[Senate Hearing 117-183]
[From the U.S. Government Publishing Office]
S. Hrg. 117-183
EXAMINING OUR COVID 19 RESPONSE:
USING LESSONS LEARNED TO ADDRESS
MENTAL HEALTH AND SUBSTANCE USE DISORDERS
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HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
FIRST SESSION
ON
EXAMINING THE RESPONSE TO COVID-19, FOCUSING ON USING LESSONS LEARNED
TO ADDRESS MENTAL HEALTH AND SUBSTANCE USE DISORDERS
__________
APRIL 28, 2021
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Printed for the use of the Committee on Health, Education, Labor, and
Pensions
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
46-763 PDF WASHINGTON : 2022
COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
PATTY MURRAY, Washington, Chair
BERNIE SANDERS (I), Vermont RICHARD BURR, North Carolina,
ROBERT P. CASEY, JR., Pennsylvania Ranking Member
TAMMY BALDWIN, Wisconsin RAND PAUL, M.D., Kentucky
CHRISTOPHER S. MURPHY, Connecticut SUSAN M. COLLINS, Maine
TIM KAINE, Virginia BILL CASSIDY, M.D., Louisiana
MAGGIE HASSAN, New Hampshire LISA MURKOWSKI, Alaska
TINA SMITH, Minnesota MIKE BRAUN, Indiana
JACKY ROSEN, Nevada ROGER MARSHALL, M.D., Kansas
BEN RAY LUJAN, New Mexico TIM SCOTT, South Carolina
JOHN HICKENLOOPER, Colorado MITT ROMNEY, Utah
TOMMY TUBERVILLE, Alabama
JERRY MORAN, Kansas
Evan T. Schatz, Staff Director
David P. Cleary, Republican Staff Director
John Righter, Deputy Staff Director
C O N T E N T S
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STATEMENTS
WEDNESDAY, APRIL 28, 2021
Page
Committee Members
Murray, Hon. Patty, Chair, Committee on Health, Education, Labor,
and Pensions, Opening statement................................ 1
Burr, Hon. Richard, Ranking Member, a U.S. Senator from the State
of North Carolina, Opening statement........................... 3
Witnesses
Benton, Tami D, M.D., Psychiatrist-in-Chief & Executive Director
and Chair of the Department of Child and Adolescent Psychiatry
and Behavioral Sciences, Children's Hospital of Philadelphia,
Philadelphia, PA............................................... 7
Prepared statement........................................... 8
Summary statement............................................ 12
Goldsby, Sara, MSW, MPH, Director, South Carolina Department of
Alcohol and Other Drug Abuse Services, Columbia, SC............ 12
Prepared statement........................................... 15
Summary statement............................................ 30
Keller, Andy, Ph.D, President and CEO & Linda Perryman Evans
Presidential Chair, Meadows Mental Health Policy Institute,
Dallas, TX..................................................... 31
Prepared statement........................................... 33
Summary statement............................................ 48
Muther, Jonathan, Ph.D, Vice President of Medical Services-
Behavioral Health, Salud Family Health Centers & Clinical
Integration Advisor, Eugene S. Farley, Jr. Health Policy
Center, Commerce City, CO...................................... 49
Prepared statement........................................... 50
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.
Kaine, Hon. Tim:
Breen Coalition letter in support of the Dr. Loma Breen
Health Care Provider Protection Act........................ 84
ACP Statement for the Record................................. 86
Pew Charitable Trust letter on Examining the Response to
COVID-19: Using Lessons Learned to Address Mental Health
and Substance Use Disorders................................ 93
EXAMINING OUR COVID-19 RESPONSE:
USING LESSONS LEARNED TO ADDRESS
MENTAL HEALTH AND SUBSTANCE USE DISORDERS
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Wednesday, April 28, 2021
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The Committee met, pursuant to notice, at 10:02 a.m., in
room 430, Dirksen Senate Office Building, Hon. Patty Murray,
Chair of the Committee, presiding.
Present: Senators Murray [presiding], Casey, Murphy, Kaine,
Hassan, Smith, Rosen, Lujan, Hickenlooper, Burr, Collins,
Cassidy, Braun, Marshall, Scott, Romney, and Tuberville.
OPENING STATEMENT OF SENATOR MURRAY
The Chair. Good morning. The Senate Health, Education,
Labor, and Pensions Committee will please come to order.
Today we are holding a hearing on our Nation's mental
health and substance use disorder crisis and how COVID-19 has
made them worse. Ranking Member Burr and I will each have an
opening statement, and then we will introduce today's
witnesses. After the witnesses give their testimony, Senators
will each have 5 minutes for a round of questions.
Before we begin, I, again, want to walk through the COVID-
19 safety protocols that are in place today. We will follow the
advice of the Attending Physician and the Sergeant at Arms in
conducting this hearing. We are all, again, very grateful to
our Clerks and everyone who has worked really hard to get this
set up and help everyone stay safe and healthy.
Committee Members are seated at least 6 feet apart, and
some Senators are participating by video conference. And while
we are unable to have the hearing fully open to the public or
media for in-person attendance, live video is again available
on our Committee website at help.senate.gov. And if you are in
need of accommodations, including closed captioning, you can
reach out to the Committee or the Office of Congressional
Accessibility Services.
This pandemic has taken a devastating toll. It has forced
millions of people out of work and students out of school. It
has taken over 570,000 of our loved ones, and the loss, the
stress, the loneliness, the trauma it has caused is doing
immense harm to our mental health. And it has been especially
hard on our essential workers, healthcare workers, and others
on the front lines of this crisis. Around half of the adults in
our Country say the stress and worry of this pandemic has
impacted their mental well-being.
When it comes to our youth, what I am hearing from people
in my state is incredibly alarming. Seattle Children's Hospital
in Washington State is seeing 170 children with mental health
emergencies a week, compared to 50 before the pandemic.
Sacred Heart Children's Hospital in Spokane saw admissions
to its adolescent psychiatric unit and admissions to its
pediatric floor for behavioral health issues both rise by
around 70 percent.
Mary Bridge Children's Hospital in Tacoma has seen mental
health admissions increase by two-thirds.
Central Washington Hospital saw a similar increase in non-
fatal suicide attempts for minors, and suicides rates in King
County are up 30 percent for youth.
When it comes to the issue of substance use disorder, a
record 87,000 people, at least, are estimated to have died from
drug overdoses in our Country over the last year. Overdose
deaths in my state increased by 38 percent over the first half
of 2020, with the biggest increases being among Black, Latino,
and Tribal communities.
We must do more to address the tragic loss of life, as well
as the terrifying effects we are learning COVID can have on
mental health, with one study suggesting one-third of patients
received a neurological or psychological diagnosis after their
infection.
The challenge is not just that more people need mental
healthcare in the wake of this pandemic. It is that too many
people cannot get it. One-third of adults who say the pandemic
has impacted their mental health also say there was a time this
past year they did not get the mental healthcare they needed,
most often because they could not afford it or they could not
find a provider. And over half of high-risk children are not
getting the mental healthcare they need, with the care furthest
out of reach for Black children.
Of course, while these are serious problems, they are not
new ones. Even before this pandemic, we were fighting epidemics
of suicide, mental health issues, drug overdoses, with a health
workforce that was stretched far too thin. Almost 120 million
Americans live in areas with a mental healthcare provider
shortage, essentially meaning they do not even have one mental
healthcare provider per 30,000 people.
In Washington, our mental healthcare workforce is only able
to meet 12 percent of our state's needs, and these challenges
are especially hard on communities of color and rural
communities, who often struggle the most to get mental
healthcare.
As we work to recover from this pandemic and rebuild our
Nation stronger and fairer, it is important we recognize mental
health as a priority in our work. We have to address the unseen
scars of trauma, depression, addiction, and other mental health
issues. And, the reality is that healing those scars will not
be quick or easy. It will take years, and we need to act
accordingly.
When we passed the SUPPORT Act in 2018 to respond to the
opioid crisis, I made clear it was only a first step and that I
would be pushing for more action and more funding. This
pandemic is a painful reminder that our work remains far from
finished.
We need to make significant investments in programs that
already exist to help our communities fight mental health
issues and substance use disorders.
We need to make dedicated annual investments in our public
health infrastructure and the local health departments on the
front lines of these fights.
We need to make it easier for people to get the care they
need by taking steps like President Biden announced yesterday
to increase access to opioid use disorder treatment, and by
looking at how to best use new tools, like telehealth, to reach
more patients while ensuring quality and equity.
Steps Congress took in the CARES Act to temporarily expand
access to telehealth services have made it easier for patients
to get mental healthcare quickly, discretely, and conveniently.
But, we cannot let the promise of telehealth be limited by a
lack of access to broadband, especially in our rural
communities and communities of color, and a lack of mental
healthcare professionals to keep up with the demand for that
care.
We must also remember that telehealth is no replacement for
making sure people have quality, affordable providers in their
own communities, which is why we need to recruit, train, and
retain enough mental healthcare professionals to actually meet
our Nation's needs and make sure they practice in underserved
communities.
I hope we will be able to work in a bipartisan way to
tackle these challenges.
Finally, any good doctor knows you cannot just treat the
symptom; you have to look at the root causes. We need to help
people get the care they need for stress and anxiety and
depression and more. But, we also need to address the issues
that have caused so much pain this past year, and that includes
not only the pandemic, but systemic racism, gun violence, and
an economy that works great for those at the top, but it does
not work well for anybody else.
I look forward to the work our Committee can do on these
issues, and mental health and substance use disorders. We have
a record of bipartisan work on some of this already, and I am
going to continue to press for action.
With that, I will recognize Ranking Member Burr for his
opening remarks.
OPENING STATEMENT OF SENATOR BURR
Senator Burr. Well, thank you, Madam Chair, and I thank you
for holding this hearing today.
Over the last year, we put in place measures to slow the
spread of coronavirus. This new virus quickly escalated from an
outbreak in China to a pandemic that has challenged countries
around the world, including the United States. While these
measures were put in place to ensure our health system could
weather the storm, these measures in the pandemic have in many
ways asked so much of Americans.
Families with critically ill and dying loved ones have not
been able to visit their parents, grandparents, and siblings,
instead, saying goodbye over video. This has compounded the
grief for so many and taken a tremendous toll on healthcare
professionals.
Sacrificing simple acts, like hugging our family members,
neighbors, and feeling a sense of purpose when we walk into the
office every day have consequences on our mental health.
A year of sitting 6 feet apart, canceling weddings,
holidays, adjusting to remote school has had an effect on the
well-being of every American. We must continue to examine these
effects as part of our review of the COVID response.
Our current surgeon general has written a lot about the
effects of loneliness. He has explained that this lack of human
connection can lead to depression, anxiety, and chronic
conditions, like heart and dementia.
It is no surprise to me that after a year of being apart,
we are seeing the heartbreaking effects of separation and
sacrifice. Prior to the pandemic, experts estimated that one in
four adults in the United States had a mental health disorder,
and we were also in the midst of responding to an opioid
crisis.
The need to respond to these challenges continued during
COVID-19. Reaching people and providing care required
innovative approaches from doctors, nurses, and other
healthcare providers all around the Country. I look forward to
hearing about those solutions from our witnesses today.
We are a resilient Country. I believe that the most
important action we can take to help people is to reopen as
much of the Country as quickly and safely as possible. Bring
back hope to the American people. Let neighbors celebrate
birthdays and milestones, and let students see and interact
with their peers.
My State of North Carolina is taking an important step in
this process, announcing plans to lift COVID restrictions on
June 1 if our metrics continue to show the progress against the
virus that it has to date. Vaccinations are a key metric.
We have got to look at the next few weeks and months down
the road to address the next phase of response--getting more
shots in arms. The return of the Johnson & Johnson vaccine is
an important part. And I am glad that CDC and FDA finally
reaffirmed the safety and efficacy of that shot, but I am
worried about the ham-handed way they handled it. This has led
to even more vaccine hesitancy than before. Americans should
know that the benefits of using the vaccine far outweigh the
potential risk.
Now, with 37 percent of adults fully vaccinated, we are
seeing the demand slow. So, painting a picture of benefits of
all three vaccines--Pfizer, Moderna, and Johnson & Johnson--
will be important to driving down our infection rate and
improving our chances of a recovery.
Getting back to work is a big part of that picture, and we
cannot do that until children are in daycare or in school.
The reopening of our restaurants, our ballparks, and small
business mean more opportunities for Americans to return to
activities they love, but it also means more jobs and more
opportunities to restore their livelihoods.
We invited the witnesses here today because they have seen
the mental health effects of the pandemic and the response in
their communities firsthand, but also because they have raised
their hands with local solutions. I look forward to hearing
about those local solutions today and how they can help to
accelerate our Country's broader recovery from COVID.
Our message and the message of this Administration should
be that we are willing to have teachers and students back in
classrooms safely this fall; that Main Street is open; that
Thanksgiving plans are on the books; and that this summer, you
can even attend a ball game with certain precautions. Even if
things look a little different, life can almost become normal.
I thank the chair.
The Chair. Thank you, Senator Burr.
We will now introduce today's witnesses, starting with
Senator Casey, who will introduce Dr. Benton.
Senator Casey. Thank you, Chair Murray.
I am pleased to introduce Dr. Tami Benton and grateful for
the expertise that she brings to this hearing today. In
addition to her decades of service caring for children and
families in my home State of Pennsylvania, Dr. Benton is
Psychiatrist-in-Chief and Chair of the Department of Child and
Adolescent Psychiatry and Behavioral Sciences at America's
first pediatric hospital--The Children's Hospital of
Philadelphia, more commonly known at CHOP.
She also directs the Child and Adolescent Mood Program and
the Youth Suicide Center at the Perelman School of Medicine at
the University of Pennsylvania.
Her clinical and research expertise focuses on pediatric
depression, suicide, and anxiety, particularly for minority
youth and those with chronic diseases.
She also has developed expertise on the crisis of our
mental health workforce shortage and potential solutions.
We want to thank Dr. Benton for all that you and your team
have done to meet the increased needs of families during this
pandemic and for sharing your insights with us today. Welcome
to the hearing.
The Chair. Thank you, Senator Casey.
Dr. Benton, glad to have you here with us today, or here on
video today with us.
Now, Senator Scott will introduce Dr. Goldsby.
Senator Scott. Thank you, Madam Chair, and thank you to all
the witnesses for being here with us today.
It is my privilege to introduce Sara Goldsby, who serves as
the Director of South Carolina's Department of Alcohol and
Other Drug Abuse Services. Having led the agency since 2016, in
her current role, Ms. Goldsby oversees the state's opioid
responsive efforts, co-chairing the State Opioid Emergency
Response Team. Her agency has played a pivotal role in
combatting the opioid crisis, particularly as the COVID-19
pandemic has exacerbated some of its most troubling effects.
As the virus and related restrictions escalated, mental
health challenges and substance use disorders, the department
responded decisively and comprehensively, supporting telehealth
service delivery and promoting virtual education and outreach,
in addition to ramping up naloxone distribution in order to
address emergency overdoses.
Through a wide range of initiatives, partnerships, and
localized solutions, the department has served as a vital asset
and a national model, particularly in recent months.
In recognition of Ms. Goldsby's exceptional work at the
department, she received the 12th Annual Ramstad/Kennedy Award
for Outstanding Leadership, among other accolades.
Thank you, Ms. Goldsby, for your service to South Carolina,
and thank you for participating in this crucial conversation. I
look forward to your testimony.
The Chair. Thank you very much, Senator Scott.
Dr. Goldsby, welcome. We look forward to your testimony.
Next, I am pleased to welcome Dr. Andy Keller. Dr. Keller
is the President and CEO and Linda Perryman Evans Presidential
Chair of Meadows Mental Health Policy Institute in Dallas,
Texas. And, he is also a licensed psychologist with more than
20 years of experience in behavioral health policy.
Dr. Keller, welcome.
He also said, told me this morning, that his family is from
my home state. So, we are especially glad to have you here
today, Dr. Keller. Welcome.
Next, I will turn it over to Senator Hickenlooper to
introduce Dr. Jonathan Muther.
Senator Hickenlooper Thank you Chair Murray and Ranking
Member Burr for inviting me to introduce Dr. Jonathan Muther to
testify today.
Dr. Muther is from the great State of Colorado, of course,
where he is Vice President of Behavioral Health at Salud Family
Health Centers in Fort Lupton, Colorado. He practices at the
Commerce City Salud Clinic. Salud Family Health Center is one
of my favorite organizations in Colorado, a federally qualified
health system with 13 community health clinics in eight
counties in Colorado, doing critical work all the time.
Dr. Muther serves as a Clinical Integration Advisor at the
Eugene Farley Health Policy Center at the University of
Colorado.
Dr. Muther's specialty is integrated primary care.
Psychology is also involved in direct patient care training and
supervision, as well as program development and evaluation.
And, as you will all see today, he is passionate about advocacy
for healthcare policy change. His primary areas of interest are
working with traditionally underserved communities by improving
access to existing systems and working with the Spanish-
speaking population.
Dr. Muther is also committed to addressing life stress and
the full spectrum of mental illness, behavioral interventions,
and evaluating health outcomes.
I am really delighted that Dr. Muther could be with us
today to discuss these critically important issues around
behavioral health, and particularly among kids and underserved
communities across Colorado and across the Country.
Thank you, Chair Murray, Ranking Member Burr, and all the
Members of the Committee. I am really looking forward to the
hearing today.
The Chair. Thank you, Senator Hickenlooper.
Thank you Dr. Muther for joining us today.
Thank you to all of our witnesses for taking the time today
to share your experiences with all of us.
With that, we will begin your testimony. Dr. Benton, let's
start with you. You may begin with your opening statement.
STATEMENT OF TAMI D. BENTON, M.D., PSYCHIATRIST-IN-CHIEF AND
EXECUTIVE DIRECTOR AND CHAIR OF THE DEPARTMENT OF CHILD AND
ADOLESCENT PSYCHIATRY AND BEHAVIORAL SCIENCES, CHILDREN'S
HOSPITAL OF PHILADELPHIA, PHILADELPHIA, PA
Dr. Benton I would like to thank Chair Murray, Ranking
Member Burr, and distinguished Members of the Committee for
this opportunity to share my knowledge about what is happening
in the crisis of children's mental health right now from my
boots-on-the-ground perspective.
As Chair Murray mentioned, there has been a crisis of
children's mental health for some time, but the pandemic has
made it all much worse. Just recently, I was called to our
emergency department to see a youngster whose family had
arrived, expressing concerns about her suicidal ideation and
threats to run into traffic to end her life. But, I was very
surprised when I arrived to find that this youngster was only 5
years old. And when I asked her what she thought would happen
when she died, she responded that, I will come back tomorrow
and I will be a good girl, and my parents will be happy again.
This was a family where the parents had recently lost their
employment through COVID-19. The mother was struggling with
depression. A previously resilient family, who were just
stressed by the demands of this pandemic, unable to provide
care for their own youngster.
But, even more disturbing to me was my inability to provide
an appropriate avenue for care for this youngster and her
family. There were no inpatient or outpatient options available
for her care that I could find. There was no place for this
youngster and their family to receive the care that they
deserved. My options were to place this child in an inpatient
pediatric medical facility, but an inpatient bed, as the only
avenue for keeping her safe and providing an opportunity for
reuniting with her family.
The option that I provided for her maintained safety, but
did not provide the care that she needed and prevented other
children from having a medical bed that was desperately needed
during that time.
I wish that I could say that this story was an uncommon
one, but it is increasingly common in our emergency
departments. We are seeing surges in volumes with young
people--30 to 50 percent increases in our own facilities,
similar to those that Chair Murray described, with young people
who previously had no mental health conditions appearing now
with concerns about depression, anxiety, eating disorders, and
suicidal ideation and behavior.
The stories around disposition and placement, where can
kids go for treatment, sometimes require that we are
transporting them across state lines to receive the care that
they deserve.
I must admit, at times, these challenges seem very
overwhelming, but I know that there are solutions to these
problems.
First, telehealth has provided an opportunity for us to
reach populations across the United States, minoritized
populations and rural populations, previously vulnerable due to
access to care. We should continue to support the opportunities
for providers to provide care across state lines so young
people can receive care where they need it.
There is also opportunities for us to continue to support
care in the community so our community mental health programs,
our primary care practices, school mental health, places where
children can receive their care in their communities, with
their families, where they belong.
Other opportunities for us are opportunities to support a
continuum of care so that young people, like the five-year old
I described, would be able to get the outpatient or intensive
outpatient or day hospital or acute inpatient treatment that
she deserved in an appropriate facility. And, our payment
structures must be aligned to provide families to have access
to these levels of care.
I believe that if we--finally, I want to mention the other
topic that Chair Murray mentioned, which was the shortage of
providers, which is a longstanding challenge in mental health.
So, we know that there is an estimate of about 15 million
children who are requiring mental health services. There are
about 8 to 9,000 child psychiatrists to serve the most severely
impacted, but there are shortages of psychologists, social
workers, nurse practitioners, nurses, community mental health
workers who could address some of the need. And loan
forgiveness would allow these professionals to remain in the
workforce to provide this care.
I believe that if we approach these solutions together, the
result will be that young people can stay in their communities
where they receive their care, where we can do prevention
before things become a crisis. If we are successful, children
will be treated in their communities, in their homes, with
their families and their friends, in their schools, where they
belong.
We do know that we anticipate--we do know from the data
that we are collecting thus far that we anticipate the impacts
of this pandemic to far exceed the time period by which we
actually get control over this virus. But, we have
opportunities to be prepared. If we plan together, if we
implement the solutions recommended, we will be able to prevent
severe illness and protect the mental health of young people in
our Nation.
Thank you.
[The prepared statement of Dr. Benton follows:]
prepared statement of tami d. benton
Chair Murray, Ranking Member Burr, and Members of the Committee:
My name is Dr. Tami Benton. I am Psychiatrist-in-Chief and Chair of
the Department of Child and Adolescent Psychiatry and Behavioral
Sciences at Children's Hospital of Philadelphia (CHOP) and the
Frederick Allen Professor of Psychiatry at the Perelman School of
Medicine at the University of Pennsylvania. I also serve as director of
the Child and Adolescent Mood Program and the Youth Suicide Center at
CHOP, a multidisciplinary clinical and research program focused on
depression and suicide among children and adolescents, with an emphasis
upon minority youth. Thank you for the opportunity to testify today
about the effects the COVID-19 pandemic has had on the mental health of
our children and youth.
Children's Hospital of Philadelphia (CHOP) was founded in 1855 as
the Nation's first pediatric hospital. Through its long-standing
commitment to providing exceptional patient care, training new
generations of pediatric healthcare professionals, and pioneering major
research initiatives, Children's Hospital has fostered many discoveries
that have benefited children worldwide. Its pediatric research program
is among the largest in the country. In addition, its unique family
centered care and public service programs have brought the 595-bed
hospital recognition as a leading advocate for children and
adolescents.
The Department of Child and Adolescent Psychiatry and Behavioral
Sciences at CHOP provides emotional and behavioral health services for
infants, children and teens. Our experts conduct thorough evaluations
with all patients and use a biopsychosocial model to identify
biological, environmental, psychological and academic factors that
contribute to a child's condition. We focus on the experience of your
whole family by involving everyone in the evaluation process and care
planning, and conduct research focusing on all aspects of mental,
emotional and behavioral health, including efforts focused and
preventing a child with elevated symptoms moving into crisis.
