
list, I called office after office. Some were no longer accepting my
insurance or new patients. Others were booking six months out. Hoping
to address the depression before it worsened, I booked a telemedicine
appointment with my primary care physician (PCP), who gave me a
prescription for an antidepressant.
It worked out for the most part. Six months later, when I was finally
able to see a psychiatrist, he changed the dosage and timing of my
medication to improve my sleep. PCPs are well intentioned, but they are
not mental health experts. If this were my first episode of depression,
or if I had a complicated illness or more than one mental illness, my
PCP might not have been able to accurately diagnose and treat me. Just
as patients with heart conditions see cardiologists, people with mental
illness need a psychiatrist who understands the complexities of mental
illness and psychotropic medications.
My experience is not unique. Many patients face similar barriers when
trying to access care. It is common practice for insurers to assemble
``ghost networks'' of providers who are licensed to practice in the
state but are not actually part of the insurance network, or are in-
network but are not taking new patients. Inadequate networks are caused
by multiple factors. One significant and correctable factor is stagnant
and low reimbursement rates, which make it difficult for providers to
keep up with the rising costs of keeping their practices or centers
open. As a result, providers move their practices out of state where
rates are higher, switch jobs frequently, or stop participating in
insurance networks. Some have permanently closed their doors.
Insurance companies have tremendous power in our country. They
typically threaten to raise the cost of premiums whenever the
government attempts to rein them in. Requiring insurers to pay
reimbursement rates that keep up with the cost of inflation is not
likely to drive up the cost of premiums. The cost of commercial
insurance premiums is influenced by a number of factors, such as the
utilization rate of outpatient services, inpatient hospitalization, and
emergency departments (the last two being the most expensive levels of
care); the rising cost of prescription medications; pharmacy benefit
managers; hospitals' administrative costs; insurers' administrative
costs; and more. It is unfair to single out providers who want to be
paid fairly, or consumers who want timely access to care, as the main
cost drivers in a complicated system.
On the contrary, raising reimbursement rates may, in fact, reduce the
cost of premiums. Higher rates will help insurers attract and retain
providers in their networks. A robust provider network will increase
access to timely outpatient mental and behavioral health services.
Early intervention improves patient outcomes and saves money in the
long term. When patients access treatment in a timely fashion, their
conditions stabilize or improve, thus decreasing the utilization of
restrictive and expensive emergency departments, inpatient hospitals,
and residential treatment centers. This, in turn, reduces insurers'
costs, and that reduction in their costs should be reflected in lower
premiums.
The Kaiser Family Foundation reports that in the spring of 2022, 19.9%
of adult Rhode Islanders had symptoms of depression and anxiety and an
unmet need for counseling and or therapy.\1\ Patients suffer when there
are not enough providers. As we wait for care, our conditions worsen
sometimes to the point of a life-
threatening crisis.
---------------------------------------------------------------------------
\1\ https://www.kff.org/statedata/mental-health-and-substance-use-
state-fact-sheets/rhode-island/.
We respectfully urge this Committee to prevent insurers from assembling
``ghost networks.'' We encourage you to examine the role of unfairly
---------------------------------------------------------------------------
low reimbursement rates on patients' access to care.
Thank you for your consideration.
Respectfully,
Laurie-Marie Pisciotta
Executive Director
[email protected]
______
National Association of Benefits and Insurance Professionals
999 E Street, NW, Suite 400
Washington, DC 20004
www.NABIP.org
I am writing on behalf of the National Association of Benefits and
Insurance Professionals (NABIP), formerly NABIP, a professional
association representing over 100,000 licensed health insurance agents,
brokers, general agents, consultants, and employee benefits
specialists. The members of NABIP 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 NABIP represents are a
vital piece of the health insurance market and play an instrumental
role in assisting employers and individual consumers with choosing the
health plan or plans that are best for them. 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\ During the 2023 open enrollment
period, agents and brokers assisted 71 percent of those who enrolled
through HealthCare.gov or a private direct enrollment partner's
website. Additionally, premiums are 13 percent lower in counties with
the greatest concentration of brokers.\3\ Consequently, the NABIP
membership has a vested interest in ensuring that consumers enjoy
affordable health coverage that is the correct fit for their clients.
