A combination of regulatory, employer, and consumer drivers are creating change in how health plans—commercial, Medicare, and Medicaid—and employers are approaching mental health services. Four forces have resulted in new regulatory action:
- The multi-faceted physical and emotional effects of the pandemic
- Unaddressed mental health trends promulgated pre-pandemic
- A lack of access to behavioral health services
- The healthcare system's pursuit to increase behavioral health integration as part of the shift to whole-person care
Health plans and employers are responding to the need to create greater access to behavioral healthcare—the most important objective—and to address practitioner shortages by making behavioral health more attractive to providers via higher reimbursement, fewer constraints, and lower administrative burden.
Beneath the overarching access and staffing objectives (which both relate, ultimately, to access), payers are partnering with provider organizations and digital health vendors to deliver care faster to more people through platforms or mobile apps, virtual services, and digital therapeutics. They're tapping community partnerships and grants along with clinician training and education.
Also, health plans are supporting behavioral health integration through investments that help primary care providers meet the needs of their patients more efficiently. Premera Blue Cross has taken steps to support 23 clinics in rural Washington and Alaska to implement Collaborative Care and has invested in the University of Washington's Psychiatry Fellowship for Advanced Nurse Practitioners to ameliorate the workforce and access issues.
Work is also being done to enhance the crisis-identification-intake operational workflow. A good example is Oregon, which was the first state in the nation to create a Medicaid mobile crisis intervention program.
Behavioral health's demand challenge
According to the American Psychological Association's 2022 COVID-19 Practitioner Impact Survey, psychologists continue to struggle to “meet demand amid a mental health crisis." Demand for anxiety and depression treatment has remained high for the third consecutive year, alongside increasing demand for treatment for other trauma- or stress-related disorders and substance use disorders (SUD). Psychologists reported having an average of 15 potential new patients seeking care each month.
Their results align with those found by other behavioral health practitioners:
- 60% no longer have openings for new patients
- 46% have been unable to meet the demand for treatment
- 72% have longer waitlists than before the pandemic
In 2022, two-thirds of psychologists surveyed said they had also seen increased patient symptom severity.
The CEO of the American Psychological Association, Arthur C. Evans Jr., PhD, highlights the complexity of the need and solution, stating, “Having timely access to psychological services is critical for addressing the needs of those diagnosed with behavioral health challenges. But we need to tackle this problem with various solutions, beyond individual therapy. We need to support and expand the workforce, promote integrated behavioral health into primary care, improve mental health literacy, use technology and innovation to expand reach, and improve efficiency."
Commercial health plans strive to address behavioral health coverage and network issues
AHIP conducted a summer 2022 survey with commercial health insurers that represent 95 million members to discover how they are improving access to mental healthcare. Their results point to a multi-pronged approach of network-building, training, and supporting PCPs, and helping patients secure appointments, including:
- 100% provide coverage for tele-behavioral health services
- 89% are actively recruiting mental healthcare providers
- 78% have increased payments to recruit more high-quality professionals
- 72% are training and supporting PCPs to care for patients with mild or moderate behavioral health conditions
- 83% have enhanced resources to assist members in finding available appointments
- 78% now use specialized case managers to transition emergency room and inpatient care
In-network behavioral health provider rosters had also grown in 3 years by an average of 48%.
In addition to recruiting more providers to accept insurance and making in-network status more attractive, industry leaders call for more value-based care, improved quality measurement, coverage parity, and integration with physical medicine services.
Payers are moving toward physical and behavioral healthcare parity
In an interview with The American Journal of Managed Care (AJMC), health plan and provider experts like Ellen Beckjord, PhD, MPH, Vice President, Population Health and Clinical Optimization, UPMC Health Plan, pointed to 3 actions health plans should take now:
1. Cover crisis services equally: For example, original Medicare, most Medicare Advantage offerings, and many commercial plans don't cover many urgent and emergent crisis services. While available to Medicaid-eligible populations, most members have few options in a psychiatric emergency.
2. Standardize the metrics used to measure quality and access: Measuring and keeping providers accountable to quality is the pathway to a level playing field that can drive increased reimbursement.
3. Insist on contracting with providers through value-based payment models: Plans are increasing incentives for performance, access, and patient experience to improve quality and bring mental healthcare in light of existing physical care performance oversight.
In addition to strategies employed by commercial health plans, new CMS policies and programs, coupled with new Medicare and Medicaid strategies, aim to broaden access and expand care networks creatively.
Federal and state regulations and benefits
Medicare and Medicaid programs have pivoted during the COVID-19 pandemic and in response to a decade's-long worsening of mental health and SUD diagnoses. These public programs are working hard to address the behavioral health crisis by adding financial incentives, simplifying reimbursement requirements, and attracting more practitioners.
Nearly 1 in 4 Medicare beneficiaries and 28% of Medicare Advantage members experience mental illness. Yet only 40-50% receive treatment. Covering both outpatient and inpatient services along with medications to treat mental illness, Medicare and Medicare Advantage plans are expanding coverage through special needs plans and additional services like grief counseling.