There were extreme shortages in pediatric behavioral health prior
to the pandemic and access to care was further complicated by high
demand and complicated payor networks. It is estimated that 1 in 6 U.S.
children between ages 2-8 years have a diagnosed mental, behavioral or
developmental disorder. \1\ Unfortunately, COVID-19 has exacerbated the
mental health stress on children and youth, highlighting the Nation's
acute shortage of mental health services and the need to reinforce and
expand the pediatric mental health delivery system and infrastructure.
According to a November 2020 report by the CDC, between March and
October 2020, the number of mental health visits for adolescents ages
12 to 17 was 31 percent higher than over the same period in 2019; for
children ages 5 to 11, it was up 24 percent.
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\1\ Cree RA, Bitsko RH, Robinson LR, Holbrook JR, Danielson ML,
Smith DS, Kaminski JW, Kenney MK, Peacock G. Health care, family, and
community factors associated with mental, behavioral, and developmental
disorders and poverty among children aged 2-8 years--United States,
2016. MMWR, 2018;67(5):1377-1383.
The pandemic also has highlighted significant disparities related
to access to mental health services, particularly in underserved
communities. Studies show the limitations of the current system is
affecting all children, but minority children, particularly Black and
Hispanic children often face inequitable access to and continuity of
care. As a result, these children are more likely to present in the
emergency rooms for mental health issues and less likely to access
child and adolescent psychiatrists and other mental health
---------------------------------------------------------------------------
professionals in the community.
Emerging data about long term impacts of the pandemic on children's
mental health suggest that we will continue to see the heightened
impact on youth mental health for some time. Like other children's
hospitals, CHOP is seeing increasing numbers of children and families
coming to the emergency department (ED) in crisis. Our psychiatric
emergency visits have increased by 60 percent over the last few years.
Since the onset of the pandemic, more than 30 percent of our ED visits
are resulting in hospitalizations for psychiatric treatment. When the
pandemic struck, we Initially saw an overall decline in emergency
department visits due to COVID-related restrictions, but we are now
seeing a surge of children and adolescents coming to the ED. These
patients come to us at a greater level of acuity, requiring more
immediate, intensive treatments as well as hospitalizations. Those
impacted the most have been youth with autism and other
neurodevelopmental disabilities, as well as those with depression,
anxiety and eating disorders.
Many of the children that we are seeing were managing well in their
communities before the pandemic, receiving care in their local mental
health agencies, schools and primary care offices but are now
presenting for emergency care due to worsening symptoms. We are also
seeing some shifts in the ages of young people who are seeking mental
health treatment. More children between the ages of 6-12 years are
complaining of severe anxiety, depression and suicidal feelings. We are
also starting to see large numbers of children and adolescents who had
no prior mental health concerns showing up in the emergency department
in larger numbers due to disruptive behaviors, anxiety, depression,
suicidality and eating disorders. Families who were resilient and
effective before the pandemic are struggling to manage children's
emotions while facing remote learning, work-related changes and their
own emotions during these times.
Even before COVID, the shortage of options, particularly across the
continuum of care, were staggeringly limited. It is, in fact, hard to
overstate this concern. One clear indicator is that we and other
children's hospitals nationwide often are forced to send children
covered by Medicaid several states away so they can access appropriate
care not available closer to home. Needless to say, this separation
from family, community and regular health care providers is
inadvisable.
The increased stress experienced by families during the pandemic
occurred at the same time that mental health services became more
limited because of COVID-related restrictions on access to hospitals
and primary care clinics. Requirements for social distancing, as well
as COVID outbreaks among staff and children in these facilities,
reduced capacity even further. These challenges increased the demand
for emergency and crisis services such as inpatient psychiatric
settings as lower levels of care were unavailable, even to those
children for whom another setting would have been more appropriate.
One important but unforeseen outcome has been that children with
mental health concerns are being admitted to pediatric medical
facilities while awaiting psychiatric inpatient care and treatment.
This is not only contrary to the treatment for that child but also
nearly always means they are in a bed that a sicker child needs. If the
system were not overloaded, specifically designated crisis centers
would provide evaluation and placements for children and youth in
mental health crisis. Now, families turning to these centers can find
themselves waiting, sometimes for days, to have any assessment, let
alone an appropriate care placement. Many of these families
understandably go to the ED instead. As a result, at CHOP, where 95
percent of the behavioral health care is provided in outpatient
settings, we have up to 50 patients waiting for mental health beds on
any given day. As we typically operate at capacity, this means that we
cannot use that space for a child with more complex medical needs.
To address this, we are in the process of expanding our services in
the hospital and our community. Even doubling our outpatient capacity,
partnering with other providers to address the full continuum of needs
and looking into establishing in-patient capacity, does not fully meet
the demand for care. While not the primary problem, regulatory hurdles,
including the restrictions on the colocation of adult and pediatric
services make it difficult to collaborate with other providers to use
existing space to meet the ever-growing needs of our community.
Recommendations
The good news is that there have been lessons learned during the
pandemic that will help advance children's mental health care going
forward. We recommended retaining those things that have effectively
supported access to care, while addressing other issues that have been
long-standing.
First, care provided in communities through schools and primary
care clinics provides the opportunity for early identification and
intervention for children and families with mental health challenges at
the right level and at the right time. We must invest in care in these
settings as the continuity of relationships between children, families,
care providers and educators helps address mental health challenges
before they become crises. Effective families and effective schools are
two of the most important elements for building resilience, prevention
of poor mental health outcomes and promotion of effective,
psychologically healthy children.
Second, we strongly recommend making permanent the telehealth
flexibilities allowed during the pandemic, particularly those that
would allow providers, including Medicaid providers, to care for
patients across state lines. Bills like the Temporary Reciprocity to
Ensure Access to Treatment (TREAT) Act, which would provide temporary
licensing reciprocity for health care professionals for any type of
services provided to a patient located in another state during the
COVID-19 pandemic, can help us serve patients wherever they are
located, and we encourage Congress to pass that legislation.
Telehealth has significantly advanced our ability to reach more
patients and to engage them in treatment. CHOP providers have completed
more than 238,000 telehealth video visits with over 108,000 unique
patients since the onset of the pandemic. The departments utilizing
telehealth most frequently are general pediatrics (46,000 visits) and
behavioral health (44,000 visits). Through telehealth, patients have
been able to receive care in their homes, preventing the travel time
and costs. While in-person visits are still required, the expansion of
telehealth services has enabled us to reach more youth and families,
made it easier for them to participate in care, expanded our reach to
vulnerable underserved populations and increased families' abilities to
keep their appointments, which, in turn, helps us maximize the limited
resource that is mental health service providers.
Telehealth has been a boon in other ways. Notably, it has allowed
increased family engagement and participation, empowering and
supporting families to be able to support their children's emotional
health. Clinicians can also provide expertise for areas of severe
shortages by consulting with community clinicians via telehealth as
well as school psychologists and counselors. Areas with severe
shortages of mental health clinicians can utilize consultations with
clinicians in areas where there are more providers with appropriate
expertise, if we can ensure that there is broadband access for rural
and other underserved areas to make such collaboration accessible.
Behavioral telehealth provides so many advantages to children,
families and providers that it should be a not only permitted but
required in Medicaid programs. Also, to allow for appropriate sharing
of health information between school psychologists and a student's
external health team and thereby maximize coordination among
caregivers, educators and families, it will also be important to
harmonize the education and health care privacy standards. \2\
---------------------------------------------------------------------------
\2\ The Health Insurance Portability and Accountability Act
(HIPAA) and the Family Education Rights and Privacy Act (FERPA) have
differing privacy standards, limiting information sharing and creating
barriers to care.
Third, we must address workforce challenges. According to the
American Psychiatric Association, there are an estimated 15 million
children and adolescents nationwide in need of care from mental health
professionals. However, there are just 8,000 to 9,000 psychiatrists
treating children and teenagers in the United States, and shortages
abound across other pediatric mental health professionals as well.
There are severe shortages of child and adolescent psychiatrists,
impacting care for youth with the highest levels of need. But there are
also shortages of mental health therapists, nurse practitioners, case
managers and community mental health workers who are all needed to
expand access to mental health care. All of these professions could
benefit from loan forgiveness programs to incentivize participation in
---------------------------------------------------------------------------
these fields.
But efforts to strengthen the pediatric behavioral health workforce
must go beyond attracting new mental health providers at all levels to
include cross-training current providers. Improvements could include
broadening the skills of the primary care workforce, ensuring school
psychologists use evidence-based techniques, properly training psych
techs and psychiatric nurses, as well as adding many more licensed
clinical social workers to the workforce.
Finally, we must advocate for changes to payment structures that
support the full continuum of care necessary to address the mental,
emotional and behavioral distress our children face. Getting this right
will mean children receive the care they need at the appropriate level,
maximizing the likely success of the treatment, ensuring that they are
taking a higher acuity spot desperately needed by another child, and
more wisely spending health care dollars.
Greater payment parity in Medicaid for mental, emotional and
behavioral health services, would make it possible to resource the
continuum of care our children and youth need, such as intensive
outpatient, partial hospitalization and limited residential treatment
facilities--and, importantly, bring that care closer to home.
An investment in earlier treatment is also needed. In particular,
we must continue to improve access to care in the community through
schools and primary care in order to identify mental and behavioral
health problems early, before crises emerge. If we prevent a crisis, we
not only improve the health of our Nation's children, but also decrease
unnecessary utilization of costly services.
Improvements in these areas would improve the care of our Nation's
children, empower families and schools to promote the emotional health
of our children, provide the right level of care to those in need, and
reduce unnecessary utilization of costly emergency and hospital
services.
Children throughout America are in crisis. Unlike many physical
illnesses, mental health illnesses are not often visible to the
untrained eye. While conversation about mental health is becoming more
comfortable, there are still many children and their families who need
help but choose to stay silent for fear of embarrassment. By elevating
the dialog here, in Congress, and providing the resources they need,
you can help us treat these children and provide them with a pathway
toward resilience and happiness.
______
[summary statement of tami benton]
There were extreme shortages in pediatric behavioral health
services prior to the pandemic. Unfortunately, COVID-19 has exacerbated
these shortages. The increased mental health stress on children and
youth has brought a spotlight on the Nation's acute shortage of mental
health services and highlighted significant disparities related to
access to mental health services, particularly in underserved
communities. The need to reinforce and expand the pediatric mental
health delivery system and infrastructure is now overwhelming.
Similar to other children's hospitals across the country, we are
seeing increasing numbers of children and families coming into the
emergency department in crisis. While there has been an increase over
the past 2-3 years, the numbers have severely escalated during the
pandemic. In particular, we have experienced surges in the volumes of
children and families who are presenting for emergency care, including
those who had previously received care in their schools or local
pediatric care facilities. This increased demand for mental health
treatment coupled with the pre-existing shortages of trained mental
health professionals has only worsened the barriers to access for
children, adolescents and their families seeking mental health care.
Despite the challenges imposed by the pandemic, there were
successes in our efforts to increase access to care for children and
families. Flexibilities that allowed rapid telehealth expansion
provided access to care that did not exist before the pandemic. Using
these new capabilities, we were able to reach populations of youth and
their families to provide care while families could not leave the
safety of their homes. We were also able to provide education for
families and teachers using telehealth for psychoeducation sessions,
better arming them to address children and adolescents' challenges.
Since the initiation of telehealth services, we have been able to reach
more youth and families, both making it easier for them to participate
in care and increasing our rates of families keeping their
appointments, which helps us better utilize the too limited mental
health workforce.
The past year has provided us with important lessons to draw from
as we seek to advance children's mental health care. Going forward we
must work to strengthen care provided in communities through schools
and primary care clinics; make permanent the telehealth flexibilities
allowed during the pandemic, particularly those that would allow
providers, including Medicaid providers, to care for patients across
state lines; address workforce challenges by attracting new mental
health providers and cross-training current providers; continue to
support parents and educators of children with mental and behavioral
health issues; and work to improve payments structures and
reimbursement for pediatric providers.
______
The Chair. Thank you, Dr. Benton.
Dr. Benton. Thank you.
The Chair. We will turn now to Dr. Goldsby.
STATEMENT OF SARA GOLDSBY, MSW, MPH, DIRECTOR, SOUTH CAROLINA
DEPARTMENT OF ALCOHOL AND OTHER DRUG ABUSE SERVICES, COLUMBIA,
SC
Ms. Goldsby. Thank you. I would like to thank and
acknowledge Senator Scott for the gracious introduction. We are
proud and grateful here for his work in Washington.
Chair Murray, Ranking Member Burr, and Members of the
Committee, my name is Sara Goldsby, and I serve as Director of
South Carolina Department of Alcohol and Other Drug Abuse
Services. I also serve as Vice Chair of the Public Policy
Committee of the National Association of State Alcohol and Drug
Abuse Directors, or NASADAD. It is a privilege to join you
today.
First, thank you for your leadership on substance use
disorder issues. We appreciate your work on CARA, the 21st
Century Cures Act, the SUPPORT Act, along with historic
investments in SAMHSA and its Substance Abuse Prevention and
Treatment, or SAPT Block Grant.
The COVID-19 pandemic has exacerbated substance use
disorders, and in our state, like all others, we have certainly
felt the impact.
We saw a 27 percent increase in alcohol sales for the
period of March 15 to June 30, 2020 when comparing the same
months during the previous years.
From April to June of last year, calls to our department's
help line seeking help for substance use disorder services
spiked anywhere from 25 to 35 percent.
Provisional mortality data from the CDC predicts 1,625
South Carolinians died of drug overdose during a 12-month
period ending in September 2020. That represents a 45.3 percent
increase over the same period in 2019. Over 62 percent of those
predicted overdose deaths were attributed to illicitly made,
synthetic opioids, including Fentanyl.
When the pandemic hit, our department knew we had to take
action, and we did. We transitioned to support telehealth
service delivery for crisis management, individual
psychotherapy, case management, and other services delivered
virtually or by phone.
We allocated state funds to providers to purchase cell
phones and data plans for those patients in need.
We partnered with our Department of Mental Health to market
and launch the SC-HOPES line, a toll-free line open 24/7 for
callers to access licensed mental health and addictions
counselors.
With the help of SAMHSA and DEA, we authorized 14-day and
28-day take-home doses of methadone for all of the nearly 7,000
patients in our state who were stable in treatment.
We shipped between 6,500 and 7,000 boxes of Narcan to our
community distributors, including recovery community
organizations. We also unveiled the 1, 2, Breathe public
education campaign to demonstrate the effectiveness,
availability, and accessibility of Narcan.
We initiated the Pause Campaign to encourage parents to use
this unprecedented pause in our daily lives to talk with their
kids about the risks and dangers of prescription drugs.
We used drive-thru events and food distribution programs to
share Deterra packets for safe medication disposal.
We distributed educational materials on the importance of
prevention.
We worked with our recovery community organizations, as
well, to support the transition of peer recovery services to
virtual formats.
In sum, we implemented an array of initiatives across the
continuum to serve those struggling with or at risk for
substance use disorders.
Now I would like to offer a few recommendations. First,
please work to ensure that Federal policy initiatives and
Federal funding for substance use disorders flows through state
alcohol and drug agencies. This approach will ensure effective
planning, implementation, oversight, and accountability. State
alcohol and drug agencies ensure evidenced-based practices and
quality through standards of care and technical assistance to
providers.
Second, we recommend a transition over time from drug-
specific grants to continued investments in SAMHSA's SAPT Block
Grant. While we are incredibly grateful for the opioid-specific
funds directed to state alcohol and drug agencies, such as the
State Opioid Response Grant, states would benefit from more
flexibility to address all substances of concern.
Third, we recommend maintaining a number of the
flexibilities that accompany the Public Health Emergency
Declaration. We hope that each category can be studied with an
eye on permanent changes for those found to be effective.
Fourth, please maintain a strong SAMHSA. We believe SAMHSA
should be the default agency for all Federal substance use
disorder programming. We appreciate the work of Tom Coderre,
SAMHSA's Acting Assistant Secretary, and we fully support
President Biden's recent nomination of Dr. Miriam Delphin-
Rittmon, Connecticut's State Director and NASADAD member, to
serve as the permanent leader of SAMHSA.
Fifth, we hope resources could be provided to states to
support recovery housing, broadband, and hardware and software
needed to ensure all have access to critical services.
Finally, we hope this Committee will consider the work done
in CARA 3.0, which was introduced by Senators Whitehouse,
Portman, and others. We appreciate, for example, Section 211 of
that bill that would create a grant program within SAMHSA to
help states bolster their primary prevention workforce.
Again, thank you for the opportunity to join you today, and
I will be happy to answer your questions.
[The prepared statement of Ms. Goldsby follows:]
prepared statement of sara goldsby
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
[summary statement of sara goldsby]
Impact of COVID-19 on substance use disorders (SUD): The pandemic
has had a significant impact on the substance use disorder system in
South Carolina. From April-June 2020, the S.C. Department of Alcohol
and Other Drug Abuse Services (DAODAS) experienced a 25 percent-35
percent increase in call volume, primarily from family and friends
seeking services for someone in need of treatment. Additionally,
providers and recovery community organizations (RCOs) reported an
increasing number of stable patients and persons in recovery returning
to substance use. Suspected overdoses were 40 percent-50 percent higher
in South Carolina in 2020 than in 2019, and provisional data predicts a
45.3 percent increase in drug overdose deaths for the 12-month period
ending in September 2020 compared to the previous year.
Past-year actions by the S.C. Department of Alcohol and Other Drug
Abuse Services (DAODAS):
``Pause'' Campaign: Shared television and social
media messaging that encouraged parents to take advantage of
the fact that life had effectively ``paused'' to have
conversations with their children about the dangers of
prescription drugs.
Naloxone distribution: Shipped over 6,500 boxes of
Narcan to community distributors, and helped ensure that
individuals with methadone take-homes had naloxone on hand.
``1, 2, Breathe'' Narcan Campaign: Developed the
``1, 2, Breathe'' campaign to demonstrate the effectiveness,
availability, and accessibility of Narcan.
Innovative prevention outreach: Through school lunch
pick-up programs, food distribution programs, and drive-thru
events, local agencies distributed educational materials on
substance use.
Education Programs: Prevention staff adapted
evidence-based programs to deliver them virtually.
Worked with opioid treatment programs (OTPs)
providing methadone services to ensure that their emergency
plans were operationalized.
Issued press releases and social media messaging
regarding the availability of treatment services.
Supported telehealth service delivery for crisis
management, individual psychotherapy, peer support, case
management, and other services delivered either virtually or
telephonically.
Established the SC HOPES Support Line, a toll-free
line with 24/7 connection for callers to access licensed mental
health and addictions counselors by phone.
Housing for those with SUDs: Utilized Federal funds
to ensure housing continuity for individuals at risk of
eviction.
Recommendations:
Route Federal resources for SUD services through the
state alcohol and drug agencies to ensure a coordinated,
efficient, high-quality substance use disorder service delivery
system.
Gradually transition from opioid-specific resources
to the SAPT Block Grant to give states more flexibility to
address all substances of concern. Avoid adding other
substances to SOR's list of allowable use of funds to promote
the transition to the SAPT Block Grant for maximum efficiency.
Maintain SUD-related flexibilities at least 1 year
after the public health emergency to further evaluate their
impact.
Invest in technology and broadband to make telehealth
SUD services more accessible.
Continue support for workforce development, including
prevention workforce proposal in CARA 3.0 (Sec. 211).
Bolster the role of the Substance Abuse and Mental
Health Services Administration (SAMHSA) as the lead Federal
agency for SUD issues.
Maintain a Strong White House Office of National Drug
Control Policy (ONDCP).
______
The Chair. Thank you, Dr. Goldsby.
We will turn to Dr. Keller.
STATEMENT OF ANDY KELLER, PH.D., PRESIDENT AND CEO & LINDA
PERRYMAN EVANS PRESIDENTIAL CHAIR, MEADOWS MENTAL HEALTH POLICY
INSTITUTE, DALLAS, TX
Dr. Keller. Good morning, Chair Murray, Ranking Member
Burr, and Members of the HELP Committee. Thank you for the
opportunity to testify today. My name is Andy Keller, and I
lead the Meadows Mental Health Policy Institute, a Texas non-
profit committed to helping Texas and the Nation improve the
availability and quality of evidence-driven mental health and
substance use care through non-partisan, data-driven, and
equitable policy and program guidance.
For over a decade prior to the pandemic, every leading
indicator related to the pre-existing mental health and
addiction epidemics were worsening. Deaths from suicide,
overdose, and comorbid health conditions driven by mental
illness and addiction were at 20-year highs.
This long-standing epidemic was made worse by systemic
inequities for Black, indigenous, and other people of color
whose access to care was inequitably impeded by barriers of
language, culture, mistrust, and geographic proximity, in
neighborhoods where the jail or detention center was too often
closer than any clinic or hospital.
The pandemic has made all of this worse, as Chair Murray
described so well. Rates of death from overdose rose 33 percent
in 1 year nationally, approaching 90,000 lost, the highest
number ever recorded.
Indicators of depression increased four-fold, and the
number of people seriously considering suicide doubled.
Mental illness is the second leading driver of COVID-19-
related deaths, following only age. And, the effects of COVID-
19 worsen underlying inequities, taking the lives of four times
as many working-age Latino Texans, and leaving nearly 50
percent more Black children without a parent because of COVID-
19 than other children.
What is more, these effects will not end as the pandemic
recedes. They will increase in the months and years ahead,
which we have seen from other disasters.
Senators, I have one main lesson to share with you today
that COVID-19 taught us, and that is that if America pairs the
will to act with the necessary resources, our health systems
and researchers can defeat a novel disease by rapidly scaling
and delivering early detection, treatment, and prevention.
With the will and resources, we can do the same for mental
illness and addiction. In fact, it will actually be easier to
do for mental illness and addiction because we already know how
to successfully detect and treat these conditions.
At Meadows, we have modeled the universal access to just
two evidence-based treatments that could save almost 40,000
lives a year from suicide and overdose. This is the same
approach we used to turn the tide on heart disease and cancer
over the last generation.
In 1976, my grandfather died of a heart attack but was
resuscitated at Memorial Hospital in Yakima and sent home then
to begin his treatment with cholesterol-lowering diet and
medication. Twenty years later, I began my--that same
treatment. Decades before, any sort of risk like that for my
heart disease in primary care, and likely will never suffer
such a crisis that my grandfather did. Contrast this to the 20
years I waited to receive a diagnosis and successful treatment
for my anxiety disorder.
We made the shift from crisis-based care for heart disease
and cancer in a generation, and we did the same for COVID-19 in
less than a year. Now, we need to make the same commitment of
will and resources to universally detect, treat, and recover
from mental illness and addiction.
Last year, the Meadows Institute joined with 14 leading
mental health and addiction policy organizations to release a
unified vision for doing just that. And, over the last year, we
have made remarkable progress in Texas, scaling many of these
approaches.