---------------------------------------------------------------------------
\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.
\3\ Karaca-Mandic, Pinar, et al. The Role of Agents and Brokers in
the Market for Health Insurance. National Bureau of Economic Research.
August 2013, https://www.nber.org/papers/w19342.
Access to mental health services is a crucial component of healthcare.
National discussion has addressed mental healthcare for years, but
often focuses more on physical health. The COVID-19 pandemic has
reminded us of the importance of adequate mental healthcare and exposed
a mental health crisis: About 4 in 10 adults in the U.S. reported
symptoms of anxiety or depressive disorder during the pandemic, a share
that has been largely consistent, up from one in ten adults who
reported these symptoms from January to June 2019.\4\ For these reasons
it is more vital than ever that consumers can access and afford mental
and behavioral health services.
---------------------------------------------------------------------------
\4\ 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.
Unfortunately, a lack of network adequacy has proven a substantial
barrier for consumers seeking mental and behavioral health services.
While attempts have been made to make improvements in this area, there
is still a significant amount of ground to cover. Often it is difficult
for patients 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. For example, it
is possible that an insurer's in-network provider directory implies a
specific plan is accepted by the provider in question, when in reality
the provider accepts only certain iterations of the plan (such as the
---------------------------------------------------------------------------
PPO and not the HMO).
Directories that appear accurate only to include providers that are not
actually in-network or are not accepting new patients are commonly
referred to as ``ghost networks.'' Inaccurate or out-of-date
information on which mental health providers are in a health plan's
network contributes to ongoing access issues for consumers and often
compels consumers to obtain out-of-network care at higher costs. A 2020
survey of privately insured patients found that 53 percent of consumers
that used provider directories found inaccuracies in their insurer's
provider directory, often leading them to receive care from out-of-
network providers.\5\ Additionally, the GAO reported in 2022 that the
problem of ghost networks in mental healthcare worsened during the
pandemic, as providers left their positions or stopped taking new
patients due to overload.\6\
---------------------------------------------------------------------------
\5\ Busch, S. and Kyanko, K. 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.
\6\ Government Accountability Office. Mental Health Care: Access
Challenges for Covered Consumers and Relevant Federal Efforts. March
2022, https://www.gao.gov/assets/gao-22-104597.pdf.
With these statistics in mind, it is crucial that Congress address the
prevalence of ghost networks and create stronger enforcement standards
to protect those seeking mental health services. NABIP believes that
the maintenance of reliable network directories should be a shared
responsibility between the providers and the insurance carriers, as
both entities have the information required to properly preserve the
list and prevent networks from becoming ghost networks. However, while
the employer is often lumped into regulatory conversations regarding
mental health services, it is important to note that they do not have
direct control over plan networks and should not be burdened with
---------------------------------------------------------------------------
additional compliance concerns.
The relevant regulatory bodies have already erroneously encumbered
employers with mental health parity standards. The Consolidated
Appropriations Act of 2021 (CAA) 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 CAA mandates and in particular the non-
quantitative treatment limits 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.
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. In 2022, 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--highlighting the
difficulty that employers have in their efforts to comply.\7\
---------------------------------------------------------------------------
\7\ 2022 MHPAEA Report to Congress: Realizing Parity, Reducing
Stigma, and Raising Awareness: Increasing Access to Mental Health and
Substance Use Disorder Coverage. January 2022, 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.
While action must be taken to ensure that carriers' mental health
provider directories are accurate, placing the regulatory obligation on
employers when they do not have direct control over the directories
would be in error and prove as burdensome as mental health parity
requirements. Small employers in particular would struggle to be in
compliance with new mental health network adequacy requirements, as
they would still rely on third-party administrators to monitor and
comply with these network requirements as well. NABIP supports
proposals that better enforce mental health network adequacy without
needlessly penalizing employers who are working to provide such
---------------------------------------------------------------------------
benefits to their employees.