In recent years, CMS has launched several new policies, billing codes, and programs to support enhanced behavioral health access and coverage, including:
2008 Medicare Improvements for Patients and Providers Act: This regulation lowered cost sharing for outpatient mental health services compared to general medical care. Ending the mandatory phase-out period, legal changes capped coinsurance for both mental health and general medical at 2%. Research has associated these policies with increases in outpatient mental health follow-ups after psychiatric hospitalization.
The Affordable Care Act: The ACA included free wellness visits for all Medicare beneficiaries, including depression screenings.
Integrating care billing in 2017: CMS introduced billing codes, permitting general medical providers to bill Medicare for mental healthcare planning and management services. Due to slow adoption, 2023 programs focus on conducting outreach to increase awareness and use with providers.
Closing the coverage gap in 2020: Because beneficiaries tended to reduce medication use upon entering the coverage gap, regulation in 2020 closed the Medicare Part D “donut hole" in prescription coverage to enhance access and adherence to mental health treatment plans.
Expanding reimbursement to include telehealth and professional counselors: While Medicare has always covered mental health diagnosis, evaluation, and treatment delivered via telehealth technology, coverage was significantly expanded through COVID-19 public health emergency rules, which were made permanent.
Reimbursement for professional counselors: Starting in 2024, Medicare will fill a long-standing gap in behavioral health access for Medicare beneficiaries through the Mental Health Access Improvement Act, allowing Medicare to reimburse licensed professional counselors, adding over 140,000 licensed counselors to the roster of accessible clinicians.
According to KFF's Behavioral Health Survey of Medicaid programs, state officials are working to address behavioral health workforce shortages in 4 key areas:
- Increasing billing rates
- Reducing administrative burden
- Extending the covered workforce
- Incentivizing provider participation
While nearly all states use at least 1 of these 4 strategies to increase the behavioral health workforce, 50% of states will launch at least a single strategy in every area, arguably putting them ahead of commercial payers when it comes to flexible, creative ways of supporting behavioral healthcare.
Increasing reimbursement rates: The American Rescue Plan Act (ARPA) provided temporary funding for states to increase provider rates or attract and retain clinicians with enhanced payments. While the COVID-19 public health emergency (PHE) allowed states to adopt temporary rate increases, of which two-thirds increased rates for 2022 or 2023, there are opportunities to continue program funding through other Section 1115 or innovation waivers to maintain recruited practitioners.
For example, Oregon's Section 1115 waiver includes a requirement to ensure comparable base payment for behavioral health providers, along with primary care and obstetrics and gynecology.
Expanding available behavioral health workforce: Many states have taken 1 of 3 steps to improve access via a larger workforce. These steps include reimbursing for new provider types, allowing provider types to bill without a supervising practitioner, loosening restrictions on in-person vs. telehealth requirements, or enabling reimbursement for care delivered by trainees, also known as license-eligible workforce. Many states and their MCOs added peer or family specialists as providers, while others extended direct reimbursement privileges to other types of mental health practitioners.
Reducing administrative burdens: Many administrative activities, including prior authorization, reimbursement documentation requirements, lengthy credentialing processes, and cumbersome denials and auditing processes, keep more behavioral health clinicians from participating in payer networks. Also, providers contracting with multiple MCOs must navigate varying requirements and procedures. Nearly 75% of states have chosen 1 or more strategies to reduce administrative burden. These include implementing centralized provider credentialing, standardized prior authorization processes, streamlined treatment plan forms, or authorizing a more significant number of initial units of care.
Incentivizing greater Medicaid participation: States are ramping up efforts to decrease reimbursement delays that research says reduce participation. Other prompt payment strategies include establishing shorter notification requirements when additional information is required from a provider to process a claim. And many strive to pay approved claims within 30 calendar days. A few states are also providing financial incentives for providers to participate in physical and behavioral health integration, while others are using creative strategies like providing staff training or student loan repayments.
One last health plan stakeholder influencing behavioral health benefits and coverage is employers.
Because over 50% of Americans have employer-sponsored healthcare coverage, including essential coverage for behavioral health services, employers have incredible influence over coverage and mental health benefits. Since the pandemic, employers have been expanding coverage.
In 2020, nearly 25% of Americans, including 6 million children, received behavioral health services through their work's health plan. And according to a Willis Towers Watson report, about 88% of employers have expanded mental health benefits or implemented new behavioral health support programs. However, research shows despite nearly 73% of employers increasing mental health support, about 40% of employees don't believe, understand, or know how to access these services.
Health plans are playing to their strengths to enhance behavioral health coverage and benefits
Health plans are uniquely positioned to bring together providers, unique benefit offerings, and technologies to address behavioral health access while enabling members to maximize the value and impact on their health and well-being.
Blue Cross of NC expanded its value-based behavioral health program to add Headway. Headway helps connect members to in-network care and helps therapists take insurance by taking on administrative burdens.
RTI Health Advance is helping payers and providers address the behavioral health crisis
RTI Health Advance works with healthcare organizations that want to address the behavioral health needs of their members more fully. We meet clients where they are in their journey by evaluating the status quo, identifying a tailored menu of appropriate and achievable options, and collaborating to implement evidence-based, industry best-practice approaches. Together, we can address behavioral health access, contracting, and reimbursement issues to support your strategies focused on ensuring timely access to quality behavioral healthcare for your members. Contact us.