We focus first on children. Mental illnesses are pediatric
illnesses. And, in 2020, Texas' 12 publicly funded medical
schools used $100 million to scale up universal access to child
psychiatry consultation in primary care, and urgent access to
psychiatric health, telehealth, in Texas schools, achieving
statewide reach in less than a year, engaging almost 5,000
primary care providers and hundreds of schools educating two
million of our five million students.
Previous COVID-19 relief bills and the American Rescue Plan
funded similar efforts, but the scope of the psychiatry access
program expansion nationally is less than what we fund in Texas
alone, and the school-based efforts lacked concrete strategies
leveraging telehealth.
We are also scaling care in Texas for suicide and
depression through grant programs to overcome startup costs for
measurement-based care and collaborative care, and hundreds of
primary care providers in North Texas, or the Cloudbreak
Initiative, in partnership with UT Southwestern.
Congress can create similar momentum nationwide providing
grants to health systems and primary care practices to cover
startup costs, plus technical assistance, to be sure they set
it up the right way to qualify for ongoing reimbursement.
In early 2021, both RAND and the Bipartisan Policy Center
made recommendations similar to this and it is fully aligned
with the evidence-based practice components of the national
response to COVID.
It would also be useful to eliminate copays for
collaborative care and Medicare, Medicaid, and commercial
coverage.
For more severe disorders, which have been severely
impacted by COVID-19, the coordinated specialty care set aside
in the Federal Mental Health Block Grant has been extremely
helpful and should be expanded.
It should also--we should also require Medicare, Medicaid,
and commercial payor coverage for coordinated specialty care,
which is the benchmark treatment for psychosis.
We have also witnessed in the last year the tragic
consequences that come from over-reliance on police response to
mental health, and we need to add 911 reform to the work of
expanding 988 access and crisis care.
Equity, workforce, and telehealth also have to be
addressed.
But, the main lesson is that in less than a year, we showed
the world that we can learn how to detect, treat, and prevent a
novel disease we had never seen before. We can do the same for
mental illness and addiction with that same will and commitment
of resources.
I am deeply grateful to the Committee for the opportunity
to share this information about our experience in Texas, and I
am happy to respond to your questions.
[The prepared statement of Dr. Keller follows:]
prepared statement of andy keller
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
[summary statement of andy keller]
For over a decade prior to the COVID-19 pandemic, every leading
indicator related to the pre-existing mental health and addiction
epidemic was worsening. Deaths from suicide, overdose, and co-morbid
health conditions were at 20-year highs, compounded by systemic
inequities for Black, indigenous, and other people of color. And the
COVID-19 pandemic has made all of this worse over the last year:
Rates of death from overdose are expected to exceed
88,000, the highest number ever.
Indicators of depression have increased four-fold and
suicide has doubled.
Mental illness is the second leading driver of COVID-
19 based mortality (after age).
And the effects of COVID-19 worsened underlying
inequities in multiple ways.
The primary lesson that needs to be learned from the COVID-19
pandemic is that the Nation can rapidly scale up and deliver early
detection, treatment, and prevention if we pair the will to act with
the necessary resources. Fortunately, this would be much easier to do
for mental illness and addiction, because we already know how to
successfully detect and treat most of these conditions. Universal
access to just two evidence-based treatments--the Collaborative Care
Model (CoCM) for depression and Medication-Assisted Treatment (MAT) for
addiction--could save almost 40,000 lives a year from suicide (14,500)
and overdose (24,000).
We are scaling such solutions today in Texas, and this can inform
national efforts:
In 2020, our 12 publicly funded medical schools
launched the Texas Child Mental Health Care Consortium with
$100 million a biennium to provide universal access to child
psychiatry consultation in primary care and urgent access to
psychiatric telehealth care in schools, engaging nearly 5,000
pediatric primary care providers and on track to reach 2
million Texas students with coverage in less than a year. We
are also working closely with the Texas Education Agency (TEA)
to create guidance and supports for local school districts.
Congress should build on similar supports in the American
Rescue Plan and scale funding commensurate with the national
need and make regulatory relief on telehealth permanent.
We are also scaling measurement-based care (MBC) and
the Collaborative Care Model (CoCM) in health systems across
Texas through our Cloudbreak Initiative. Congress can create
similar momentum nationwide by providing grants to primary care
practices and health systems, as well as technical assistance
to enable them to scale effectively. It should also eliminate
co-pays in Medicare, Medicaid, and commercial coverage. Full
enforcement of the Mental Health Parity and Addiction Equity
Act is also key, as is coordination across Federal agencies to
align policies and braid funding.
Texas has used Federal Mental Health Block Grant set
asides to scale up the benchmark treatment for psychosis,
Coordinated Specialty Care (CSC), but Congress should partner
with states to scale up CSC resources to reach all 100,000
Americans in need each year and require third-party coverage.
Housing supports and vaccine outreach should also be targeted
to people with severe needs.
Major communities across Texas are also reforming 911
response systems away from overreliance on public-safety to a
health-driven response with Multi-Disciplinary Response Teams.
Congress should add broader 911 reform alongside 988 crisis
response and community treatment expansion.
Health equity broadly and the primary care and peer
support workforces must also be addressed.
______
The Chair. Thank you so much, Dr. Keller.
We will turn to Dr. Muther.
STATEMENT OF JONATHAN MUTHER, PH.D., VICE PRESIDENT OF MEDICAL
SERVICES--BEHAVIORAL HEALTH, SALUD FAMILY HEATH CENTERS, AND
CLINICAL INTEGRATION ADVISOR, EUGENE S. FARLEY, JR. HEALTH
POLICY CENTER, COMMERCE CITY, CO
Dr. Muther. Good morning. Thank you very much, Chair
Murray, Ranking Member Burr. And Senator Hickenlooper, thank
you for the introduction. Members of the Committee, thank you
for the opportunity to testify on the critical topic of mental
health and substance use disorders.
My name is Jonathan Muther, and I am the Vice President of
Behavioral Health at Salud Family Health Centers, a federally
qualified health system with 13 community health clinics in
eight mostly rural counties throughout Colorado. We are one of
1,400 community health center organizations serving over 30
million Americans.
Health centers are the family doctor of people of all ages
and walks of life--newborns, seniors, the homeless, veterans,
and agricultural workers, just to name a few. Health centers
provide easy access to services that would otherwise be
unaffordable and unattainable. Care in our clinics involves a
team of various professions, working together to address the
physical, oral, behavioral, and social needs all in one place.
This is the most efficient and accessible way to have the
majority of mental illness and substance use disorders treated.
As a psychologist, I have seen firsthand the impact of
COVID-19 on our communities. This includes the quadrupling of
mental illness and substance use disorders within what was
already an overburdened behavioral health system.
More than one out of three individuals are experiencing
increased substance use, worsening anxiety, depressed mood,
and, as has been mentioned, we are seeing unprecedented rates
of suicide. Worse, even before the pandemic, over half of the
individuals with a mental illness or substance use disorders
did not receive care. This devastating gap in access to care
has only worsened in the past year.
But, there are opportunities for things to get better, and
I would like to put forth three key elements to improving
healthcare that will address the problem.
No. 1, reinforcing primary care as the backbone of
healthcare in this Country so we can properly address the
mental, emotional, and behavioral demands that are most likely
to present in these settings. It is essential to achieving
better total health outcomes, containing costs, and relieving
inequities.
No. 2, we must continue to innovate models of care, invest
in behavioral health specialists working in concert with
medical providers, and eliminate fragmented systems that do not
allow for the whole-person approach.
No. 3, opportunities exist to transform behavioral health
service delivery in a meaningful way that includes telehealth,
advancing payment models, and enhancing our workforce.
We must engage in these strategies now.
To emphasize the work that must be done, I want to share a
patient story of a man named Marco, a 38-year old gentleman,
living in a 600 square foot shipping container repurposed as
housing, who was forced out of the food service industry due to
the pandemic.
During a screening phone call conducted by a behavioral
health provider, Marco stated, I am so surprised and glad to
hear from someone. He endorsed multiple symptoms of depression
and anxiety, alcohol abuse, and thoughts of suicide. Marco
acknowledged, this is the first I have spoken to someone in
days, and I never would have known what to do had you not
called.
Waiting for individuals like Marco to ask for help is too
late. We have to equip our clinics with behavioral health
clinicians who can proactively outreach individuals like Marco,
who would otherwise fall through the cracks.
To do this, it is essential to keep telehealth, as has been
mentioned. Keep telehealth as a core aspect of service
delivery. Telehealth has allowed us to provide mental health
services at a rate on par with rates pre-pandemic. Very simply,
telehealth reduces barriers to care.
We also need to build on existing advancements of
alternative payment models. Many types of effective clinical
encounters, including the one I mentioned with Marco, are not
billable in a fee-for-service model. It is essential to reform
our current payment models and governance structures so that
outcomes and value are rewarded over volume.
A workforce pipeline is also needed that supports
recruitment and retention into mental health training programs
through loan forgiveness and other financial incentives. We
should broaden the workforce to include roles like peer
specialist, community health workers, and mental health first
responders.
We must be strategic about workforce allocation and ensure
that clinicians are able to treat professionals--excuse me--
ensure clinicians are able to treat individuals and families
where they are most likely to present, such as school-based
health centers and primary care.
Quickly, I would like to fully endorse the work that has
been done by the Bipartisan Policy Center. They have a report
called Tackling America's Mental Health and Addiction Crisis
Through Primary Care Integration. Their report further details
what I have only been able to briefly touch on today.
But, the concerns are rising, the need is clear, and the
solutions are there. We can and must do better.
Thank you again, Chair Murray and Ranking Member Burr.
Thank you for allowing me to share my thoughts and ideas. Thank
you for your attention to this important topic, and I look
forward to questions.
Thanks.
[The prepared statement of Dr. Muther follows:]
prepared statement of jonathan muther
Introduction
Chair Murray, Ranking Member Burr, and Members of the Committee,
thank you for the opportunity to testify on the critical topic of
mental health and substance use disorders. My name is Jonathan Muther
and I am the Vice President of Behavioral Health at Salud Family Health
Centers, a federally qualified health system with 13 community health
clinics in 8 mostly rural counties throughout Colorado.
As a psychologist, I have spent my entire career to date in a
primary care community health setting. As a behavioral health
clinician, I have seen first-hand the impact of COVID-19 on our
communities, including and especially the worsening of both the
frequency and severity of mental illness and substance use disorders.
From this perspective, and the experiences of countless patients, I
will be sharing my testimony today. There are three elements for
improving healthcare I would like to put forth, these include:
1. Primary care is the backbone of health care in this country
and properly addressing mental, emotional, and behavioral
demands in this setting is essential to achieving better
health, containing costs, and relieving inequities.
2. We must look at new models of care, including behavioral
health specialists working in concert with primary care medical
providers, in order to meet the demand for behavioral health
care that has grown exponentially since the onset of COVID-19.
3. Opportunities exist to further transform behavioral health
service delivery in a meaningful way that include telehealth,
advancing payment models, and enhancing our workforce.
Salud is one of 1,400 Community Health Center organizations spread
across 14,000 rural and urban communities serving over 30 million
Americans. Health centers are the family doctor to people of all ages
and walks of life--newborns, the seniors, the homeless, veterans, and
agricultural workers. Health centers are problem-solvers, protectors of
public health, and innovators in illness prevention, even in
unprecedented pandemics like COVID-19. Health centers provide easy
access to services that individuals would otherwise find unaffordable
and unattainable. We look beyond the medical chart for answers that not
only prevent illness but address the environmental and social factors
that can make people sick--lack of nutrition, exercise, homelessness,
and most certainly mental health, and addiction. In providing access to
affordable care for people least likely to have it, unnecessary
hospitalizations and ER visits are significantly reduced and so are
costs to the American taxpayer.
Community Health Centers across the country have stepped up to meet
the needs of the communities they serve first through continued care
for underlying health conditions, as well as COVID-19 testing and
vaccinations. Since the onset of the pandemic, health centers across
the country have tested over 10 million patients and conducted over 3.6
million vaccinations. Nearly half of the patients vaccinated are racial
or ethnic minorities.
Health centers have been able to thrive in communities because of
the ongoing support you have shown for federally Qualified Community
Health Centers (FQHC). For example, the three-year extension of the
mandatory Community Health Center Fund has provided multi-year
certainty for my health center and others across the country.
Additionally, the COVID funding from last year, along with the $7.6
billion from the American Rescue Plan is enabling health centers to
care for their patients during this difficult time. Salud has received
over $16 million from this funding and will now be better positioned to
test, vaccinate and care for our patients. We are using this funding to
hire staff for vaccine clinics, to develop, maintain, or resurrect
programs related to quality improvement, and to develop meaningful
changes the pandemic has brought on such as ensuring separate clinic
space for sick and well patients. Most importantly, we seek to shrink
the disparities that have always impacted communities of color that
were made worse by the COVID pandemic.
A conversation about behavioral health (which includes mental
illness and substance use disorders) is a conversation about health.
There is no health without mental health. We know, from clinical
experience and decades of research, that wellness promotion, improving
mental health, and reducing risk for substance abuse, improves all
health outcomes. However, access to behavioral health treatment is, in
and of itself, a health disparity. Our current system allows for
inadequate attention to be afforded to behavioral health treatment,
coverage, and policy, as compared to medical care. This needs to
change.
Background
A model of integrated care involves a team of clinicians from
various professions all working together to meet the healthcare needs
of individuals and families. In a traditional model, you go to your
doctor's office when you have a cold, and a separate dentist office for
a toothache. And if one of these providers is able to identify a
concern, or less likely, the patient is able to recognize they might be
experiencing symptoms of depression or anxiety, there might be a
referral placed for a third visit in yet another clinic at another
time. With each separate visit, patients face the added burden of
transportation, time away from work or caring for children, another
copay, and navigating a system that is confusing and disjointed because
these treating providers cannot communicate with one another. In an
integrated model, each of these concerns can be addressed in the same
place on the same day. A visit to the doctor also includes a
structurally embedded visit with a behavioral health provider--whether
the patient is seeking this service or not. Just as height, weight,
blood pressure and other routine information is gathered for the
medical visit, so too are questions relating to mood, stress and
substance use to inform the behavioral health part of the visit. This
allows members of the care team to achieve a global picture of the
presenting concern, and for the individual seeking care to know every
aspect of their health is being addressed.
I oversee a team of about 40 behavioral health clinicians at Salud
Family Health Centers that are dedicated to increasing access to
behavioral health services for Coloradans every day. Each clinician
conducts between 8-12 brief encounters per day, most often in the
context of a medical visit, alongside a primary care provider,
regardless of whether an individual has requested--or is even
expecting--behavioral health as part of their care. Behavioral health
providers coordinate, collaborate, and consult with medical providers
to treat mental illness and substance use disorders, create health
behavioral interventions for chronic physical health conditions, and
most commonly, address comorbidities that often go untreated. We are
seamless with patients receiving mental health treatment where they go
to fill their medications, receive their COVID-19 vaccination, and get
their annual physical.
However, we still face barriers--challenges that are driven by the
fragmented system we operate in. The COVID-19 pandemic has exposed and
exacerbated longstanding difficulties for individuals experiencing
mental illness and/or substance use disorders. The challenges are many.
However, I would like to focus my testimony on the opportunities we
have to do better for the individuals and families of this country.
We must look at innovative practices that focus on integrating
behavioral health and primary care as a means to reducing the silos
that have historically existed within our healthcare system. We have
decades of reports and evidence that integrating mental health into
places like primary care works. And while these models still are a
novelty and not so much the standard of care, we should pursue a system
that prioritizes a whole-person approach, in which addressing an
individual's entire health needs, be it behavioral and emotional, oral,
medical, or social, begin and end in one place--ideally the place of
the person's choosing.
The Value of Integrated Care Over Traditional ``Siloed'' Care
A set of professionals from various disciplines working together in
one place increases efficiency, has demonstrated cost-effectiveness,
and improves health outcomes. The integration of behavioral health and
primary care is the linchpin to resolving our inadequate system of care
for both behavioral and physical health outcomes. We can no longer
afford, neither fiscally nor in reduced quality of life; neither in
untold healthcare spending nor well-intended grant dollars; neither in
increasing rates of deaths by suicide nor other deaths of despair, to
maintain the outdated, entrenched silos that separate physical and
behavioral health.
Like all health-related concerns, we know that individuals with
mental illness or substance use disorders are most likely to initially
present for help at their doctor's office. A model of integrated
primary care allows for brief behavioral health assessments and
interventions offered in real-time, at the point of contact with one's
primary care provider. This model is effective, efficient, and suitable
to consumer needs and preferences.
I want to share the story of ``Marco'', a 38-year-old man and
patient at Salud Family Health Centers, living in a 600 square foot
shipping container repurposed as a rudimentary home in rural Colorado.
He has no running water and a small wood-burning stove for heat. He had
previously been employed in the food service industry until he was
forced out of work last April. During a screening phone call by a Salud
behavioral health provider--a routine outreach effort to assess need
and ``normalize'' behavioral health as part of care, Marco stated,
``I'm so surprised and glad to hear from someone, this is exactly what
I need right now.'' He then endorsed multiple symptoms of depression,
anxiety, alcohol abuse, and thoughts of ending his life. The patient
acknowledged, ``this is the first I've spoken to someone in days and I
never would have known what to do had you not called.'' Waiting for
individuals like Marco to ask for help is too late. Expecting Marco to
know where to receive help from a system with uncertain points of entry
is unrealistic. We have to equip our clinics with behavioral health
clinicians who can proactively outreach individuals experiencing the
many barriers to care.
This model needs to be incorporated in all clinical settings.
Primary care and school settings are the most likely starting points
for accessing behavioral health services for adults and children,
respectively. Placing behavioral health providers where individuals are
most likely to be allows clinicians to proactively address the rising
rates of mental illness and substance abuse risk factors. Integrated
models must be the norm in other settings as well, including specialty
medical clinics, hospitals, and emergency departments. Imagine an
avoidable emergency department visits because of a timely intervention
when an individual disclosed stress to their primary care doctor.
Prevalence of Behavioral Health
Even prior to the COVID-19 pandemic, there was a mental health
crisis in the country related to unmet need, in which the demand for
services far exceeded our capacity to adequately address the rates of
distress. Over half of American youth and adults living with a mental
illness or substance use disorder report receiving no treatment. Pre-
COVID, rates of adult mental illness of any type were about 19 percent
on average (ranging from 16-25 percent). \1\ Over 20 million Americans
aged 12 or older in this country experience addiction and substance
dependence. \2\ Of these adult individuals who report a mental illness,
as many as 57 percent report receiving no treatment. Of the nearly 14
percent of youth experiencing symptoms of depression, almost 60 percent
did not receive any mental health treatment. Adults experiencing a
substance use disorder fared even worse, with as many as 80 percent
reporting they did not receive treatment.
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\1\ Mental Health America, State Ranking (2020). https://
www.mhanational.org/mentalhealthfacts.
\2\ Substance Abuse and Mental Health Services Administration
(SAMHSA) (2021). Key Substance Use and Mental Health Indicators in the
United States: Results from the 2019 National Survey on Drug Use and
Health. https://www.samhsa.gov/data/sites/default/files/reports/
rpt29393/2019NSDUHFFRPDFW HTML/2019NSDUHFFR090120.htm#:-:text=Among-
percent20the-percent2020.4-percent20million-percent20people,alcohol-
percent20use-percent20disorder percent20and-percent20an.
Furthermore, since the onset of the pandemic, rates of mental
illness have multiplied, and the unmet need is now further burdening a
system already cracking at the seams. Even more alarming is the mental
health impact on our Nation following the pandemic will last far beyond
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the physical health impact and into future generations.
No segment of our population is immune to the toll that necessary
disease mitigation efforts have had on our collective psyche. Social
isolation, financial uncertainty, job loss, and loss of a loved one are
risk factors for mental illness and substance use disorders. The very
measures needed to keep our communities safe, including physical
distancing, stay-at-home orders, school closures, and others, have
unintentionally increased the risk and put forth new challenges on our
behavioral health system.
Unsurprisingly, prevalence rates for mental illness and substance
use disorders are rising at a staggering rate. US adults with symptoms
of an anxiety disorder and/or depressive disorder has at least
quadrupled since before the pandemic. \3\ The CDC has reported rates of
anxiety to be three times higher and rates of depression four times
higher in 2020 as compared to the year before the pandemic. That makes
30-40 percent of our population currently experiencing these symptoms
as compared to 11 percent in 2019.
---------------------------------------------------------------------------
\3\ Centers for Disease Control and Prevention (CDC). Morbidity
and Mortality Weekly Report, August 14, 2020. (Czeisler et al. (2020).
Mental health, substance use, and suicidal ideation during the COVID-19
pandemic--United States, June 24-30 2020. Morbidity and Mortality
Weekly Report, 69 (32), 1049-1057. https://www.cdc.gov/mmwr/volumes/69/
wr/pdfs/mm6932a1-H.pdf.
We cannot ignore the fact that these rising rates of mental illness
and substance use are disproportionately affecting specific populations
of our country. Younger adults (18-26 years old), racial/ethnic
minorities, essential workers, and unpaid adult caregivers reported
having experienced disproportionately worse mental health outcomes,
increased substance use, and elevated suicidal ideation as a result of
the pandemic.
Redesigning Behavioral Health Post COVID-19
First, we need to ensure that telehealth continues to be a core
platform of health care delivery. Prior to 2020, only 1 percent of
mental health was via telehealth and skyrocketed to 75 percent of
visits during 2020. \4\ The increased presence of telehealth during the
pandemic has been a saving grace. It has allowed us to maintain a rate
of service delivery roughly on par with rates of delivery pre-pandemic,
but in a way that decreases barriers to care. Like utilization rates
for all healthcare, behavioral health utilization fell. However, the
behavioral health utilization soon came back to rates equal to that or
higher than rates seen in 2019 because of the deployment of telehealth.
Yet we must remember, the gap of unmet need has still widened further
because of the dramatic increase in prevalence rates due to COVID
stressors.
---------------------------------------------------------------------------
\4\ Davenport S., Melek, S., and Gray, T.J. (2021) Behavioral
healthcare utilization changes during the COVID-19 pandemic: An
analysis of claims data through August 2020 for 12.5 million
individuals. https://wellbeingtrust.org/wp-content/uploads/2021/03/
Milliman-COVID-BH-Impact-2021-02-17.pdf.
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Therefore, we need to continue to utilize smart technologies in
innovative ways and think beyond the realm of a traditional therapy
session. Examples include more frequent symptom screenings, periodic
check-ins with clinicians (e.g., brief instant messaging) in addition
to a typical in-clinic visit, and virtual group visits and group chats,
all designed to maximize interventions and extend the availability of
our limited number of licensed clinicians.
Second, we need to build on the existing advancements of
alternative payment models. Marco's experience reminds us of the
importance of a meaningful intervention that occurs because of
proactive outreach to patients. We can no longer force a patient to
experience the barriers of limited transportation, high cost of care
with insurance that does not cover behavioral health treatment
equitably, long wait lists, and stigma. This is especially true for
those whose first language is something other than English.