Mental health services are up to six times more likely than other
medical services to be delivered by an out-of-network provider, in part
because so many mental health providers do not accept commercial
insurance.\8\ NABIP recommends that Congress consider incentives to
encourage providers to participate in network plans including plans
that use mental health carve-outs, as well as increase incentives for
plans with mental health carve-outs to contract with willing mental
health providers. We also recommend increasing incentives for carriers
with mental health carve-out plans to expedite the contracting process
and prioritize updating provider lists. The contract negotiation
process between carriers and providers is a source of inefficiency, as
the process can take a significant amount of time and can add yet
another barrier to receiving care.
---------------------------------------------------------------------------
\8\ Busch, S. and Kyanko, K. 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.
Switching focus from network adequacy to the shortage of mental health
providers themselves, 119 million Americans live in areas designated as
mental health professional shortage areas--despite the clear need for
mental health services across the country.\9\ In addition to
contributing to challenges consumers face in finding in-
network providers, representatives from 17 of the 29 stakeholder
organizations that the GAO interviewed in 2022 indicated that workforce
shortages have contributed to constraints on overall capacity of the
mental health system.\10\ Recent American Academy of Pediatrics data
also 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.\11\ According to the
Health Resources & Services Administration, an additional 6,586
providers would be needed to bridge the gap for consumers living in
these shortage areas.\12\
---------------------------------------------------------------------------
\9\ Kaiser Family Foundation. Mental Health Care Health
Professional Shortage Areas (HPSAs). 30 September 2022, 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.
\10\ Government Accountability Office. Mental Health Care: Access
Challenges for Covered Consumers and Relevant Federal Efforts. March
2022, https://www.gao.gov/assets/gao-22-104597.pdf.
\11\ McBain, Ryan, et al. Growth and Distribution of Child
Psychiatrists in the United States: 2007-2016. American Academy of
Pediatrics. 1 December 2019, https://publications.aap.org/pediatrics/
article/144/6/e20191576/77002/Growth-and-Distribution-of-Child-
Psychiatrists-in?autologincheck=redirected.
\12\ Health Resources and Services Administration. Health Workforce
Shortage Areas. 1 May 2023, 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.\13\
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 2 or 3 years; this was a 10-point jump
from when the question was asked in 2015.\14\ To enhance Americans'
access to mental and behavioral health care, strengthening both the
mental health and primary care workforce must be a top priority. NABIP
supports workforce development and training programs that aim to
increase the amount of mental health and primary care professionals.
---------------------------------------------------------------------------
\13\ 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.
\14\ 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.\15\ 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 most
psychotropic medications.
---------------------------------------------------------------------------
\15\ 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.
Outside of workforce issues, 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 mental
healthcare consumers. For these reasons, NABIP 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 NABIP 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
______
Zocdoc
https://www.zocdoc.com/
On behalf of the millions of patients and tens of thousands of
providers that use Zocdoc every month, thank you for holding this
hearing to discuss a barrier to patients' access to care: the
prevalence of inaccurate provider directories and ghost networks. We
appreciate the Committee's commitment to investigating the issue and
learning from experts in the field regarding scalable solutions. As a
company that operates an intuitive, accurate, and functional provider
directory, our product can offer insight into how we can work together
to improve the patient experience.
In particular, through Zocdoc's healthcare marketplace, we have solved
the ghost network problem. In addition, we have increased provider
availability through advanced inventory management that unlocks a
hidden capacity for patients to receive care. As the Senate Finance
Committee continues its deliberation and considers initiatives to
increase access to healthcare, we have the following recommendations:
1. The proposed CMS National Directory of Healthcare Providers and
Services should be an accurate data hub accessible by Application
Programming Interface (API) so that third parties can effectively
leverage and build upon it.
2. Ensure standardization of data requirements, form, and
functionality to make it easier for providers to comply.
3. Ensure regulatory policies and incentives are aligned to
encourage providers to have the most accurate information (not just
insurance, but availability, specialty, visit reasons, etc.) and to
update that information in an efficient, scalable way.
About Zocdoc
Zocdoc was founded in 2007 with a mission to give power to the patient.
In furtherance of this mission, we operate an online marketplace that
enables millions of Americans each month to independently find in-
network doctors, see their real-time availability, and instantly book
appointments online for in-person or telehealth visits. Our user-
friendly service is free to patients, available in all 50 states, and
facilitates in-network scheduling for 200+ different specialties across
+12,000 different insurance plans.