But payment without addressing coverage is only telling part of the
story. We know that many patients avoid care because of the cost, and
despite mental health parity being a Federal law for decades, we still
have limited enforcement. In fact, under current law, the United States
Department of Labor lacks the ability to assess civil monetary
penalties against health issuers and plan sponsors for violations of
the Mental Health Parity and Addiction Equity Act (MHPAEA), which
requires insurers to cover illnesses of the brain, such as depression
or opioid use disorder, no more restrictively than illnesses of the
body, such as diabetes or cancer. Without this power, USDOL can only
require plans to reimburse consumers for wrongly denied coverage of
care that was nevertheless provided. Such meager authority is not
enough and is unlikely to change plans' coverage practices. USDOL must
finally be able to hold plan issuers and sponsors accountable for
illegal denials of mental health and substance use coverage more than
12 years after enactment of the MHPAEA.
The types of clinical encounters that I have described may not be
billable at all. If these services are reimbursable, then it may be at
an extremely low rate, and/or require only certain credentials to
obtain reimbursement under current payment models and governance
structures. These are exactly the types of clinical encounters that are
meaningful for the patient, efficient for the clinician, and a perfect
example of the type of flexibility in service delivery that service
organizations are seeking to provide under alternative payment models
that reward outcomes and value over volume. We need to pursue other
encounter types such as brief screens and check-ins with patients,
commensurate with their clinical needs and not bound by outdated
payment and regulatory constraints. This is attainable for the vast
majority of those needing behavioral health services. We must reform
our billing and reimbursement models if we are to prevent an ongoing
undercurrent to this current pandemic for generations to come.
Prior to the pandemic, clinics like mine were not able to bill for
telehealth services in any capacity. Congressional action through the
CARES Act and other state-based initiatives have enhanced flexibility
in payment for telehealth services allowed us to switch our clinical
approach, quite literally overnight, to an approach that is easy and
effective for both clinicians and consumers of behavioral health. But
we need more. Telehealth services must be here to stay if we want
progress in closing the gap between unmet need and service acquisition.
Telehealth services, regardless of mode/platform (phone, video
conference, face-to-face in-person) should all be reimbursed and at the
same rate. As a result, I would encourage you to continue the
telehealth flexibilities that the Public Health Emergency has enabled,
including recognizing health centers as distant site providers and
removing originating site restrictions, as well as allowing the use of
audio-only encounters.
We must also increase the workforce and invest in a robust pipeline
that supports recruitment and retention of individuals of diverse
backgrounds into mental health training programs through loan
forgiveness programs and other financial incentives to make this career
attractive and sustainable.
At Salud, we have a training program bringing in highly skilled
clinicians from Puerto Rico to help meet the needs of a culturally and
linguistically diverse community. Once the pipeline has been created
and our healthcare system is attracting and supporting behavioral
health-trained clinicians, we must also broaden the workforce to be
more inclusive of other roles like peer specialists (individuals with
lived experience of mental illness and/or substance use disorders),
community health workers, mental health first responders, and others.
Health centers have tripled their behavioral health staffs over the
last 10 years, performing evidence-based screenings and intervention,
including Medication Assisted Treatment and referral. However, demand
remains very high with nearly a five-fold increase in patients seeking
treatment for opioid addiction and other substance use disorders. The
recent investment of $1 billion for the National Health Service Corps
and the Nurse Corps is an example of the large-scale commitment to the
health care workforce that is needed to address severe and chronic
workforce challenges at the community level. Let's continue this line
of investment and seek to train this new workforce in mental health as
well.
What cannot be overstated, is the allocation and distribution of
our workforce needs to be where presenting concerns are most evident,
namely primary care and schools. Another example, the mental health
first responder, often termed the ``co-responder'' model, is among the
most innovative and should be expanded. This enables the provider to
appropriately address the needs of the patient at the first point of
contact, averting expensive emergency department visits. It also avoids
the ``criminalization'' of mental illness and prevents unnecessary
involvement with law enforcement and corrections, which unfortunately
has become the ``de-facto'' mental health system.
Last, I would like to fully endorse the work done by the Bipartisan
Policy Center (BPC) and the recommendations included in BPC's recent
report entitled, Tackling America's Mental Health and Addiction Crisis
Through Primary Care Integration. I believe the report offers a clear
distillation of the current challenges and provides additional
recommendations to chart a new path forward.
Conclusion
The concerns are rising. The need is clear. We know what will
happen if we expect our current system to accommodate the quadrupling
of need. More than 1 out of 3 of our fellow citizens right now are
experiencing the effects of increased substance use, feelings of
worsening anxiety, and/or significant impacts on their mood as a result
of depression.
The good news is that health centers are a proven model of care and
are staffed with dedicated professionals who know how to help. We know
where to be so that we can ask the right questions and offer the right
help and make the right recommendations. We have shown that we can
improve the health of our communities by making it normal to treat the
emotional toll of stress and illness when you go to school or see your
primary care doctor. We have the road map, but now need to ensure we
have the resources, so the roads are sturdy and equipped to handle the
increase in traffic needed to get to our destination of improved health
and well-being for us all.
Again, Chair Murray and Ranking Member Burr thank you for allowing
me to share my thoughts and experiences from Salud Family Health
Centers. I appreciate your commitment to these issues and would welcome
any questions that you may have.
______
The Chair. Thank you so much, Dr. Muther, and thank you to
all of our witnesses today.
We will now begin a round of five-minute questions of our
witnesses. I, again, ask my colleagues to please keep track of
your clock, stay within the 5 minutes.
In the midst of the COVID-19 pandemic, the Country has also
been grappling with systemic racisms and resulting health
inequities, both of which had significant impacts on mental
health. COVID-19 has been hardest on communities of color, who
also continue to have less access to mental healthcare and
substance use treatment options.
I would like to hear from each of you. In your view, how
can we ensure mental health and substance use disorder
treatments are accessible and affordable to communities of
color and others experiencing greater need?
Dr. Muther, I will start with you.
Dr. Muther. Well, thank you very much for the question and
the opportunity to speak to that.
You know, in addition to the challenges faced by
individuals of color, you also mentioned in your opening
comments, Chair Murray, some of the other barriers to care that
include affordability or lack of capacity to find a provider.
And this is the importance of the emphasis on the integrated
primary care model, is we address all those barriers to care,
and we strategically place clinics, and through telehealth,
certainly can do more intentional outreach to those individuals
most likely to be experiencing difficulties to access to care.
But, I think there is an intentionality in access,
increasing access, and making it easy. So, when individuals
come to their primary care doctor, we also are able to provide
a behavioral health clinician in the same time, at the same
place in order to proactively recognize early on symptoms of
mental illness and substance use disorders and providing
meaningful interactions.
Both with the telehealth and providing the team-based
approach is the best way to ensure that we are meeting the
needs of those most vulnerable.
The Chair. Dr. Benton, do you have any thoughts on that?
Dr. Benton. Thank you, Chair Murray. This is an excellent
question. I agree with Dr. Muther's comments. The underserved
populations, for minoritized populations, particularly during--
before and during the pandemic, there were significant concerns
around access and engagement in care. And what we have done is
created approaches that require us to do more outreach.
In addition to that, we have had to look at culturally
competent interventions to engage minoritized populations in
care. So much of the data is very clear that frequently,
minority youth are seen in emergency care or crisis programs,
but less than 50 percent of them actually receive the follow-up
care that is needed for treatment.
We have to look at ways to use patient navigators, peer
navigators, as Dr. Muther mentioned, to do consistent outreach
and to make sure that those connections are made.
Increasing diversity among the caring--caregiving workforce
would make a tremendous difference. So, as you are aware, the
number of physicians and psychologists who are minority
populations is actually quite limited. And, so, you know, we
will never catch up so that there is actual matching based on
race. But, what we can do is build cultural competence among
the clinicians who are working with minority populations to
engage and retain them in care.
The Chair. Thank you.
Dr. Goldsby.
Ms. Goldsby. Thank you. In addition to the other two
responses, which I agree with, in South Carolina, we have
mental health and addiction services in every single county in
the state where anyone, regardless of their ability to pay, can
access services. But, we agree that more outreach and
engagement needs to be done, particularly in underserved
communities and in rural pockets of some of our counties.
Over the pandemic, we did a couple of things to address
this. First, with our SC-HOPE support line, we made sure that
Spanish-speaking support was available through that support
line, and we advertised that state-wide and were surprised to
get a number of calls of our Spanish-speaking population to
that support line to engage in services with translational
services.
In addition to that, we have been and continue to be doing
more outreach events with trusted local leaders with our
behavioral health providers, using mobile services to get into
faith communities, residential communities, and rural areas
where folks are in need of services but would not typically
leave that area or transport to a center for services.
I think that this is really just a theme and a trend of
going to where the folks need the services instead of waiting
for us, but waiting for them to come to us.
The Chair. Okay.
Dr. Keller, I am running out of time, but I want you to
have an opportunity to answer the question, so go ahead.
Dr. Keller. Well, I appreciate it. Fortunately, I agree
with everything my colleagues said. I think the primary care,
in particular, is critical.
I would just emphasize three quick things. Community health
workers can expand the diversity of our workforce, but we
should technology-enable them. There is things we can do to
help them be more effective, and I shared some of that in my
written testimony.
Second thing is to remember, with telehealth, that audio-
only gets access now. We need more broadband, but almost
everyone has a phone. Medicare adding audio-only was a huge
improvement. Please keep that.
Then the third thing is 911 reform. It is great that we are
doing 988 and setting up crisis services, but people are still
going to just call 911, and we need to make sure that people
with health needs get health responses, not public safety
responses.
The Chair. Thank you very much.
Senator Burr.
Senator Burr. Thank you, Chair.
Here is my takeaway from hearing all the testimony.
Telehealth has been a key to treatment during COVID and it must
not be rolled back post-COVID.
Here is my question to each of you. And this is really a
yes or no answer, and I will go to you first, Dr. Keller.
Do you believe that Medicaid should require assignment of a
medical home to every beneficiary for both the coordination of
clinical and behavioral care?
Dr. Keller. Yes, as long as that is a primary care
practice.
Senator Burr. Dr. Muther.
Dr. Muther. Yes. There are challenges with comprehensive
and complete attribution, such as people moving around and
difficulties with care coordination. But, the answer is
absolutely yes.
Senator Burr. Ms. Goldsby.
Ms. Goldsby. Well, NASADAD may not have consensus on that.
I will say, in South Carolina, we would probably see some
benefit for that guaranteed connection to services, especially
with some payment reform, to ensure payment for success.
Senator Burr. Dr. Benton.
Dr. Benton. Yes. You have got a consensus. I agree. This
should be an option, primary care.
Senator Burr. Ms. Goldsby, your program, I think, is
forward-looking and, during the pandemic, it has leveraged data
to best target overdose hotspots and respond to the emerging
trends that you saw. What are some of the successful changes
that you think ought to stay in place after we have moved past
the pandemic? And, what would you have done differently?
Ms. Goldsby. I think some of the success that we have seen
in this state is the coordination, communication, and
collaboration that we have done during the pandemic to make
sure that we are responding to citizens' needs in real time
across sectors.
You noted our rapid response team to address overdose, and
we are going to continue that because as we, with public
safety, public health, look at the overdose occurrences in our
state with weekly surveillance and a communication framework
that drives local action. We communicate with locals as we see
hotspots for overdose in real time and drive their innovation
for addressing overdoses with unique ways. You know, outreach
and engagement again being the key, going to where the folks
need the services, offering support and intervention in those
locations.
Lessons learned, I think we knew that isolation was going
to drive addiction as soon as we saw isolation measures being
taken. That old adage that the opposite of addiction is
connection, that is really true. I think that, you know,
lessons learned, we needed to be even more proactive on
engaging, on engaging, engaging. Keeping people connected to
peer support specialists and to counseling. We did the best we
could, but you know, I think the connection is key.
Senator Burr. Dr. Muther, how does a community health
center work in partnership with other organizations in the
community to improve access to behavioral care? And has that
changed during COVID?
Dr. Muther. Such an important question, and thank you for
asking it.
Connection with community partners is absolutely critical.
So, the statements that I made and the moment--excuse me, the
model that I put forth as it relates to integrated primary care
is best to treat individuals up to mild to moderate--
subclinical stressors up to mild to moderate severity. We need
to rely on and partner with and really integrate and partner
intimately with our specialty mental health practices so that
they are able to treat individuals of higher severity that
present to our clinics on a regular basis, but yet we are not
ideally suited to meet their needs from an acuity and higher
severity standpoint.
That is--so we need to partner and build bridges as it
relates to provide the full spectrum or the full continuum of
behavioral healthcare.
Not only that, we need to partner with other community
agencies to better address social determinants of health, such
as housing, food, transportation, education, employment, some
of those other basic needs that greatly impact healthcare.
Senator Burr. Madam Chair, let me just add, as we started
into this phase of vaccination, I always thought the greatest
motivation to be vaccinated was you are not going to go to the
hospital and you are not going to die. Having been vaccinated,
I now know that the greatest reason to be vaccinated is the
first hug that you are able to give somebody that you have not
been able to do for a year. And I think sometimes we look at
the obvious things in the wrong order, and the ability to
interact with each other, to do the things that we naturally
have always done. For those to be able to happen again are the
greatest motivating factor, and you can understand why there
has been a mental health problem.
I thank the chair.
The Chair. Thank you, Senator Burr.
Senator Casey.
Senator Casey. Chair Murray, thank you very much.
I want to thank our panel for providing the kind of
perspective on these challenges that I am not sure any of us--
or at least I was not able to fully appreciate until more
recently.
I want to start with Dr. Benton. Doctor, as you emphasized
in your testimony, it is absolutely critical that we address
these workforce challenges that you and others have spoken
about, not only by attracting new healthcare providers, but
also by cross-training primary care clinicians and other
providers.
We know that unless we equip more providers with the
knowledge they need to respond to these really significant
mental health concerns, far too many of the 15 million children
and adolescents nationwide who are in need of care from mental
health professionals will go without it, thereby facing
terribly debilitating challenges throughout their development
and well into adulthood.
In addition to loan forgiveness--and I know you spoke about
loan forgiveness in your testimony--as well as other programs
to incentivize healthcare providers to choose to work in the
mental health field, it is also important that we consider how
we could better integrate mental health competencies into
medical education and graduate medical education.
Here is the question. How can we engage students of
medicine and other health professionals, or professionals who
are continuing their education, how can we engage all of them
in mental healthcare?
Dr. Benton. Thank you for that question. So, currently,
there are multiple initiatives focused on engaging primary care
providers and other partners in mental health treatments. Some
of those efforts involve consultation through access programs
where, you know, pediatricians and other primary care
providers, school counselors, can pick up the phone and call a
mental health professional in their region. And many of these
programs are regional. Many of them are national. It is one way
that clinicians can get real time support for mental healthcare
access and expansion of their knowledge.
There are also many national programs that are focused on
educating primary care providers to have more mental health
expertise given that over 30 percent of the chief complaints
presenting to pediatricians are mental health concerns. So,
primary care is absolutely the way to go.
One of the barriers to education for pediatricians and a
barrier to actually providing the service really relates to
reimbursement for their time. So, currently, the primary care
providers have very limited time for physicals, for well-child
visits, which are frequently the times that families present
these complaints to their pediatricians, and they really do not
have a way to respond.
Some things we could do to address that is increasing the
number of mental health clinicians, such as social workers,
case managers, community workers, that are integrated in these
primary care settings. There is opportunities for increased
consultation with mental health professionals, which is a way
for people to learn about mental health treatments, working
side by side in partnerships with medical professionals.
There are some easy wins and easy ways to increase the
competencies of professionals who are working with children and
adults who are impacted by mental health conditions.
Senator Casey. Dr. Benton, thank you, and I want to thank
you for the work you do at CHOP. It has never been more
essential.
For my last question, I turn to Dr. Keller. You spoke of
the Texas Child Mental Healthcare Consortium's work to expand
child--I am sorry, to expand psychiatric telehealth care in
schools and its partnership with the Texas Education Agency on
systemic supports for mental health. This is a critical
partnership. And I just wanted to ask you, in your experience,
what kind of guidance and support do states and local school
districts need to comprehensively respond to mental health
needs?
Dr. Keller. Well, thank you, Senator Casey. I think the
first thing we need to do in conceptualizing that is we need to
think of it reaching every student. I mean, we can't just think
of incremental, like let's add one more counselor.
We need to have a comprehensive plan. And that is a lot of
what we are partnering with the Texas Education Agency on, is
to develop guidance to school districts, to the agencies that
support school districts, so they can develop a multi-tiered
system of supports, framework within the school, that looks not
just at students in need, but students at risk, as well as
healthy emotional development, as well as an interconnected
schools framework that makes sure that the healthcare providers
in that community are available to respond when there are
needs.
Because schools are not health providers. They are
education providers. And that is basically what our medical
schools did. They put together a telehealth network to be that
interconnected systems framework for schools that did not have
other ways to provide care to their students.
Senator Casey. Doctor, thanks very much.
Thank you, Chair Murray.
The Chair. Thank you.
Senator Collins.
Senator Collins. Thank you.
Ms. Goldsby, I would like to start with a startling
statistic. More Mainers died of drug overdoses last year than
died from COVID. We set a new record of 502 Mainers who died
from drug overdoses. That was an increase of more than 30
percent from 2019.
Now, COVID clearly played an indirect role through the
increased isolation, the cutbacks in peer-to-peer counseling,
the lack of the ability to deliver services in rural Maine,
where approximately 15 percent statewide of households do not
have access to high-speed internet, so they cannot participate
in telemedicine sessions. So, this is a real problem.
In Maine, we have seen access to high-quality mental health
and addiction treatment through the expansion of certified
community behavioral health clinics. I am wondering if you are
familiar with these community-based hubs for behavioral
healthcare and how you see them fitting into our national
strategy to combat this terrible problem.
Ms. Goldsby. Senator Collins, thank you for the question.
And I just want to say that South Carolina experienced
remarkably similar impact from overdose last year. Our rates
are also up. We had record-breaking rates of overdose in the
month of May last year, and we expect to have lost more South
Carolinians in 2020 than ever before from opioid overdose.
In our state, we have a county alcohol and drug authority
and a community mental health center in every county in the
state, that is open to any citizen for services, regardless of
their ability to pay and regardless of their diagnosis.
The community mental health center model that you speak of,
unfortunately, we do not have any of those centers in our
state. We know that I think 19 or so other states do have those
and that they have been successful programming. So, I cannot
speak specifically from South Carolina's perspective, but we
know that they are effective in other states.
Senator Collins. Thank you.
Dr. Keller, I want to follow-up with you on telehealth. I
totally agree with Senator Burr's comments that we need to make
this a permanent part of our healthcare structure.
Earlier this month, I visited the Aroostook Mental Health
Center new adult stabilization unit, which recently moved into
a new facility to increase its bed capacity. It provides crisis
beds in very rural counties in Maine. It serves three counties.
Now, here is what is interesting to me. What the center
reported to me is, through their outpatient services, where
they do use telemedicine, that they had actually seen a 20
percent increase in mental health visits and a sharp decline in
no-shows or cancellations as a direct result of visits that
were virtual. Similar, the head of a major hospital in Maine
told me that for mental health services, their no-show rate had
dropped to zero since they switched to telemedicine.
In addition to the need to expand telemedicine so those
83,000 Maine households have access, is there also a benefit--
because there are still some people in this Country,
particularly groups that have been known for not embracing
mental health services in the past--namely men, individuals on
Medicaid, and patients over age 65--having access through
telemedicine where they may not feel the stigma, which
unfortunately, regrettably, still is attached to seeking help
for mental health problems?
Dr. Keller. Senator Collins, that is a great question, and
your point is right on. That, in fact, is the dynamic which
leads telehealth to be so successful. One of the main ones is
the lack of stigma. We have seen exactly the same things across
Texas. Productivity targets being exceeded by 33 percent; no-
shows dropping to zero.
The other thing is the research shows that telehealth works
in many cases better, and I think that is because of that
anonymity. It is a little easier to sort of tell the truth. I
mean, you see that sometimes in email. People will write things
in email they would never say in person. That can kind of
happen sometimes in the therapeutic exchange, as well.
Please include audio-only when you make those things
permanent because that is a huge expansion, particularly in
rural areas, impoverished areas, that will get broadband one
day, but it is still going to be expensive. And I think, you
know, the phone is a great way to do that.
Could I just add that we have many certified community
behavioral health centers in Texas, and they are doing exactly
what you said they are in terms of being able to provide that
comprehensive help, and we thank Congress for expanding funding
there and encourage you to do more.
Senator Collins. Thank you so much.
The Chair. Thank you.
Senator Kaine.
Senator Kaine. Thank you, Chair Murray, Ranking Member
Burr. And what a great witness panel. This is the hearing that
makes me wish we had 30-minute question rounds because there is
so much I would want to talk to you about. I think where I will
start is a passion of mine, which is the mental health needs of
our healthcare providers, keeping our healers healthy.
This week marks a year from the death by suicide of a very
talented New York emergency room physician, Lorna Breen, who
was a Virginian, family from Charlottesville, and I have worked
together with her family and others to kind of promote keeping
our healers healthy.
I recently re-introduced with a great bipartisan group of
colleagues a bill, the Dr. Lorna Breen Healthcare Provider
Protection Act, to really push this issue of mental health for
frontline healthcare providers. With the strong advocacy of
Chair Murray, we were able to get $140 million of funding for
these efforts in the American Rescue Plan. That is great. I am
hoping that we can now move to pass the underlying bill S. 610
to ensure that HHS implements the provisions and uses the funds
consistent with congressional intent and, in doing so, honor
Dr. Breen and others.
Chair Murray, I would like to submit for the record a
letter of support for S. 610 from both Jennifer and Corey
Feist, Dr. Breen's sister and brother-in-law, but also a second
letter from a coalition of 31 other national medical and
healthcare organizations.
The Chair. So ordered.
Senator Kaine. If I could just ask the witnesses, either--
what should--I think we know some things Congress should do.
But, what should states do and what should healthcare
providers--hospitals or healthcare networks or community health
centers--do to really promote healthy practices among our
healthcare professionals and reduce any stigma or worry that
people might have that, if they seek mental health counseling,
could their licensure, could their credentialing, could their
jobs, be at risk? That was a sad factor in Dr. Breen's life.
Tragically, she did not feel like she could seek help without
her professional career being somewhat at risk for doing that.
Share with us what states and healthcare providers can do
to help with this challenge.
Dr. Benton. Thank you, Senator, for that question. That is
an incredibly important issue that you have highlighted.
States could work with their regulatory and licensing
agencies to eliminate the repercussions of reporting on mental
health conditions. So, now, many physicians are very afraid to
report that they have ever had a mental health concern,
particularly if there was a substance use concern, for fear
that they might lose their license, and that is a major barrier
to seeking care.
There is the remaining stigma of mental health, and many
physicians work hours that are not easily available for
treatment. Telehealth actually provides some opportunities for
flexibility in care, and being able to support the continuation
of telehealth would actually be supportive to physicians who
are seeking care.
Then, I think there is a--must be the recognition that
physicians often will not seek care for a variety of reasons.
But, the regulatory issues are major barriers to seeking
sufficient healthcare for physicians. And advocacy at the state
level to eliminate the barriers, the questions, or the
repercussions for positives to the questions would be really
important.