The Zocdoc Marketplace
By building a true healthcare marketplace over the last 15 years, we
are bringing choice, competition, and transparency to the largest and
most important consumer service in our country: healthcare. We are
building this because the fragmented healthcare industry needs a
unifier--a connective tissue that brings together all the participants,
technologies, and applications. Unlike other technology-focused
entrants in the space, we are not trying to replace the provider, the
payor, or the EHR, but rather wrangle all of the underlying complexity
in those players to make it easy for patients to find and book in-
network care. Users can intuitively research options based on what is
most important to them (insurance, reviews,\1\ location, availability,
etc.), independently select the provider who best suits their needs,
and instantly book an appointment online.\2\
---------------------------------------------------------------------------
\1\ Zocdoc, ``How Reviews Work on Zocdoc,'' https://www.zocdoc.com/
about/verifiedreviews/.
\2\ Zocdoc, ``How Zocdoc Search Works,'' https://www.zocdoc.com/
about/how-search-works/.
In addition to simplifying Americans' healthcare experience, Zocdoc
also accelerates access to care. As noted in the hearing, unnecessarily
long wait times have a real and lasting impact on patients, especially
when they might be experiencing an acute mental health crisis. Overall,
the national wait time to see a primary care provider is 26 days on
average when booked over the phone,\3\ and these wait times continue to
rise.\4\
---------------------------------------------------------------------------
\3\ Merritt Hawkins. Survey of Physician Appointment Wait Times,
2022, https://www.merritthawkins.com/uploadedFiles/MerrittHawkins/
Content/News_and_Insights/Articles/mha-2022-wait-time-survey.pdf.
\4\ Ibid.
Zocdoc dramatically expedites patients' access by uncovering the
``hidden supply of care,'' meaning the 20% to 30% of appointments that
become available last minute due to cancellations and rescheduled
appointments, that would otherwise go to waste.\5\ Our marketplace
surfaces this hidden appointment inventory in real-time to users who
are actively seeking care. In doing so, we accelerate access to care:
the typical appointment booked through Zocdoc takes place within 24-72
hours--an order of magnitude sooner than the national average wait.
---------------------------------------------------------------------------
\5\ McKinsey and Company. ``Revisiting the access imperative,'' May
2018, https://healthcare.mckinsey.com/revisiting-access-imperative.
Beyond reducing wait times for patients, the convenience of booking an
appointment at any time of the day is vital to ensuring access to care.
On Zocdoc, 37% of all appointments are booked between 5pm and 9am, when
a doctor's office is typically closed.\6\ Plus, 17% of all appointments
are booked on a Saturday or Sunday.\7\ The popularity of after-hours
booking makes intuitive sense, especially in healthcare, where the
impulse to book care often strikes the moment a patient decides they
need to see a doctor. Those moments don't always happen during a
provider's relatively narrow office hours, and without this access to
after-hours booking, families might seek care in ERs for immediate
relief, or delay care entirely.
---------------------------------------------------------------------------
\6\ Between August 2021 and August 2022
\7\ Ibid.
Easy access to healthcare appointment scheduling enables patients to
get last-minute care in an appropriate, and often lower-cost setting.
Nearly one in five Zocdoc users (19%) who booked a same-day appointment
said they may have gone to the emergency room had Zocdoc not
facilitated timely access to care.\8\ According to a study in the
Harvard Health Policy Review, 45% of patients cited access barriers to
primary care as their reason for using the emergency room, while only
13% of patients had conditions that required it.\9\ Zocdoc enables
timely access to care, which is crucial, as emergency room over-
utilization has costly impacts on families, providers, and the
healthcare system alike.
---------------------------------------------------------------------------
\8\ Zocdoc. Study: Nearly 3 in 4 Americans Say It's Easier to Go to
the ER Than to Get a Doctor's Appointment. September 2019, https://
www.zocdoc.com/about/news/2019-er-report/.
\9\ Harvard Health Policy Review, ``Targeting National Emergency
Department Overuse: A Case for Primary Care, Financial Incentives, and
Community Awareness.'' 2014, https://scholar.harvard.edu/files/
christinaangienguyen/files/targeting-national-emergency-department-
overuse-nguyen.pdf.