Senator Kaine. Dr. Benton, when you were speaking, Dr.
Keller was nodding a lot, so I think maybe I will see if Dr.
Keller----
Dr. Keller. Yes. Well, I am so glad Dr. Benton said that. I
mean, we single out addiction and depression and mental illness
in ways we do not single out other debilitating illnesses. So,
we stigmatize into our regulatory frameworks. We need to remove
that stigmatizing language and create an even playing field
around functional impairment.
The second thing we need to do is prepare for more. We did
not see PTSD rates go up during the wars. It was when people
came home. And, so, in the years ahead, and we know that post-
traumatic stress is normal. Post-traumatic stress disorders are
something we can prevent. So, we have to normalize the
experience that people are going to suffer from post-traumatic
stress. Its rates are going to go up after the pandemic
recedes. Because right now, people are kind of caught up in the
sort of still kind of making through the disaster, through the
trauma, of actually responding to the pandemic. And once that
actually pressure goes down--we have seen this after
hurricanes, after people come back from war. It is in the years
after you return that you start to see the problem.
We have to prepare for this for the long haul and normalize
that post-traumatic stress is something, of course, you are
going to experience by going through this. But, if we can give
sort of a moral framework for that and a support for that and
to say that is something that you can still practice
effectively, that will really help people not just seek care,
but prevent illness.
Senator Kaine. In conclusion, Chair Murray, just one thing.
I really am worried about this, not just for healthcare
providers, but I am really worried about it for first
responders--police, EMT, fire. It has been such a tough year.
And, you know, the police issues tend to always be in the
Judiciary Committee. But, I will tell you, when I go out and
talk to law enforcement professionals there, and first
responders, they usually are bringing up mental health before
they bring up anything else. And, then, if we start with mental
health, usually the whole meeting ends up being about mental
health. So, there may be an opportunity for this Committee to
look at some of the needs of our first responder community with
kind of a different lens than maybe a judiciary committee
might, and I hope we might consider doing that sometime in the
future.
The Chair. Excellent suggestion. Thank you, Senator Kaine.
Senator Cassidy.
Senator Cassidy. Way to go, Senator Kaine. Whenever you ask
a chair to take on more jurisdiction, I find it is very
receptive, so----
The Chair. Always. Always.
Senator Cassidy [continuing]. Good job.
[Laughter.]
Senator Cassidy. I am with you, Madam Chair.
Dr. Keller, I am also a doc, and I worked with Senator
Chris Murphy back in 2016 on our Mental Health Reform bill. It
actually got included in the 21st Century Cures. One thing we
really were interested in was what you are calling the
collaborative care model. As I would tell folks, my gosh, the
diabetic is psychotic, but the primary care doctor cannot walk
the patient down to the psychiatrist or the--you know, and you
can go back and forth either way on that.
In your experience in Texas, what makes the collaborative
care model so effective in terms of accessing mental health and
addictive services?
Dr. Keller. Well, it is a great question, Senator Cassidy.
Thanks for asking.
There is really--there are several factors. Let me
highlight a couple. One is that the collaborative care model
requires measurement-based care; requires universal screening
for depression, anxiety; and then following up with symptom
measures to see if the medications worked, which unfortunately,
over 80 percent of clinical settings do not do. So, having
accountability around symptoms, just like we do for blood
pressure, just like we--it is the sixth vital sign, and we need
to add it in.
The second thing collaborative care does is that the
behavioral health specialist works for the primary care
practitioner. It is not a matter like in, you know, when
someone sends me a referral as a psychologist, I can make a
decision, do I want to see this person? Do they really fit my
practice?
If I work for--it is just like the nurse who works for my
primary care doctor. When my doctor asks the nurse to take my
blood pressure, he does. And then when she asks the primary
care provider--I mean the behavioral health specialist in the
collaborative care model to follow-up on my depression, he
does. So, working within a team-based model is critical.
The practical thing about why collaborative care is so
helpful is that it is almost universally covered now, and a lot
of folks do not know this because this happened in the last
couple years. Medicare added coverage for that in 2017. By the
end of 2019, nearly every commercial coverage had added it. We
only have about 19 state Medicaid programs. We are about to add
Texas. And if we are adding Texas, we would think everybody
else should be adding that, as well.
[Laughter.]
Dr. Keller. We are going to be covering that in every--and
that is so--so that makes the work now so much easier than when
you looked at this in the Cures Act. Because all we really need
you to do is provide startup grants to accelerate the change
that eventually will happen. But, if we can do it sooner than
10 years, we are going to save hundreds of thousands of lives.
Senator Cassidy. A couple of things. I like the way that
you phrase this in terms of a business model. Most folks in DC
do not understand that your practicing physician, your you-
name-it, has to have a business model which works. And, in this
case, you have a parallel aspect to the practice, in itself
generating revenue to pay for the resource in a way which
expands the service and gives better follow-up. So, the
business model, we just have to focus on. So, it kind of leads
me to my next question.
If we have payment for this already built into various
payors, why would grants be required? If I am an FP, I am
already having a physician extender check on the blood pressure
and do pap smears and, on and on. Those things are time
consuming but do not require, cognitive sort of, oh, my gosh,
this is a very complicated hypertension.
Similarly, screening for depression and that sort of
follow-up is now covered with this sort of payment mechanism.
Why are grants required?
Dr. Keller. Well, I will just--the same business facts that
we talked about earlier, Senator. One is that I guess mental
health folks are not as good a negotiator for rates as
cardiologists are and orthopedic surgeons are. Because you can
set up a cath lab to add in additional heart patients. You are
going to make money because the rates pay so well.
That is not this case for collaborative care. Collaborative
care, the rates cover the costs. They do not cover--there is
not a profit margin built in. They just--they are just a little
bit more than the cost.
Senator Cassidy. The reason I say that is because there are
business models within the primary care setting in which you do
have just like the cardiologist has--somebody over here running
the treadmill and someone here doing the echo and someone here
doing the prothrombin time, and he or she is basically
supervising, but all of them are bringing in revenue. Here, you
have the primary care physician monitoring, but you have the
same sort of parallel activity that just seems like it defrays
your overall expense. And I say this not to challenge, but just
to explore.
Dr. Keller. No, I appreciate that. It covers the ongoing
expenses, not the startup costs. You have to hire that person
and bring them in, get them up to speed, train them. You have
to make technology changes.
That is the biggest barrier in health systems is the
technology changes, adding in that measurement into the
electronic health records, making sure it is done correctly.
And you cannot just--you have to pay--each health system has to
pay Epic, Cerner, whoever. It would be great, actually, if you
required all the electronic healthcare providers to add this to
their systems. But, each system has to do that independently.
There are startup costs that get in the way, and they are a
huge barrier. And we found in Texas that if we cover those
startup costs, health systems will commit, and then it creates
a virtuous cycle where, once you get those initial costs done,
those ongoing reimbursement allows you to then spread
throughout the entire health system over time.
Senator Cassidy. Madam Chair, my time is up. But, I will
add that I do think electronic health records are under our
jurisdiction, and, so, if Dr. Keller gives us a good
suggestion, I am open to your leadership. Thank you.
The Chair. Good. Well, if it is not, we will expand our
jurisdiction, so----
[Laughter.]
The Chair. Senator Hassan.
Senator Hassan. Well, thank you, Madam Chair, to you and
the Ranking Member. I thank you for this hearing.
I just also want to echo what Senator Kaine said about the
behavioral health challenges of all of our first responders,
not just in healthcare. I have been hearing the same thing from
police and fire fighters and EMTs in New Hampshire. Among other
things, a number of them have just said to me they have not had
a day off in a year. And anybody who has not had a day off in a
year is going to be struggling with some challenges, so I look
forward to addressing that issue.
I wanted to start with--it is a distinguished panel and I
am grateful to all of you for your work. I wanted to start with
a question to Dr. Muther. Earlier this year, I re-introduced
bipartisan legislation with Senator Murkowski, which would
expand access to medication-assisted treatment for those
struggling with opioid use disorder by eliminating the outdated
waiver requirement that keeps many providers from prescribing
medication-assisted treatment to their patients.
Yesterday, the Biden administration announced steps to
remove some of the burdensome training requirements that
practitioners must meet before they can prescribe medication-
assisted treatment. But, there are additional steps that
Congress must take to eliminate all of the existing barriers
and to ensure access to opioid use disorder treatment for those
who need it.
Dr. Muther, you have spoken in the past about the
importance of medication-assisted treatment and the myths that
contribute to the barriers individuals face when they are
trying to access this treatment. How do we fully address these
challenges and expand access to medication-assisted treatment
during the pandemic and beyond?
Dr. Muther. Wow, thank you so much for the question. That
is a big question. I think considerations for the medical
providers and how we can expand the workforce to have clinical
availability, not only for the medical prescribers, but also
for the behavioral health specialists, as I have mentioned. We
are in no--we are facing workforce shortage, and, so, if we do
not have clinicians available and if we do not have clinicians
working in the right places, we are never going to meet the
need.
There are so many other barriers to care that I have
mentioned for patients, as well. And, so, stigma has been
touched on. There is the logistical and transportation--
logistical barriers, such as transportation, conflicts, work
conflicts, and so forth. So, we need to eliminate the barriers
to care and make care accessible.
One thing that we have done is, right at the start of the
pandemic was related to home-based inductions and developing
rapport with patients and building trust so that we can do
home-based inductions, for example, safely and effectively.
So----
There is also tons of room--I think 95 percent of our
encounters at Salud by behavioral health clinician have been
done via telehealth. And, that is not only as effective; in
many ways, seems to be more effective in meeting the needs of
that population. So, it is really about eliminating barriers to
care, building the workforce, and building that rapport with
the patient community.
Senator Hassan. Thank you. I appreciate that very much.
Let me move on to a question to Dr. Benton because I want
to turn now to another devastating public health crisis that we
have talked a little bit about this morning and that Congress
has to work to address, which is the issue of youth suicide.
In 2017, Martha Dickey from Boscawen, New Hampshire was
traveling for work when she received a phone call that is every
parent's worst nightmare. Her 19-year old son, Jason, had died
by suicide. After experiencing that unimaginable loss, Martha
joined a network of Granite Staters dedicated to suicide
prevention and awareness efforts. Advocates, including a local
non-profit, the Connor's Climb Foundation, who have worked
tirelessly to raise awareness, increase education efforts, and
reduce the stigma associated with suicide.
To help build on the brave efforts of these Granite
Staters, I am working to introduce bipartisan legislation that
would work to expand access to suicide awareness and prevention
training for students.
Dr. Benton, can you speak to the importance of providing
kids and teenagers with the tools that they need to recognize
if they or someone they know is at increased risk of suicide?
Dr. Benton. Thank you for that question, Senator Hassan.
You have asked such an important question.
Most of the time, as you know, young people speak to their
peers about their suicidal feelings. So, as much as we
discourage young people from going to their peers and asking
them to speak with trusted adults, it is not usually the
pathway that is taken by most young people. And young people in
those situations will tell you that they do not know what to
say and they do not know what to do when their peers and their
classmates tell them, I feel like killing myself.
We have seen tremendous success with peer counselors who
work with suicidal youth. But, the training is absolutely
essential. Training youngsters to know how to respond is
essential. Providing opportunities for identification of
suicidal youth in all community settings is essential.
In the primary care setting, in the schools, by school
counselors, in communities, communities' religious
organizations, making that training available in one of its
many forms--because there are many training opportunities out
there--could save lives. We know that for young people who have
suicidal feelings, most of them, more than 50 percent, have
seen a primary care provider within the week before the time
they make the attempt.
There are many opportunities to just ask someone the
questions, to get comfortable with knowing what to say,
understanding that asking a question about suicide will not
make that person suicidal is essential to suicide prevention.
As you referenced, the suicide rates for young people have
continued to increase. This year, there were some--there was
data suggesting that suicide rates had decreased nationally,
but we have not separated that data for young people versus
adults. And, what we are seeing on the ground is increasing
numbers of young people presenting to emergency departments
with suicidal ideation. And I a hundred percent support your
assertion that we have to have a public health approach to this
problem. That is the way we will end suicide.
Senator Hassan. Thank you very much.
Thank you, Madam Chair.
Dr. Benton. Thank you.
The Chair. Thank you so much.
Senator Braun.
Senator Braun. Thank you, Madam Chair.
During the COVID challenge, many prisoners were released
early due to overcrowding, and they are more apt, when they are
released, to--since they lose some tolerance to opioids and
drugs, have a very, very high rate of overdose and a lot of
times, death.
Senator Baldwin and I introduced the Medicare Reentry Act,
which would try to get the treatment started prior to when you
leave prison. COVID just kind of accentuated the number of
cases.
I would like each witness to comment on do you think that
makes sense? Is that going to be an effective tool to try to
prevent the tragedy of overdose when you finally are released?
It seems like it should make sense simply because we had kind
of a sad test case through COVID. Start with Dr. Keller, and
then the rest of the witnesses.
Dr. Keller. Well, thank you, Senator, and that is--we do
applaud that, the Reentry Act. And I think Ms. Goldsby can
probably give more specifics on overdose given her experience.
But, I will tell you that it really applies across the board.
That coverage--and getting rid of the artificial barrier that
says just because somebody is incarcerated, we cannot provide
access to their healthcare benefits. I mean, those are outdated
things from the 60's. We need to get rid of those barriers and
just recognize that there is a practical issue around
coordination that we need to do, and it certainly can help with
addiction.
There are other things we will need to do, too, to make the
care more available once they get out, but certainly the
coverage is essential.
Senator Braun. Thank you. It is actually the Medicaid
Reentry Act. Go ahead with the other witnesses.
Ms. Goldsby. Yes, Senator, we agree that it would be very
beneficial for Medicaid coverage to extend to cover 30 days
prior to release. In South Carolina, we do a lot with overdose
education and naloxone distribution for our inmates prior to
reentry.
We actually have peer support specialists working in our
Department of Corrections to coordinate their reentry, equip
them with naloxone, initiate them with medical providers in the
prisons, and continue that care with medication-assisted
treatment when they need it in an outpatient setting. Our peer
support specialists work to get them into recovery residences
around the state, back to where they are going, and we hope to
expand that work with a supplement to the block grant that this
Committee has supported. We hope to expand that work to more
than 200 jails in our state as we continue with that overdose
education and naloxone distribution to more local settings.
Dr. Muther. Well, I will echo my colleagues. And not only
is it important for individuals experiencing substance use
disorder; it is important for all individuals with all
psychiatric medications.
There was a question before from Ranking Member Burr on the
comprehensiveness of attribution and is that a good idea, and I
mentioned that it is not without challenges. We see this in
primary care all the time when people show up and they are out
of their medications and they need help. And there are other
points of entry and other points of service that they need to
get to, each of which runs the risk of that individual falling
through the cracks. So, I echo my colleagues' yes and would be
supportive of this.
Dr. Benton. I [inaudible] my colleagues' comments.
Senator Braun. Thank you. I had another question on
telehealth, but I think it has already been covered. I will
yield the balance of my time.
The Chair. Thank you.
Senator Murphy.
Senator Murphy. Thank you very much, Madam Chair.
Thank you all for the great work that you do and spending
time with us this morning.
Dr. Benton, I want to thank you for drawing attention in
your testimony to the Temporary Reciprocity to Ensure Access to
Treatment Act. This is the TREAT Act. Senator Blunt and I have
been working on this together. And I will be honest, I continue
to hear from providers about the difficulties that they have
treating their patients because of the patchwork of state
licensing requirements.
In my state, I recently heard from a college that has
effectively had to stop treating their students from out of
state because of just the enormous workload connected with
tracking state rules and expiration dates. It just became
ultimately unmanageable.
I just wanted to ask you to spend a little bit more time on
why you referenced the TREAT Act and what barriers that you
have experienced during COVID response related to these
licensing requirements. And, how might, at the very least, a
temporary lifting of that requirement help us in the work that
we do around recovery?
Dr. Benton. Well, thank you, Senator Murphy, for that
question. Initially, during the pandemic, as we started to work
on pivoting to telehealth as most practices were limited, we
experienced delays related to clarification around licensing
requirements, so that if you were a practitioner in the state
of Pennsylvania, you actually could not see your patients in
New Jersey.
Fortunately, legislators responded quickly to address some
of those barriers, and the flexibility imposed by those
temporary restrictions was really remarkable. We were able to
start to practice at least in our immediate tri-state areas,
which included Delaware and New Jersey.
What it did not do was address those young people who were
in colleges in other states who needed continued treatment.
And, so, it--they became significant barriers. In our region,
not very far away, there are states where there are very
limited numbers of mental health providers, and so it is
essential that individuals be able to reach across state lines.
Then, for other populations, for some of our families, they
drive several hours to come in for a one-hour appointment, and
the flexibility to be able to reach them in their home would
expand access. That is especially true for rural and
minoritized populations of individuals needing care.
The flexibilities that were permitted during the pandemic
are essential for us to be able to provide services. There were
unintended benefits of telehealth, including the opportunity to
work with families. So, with young people, the 9-year olds
cannot drive themselves to their appointments, even though some
of them think that they can. But, their parents have to come
with them. And, the reality is that their parents are able to
engage in treatment now without the long trips. So, we are able
to work with entire families in the treatment.
The other barrier is that about 50 percent of young people
are covered by Medicaid, and most of the telehealth coverage
occurs through Medicare. So, there are some young people who
are not eligible.
Maintaining the flexibilities that we experienced through
the pandemic would allow us to reach more children and empower
families to support the mental health of their children by
partnering with the providers.
Senator Murphy. Great. Well, I appreciate that. And again,
I will just, be clear. The TREAT Act is really specific to the
pandemic. It is an emergency. We should treat it like one.
Dr. Muther, one additional question for you. In
Connecticut, so many of our community health centers are
engaged with schools in school-based health centers, and
schools are going to find themselves with additional funding
over the next year to respond to the pandemic. And I wanted to
just ask for your recommendation and thoughts about whether
they should be spending that money to build new school-based
health centers, supplement existing health centers, or whether
we should be pursuing a model where we are just making sure
that there is community services for all of these kids.
I have always worried--our school-based health centers are
fantastic in Connecticut, but it is really arbitrary whether
you have one or you do not. There are plenty of low-income
communities in Connecticut that have no school-based health
center, and, so, I sometimes worry that we sort of have made a
decision not to build the system either inside the school or
outside the school. We have a little bit of both.
What is your sort of thought on what schools--how schools
should approach using this money for school-based services
versus community-based services?
Dr. Benton. I would have to say that the immediate big
demands for schools are generally local, so they have a pretty
good sense of what their communities are like. But, what we do
know is that school-based mental health services support like
15 to 20 percent of children in the United States, and it is a
good way for families and children to receive their care
because children are there every day in their communities, and
schools are important connections for families.
School-based mental health is a very effective way to reach
children and engage families. And, if there are opportunities
to systematize that in a way that is accessible to everyone, it
would help us with identification of mental health concerns
early. It would allow us to participate in a public health
approach to prevention so that things do not become crisis and
young people end up in our emergency departments.
I would definitely support initiatives that supported the
expansion of school-based mental health in all school
communities. That could support the young people in our Nation.
Senator Murphy. Thank you, Madam Chair.
The Chair. Thank you very much.
Senator Tuberville.
Senator Tuberville. Thank you, Madam Chair.
This has been interesting. I have enjoyed this. Thank you
very much. I have been a mental health coach all my life. Most
of you probably know I coached and taught for the last 40
years. And I thought I was a football coach, but I turned into
a mental health coach for the last 10, 12 years.
I do not think even my colleagues here really understand
the problem that we are having, and it is getting worse in our
communities, in our schools. And I want to thank you all for
your help and what you do. It is hard. It really is.
It is great to hear the identification part. You have to be
able to identify a problem before you can solve it, and we have
so many problems. I did, my staff did, our medical staff did.
The problem that I see coming, we are not going to be able
to print enough money to pay for mental health programs in the
future, No. 1, if we do not do something about our border. We
have drugs coming across the border that is unbelievable. And
it is amazing to me that we continue to talk about problems,
and then we do not stop the occurrence of problems that are the
main problem to begin with.
But, it starts with family. Seventy percent of minorities
that I coached had one or no parent. And I think a lot of you
would agree with that, it starts in the nuclear family, and we
are still trying to tear that down. But, there is a lot of
things that we can address, but it all goes back just to
identification and understanding the problems that we are
having in terms of addiction.
I see one of the addictions that we have--and I hope some
of you would agree with this. We have alcohol. We have drugs.
Social media addiction was absolutely a huge problem on the
kids that I coached. Huge problem, because they were addicted
to it. They were bullying. There were problems that we had to
face every day, and I had to put special rules in for social
media.
But, that being said, I wanted to tell you a little bit
about something we are doing in Alabama that is actually
working. And we got a problem, and we are trying to solve it.
We basically took our money in Alabama and we said what we are
doing is not working. And, so, we started a broader area, and
it was a----
The mental health problem was just going over the top, so
we took our mental health and we set it up in the crisis
centers all over the state, different regions. And we included
the EMS. We included our law enforcement. We included the
teachers and everybody in the area. And what we did is we
identified the kids or the adults that had mental problems or
addiction problems, and we got them to those crisis centers,
and it was somewhere that they were away from their classmates,
because sometimes you cannot work if you are close to the
classmates. They are embarrassed. They will not go. And Alabama
is making a huge, huge step forward in our mental health
problem. Now, it is not the answer.
But, I want to ask some of you, what can be done on the
Federal level to incentivize programs like this to help? Ms.
Goldsby, what do you think?
Ms. Goldsby. Senator, it is an excellent question, and I
think we can look to prevention as an answer. The Substance
Abuse Prevention and Treatment Block Grant through SAMHSA
supports states in, disseminating evidence-based prevention
work. And we do this with our communities by supporting
coalitions that use this strategic prevention framework to work
with stakeholders at the local level to build protective
factors and reduce risk factors to protect our kids so that we
are not letting them escalate to crisis.
To your point, Senator, that takes parents, that takes
school districts, that takes coaches, that takes, law
enforcement, and our healthcare leaders to address the local
needs for our children. And, so, we just want to say again that
the Substance Abuse Prevention and Treatment Block Grant is a
huge support for that work in our state and in others states.
Senator Tuberville. Yes. I started noticing more and more
in the last 10 years, we were giving out more drugs, way too
many drugs, to our kids for attention deficit, anxiety. I
actually had to intervene with kids that were bringing drugs
from their hometowns to our college campuses and giving it to
our doctors to make sure that they were giving it out properly.
A lot of these kids do not take it properly, and it needs to be
a better regimen of how to do that.
But, I want to thank you again. I do not have another
question. Just thank you for what you are doing. Again, it is
about money, but at the end of the day, it comes down to
people, and we need more people in education that get into
mental health. And if we do not do that, we are not going to
have enough people to be able to answer these problems as they
arise down the road because they are going to get worse and
worse. So, thank you very much for what you do and for being
here today. Thank you.
The Chair. Thank you.
Senator Smith.
Senator Smith. Thank you so much, Chair Murray, and all of
you for this testimony today. I think that we are touching on
the trauma and the devastation, really, that so many Americans
have experienced due to this pandemic. Unprecedented levels of
loneliness and grief and anxiety that have been exacerbated by
what everybody has been going through. And, so, I just really
appreciate Chair Murray and Ranking Member Burr that you are
focusing our attention on this today.
I would like to start with Dr. Muther and talk a little bit
about the challenges that access to mental healthcare services,
behavioral healthcare services in rural parts of the Country.
We have the Sawtooth Mountain Clinic in Minnesota. It is a
federally qualified health center located in Grand Marais,
Minnesota. The Sawtooth Mountain Clinic has only two full-time
independently licensed mental health providers for all of Cook
County. Cook County is right up in the far northeastern part of
Minnesota. It is 3,340 square miles, so roughly the size of
Delaware. Two full-time independently licensed providers there.
In 2020, they saw 253 patients through about 1,100 visits.
But, it was so clear that the demand was so much higher,
especially, given what was happening, and they are just so
concerned that they do not have the resources and the capacity
to meet the need that is there.
I am wondering, Dr. Muther, if you could just talk a little
bit about what can we do. What have you seen? What do we need
to do to support access to mental healthcare and behavioral
healthcare, especially with the challenges serving in our rural
areas, small towns, and rural places?
Dr. Muther. Well, thank you so much for that question. I
know Sawtooth is another community health center.
Senator Smith. Yes, it is.
Dr. Muther. The challenges are immense. And, I think when
we talk about rural communities, of course we have to talk
about broadband and extending internet access, but also cell
phone service. And, as has been mentioned, the audio-only,
phone call only to, say, landlines in order to reach patients
is critically important.
From a clinical perspective, I know they are stretched thin
and the numbers that you showed bear out that, again, we
clearly do not have enough clinicians to meet the need.
As has been mentioned, the collaborative care model and any
type of consultation availability with specialty mental health
providers, not only psychiatrists, but psychiatric nurse
practitioners and other clinicians with expertise.
If there is any kind of specialty mental health system,
say, a community mental health center, how can they partner
with those agencies to, again, develop and expand or--and
ensure for the entire community collectively and in
partnership, is there an entire continuum of behavioral health
services.
I might also mention what is commonly known as the ECHO
model----
Senator Smith. Yes.
Dr. Muther [continuing]. And share training for any type
of--this has been expanded to address a multitude of medical
conditions for primary care medical providers, but certainly
has been expanded to behavioral health. And, so, the ECHO
models in terms of shared learning, shared training, and
providing that shared expertise to those clinicians, albeit a
limited number of them, is a great way to have an impact.
Senator Smith. I appreciate you bringing up the ECHO model.
We have some great examples of ECHO model implementation in
Minnesota, also, and it gets at that collaborative model that
is so important.
I also appreciate you talking about a continuum of care
because, in addition to a real shortage of access to mental
healthcare services, there is a terrible shortage of inpatient
beds. And this is a particular challenge--it is a challenge
everywhere and for everyone, but especially for youth. And I do
not ever want to have to talk again to a parent who is so
traumatized by having their child have to go, hours and hours
and hours away, if they can go at all, and that child ends up--
child or youth ends up sort of stuck either in a hospital bed;
or even worse, if they have had an interaction with law
enforcement, stuck in a county jail or, where there is no
access for them to get help. And that is really traumatizing.
I appreciate the testimony earlier today at the beginning
about your experience with that, also, Doctor, and how terrible
that can be.
Chair Murray, I know I am out of time. I want to just note
one thing, which is I know there have also been some successes
with mobile crisis units that have been able to do--kind of
connect between emergency room calls and then having a mobile
crisis intervention in that moment, which is also another
strategy that has been used in Virginia, Minnesota. They are
calling it the CAHOOTS model, and I believe that it is based on
other efforts in other parts of the Country to get that kind of
early intervention when somebody is in crisis, and that is
another thing that we could do.
Thank you, Chair Murray.
The Chair. Thank you.
Senator Rosen.
Senator Rosen. Well, thank you, Chair Murray, Ranking
Member Burr. I appreciate this really important hearing today
because, as so many of my colleagues have been asking and your
thoughtful answers on this mental healthcare is critical for
our students.
In Nevada, our K through--well, all across the Country, but
our K through 12 students, they have suffered some of the worst
outcomes over the course of the pandemic. Tragically, in
Nevada, Clark County, Clark County School District, has had 19
students, 19, take their own lives since March 2020. They
have--CCSD, they have conducted more than 4,300 virtual
wellness checks, more than 1,400 in-person wellness checks to
promote student safety, well-being.
But, it is clear that we have to do more to engage students
and their parents to help our support staff. Nevada is atop--
heading on the top of the list that nobody wants to be on the
top of. And, so, I thank you for your thoughtful answers to
Senator Murphy's questions and to others. But, I would like to
move on to a little bit about trauma training.
My office has heard from Nevada childcare advocates, child
welfare advocates, that they are finding particular trouble
having people who have done trauma-informed training. And, so,
how do you recommend as for boosting the specialized mental
health workforce to ensure that our mental health professionals
have the training and ongoing training opportunities to assist
our children through this trauma-informed lens? Of course,
child abuse, a lot of things now with the pandemic, people have
suffered, families even, through many more things. What do you
think we can do to help you there? Dr. Benton.
Dr. Benton. Thank you for that question, Senator Rosen.
One of the things that we can do is foster the partnerships
that my colleagues have described earlier. So, partnerships
between community health agencies, schools, places where--the
primary care offices where individuals are trained.
There have been successful models of trauma-informed care
training for systems in partnership with the payor agencies or
the community agencies who actually have the expertise to
provide that training. So, for example, to be explicit, one of
the things that is occurring in Pennsylvania is community
mental health centers are partnering with a cluster of schools
to assure that they are doing trauma-informed care training for
teachers, and for families when possible, for school
administrators, and we are using that model in many other
communities.
For the young people, because they are in schools and
because they are in their primary care offices, it is a little
bit easier, I think, in some ways to navigate those systems.
But, we are actually sharing expertise at the community level
so that everyone involved with young people could have that
access.
That is so important through this pandemic because for
minoritized populations and rural populations who have
sustained heavy losses. Many of the young people have
experienced loss for the first time. And there was no saying
goodbye; there was no rituals. So, it is really important that
we get out in front of these interventions.
Senator Rosen. Now, I agree on the collaborative model, for
sure. I would like to talk about this particularly for rural,
underserved communities or people who may have other kinds of
issues. Audio-only telehealth, I continue to hear from
providers across my state that audio-only telehealth has been
critical to providing timely access to mental healthcare
services. Sometimes it is the only thing they have. And,
oftentimes, people--there is a security to be on the phone,
maybe not showing their face, maybe not letting you into their
home. Maybe they can go to safe space and use a telephone
somewhere. So, it is really important that we have the
flexibility for this delivery model.
I know I just have a few seconds left. So, for Dr. Muther
and then Dr. Keller, what--can you talk about your experience
with audio-only telehealth for our rural, our underserved
communities, or just in general--but, a lot of people do not
have access to broadband, we will throw that in there--how
important it is that we retain this for mental health services?
Dr. Muther. Yes, that is pretty essential.
Senator Rosen. Not just----
Dr. Muther. Thank you. Thank you for the question. Sorry to
cut you off.
Senator Rosen. No, I was going to tell you to go first.
Dr. Muther. Yes, absolutely essential. We have talked about
rates, prevalence rates, being on the rise since the onset of
the pandemic. The truth is the rates--the suspected rates of
prevalence for mental illness and substance use disorders are a
gross underestimate, and the reason is we do not ask enough
people. And, the reason because of that is we do not have the
capacity to ask everyone. Say we do not ask the people who are
living in more rural areas. We do not have--ask the people who
are--who do not have access to internet. So, that is just one
example.
I think the phone-only is absolutely essential for the
very, very brief, quick check-in encounters that--I shared our
patient story--that are meaningful and not reliant on, say, a
traditional, 45-minute, face-to-face, lay on the couch therapy
hour. This allows for brief check-ins to see how individuals
are doing and monitor follow-ups in a way that is quick, easy,
and accessible for both the patient and the provider.
Senator Rosen. Thank you.
Madam Chair, I know my time has expired. I am not sure if
there is someone after me, if you would like Dr. Keller to
respond. Otherwise, I can take her questions for the record.
The Chair. Okay. Let's take the questions for the record.
We do have a few more Senators who have questions.
Senator Rosen. Thank you.
The Chair. Thank you. We will take that for the record.
Senator Lujan.
Senator Lujan. Thank you, Chair Murray, and also the
Ranking Member. Thank you for this important hearing.
I appreciate all the conversation that is taking place
surrounding Project ECHO, which we all know is a telementoring
program for health professionals developed at the University of
New Mexico by Dr. Sanjeev Arora.
Dr. Arora, if you are watching and listening, I want to
thank you for transforming people's lives and for developing
this important program. It has been an honor to be able to work
with you.
I know, Chair Murray, you have also been a staunch
supporter of Project ECHO, so thank you so very much.
I want to jump into an area with medically assisted
treatment. According to the National Academies of Science, more
than 80 percent of the two million people with opioid use
disorder are not receiving medication-assisted treatment. I was
pleased to see Secretary Becerra issue guidance this morning,
removing barriers for qualified practitioners to treat with
buprenorphine for opioid use disorder.
Dr. Keller, what policy recommendation would you make to
ensure that there is a broad provider network that is
adequately trained in medically assisted treatment?
Dr. Keller. Well, thank you, Senator Lujan, for that
question. I mean, I think the best thing you could do is remove
all the restrictions. There are no restrictions on the
prescription of opioid pain relief. Why would there be
restrictions for the exact same providers on the provision of
treatment to save the lives of people who could potentially
become addicted to those pain killers?
It just--this is the kind of thing--I have got to be a
little careful on my language here. When I would explain to my
grandmother what I did, because she was often perplexed, and I
would say we are doing a study, for example, comparing, these
two things, she would say, they pay you money to do comparisons
like that?
Because I think it is just common sense that the exact same
providers who provide the pain killers could also provide the
treatment to prevent death from addiction. So, I just think
removing them entirely is--and I understand that there are
folks who, promote kind of a gold standard, people deserve
better treatment, and I understand that sentiment. But, we
cannot let the perfect be the enemy of the very good.
There are decades of research in other countries that have
shown that these medications--including buprenorphine--are
incredibly safe if done in the right hands. I do not understand
why there are any restrictions, frankly.
Senator Lujan. Thank you for that, Dr. Keller. I certainly
agree with you. And I certainly agree that one way we can
ensure more patients have access to the treatment they need is
by eliminating these outdated requirements for providers who
are qualified and willing to provide medication-assisted
treatment.
That is why I was proud to work with Congressman Tonko last
Congress to introduce the Mainstreaming Addiction Treatment
Act, and I look forward to working with Senators Hassan and
Murkowski on expanding that access. So, thank you so much for
that response.
In my time remaining, peer support is something that I
really support. Peer support specialists, I am a big supporter
and fan of them. I think they make a positive difference in
people's lives.
Dr. Keller, as you deploy peer specialists and community
health workers in North Texas to expand your mental and
substance use disorder workforce, what benefits do peer support
providers bring through their lived experiences? And if you
could keep that as concise as you can, because I also want to
ask Ms. Goldsby her perspective on some of the work she has
done with telehealth peer support.
Dr. Keller. Well, I think the traditional approach--I mean,
the main reason why community health workers are helpful is
their lived experience. And it is not just lived experience
with mental illness or addiction, which is super helpful, but
also lived experience of living alongside people in their
communities across, you know, racial, ethnic, other
demographics. So, I--it is a wonderful intervention.
The second thing I would just add is we have actually
partnered with the Harvard Global Health Program to take an
approach that was actually developed in India to equip these
community health workers with technology--the same types of
telesupports that help other workers be able to be more
evidence-based. And I would just add that those technology
enablements really add efficacy to those community health
workers.
Senator Lujan. I appreciate that.
Ms. Goldsby, South Carolina supported telehealth through
support with reimbursement from grant funding. What are some of
the positive results that you observed through this innovative
delivery of peer support? And what recommendations would you
make to policymakers looking to build on your successful
delivery of peer support?
Ms. Goldsby. Thank you, Senator Lujan. Everybody in South
Carolina has probably heard me say that I would like to see an
army of peer support specialists in this state, and we are
working to build that army, getting them into many locations
across the state.
During the pandemic, we did support peer support
specialists' use of telehealth in connection to folks for safe
distancing measures. I think we need to see better
reimbursement rates in our states. We need to see these
paraprofessionals supported at a living wage so that they can
continue to be supported by the health systems and health
centers that they work and continue to do that good work.
Senator Lujan. Thank you so much, Representative. I
appreciate the work that you do down that way.
Chair Murray, I also just want to join my colleagues who
have asked for making permanent access to both video and audio
mental, behavioral health services, making that permanent, and
also addressing the reimbursement challenges so that way we can
make it more useful.
Thank you for the time today, and I yield back.
The Chair. Thank you. And I am going to take the
prerogative of the Chair and let Dr. Goldsby answer your
question on medically--on MAT treatment because that is her
specialty. I could see she was--really wanted to answer that
and would love to hear your response.
Ms. Goldsby. Thank you, Chair. I will answer that from my
perspective in South Carolina. And I just want to say we have
done a tremendous amount of work with the state opioid response
grants to expand capacity for medication-assisted services
across the state, enabling our providers in every county to
have that service and have patients be able to access that
service.
That being said, I keep a spreadsheet of the over 1,000
prescribers in our state who have the DATA 2000 X waiver, and
we cross-check that with our state's prescription monitoring
program and the prescriptions of buprenorphine dispensed. We
are finding that fewer than 10 percent of our prescribers who
can treat with buprenorphine, treat addiction, are actually
treating addiction.
I think from our perspective in South Carolina, we know we
have some work to do with practice transformation. I think we
talked about it earlier. How do we enable these primary care
and hospital-based services to transform to address addiction
as other chronic diseases, giving prescribers and providers the
comfort that they can actually help patients manage addiction,
this other chronic illness, just like they help patients
manage, you know, their hypertension or diabetes. And I think
we have a way to go at that, and it is really based in culture.
The Chair. Thank you very much.
Senator Hickenlooper.
[Brief silence.]
The Chair. Senator Hickenlooper, I think you are muted.
Senator Hickenlooper. I hit the mute. Am I still----
The Chair. No.
Senator Hickenlooper. I am not muted?
The Chair. Now we have you. Go ahead.
Senator Hickenlooper. There is--when did we add a delay
function to the mute button? That must be new.
Dr. Muther, you said that the expansion of telehealth
during the pandemic was a saving grace, but we still have a gap
in care because the impact the pandemic has at the same time
really, as you have all been saying, exacerbated the crisis of
mental health.
How has the increased flexibility to provide more services
through telehealth helped you reach more patients more
frequently during the pandemic?
Dr. Muther. Yes, that is absolutely right, and thank you
for the question, Senator.
We have to keep in mind that before the pandemic, the
system was really overwhelmed such that the demand for
behavioral health services far exceeded our capacity to provide
those services. And, as I mentioned, the end result was that
over 50 percent of individuals experiencing mental illness--and
it is more like 80 percent for individuals with substance use
disorders--still do not receive care.
That--despite maintaining productivity and high rates of
services, because of telehealth throughout the pandemic,
because of the added stressors, that gap has only widened,
despite the work and the amazing efforts of our amazing
clinicians.
We have our work cut out for us, and we need to get
creative. As it relates to telehealth, something that is
important to mention--and no-show rates was mentioned before.
If I am a clinician seeing eight therapy patients, I might get
six to show up in person, whereas I might get all eight to
attend a telehealth visit. So, it helps with the no-show rate.
But, that is only eight visits per clinician, per day. I think
we need to expand telehealth well beyond the direct service
clinical encounters and use smart technologies for brief check-
ins, mood assessments, instant messaging between clinician and
consumer throughout the week or between sessions, and other
kinds of technologies to really broaden and deepen the impact.
To think that only face-to-face or video conference, phone
encounter, whatever it is, while that clinician is maintaining
the same schedule of only eight patients a day, we are not
going to get anywhere, to be totally frank about it. We have to
use other technologies, group services and other things that we
can do via telehealth in order to broaden the reach.
Senator Hickenlooper. Now, that is an excellent point, and
I agree completely.
Does anybody else want to add on to that telehealth issue?
I think it is a key point.
Dr. Benton. Yes. Hi. I agree with Dr. Muther a hundred
percent. One of the things that we have observed with
telehealth is that capacity for families to come in for
treatment.
When we think about keeping an appointment, for adults, we
just need to get out of work. For parents who need to come in
for treatment, they need to get out of work, get their kids out
of school, make a ton of arrangements, make a travel. And, if
in fact you have a child who is struggling with a pretty
significant mental health condition, that car ride can be
pretty awful.
Telehealth has allowed us to expand access to families who
would not be able to come in, particularly those who cannot
make a two-hour car ride in our state.
We have also been able to see more patients at more
flexible hours. So, we have been able to use telehealth to see
patients overnight in our emergency department, which really
expands our access. We can vary hours. We can see people early,
and we can see folks late.
It has really given us a lot more flexibility and given
families more flexibility.
Dr. Keller. Senator Hickenlooper----
Dr. Muther. Senator, if I may quickly, we would be remiss
to not touch on the payment models as it relates to the use of
telehealth, as well. So, as I mentioned, the smart technologies
and the brief check-ins throughout the week, that is not
capable or that is not possible in a fee-for-service model, so
we have to explore the global payments that allow the--that
afford the clinician the flexibility to provide the service
that the individual really needs.
Dr. Keller. [Continuing].Senator Hickenlooper, if I could
just add, I think the primary care transformation process that
Ms. Goldsby talked about earlier, about increasing capacity to
treat addiction, can also be enabled through telehealth by
allowing collaborative care to be delivered virtually, and that
certainly works just as well. The V.A. has shown that. Many
demonstrations have shown that. So, that is another advantage
that I think the telehealth extensions will allow.
Senator Hickenlooper. Yes. No, absolutely. That is--what a
great answer that was from all of you, and I really appreciate
all of your willingness to come and be part of this panel.
Anyway, I am out of time, as always is the case.
Madam Chair, I will yield back my time to the Chair.
The Chair. Thank you very much.
I will turn it over to Senator Burr for any final questions
or comments.
Senator Burr. Thank you, Madam Chair. Let me say to our
Members, thank you for a tremendous amount of quality questions
today. But, more importantly, to our witnesses, thank you for
your very candid and knowledgeable answers.
My takeaway earlier when I started was telehealth, and my
closing comment is going to be on that.
One year ago, few, if any, of us thought that today we
would actually be vaccinating people around the world for COVID
because history taught us it cannot happen that quickly.
Technology has been a tremendous force multiplier in
healthcare.
But, what we have learned is that until there is a stream
to fund the application of that technology, technology will
always migrate to areas that have a funding stream, and
healthcare has never been an embracer of telehealth. Even
though it did get its origins at East Carolina University early
on, it is used actively by the Veterans Administration for much
of their delivery of care for the single reason that the number
one problem that they had was transportation. This eliminated
the number one no-show reason for a veteran.
Now we have an opportunity to not only expand the use of
telemedicine, but to leverage that application for other
technologies that can provide force multipliers in the delivery
of healthcare overall.
It is a tremendous benefit for mental health, for substance
abuse, but we also have to have the realization that the
leverage of technology is going to allow us to do things that
today we do not think are possible. And in many ways, shapes,
or forms, even for mental health, it is because we just do not
know that the technology is available, and we have not tried
how to use it yet.
I hope what we are doing is opening the door of opportunity
today for new and exciting technological treatments for mental
health.
I thank the Chair.
The Chair. Thank you, Senator Burr.
I have heard from so many women in my home State of
Washington and nationwide about how tough this pandemic has
been for them in particular--job loss, more caregiving, having
to work and teach their kids at the same time, lack of
childcare, all of these impacts, not to mention pregnant or
postpartum women who had the additional challenge of trying to
access healthcare during a pandemic.
I wanted to ask Dr. Muther and Ms. Goldsby, what has the
pandemic taught us about how to improve access to mental health
and substance use disorder treatment for women? And I will
start with Dr. Muther.
Dr. Muther. Well, I--yes. Your question is an important
one, and you are exactly right. I mean, the school closures,
the caring for older parents, likely, the pregnancy issue, and
especially as it relates to pregnancy-related depression is
another critical issue. And, so, not providing the mental
health, behavioral health part of the pregnancy care for women
during and after pregnancy is a mistake that we can no longer
afford to provide--or leave absent.
One of the most profound things that we do as an
intervention is to teach pregnant women about parenting skills,
about sleep, about feeding routines, about discipline, while
that child is in utero. And, we provide resources on coping
skills, stress relief, managing mood postpartum.
By managing that mother's stress, with everything going on,
we can actually do better to break this generational cycle of
trauma. And if we have a meaningful intervention with that
mother and have her coping effectively and parenting
effectively, she may be less likely to allow her child to have
what is called an adverse childhood event, and whereby
preventing her child from having negative mental health
outcomes themselves.
The Chair. Thank you.
Dr. Goldsby.
Ms. Goldsby. Chair Murray, thank you for this question. It
just so happens I was pregnant and had a baby during 2020 in
unique circumstances. I think the NIH has recently come out
with some studies suggesting that this year has certainly
impacted women differently in terms of their consumption of
alcohol and other substances, the consequences of which we may
not see for many years to come.
That being said, the SAPT Block Grant, prioritizes how
states prioritize pregnant and parenting women as a special
population that need topnotch services in terms of quality and
immediate services in terms of access. I think as single state
agencies, our role is to coordinate the care of those services
and the access for those women across our states.
In South Carolina, I have a liaison who works for me but
works at the Department of Social Services. Her role is to help
us align our policy and our programs so that we are
implementing best practices when it comes to our women and
families in need of substance use disorder services. What that
looks like right now is us working together with many
stakeholders--all of our OB-GYNs across the state--to develop
what we are calling a plan of safe care.
We have a culture shift in our state that we are working on
so that women are not afraid of punitive action. If they are
drinking or misusing substances, we want them to still access
prenatal care, and we want them to not be afraid to do so.
We want to make sure we have wraparound services and that
our OB-GYNs and healthcare providers know what to do when they
do have a woman in need of services, and that includes further
down the line identifying fetal alcohol spectrum disorder. Of
course, we want to get ahead of that, but there is work to do
down the road.
All of these things tied together, and that is really, our
role in terms of coordinating and supporting those women's
needs.
The Chair. Thank you very much. I think this is a critical
issue we all need to be aware of and focus on. I appreciate
those answers.
Finally, let me just say this. The past year has really
taught us that we have to be better prepared for the next
public health emergency, and improving the healthcare workforce
is really a key part of that. Senator Burr and I are working
together on a bipartisan basis to improve workforce programs.
Additionally, I have reintroduced the Public Health
Infrastructure Saves Lives Act to really strengthen the
Country's ability to address public health crises in the
future.
Dr. Benton, let me ask you, how can we support the
pediatric mental health workforce so we can better address the
mental health needs of our kids?