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Zocdoc for Developers
Today, more than a third of patients in the U.S. are referred to a
specialist each year, but the vast majority are scheduled over the
phone, which is inefficient and untrackable.\10\ Providers and payors
typically have the choice between a 20+ minute three-way-call or simply
passing on a provider's phone number to the patient, which removes the
trackability of the encounter and puts the onus on the patient to
follow up, creating blind spots for care outcomes and gaps in
continuity of care.
---------------------------------------------------------------------------
\10\ The Milbank Quarterly, Dropping the Baton: Specialty Referrals
in the United States. March 2011, https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC3160594/.
With the recent launch of Zocdoc for Developers, Zocdoc's first-ever
API, developers can build on top of the same standardized, scalable
technology that powers Zocdoc's Marketplace.\11\ This has the potential
to transform the way providers make and receive referral appointments,
close patient care gaps, and more. Our first use case, Care Navigation,
empowers physician groups and care coordinators to build tools using
our API that allow them to search for availability and directly book a
referred patient into a provider's schedule. We look forward to
building additional use cases with new partners over time, and having
reliable information accessible through the National Directory of
Healthcare Providers and Services, as proposed by CMS earlier this
year, would be a tremendous boon to those efforts.\12\
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\11\ Zocdoc, ``Zocdoc for Developers,'' http://
developer.zocdoc.com/.
\12\ CMS, ``Request for Information; National Directory of
Healthcare Providers and Services,'' December 2022, https://
www.federalregister.gov/documents/2022/10/07/2022-21904/request-for-
information-national-directory-of-healthcare-providers-and-
services#footnote-5-p61018.
As the Committee explores solutions to eradicate ghost networks for the
betterment of the patient experience, we urge you to look at private
sector solutions that have aligned incentives and continuous
accountability structures. We applaud the Committee's bipartisan
investigation into the issue and appreciated hearing from the witnesses
about the impact of ghost networks on patients, providers, and health
systems. We concur that there should be more auditing and penalties for
bad actors. We especially agree with Dr. Resnick's comments that
standardization of data elements will go a long way in reducing the
administrative burdens on providers. Herein we detail how we might be
able to work together to build a better patient experience.
Ghost Networks have a negative impact on the patient experience
As the witnesses discussed, accessing healthcare is often a frustrating
experience for patients. One of patients' biggest hurdles is not only
finding a doctor but also finding one that is in-network and available.
When patients search through the years-old provider directories (many
of which are stagnant downloadable .pdf files) listed on insurers'
sites and start the process of calling around only to find that most
providers listed are either no longer in-network or not accepting new
patients, they can become disheartened and delay care.
Delayed care is bad for the patient and bad for the economy. According
to a study by Harvard Public Health Review, faster care reduces
healthcare costs by 51%.\13\ When healthcare costs are outpacing
rampant inflation, faster access to in-network providers is more
important than ever.
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\13\ Harvard Public Health Review, ``The Effect of Delays in Acute
Medical Treatment on Total Cost and Potential Ramifications Due to the
Coronavirus Pandemic.'' 2021, https://hphr.org/26-article-haque/.
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Ghost networks do not exist on Zocdoc
We are proud of the fact that ghost networks do not exist on Zocdoc,
and the reason is quite simple: Zocdoc incentivizes providers to
maintain accurate information. Providers join Zocdoc to reach new
patients and they pay a new patient booking fee each time a new patient
finds and books an appointment with them through our marketplace.
Because they pay a fee for each new patient booking, providers have an
interest in advertising themselves accurately to prospective patients.
When a provider joins the marketplace, we help them through the process
of accurately listing all of their insurances as part of the onboarding
process, and have regular touchpoints with providers thereafter to
ensure that the information stays accurate.
As discussed at the hearing, ghost networks are able to proliferate
because publishers have no incentive to update information, and there
is no efficient system to update a stagnant document at the scale and
volume needed to be useful for patients. In contrast, Zocdoc's
marketplace is more like Wikipedia than Encyclopedia Britannica in that
it evolves by the minute, versus being out of date the moment it is
published. Providers regularly engage with their Zocdoc account to
update insurance information, visit reasons, availability, etc. This
means that providers are not only incentivized to have the most
accurate information (not just insurance, but availability, specialty,
visit reasons, etc.), but also able to update it in an efficient,
scalable way. A provider's time is valuable, as is each appointment
booking, and that's why we make it as easy as possible to list and
update accurate information.