Dr. Benton. Thank you, Chair Murray. The loan forgiveness
program, I think, will be a major component of that so that--
many people who are entering this field cannot afford to enter
mental health treatment following any training. So, I think
that supporting the loan forgiveness would play a major part.
I think expanding access to educational programs for not
just the child psychiatrist, but other community partners, peer
specialists, and others. I think it would expand our
opportunities to expand the mental health workforce.
But, I think the loan forgiveness is a major component of
what we could do to support mental health access.
The Chair. Dr. Keller, how does a robust public health
infrastructure help us with the issues we have been talking
about today?
Dr. Keller. Well, I think beginning with shoring up our
primary care infrastructure I think is one of the most
important ways because we--the hallmark of a public health
approach is we have to detect illness early, and we have to do
everything we can to prevent it. Primary care is the best-
positioned part of our system, of our health system, to detect.
Then, I think furthermore, including that public health
framework with our schools. That really--when we talked about
social, emotional development in schools and a multi-tiered
system of supports within schools, it is a public health model
that looks at the universal interventions that we can do for
every student to prevent bullying, to help them not become
bullies, to help them develop in a healthy way their emotions
and their cognitive skills.
Then, targeting and be able to provide selected services to
students who are at risk, and then really making sure we have
quick access. And telehealth, we think, is the best way to do
that universally across schools so we get children help as soon
as the needs emerge.
I think we have to take that full public health framework
and embed it both in primary care and in our public schools so
they can leverage that public health infrastructure further.
The Chair. Well, thank you.
Dr. Goldsby, how does a robust public health infrastructure
help us prevent substance use disorders?
Ms. Goldsby. Thank you, Chair Murray. I think, substance
use disorders are one of many complex public health issues.
And, our response to it collectively is only as good as the
infrastructure that we have.
I think we have learned a lot of lessons in the last year
about our public health infrastructure. I think probably in
each state we have recognized our strengths and weaknesses and
where we need to fortify in the moment now and with the
supplements that Congress has provided for states so that we
have the infrastructure to carry programs and services that
will be needed in the future.
I think it comes back collaboration, coordination, and
communication, and really strengthening at the state level and
at the local level our response with that infrastructure.
The Chair. Well, thank you.
That will end our hearing today. And I really want to thank
Dr. Muther, Dr. Benton, Director Goldsby, and Dr. Keller for
joining us today for really a thoughtful discussion. We
appreciated it very much.
This past year has been incredibly hard on a lot of people,
and it is clear that we have to take action to make sure our
families can get the mental healthcare and the substance use
disorder treatment that they need. So, I hope we will be able
to work together in a bipartisan way on this.
For any Senators who wish to ask additional questions,
questions for the record will be due in 10 business days, on
Wednesday, May 12, at 5 p.m. The hearing record will also
remain open until then for Members who wish to submit
additional material for the record.
This Committee will next meet tomorrow, April 29, at 10:00
a.m. in room 106 of the Dirksen Senate Office Building for a
hearing on the nominations of Jennifer Abruzzo to serve as
General Counsel of the National Labor Relations Board, and
Seema Nanda to serve as Solicitor for the Department of Labor.
With that, thank you again to our witnesses, and this
Committee is adjourned.
ADDITIONAL MATERIAL
Breen Coalition,
March 25, 2021.
Hon. Tim Kaine,
U.S. Senate,
231 Russell Senate Office Building,
Washington, DC.
Hon. Todd Young,
U.S. Senate,
185 Dirksen Senate Office Building,
Washington, DC.
Hon. Susan Wild,
U.S. House of Representatives,
1027 Longworth House Office Building,
Washington, DC.
Hon. David McKinley,
U.S. House of Representatives,
2239 Rayburn House Office Building,
Washington, DC.
Dear Senators Kaine and Young and Representatives Wild and
McKinley:
On behalf of the undersigned organizations, we would like to thank
you for introducing the ``Dr. Lorna Breen Health Care Provider
Protection Act'' (S. 610/H.R. 1667). This bipartisan, bicameral
legislation will help reduce and prevent mental and behavioral health
conditions, suicide, and burnout, as well as increase access to
evidence-based treatment for physicians, medical students, and other
health care professionals, especially those who continue to be
overwhelmed by the COVID-19 pandemic.
The stigma surrounding mental illness is a well-known barrier to
seeking care among the general population, but it can have an even
stronger impact among health care professionals. For most physicians
and other clinicians, seeking treatment for mental health sparks
legitimate fear of resultant loss of licensure, loss of income, or
other meaningful career setbacks as a result of ongoing stigma. Such
fears have deterred them from accessing necessary mental health care,
leaving many to suffer in silence, or worse. In fact, physicians have a
significantly higher risk of dying by suicide than the general public.
Ensuring clinicians can freely seek mental health treatment and
services without fear of professional setback means their mental health
care needs can be resolved, rather than hidden away and suffered
through. Furthermore, optimal clinician mental health is essential to
ensuring that patients have a strong and capable health care workforce
to provide the care they need and deserve.
To ensure patient access to medically necessary care can be
maintained, it is vital that we work to preserve and protect the health
of our medical workforce. Your legislation will help establish grants
for training health profession students, residents, or health care
professionals to reduce and prevent suicide, burnout, substance use
disorders, and other mental health conditions; identify and disseminate
best practices for reducing and preventing suicide and burnout among
health care professionals; establish a national education and awareness
campaign to encourage health care workers to seek support and
treatment; establish grants for employee education, peer-support
programming, and mental and behavioral health treatment; and commission
a Federal study into health care professional mental health and
burnout, as well as barriers to seeking appropriate care.
Thank you again for your leadership on this important issue and for
introducing this legislation. We look forward to working with you to
ensure the ``Dr. Lorna Breen Health Care Provider Protection Act'' is
signed into law.
Sincerely,
American College of Emergency Physicians
American Academy of Dermatology Association
American Academy of Family Physicians
American Academy of Neurology
American Association of Child and Adolescent Psychiatry
American Association of Clinical Urologists
American Association of Neurological Surgeons
American Association of Orthopaedic Surgeons
American College of Cardiology
American College of Obstetricians and Gynecologists
American College of Radiology
American College of Rheumatology
American College of Surgeons
American Foundation for Suicide Prevention
American Gastroenterological Association
American Medical Association
American Medical Group Association
American Nurses Association
American Osteopathic Association
American Psychiatric Association
American Society of Anesthesiologists
Association for Clinical Oncology
Association of American Medical Colleges
Congress of Neurological Surgeons
Dr. Lorna Breen Heroes' Foundation
Emergency Nurses Association
National Alliance on Mental Illness
National Association of Spine Specialists
Physicians Advocacy Institute
Renal Physicians Association
Society for Vascular Surgery
The Society of Thoracic Surgeons
______
acp statement for the record
The American College of Physicians (ACP) is pleased to submit this
statement and offer our views regarding mental health and substance use
disorders (SUDs) and how they relate to the public health emergency
(PHE) caused by Coronavirus (COVID-19). We greatly appreciate that
Chair Murray, Ranking Member Burr, and the Health, Education, Labor,
and Pensions (HELP) Committee have convened this hearing, ``Examining
Our COVID-19 Response: Using Lessons Learned to Address Mental Health
and Substance Use Disorders,'' held on April 28, 2021. Thank you for
your commitment to ensuring that clinicians have the opportunity to
share their views about the response to the PHE caused by COVID-19
including how we can use the lessons learned during the PHE caused by
COVID-19 to improve how the medical community treats patients with
mental health and SUDs. Through the experiences of its physicians on
the frontlines of furnishing primary care during the COVID-19 pandemic,
ACP would like to share its input and recommendations surrounding
COVID-19 and mental health and substance use disorders (SUDs),
including integrating primary care and behavioral health, expanding the
available tools to treat mental health SUDs, and increasing the
physician workforce.
The American College of Physicians is the largest medical specialty
organization and the second-largest physician membership society in the
United States. ACP members include 163,000 internal medicine physicians
(internists), related subspecialists, and medical students. Internal
medicine physicians are specialists who apply scientific knowledge and
clinical expertise to the diagnosis, treatment, and compassionate care
of adults across the spectrum from health to complex illness. Internal
medicine specialists treat many of the patients at greatest risk from
COVID-19, including the elderly and patients with pre-existing
conditions like diabetes, heart disease and asthma.
The Pandemic Increased Demand for Mental Health and Substance Use
Disorder Services
Recently, the U.S. Government Accountability Office (GAO) released
a report, Behavioral Health: Patient Access, Provider Claims Payment,
and the Effects of the COVID-19 Pandemic. The purpose of the report was
to determine if the need for and access to mental health and SUD
services varied as the availability to care diminished during the PHE
caused by COVID-19. The report showed several concerning trends. The
Centers for Disease Control and Prevention (CDC) found that 38 percent
of individuals surveyed reported symptoms of anxiety or depression from
April 2020 to February 2021. This was a 27 percent increase from 2019
for the same time period. CDC data found that emergency department
visits for overdoses was 26 percent higher and suicide attempts was 36
percent higher for the time period of mid-March through mid-October
2020 when compared to that period during 2019. The Substance Abuse and
Mental Health Services Administration (SAMHSA) found that in September
2020 opioid deaths in certain sections of the United States increased
anywhere from 25 to 50 percent when compared to the same time during
2019. SAMHSA data also showed that contacts by individuals to the
Disaster Distress Helpline increased during the PHE caused by COVID-19
in 2020 over comparable time frames in 2019. For example, between March
and August 2020, calls hit a high in April 2020 at almost 10,000 calls,
which is an 890 percent increase over April 2019. In August 2020, a
survey conducted by the National Council for Behavioral Health's
(NCBH), found that over half of their member organizations an increased
in demand for their services in the three-month period before the
survey. A February 2021 follow-up survey by NCBH discovered that the
demand for services had increased by 67 percent. \1\ Clearly, the U.S.
population has experienced a sharp increase in mental health issues and
SUDs during the COVID-19 pandemic.
---------------------------------------------------------------------------
\1\ U.S. Government Accountability Office. (2021) Behavioral
Health: Patient Access, Provider Claims Payment, and the Effect of the
COVID-19 Pandemic. GAO-21-437R. https://www.gao.gov/assets/gao-21-
437r.pdf.
---------------------------------------------------------------------------
Mental Health and Substance Use Disorder Workforce Shortage Made Worse
by the COVID-19 Pandemic
Meanwhile, persistent mental health and SUD workforce shortages
from before the pandemic only worsened during the PHE caused by COVID-
19. Before the pandemic, the Health Resources and Services
Administration (HRSA) found that by 2025, shortages of seven different
types of mental health clinicians were anticipated, with shortages of
10,000 and above in some clinician fields of practice. In September
2020, HRSA designated over 5,700 mental health provider shortage areas
with 119 million people living in one of these areas. HRSA estimated
that available mental health clinicians in these areas were only
adequate enough to meet 27 percent of the need for services. \2\ SAMHSA
reported that due to a combination of reasons, including laying off of
staff and the closure of clinicians that could not sustain themselves
financially, led to a decrease in access. In February 2021, NCBH
reported that member organizations had decreased staff and services
because of the pandemic caused by COVID-19, including 27 percent laying
off of staff and 23 percent furloughing staff, resulting in 68 percent
of member organizations canceling, rescheduling, or turning away
patients. \3\ Not unexpectedly, the demand for mental health and SUD
services rapidly increased during the PHE caused by COVID-19 while at
the same time access to these services diminished.
---------------------------------------------------------------------------
\2\ U.S. Government Accountability Office. (2021) Behavioral
Health: Patient Access, Provider Claims Payment, and the Effect of the
COVID-19 Pandemic. GAO-21-437R. https://www.gao.gov/assets/gao-21-
437r.pdf.
\3\ U.S. Government Accountability Office. (2021) Behavioral
Health: Patient Access, Provider Claims Payment, and the Effect of the
COVID-19 Pandemic. GAO-21-437R. https://www.gao.gov/assets/gao-21-
437r.pdf.
---------------------------------------------------------------------------
Integrate Primary Care and Behavioral Health
ACP strongly supports the integration of behavioral health care
into primary care and encourages its members to address behavioral
health issues within the limits of their competencies and resources.
Accordingly, ACP supports using the primary care setting as the
springboard for addressing both physical and behavioral health care.
The basis for using the primary care setting to integrate behavioral
health is consistent with the concept of ``whole-person'' care, which
is a foundational element of primary care delivery. It recognizes that
physical and behavioral health conditions are intermingled: Many
physical health conditions have behavioral health consequences, and
many behavioral health conditions are linked to increased risk for
physical illnesses. In addition, the primary care practice is currently
the entry point and the most common source of care for most persons
with behavioral health issues--it is already the de facto center for
this care. The degree of medical practice integration can vary, from
basic coordination between a primary care physician and behavioral
health clinicians, to colocation with a behavioral health clinician
practicing in close proximity to the primary care physician, to a truly
integrated care approach in which all aspects of care delivered in the
primary care setting recognize both the physical and behavioral
perspective. For example, the patient-centered medical home (PCMH) has
been proposed as an appropriate model to address the integration of
primary and behavioral care, highlighting its emphasis on primary care,
care coordination, and delivery of care by a team of professionals. The
Affordable Care Act incentivized the development of Medicaid health
homes, which promote addressing behavioral health issues in the primary
care setting. Evidence also shows opportunities in the primary care
setting not only to address current behavioral health conditions but
also to serve as a platform to promote prevention in at-risk patients
or populations and address behavioral health conditions before symptoms
can occur in patients. \4\
---------------------------------------------------------------------------
\4\ Crowley R, Kirschner N; Health and Public Policy Committee of
the American College of Physicians. The Integration of Care for Mental
Health, Substance Abuse, and Other Behavioral Health Conditions into
Primary Care: An American College of Physicians Position Paper.
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M15-0510.
---------------------------------------------------------------------------
ACP recommends that public and private health insurance payers,
policymakers, and primary care and behavioral health care professionals
work to remove payment barriers that impede behavioral health and
primary care integration. Stakeholders should also ensure the
availability of adequate financial resources to support the practice
infrastructure required to effectively provide such care. The barriers
to seamless integration of behavioral and primary care are both
administrative and financial. Behavioral and physical health care
clinicians have a long history of operating in different care silos.
The artificial separation of behavioral and physical health care is
reflected in many ways. For example, primary care physicians generally
lack extensive clinical training in behavioral health, and traditional
medical and mental health training models and practice environments are
substantially different, which may lead to cultural clashes if they are
not thoughtfully integrated. \5\
---------------------------------------------------------------------------
\5\ Crowley R, Kirschner N; Health and Public Policy Committee of
the American College of Physicians. The Integration of Care for Mental
Health, Substance Abuse, and Other Behavioral Health Conditions into
Primary Care: An American College of Physicians Position Paper.
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M15-0510.
Even though there are challenges, the evidence shows that
integrating behavioral health and primary care leads to improved mental
health outcomes, improved physical health, improved quality of life,
and lower costs. The available research evidence, while limited, does
support the efficacy of this approach. \6\ The Behavioral Health
Integration (BHI) Collaborative, in which ACP participates, has found
that benefits of integration can include promoting long-term value,
improved patient satisfaction, and reducing the stigma of mental health
issues and SUD. \7\ Primary care physicians also support integrated
care and report that the integrated care model encourages better
communication and coordination among behavioral health and primary care
physicians and reduces mental health stigma. \8\
---------------------------------------------------------------------------
\6\ Crowley R, Kirschner N; Health and Public Policy Committee of
the American College of Physicians. The Integration of Care for Mental
Health, Substance Abuse, and Other Behavioral Health Conditions into
Primary Care: An American College of Physicians Position Paper.
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M150510.
\7\ Behavioral Health Integration Collaborative. Behavioral Health
Integration Compendium. American Medical Association, 2020. https://
www.ama-assn.org/system/files/2020-12/bhi-compendium.pdf.
\8\ Crowley R, Kirschner N; Health and Public Policy Committee of
the American College of Physicians. The Integration of Care for Mental
Health, Substance Abuse, and Other Behavioral Health Conditions into
Primary Care: An American College of Physicians Position Paper.
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M15-0510.
---------------------------------------------------------------------------
Accordingly, Congress can and should take action to encourage
primary care and behavioral health integration. Congress could
establish grant programs with adequate funding to incentivize primary
care uptake of the various integrated care models. These grants could
help defray costs of establishing and delivering integrated primary and
behavioral health services. These costs can include but are not limited
to, hiring additional staff such as behavioral health managers,
contracts with other needed healthcare clinicians such as psychiatrist
consultants and behavioral health managers, and purchasing or upgrading
software and other resources to provide new services such as more
coordinated care. Congress could also encourage additional payment
models that potentially facilitate integrated care include bundling
payments, partial and full capitation, and even fee-for-service. For
example, additional fee-for-service payment codes could be aligned to
incentivize integration by establishing payment for behavioral health--
primary care consultations, multidiscipline care plan development, and
related activities. \9\
---------------------------------------------------------------------------
\9\ Crowley R, Kirschner N; Health and Public Policy Committee of
the American College of Physicians. The Integration of Care for Mental
Health, Substance Abuse, and Other Behavioral Health Conditions into
Primary Care: An American College of Physicians Position Paper.
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M15-0510.
---------------------------------------------------------------------------
ACP also strongly supports increased research to define the most
effective and efficient approaches to integrate behavioral health care
in the primary care setting and Congress should prioritize research in
this area. Although a review of the current literature supports the
efficacy of the integration of behavioral health care in the primary
care setting, it is limited and filled with many gaps. Substantial
research is needed to focus on the efficacy of various models of
integration, as well as the diagnostic and treatment interventions most
appropriate for use in these models. The following additional factors
should be considered within research efforts: specific conditions
addressed, populations involved (such as child vs. adult), funding
structures, personnel employed, and resources available to the
participating practices. \10\ Federal research agencies, such as the
Agency for Healthcare Research and Quality (AHRQ) are well situated to
study the best ways of integrating behavioral health care in the
primary care setting and Congress should provide the resources to so.
---------------------------------------------------------------------------
\10\ Crowley R, Kirschner N; Health and Public Policy Committee of
the American College of Physicians. The Integration of Care for Mental
Health, Substance Abuse, and Other Behavioral Health Conditions into
Primary Care: An American College of Physicians Position Paper.
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M15-0510.
---------------------------------------------------------------------------
Improve Mental Health Parity with Increased Federal Oversight and
Enforcement
One of the barriers to true integrated primary and behavioral
health care are the likely instances of noncompliance by insurance
plans with mental and SUD coverage parity required by Federal law.
While the Paul Wellstone and Pete Domenici Mental Health Parity and
Addiction Equity Act of 2008 (MHPAEA) requires parity for mental health
and SUD coverage, state and Federal oversight and compliance efforts
have been uneven. Unfortunately, according to the GAO, the true nature
of the problem of noncompliance with MHPAEA is not well known. \11\
While noncompliance violations have been reported, these complaints
were relatively small in number and not considered a true snapshot of
the magnitude of noncompliance. While the GAO found that insurance-plan
compliance with Federal parity law was key to coverage parity, Federal
agencies are only aware of a small number of patient complaints and
discovered violations of coverage parity law. In addition, the GAO
found that when Federal agencies did engage in compliance reviews for
coverage parity that there was a high rate of insurance plan
violations. This frequency, the GAO determined, could indicate that
insurance-plan noncompliance with mental health and SUD coverage parity
law could be a common occurrence. \12\ In response, the GAO recommended
that the Federal Government should determine whether current targeted
oversight of compliance efforts are sufficient and effective and then
develop better ways in which to enforce MHPAEA as well as attain
greater oversight authority if needed. \13\ ACP strongly recommends
that Federal and state governments, insurance regulators, payers, and
other stakeholders address behavioral health insurance coverage gaps
that remain barriers to integrated care. This includes strengthening
and enforcing relevant nondiscrimination laws, including oversight and
compliance efforts by Federal and state agencies. \14\
---------------------------------------------------------------------------
\11\ U.S. Government Accountability Office. (2019) Mental Health
and Substance Use, State and Federal Oversight of Compliance with
Parity Requirements Varies. GAO-20-150. https://www.gao.gov/assets/gao-
20-150.pdf.
\12\ U.S. Government Accountability Office. (2019) Mental Health
and Substance Use, State and Federal Oversight of Compliance with
Parity Requirements Varies. GAO-20-150. https://www.gao.gov/assets/gao-
20-150.pdf.
\13\ U.S. Government Accountability Office. (2019) Mental Health
and Substance Use, State and Federal Oversight of Compliance with
Parity Requirements Varies. GAO-20-150. https://www.gao.gov/assets/gao-
20-150.pdf.
\14\ Crowley R, Kirschner N; Health and Public Policy Committee of
the American College of Physicians. The Integration of Care for Mental
Health, Substance Abuse, and Other Behavioral Health Conditions into
Primary Care: An American College of Physicians Position Paper.
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M15-0510.
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Make Naloxone More Available to Prevent Overdoses
ACP supports funding to distribute naloxone to individuals with
opioid use disorder to prevent overdose deaths and train law
enforcement and emergency medical personnel in its use. A 2019 CDC
report found that not all individuals in need of naloxone are receiving
it due to prescribing and dispensing variations across the country. The
CDC recommended actions to improve naloxone access such as reducing
patient insurance copays, enhancing clinician training and education,
and focusing allocation, especially to rural areas. \15\ Legal
protections (that is, Good Samaritan laws) should continue to be
established or refined to encourage use of naloxone and the reporting
of opioid overdoses in instances where an individual's life is in
danger. A GAO review found that overall state Good Samaritan laws
helped in reducing deaths by overdose and that states that enacted such
laws have lower rates of opioid overdose deaths when compared to before
the law's enactment or to states without these laws at all. \16\
Physician standing orders to permit pharmacies to provide naloxone to
eligible individuals without a prescription should be explored.
Insurance and cost related barriers that limit access to naloxone
should also be addressed. As the need for naloxone has grown, so has
its price. In response, government representatives and private sector
entities have partnered to make bulk purchases of naloxone at
substantial discounts for state and local jurisdictions fighting the
opioid epidemic. These and other efforts must be accelerated to ensure
that naloxone continues to reach those in need. \17\
---------------------------------------------------------------------------
\15\ Life-Saving Naloxone from Pharmacies, More dispensing needed
despite progress. CDC Vital Signs. Centers for Disease Control and
Prevention, August 2019. https://www.cdc.gov/vitalsigns/naloxone/
index.html.
\16\ U.S. Government Accountability Office. (2020) Drug Misuse,
Most States Have Good Samaritan Laws and Research Indicates They May
Have Positive Effects. https://www.gao.gov/assets/gao-21-248.pdf.
\17\ Crowley R, Kirschner N, Dunn A, Bornstein S; Health and
Public Policy Committee of the American College of Physicians. Health
and Public Policy to Facilitate Effective Prevention and Treatment of
Substance Use Disorders Involving Illicit and Prescription Drugs: An
American College of Physicians Position Paper. Washington, DC: American
College of Physicians, 2017. https://www.acpjournals.org/doi/pdf/
10.7326/M16-2953.