Additionally, because we maintain a direct relationship with the
provider, we have regular opportunities to double-check the accuracy of
the information they've listed. We also have a team dedicated to
maintaining the accuracy of this information, so that if a patient
reports to us that a provider's information was not correct, we can
quickly follow up with the practice to address the discrepancy.
Standardizing data requirements, form, and functionality
Last year, Zocdoc joined hundreds of other organizations to comment on
an RFI from CMS seeking input on the potential creation of a National
Directory of Healthcare Providers and Services (NDH).\14\ We were
particularly interested in the types of data that should be publicly
accessible from an NDH (either from a
consumer-facing CMS website or via an API). As a company that has
unique expertise in this space, we strongly recommend that CMS mandates
the fewest data inputs required to make this both feasible for
providers and useful to stakeholders. The information we recommend
mandating to collect is:
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\14\ See Zocdoc's comments here: https://www.regulations.gov/
comment/CMS-2022-0163-0377.
Name
NPI (if applicable) or Specialty from a dropdown list by license
type
Mailing address for the physical location of the provider's
office (rather than billing address)
Email address
Phone number for the physical location of the provider's office
(rather than billing office)
Board certifications (if any)
As discussed above, the tens of thousands of providers that utilize
Zocdoc are incentivized to have all of their information accurately
listed on Zocdoc, as they are leveraging our platform to advertise
their services to new, in-network patients they are able to treat. We
invest significant capital in making sure this information is accurate
to ensure the best experience for both patients and providers. Because
the NDH, as described, does not present the same incentives for
accurate information from providers, we urged them to operate with a
``less is more'' approach to the information required. To help mitigate
the preponderance of ghost networks, the focus should be on making the
NDH an accurate data hub accessible by API, so that third-parties can
effectively leverage and build upon the available information.
A consolidated directory of provider information can solve
fragmentation and inaccuracy of disparate data sources, but only if it
is limited to the lowest common denominator of information needed. That
way, developers, like Zocdoc, can build on that core, accurate data
set.
The creation of an NDH as an open API would allow innovators to build
useful tools from accurate, validated data, eliminating the ghost
network effect. With that in mind, creating an NDH without mandating
compliance perpetuates the same problems we are facing today with both
the National Plan and Provider Enumeration System (NPPES) and outdated
insurance directories that result in the proliferation of the very
ghost networks the Committee is investigating.\15\ Providers are not
incentivized to voluntarily update their information at a national
level, but there is an opportunity to leverage the current state-based
licensing systems to create a ``superset'' of data at a national level.
This way, the federal government can play a vital role in building upon
and improving the tools that already exist.
\15\ Testimony of John E. Dicken, Director, Health Care of GAO
before the U.S. Senate Committee on Finance, March 30, 2022. ``Mental
Health Care: Consumers with Coverage Face Access Challenges,'' https://
www.gao.gov/assets/gao-22-105912.pdf.
As noted by witnesses, payor penalties for noncompliance and consistent
audits can serve as a ``stick'' to push insurance companies to maintain
accurate directories. But Zocdoc offers a model of how policymakers can
learn from a ``carrot'' approach, which incentivizes providers to
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maintain up-to-date information.
Zocdoc shares the goal of achieving true transparency for patients,
empowering them to make informed choices about their care, free from
the trap of ghost networks. We remain committed to building tools to
get us there. In fact, this is at the core of our daily work pursuing
our mission to give power to the patient.
Thank you for the opportunity to provide comments on a potential
solution to ghost networks. We would be delighted to expand on our
comments or provide any additional information that might be helpful.
Links:
https://developer.zocdoc.com/
?utm_medium=organicpro&utm_routing=API_Sender
https://www.federalregister.gov/documents/2022/10/07/2022-21904/
request-for-information-national-directory-of-healthcare-providers-and-
services#p-1
https://hphr.org/26-article-haque/
[all]