---------------------------------------------------------------------------
Expand Medication-Assisted Treatment (MAT) for Physicians
In order to expand access to medication-assisted treatment (MAT) of
opioid use disorders, improved training in the treatment of substance
use disorders is necessary, including for buprenorphine-based
treatment. Pre-and post-buprenorphine training support and education
tools and resources should be made available and widely disseminated to
assist physicians in their treatment efforts. Physician support
initiatives, such as mentor programs, shadowing experienced providers,
and telemedicine, can help improve education and support efforts around
substance use treatment. \18\ In addition, continued efforts are needed
to remove barriers or administrative burdens for physicians to fully
take advantage of using MAT to treat their patients, such as
eliminating burdensome prior-authorization requirements. These
roadblocks can delay or deny needed treatment that utilize already
approved medications in the course of MAT to treat SUDs. Several states
have already taken action to eliminate or reduce prior authorization
requirements for MAT and Congress should explore legislative options on
the Federal level. \19\
---------------------------------------------------------------------------
\18\ Crowley R, Kirschner N, Dunn A, Bornstein S; Health and
Public Policy Committee of the American College of Physicians. Health
and Public Policy to Facilitate Effective Prevention and Treatment of
Substance Use Disorders Involving Illicit and Prescription Drugs: An
American College of Physicians Position Paper. Washington, DC: American
College of Physicians, 2017. https://www.acpjournals.org/doi/pdf/
10.7326/M16-2953.
\19\ American Medical Association. Opioid Task Force 2019 Progress
Report. https://www.end-opioid-epidemic.org/wp-content/uploads/2019/06/
AMA-Opioid-Task-Force-2019-Progress-Report-web-1.pdf.
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Establish a National Prescription Drug Monitoring Program (PDMP)
ACP reiterates its support for the establishment of a national
Prescription Drug Monitoring Program (PDMP). Until such a program is
implemented, ACP supports efforts to standardize state PDMPs through
the Federal National All Schedules Prescription Electronic Reporting
program. The College strongly urges prescribers and dispensers to check
PDMPs in their own and neighboring states (as permitted) before writing
and filling prescriptions for medications containing controlled
substances. All PDMPs should maintain strong protections to ensure
confidentiality and privacy. In addition to a national PDMP, ACP
strongly encourages Congress to be helpful in this area by requiring
efforts to facilitate the use of PDMPs, such as by linking information
with electronic medical records and permitting other members of the
health care team to consult PDMPs. \20\
---------------------------------------------------------------------------
\20\ Crowley R, Kirschner N, Dunn A, Bornstein S; Health and
Public Policy Committee of the American College of Physicians. Health
and Public Policy to Facilitate Effective Prevention and Treatment of
Substance Use Disorders Involving Illicit and Prescription Drugs: An
American College of Physicians Position Paper. Washington, DC: American
College of Physicians, 2017. https://www.acpjournals.org/doi/pdf/
10.7326/M16-2953.
---------------------------------------------------------------------------
Conduct Research to Implement Effective Public Health Interventions
ACP believes more Federal research is needed. The effectiveness of
public health interventions to combat substance use disorders and
associated health problems should be studied further. Public health-
based substance use disorder interventions, such as syringe exchange
programs (SEPs) and safe injection sites that connect the user with
effective treatment programs should be explored and tested. Risky
injection drug use habits, such as needle sharing, contribute to the
spread of HIV, Hepatitis C virus, and other blood-borne pathogens.
Several SEPs have shown the potential to reduce the spread of these
diseases. Indeed, the Federal Government has already established and
funded Syringe Services Programs (SSPs) through the CDC. \21\ These
community-based prevention programs have a track record of furnishing
much-needed services, such as disposal of sterile syringes,
vaccination, testing, infectious disease care, and most critically, SUD
treatment. \22\ These programs may also connect individuals with other
health and social services, as well as referrals to SUD treatment, as
mentioned above, prevention supplies, and health screenings. As the
opioid epidemic continues to increase the number of people who inject
drugs, Federal and state funding should be directed to communities to
prevent the spread of blood-borne diseases, such as HIV infection and
Hepatitis C, as well as connect people to social and health care
services that can provide necessary assistance. Because safe injection
facilities have not been extensively tested in the United States, state
and local health officials need the resources to conduct pilot tests
prior to any possible full implementation. \23\
---------------------------------------------------------------------------
\21\ Centers for Disease Control and Prevention. Syringe Services
Programs (SSPs) Funding. Accessed at https://www.cdc.gov/ssp/ssp-
funding.html.
\22\ Centers for Disease Control and Prevention. Syringe Services
Programs (SSPs) Safety and Effectiveness Summary. Accessed at https://
www.cdc.gov/ssp/syringe-services-programs-summary.html.
\23\ Crowley R, Kirschner N, Dunn A, Bornstein S; Health and
Public Policy Committee of the American College of Physicians. Health
and Public Policy to Facilitate Effective Prevention and Treatment of
Substance Use Disorders Involving Illicit and Prescription Drugs: An
American College of Physicians Position Paper. Washington, DC: American
College of Physicians, 2017. https://www.acpjournals.org/doi/pdf/
10.7326/M16-2953.
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Ensure Adequate Physician Workforce to Integrate Behavioral Health and
Primary Care
ACP encourages efforts by Federal and state governments, relevant
training programs, and continuing education providers to ensure an
adequate workforce to provide for integrated behavioral health care in
the primary care setting. Cross-discipline training is needed to
prepare behavioral health and primary care physicians to effectively
integrate their respective specialties. Primary care physicians need to
be trained to screen, manage, and treat common behavioral health
conditions, and behavioral health providers need to be trained to
understand care for common medical needs. Both sectors need to overcome
the operational and cultural barriers that prevent seamless
integration. A report from the SAMHSA--HRSA Center for Integrated
Health Solutions cited inadequate skills for integrated practices and
reluctance to change practice patterns. \24\
---------------------------------------------------------------------------
\24\ Crowley R, Kirschner N; Health and Public Policy Committee of
the American College of Physicians. The Integration of Care for Mental
Health, Substance Abuse, and Other Behavioral Health Conditions into
Primary Care: An American College of Physicians Position Paper.
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M15-0510.
The workforce of professionals qualified to treat behavioral health
and substance use disorders should be expanded. ACP supports policies
to increase the professional workforce engaged in treatment of behavior
health and substance use disorder. Loan forgiveness programs, mentoring
initiatives, and increased payment may encourage more individuals to
train and practice as behavioral health professionals. \25\
---------------------------------------------------------------------------
\25\ Crowley R, Kirschner N, Dunn A, Bornstein S; Health and
Public Policy Committee of the American College of Physicians. Health
and Public Policy to Facilitate Effective Prevention and Treatment of
Substance Use Disorders Involving Illicit and Prescription Drugs: An
American College of Physicians Position Paper. Washington, DC: American
College of Physicians, 2017. https://www.acpjournals.org/doi/pdf/
10.7326/M16-2953.
---------------------------------------------------------------------------
Primary care physicians, including internal medicine specialists,
continue to serve on the frontlines of patient care during this
pandemic with increasing demands placed on them. Funding should be
continued and increased for programs and initiatives that work to
increase the number of physicians and other health care professionals
providing care for all communities, including for racial and ethnic
communities historically underserved and disenfranchised. \26\
According to the Association of American Medical Colleges (AAMC),
before the Coronavirus crisis, estimates were that there would be a
shortage of 21,400 to 55,200 primary care physicians by 2033. In
addition, the Federal Government determined that an additional 14,900
primary care physicians and 6,894 psychiatrists were needed in 2018 to
provide services that would have eliminated a HPSA designation for
areas with primary care and mental health shortages. \27\ Now, with the
closure of many physician practices and near-retirement physicians not
returning to the workforce due to COVID-19, it is even more imperative
to assist those clinicians serving on the frontlines and increasing the
number of future physicians in the pipeline.
---------------------------------------------------------------------------
\26\ Serchen J, Doherty R, Hewett-Abbott G, Atiq O, Hilden D;
Health and Public Policy Committee of the American College of
Physicians. Understanding and Addressing Disparities and Discrimination
Affecting the Health and Health Care of Persons and Populations at
Highest Risk: A Position Paper of the American College of Physicians.
Philadelphia: American College of Physicians; 2021. https://
www.acponline.org/acp-policy/policies/understanding-discrimination-
affecting-health-and-health-care-persons-populations-highest-risk-
2021.pdf.
\27\ Prepared for the AAMC by IHS Markit Ltd. The Complexities of
Physician Supply and Demand: Projections From 2018 to 2033. Association
of American Medical Colleges, June 2020. https://www.aamc.org/media/
45976/download.
For example, many residents and medical students are playing a
critical role in responding to the COVID-19 crisis all while they carry
an average debt of over $200,000. In addition, international medical
graduates (IMGs) are currently serving on the frontlines of the U.S.
health care system, both under J-1 training and H-1B work visas and in
other forms. These physicians serve an integral role in the delivery of
health care in the United States. IMGs help to meet a critical
workforce need by providing health care for underserved populations in
the United States. They are often more willing than their U.S. medical
graduate counterparts to practice in remote, rural areas and in poor
underserved urban areas. More must be done to support their vital role
---------------------------------------------------------------------------
in health care delivery in the United States.
ACP supports several pieces of legislation from the 116th and 117th
Congresses that should be reintroduced, if applicable, and passed in
the current 117th Congress to assist medical graduates and the overall
physician workforce as well as address the mental and behavioral health
needs of physicians themselves.
The Resident Education Deferred Interest Act (H.R.
1554, 116th Congress) would make it possible for residents to
defer interest on their loans.
The Conrad State 30 and Physician Access
Reauthorization Act (S. 948, 116th Congress) and the Healthcare
Workforce Resilience Act (S. 3599, 116th Congress), would help
with medical student loan forgiveness and support IMGs and
their families by temporarily easing immigration-related
restrictions so IMGs and other critical health care workers can
enter the U.S. to train in internal medicine residency
programs, assist in the fight against COVID-19, and provide a
pathway to permanent residency status.
The Student Loan Forgiveness for Frontline Health
Workers Act (H.R. 2418, 117th Congress) would assist frontline
clinicians as they provide care during the pandemic.
The Dr. Lorna Breen Health Care Provider Protection
Act (H.R. 1667/S. 610, 117th Congress) is an important proposal
because it aims to prevent and reduce incidences of suicide,
mental health conditions, substance use disorders, and long-
term stress, sometimes referred to as ``burnout'' among
physicians themselves. Through grants, education, and awareness
campaigns, the legislation will help reduce stigma and identify
resources for health care clinicians seeking assistance. The
legislation also supports research on health care professional
mental and behavioral health, including the effect of the
COVID-19 pandemic. View ACP's letter of support to the House
and Senate for H.R. 1667 and S. 610.
In addition, ACP was encouraged that bipartisan congressional
leaders worked together last year to provide 1,000 new Medicare-
supported Graduate Medical Education (GME) positions in the
Consolidated Appropriations Act, 2021 (H.R. 133)--the first increase of
its kind in nearly 25 years--and that some of those new slots will be
prioritized for hospitals that serve Health Professional Shortage Areas
(HPSAs).
ACP now calls on Congress to pass the Resident
Physician Reduction Shortage Act of 2021 (H.R. 2256/S. 834,
117th Congress) which would provide 14,000 new GME positions
over 7 years, or 2,000 per year to build on the 1,000 new GME
slots mentioned above.
Congress should also pass the Opioid Workforce Act of
2021 (S. 1483, 117th Congress). This bill would provide
Medicare funding for 1,000 more GME positions over 5 years in
hospitals that already have established, or are in the process
of establishing, accredited residency programs in addiction
medicine, addiction psychiatry, or pain medicine.
ACP also supports other physician and clinician workforce programs
and we strongly supported providing $800 million for the National
Health Service Corps (NHSC) and $330 million to expand the number of
Teaching Health Centers (THC) Graduate Medical Education (GME) sites
nationwide and increase the per resident allocation that were enacted
in the American Rescue Plan (ARP) Act, H.R. 1319. Indeed, a recent
study appearing in the Annals of Internal Medicine showed that in
counties with fewer primary care physicians (PCP) per population,
increases in PCP density would be expected to substantially improve
life expectancy. \28\ Accordingly, Congress should enact policies that
will not only increase the overall number of PCPs, but also ensure that
these additional PCPs are located in the communities where they are
most needed in order to furnish primary care, behavioral health, and
SUD services. Enhanced investments in programs such as the NHSC and
THCGME that increase the physician workforce should be sustained after
the pandemic caused by COVID-19 has come to an end.
---------------------------------------------------------------------------
\28\ Sanjay Basu, MD, Ph.D; Russell S. Phillips, MD; Seth A.
Berkowitz, MD, MPH. Estimated Effect on Life Expectancy of Alleviating
Primary Care Shortages in the United States. Ann Intern Med. 2021.
https://www.acpjournals.org/doi/pdf/10.7326/M20-7381.
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Conclusion
We commend you and your colleagues for working in a bipartisan
fashion to examine any lessons learned about treating mental health and
SUD during the COVID-19 pandemic to improve health outcomes and to
develop legislative proposals to combat not only the ongoing
Coronavirus crisis--but to address any issues caused by the current
pandemic as well as future pandemics. We wish to assist in the HELP
Committee's efforts in this area by offering our input and suggestions
about ways that Congress and Federal health departments and agencies
can intervene through evidence-based policies both now and beyond the
PHE. Thank you for consideration of our recommendations that are
offered in the spirit of providing the necessary support to physicians
and their patients going forward. Please contact Jared Frost, Senior
Associate, Legislative Affairs, with any further questions or if you
need additional information.
______
The PEW Charitable Trusts,
Philadelphia, PA and, Washington DC,
April 28, 2021.
Hon. Patty Murray, Madam Chair,
Hon. Richard Burr, Ranking Member,
Senate Committee on Health, Education, Labor, and Pensions,
428 Dirksen Senate Office Building,
Washington, DC.
Dear Chair Murray and Ranking Member Burr:
With more than 570,000 Americans lost to COVID-19, we must not
forget that before the pandemic, our Nation was already in the midst of
an opioid overdose crisis that continues to kill hundreds of Americans
each day. While we do not yet know the full impact the pandemic will
have on the opioid overdose crisis, provisional data from the Centers
for Disease Control and Prevention (CDC) predicts that more than 90,000
people died of an overdose in the 12-month period ending in September
2020, the vast majority involving opioids. \1\ This represents a nearly
29 percent increase in 1 year--a staggering and growing death toll is
impacting communities from coast to coast. Every state and the District
of Columbia has seen overdose deaths rise, and it has accelerated
during COVID-19.
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\1\ Ahmad FB, Rossen LM, Sutton P. Provisional drug overdose death
counts. National Center for Health Statistics. 2021. https://
www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.
Thank you for holding the hearing ``Examining Our COVID-19
Response: Using Lessons Learned to Address Mental Health and Substance
Use Disorders.'' This hearing is not only timely, but the lessons
---------------------------------------------------------------------------
learned could have a life-saving impact long after the pandemic.
The Pew Charitable Trusts (Pew) is an independent, nonpartisan
research and policy organization. Through its Substance Use Prevention
and Treatment Initiative, Pew works with states and at the Federal
level to address the Nation's opioid overdose crisis by developing
solutions that improve access to timely, comprehensive, evidence-based,
and sustainable treatment for opioid use disorder (OUD).
Over the past year, our team has monitored the impact of the COVID-
19 pandemic on the U.S. substance use treatment system. The pandemic
has underscored the need for policy changes that increase access to
life-saving treatment for OUD.
Eliminate Barriers to Medications for Opioid Use Disorder (MOUD)
The devastating loss of life from opioid overdose is even more
tragic because it is preventable. OUD is a chronic brain disease that,
like other chronic diseases, can be successfully treated with
medications approved by the Food and Drug Administration (FDA). A
conclusive body of research demonstrates that medication for opioid use
disorder (MOUD) is the most effective way to treat the disease and
substantially reduces mortality from overdoses. Two of the medications
approved by FDA to treat OUD--methadone and buprenorphine--have been
found to reduce mortality from OUD by up to 50 percent. \2\
---------------------------------------------------------------------------
\2\ National Academies of Sciences, Engineering, and Medicine.
2019. Medications for opioid use disorder save lives. Washington, DC:
The National Academies Press. doi: https://doi.org/10.17226/25310.
Prior to the pandemic, individuals with OUD struggled to get
effective care: In 2019, only 18.1 percent of the 1.6 million people
aged 12 or older with opioid use disorder received MOUD. As the
pandemic continues to strain the U.S. health care system, it is
---------------------------------------------------------------------------
creating even greater hardships for individuals seeking OUD treatment.
Of the three medications approved by FDA to treat OUD, access to
buprenorphine in particular has proven to be critical in response to
COVID-19. Unlike opioids commonly prescribed to control pain,
buprenorphine has a ceiling effect, meaning that its effects will not
increase even with repeated dosing, minimizing the risk of respiratory
depression leading to fatal overdose compared to other opioid
medications. Prescribing buprenorphine for OUD is no more complex to
manage than other chronic conditions treated in primary care and is
safe to dispense from a pharmacy and take at home.
During the pandemic, buprenorphine is the only FDA-approved
medication for OUD that can be prescribed without an in-person visit to
a doctor or treatment facility. While COVID-19 had made this medication
even more critical for people experiencing self-isolation and
quarantine, outdated Federal regulations continue to limit access to
the medication.
Yet despite the relative safety of the drug, Federal rules
established by the DATA 2000 Act require practitioners who prescribe
buprenorphine to receive additional training, registration, and
oversight, as well as obtain an additional waiver (known as the X-
waiver) from the Drug Enforcement Administration (DEA). DEA data show
that only about 6 percent of American doctors have chosen to obtain an
X-waiver, and 2020 HHS Office of Inspector General report found that 40
percent of U.S. counties did not have a single waivered provider who
can prescribe buprenorphine. \3\ This lack of providers leaves millions
of Americans, disproportionately in rural areas, without access to
local health care providers who can prescribe this life-saving
medication.
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\3\ Department of Health and Human Services Office of Inspector
General, ``Geographic Disparities Affect Access to Buprenorphine
Services for Opioid Use Disorder'' (2020).
On Tuesday, April 27, the Biden Administration announced
prescribing guidelines for buprenorphine that go into effect today.
These guidelines will exempt eligible practitioners (including
physicians and mid-level practitioners) from required training for
prescribing buprenorphine to as many as 30 patients. This action
signals a significant step forward in expanding access to MOUD.
However, the Administration does not have the authority to eliminate
the X-waiver in its entirety without legislative action by Congress,
and the new policy's prescribing flexibility leaves critical procedural
requirements and patient count limitations in place--legislation is
still needed to fully ensure that all prescribers can assist OUD
---------------------------------------------------------------------------
patients.
Pew strongly encourages Congress to pass the Mainstreaming
Addiction Treatment Act (S. 445). This bipartisan legislation would
remove the outdated and burdensome Federal rules established by the
DATA 2000 Act that require health care practitioners to obtain a waiver
from the DEA before prescribing buprenorphine to treat OUD. As the U.S.
health care system is being pushed past its capacity by the pandemic,
having regulations in place that further limits OUD treatment to a
small minority of physicians can no longer be justified.
Telehealth for Buprenorphine Initiation
The telehealth regulatory flexibilities during the COVID-19
emergency that allow patients to initiate buprenorphine after a
telehealth consultation with a prescriber have expanded access to OUD
treatment for people who would otherwise be without care. In
particular, audio-only telehealth for buprenorphine initiation has been
able to reach people facing economic hardship--like individuals leaving
incarceration or experiencing homelessness--or living in areas with
inadequate broadband access who are less likely to have technology for
audiovisual telehealth visits. \4\ Audio-only flexibility is also
spurring innovative approaches to engage people in treatment, such as
Rhode Island's 24/7 telephone hotline that initiated buprenorphine for
74 new patients from mid-April 2020 to mid-November 2020, and linked
them to community providers for ongoing care. \5\
---------------------------------------------------------------------------
\4\ U. Khatri et al., ``These Key Telehealth Policy Changes Would
Improve Buprenorphine Access While Advancing Health Equity,'' Health
Affairs (2020), https://www.healthaffairs.org/do/10.1377/
hblog20200910.498716/full/. L. Wang et al., ``Telemedicine increases
access to buprenorphine initiation during the COVID-19 pandemic,''
Journal of Substance Abuse Treatment 124 (2021): 108272, https://
doi.org/10.1016/j.jsat.2020.108272; M. Harris et al., ``Low Barrier
Tele-Buprenorphine in the Time of COVID-19: A Case Report,'' Journal of
Addiction Medicine 14, no. 4 (2020): e136-e138, https://doi.org/
10.1097/adm.0000000000000682; R. Tringale and A.M. Subica, ``COVID-19
innovations in medication for addiction treatment at a Skid Row syringe
exchange,'' Journal of Substance Abuse Treatment 121 (2021): 108181,
https://doi.org/10.1016/j.jsat.2020.108181.
\5\ S.A. Clark et al., ``Using telehealth to improve buprenorphine
access during and after COVID-19: A rapid response initiative in Rhode
Island,'' Journal of Substance Abuse Treatment 124 (2021): 108283,
https://doi.org/10.1016/j.jsat.2021.108283.
As evaluations showing positive outcomes from new telehealth
programs continue to emerge, there is still no evidence that in-person
visits are more effective than telemedicine visits in improving
treatment outcomes or curtailing diversion. \6\ In fact, studies show
no difference in adverse events or 30-day retention between patients
initiating buprenorphine treatment at home compared to in-office, and
suggest that patients are less likely to no-show for telehealth
appointments versus in-person visits. \7\
---------------------------------------------------------------------------
\6\ L. Wang et al., ``Telemedicine increases access to
buprenorphine initiation during the COVID-19 pandemic,'' Journal of
Substance Abuse Treatment 124 (2021): 108272, https://doi.org/10.1016/
j.jsat.2020.108272.
\7\ N.L. Sohler et al., ``Home-Versus Office-Based Buprenorphine
Inductions for Opioid-Dependent Patients,'' Journal of Substance Abuse
Treatment 38, no. 2 (2010): 153-59, http://www.sciencedirect.com/
science/article/pii/S074054720900124X. S.A. Clark et al., ``Using
telehealth to improve buprenorphine access during and after COVID-19: A
rapid response initiative in Rhode Island,'' Journal of Substance Abuse
Treatment 124 (2021): 108283, https://doi.org/10.1016/
j.jsat.2021.108283.
Given the transformative impact on access to treatment from these
telehealth flexibilities, practitioners and public health experts are
concerned about returning to restrictive telehealth regulations once
the COVID-19 emergency declaration ends. A recent report by George
Washington University's Center for Regulatory Studies found that DEA
and the Substance Abuse and Mental Health Services Administration
(SAMHSA) jointly have authority to continue allowing practitioners to
prescribe buprenorphine without first conducting an in-person medical
evaluation. \8\ Accordingly, Congress should use its oversight role to
encourage the agencies to make this policy permanent.
---------------------------------------------------------------------------
\8\ Dooley, B. C.E. and Stanley, L.E., ``Telemedicine & Initiating
Buprenorphine Treatment,'' February 23, 2021, George Washington
University Regulatory Studies Center, https://
regulatorystudies.columbian.gwu.edu/telemedicine-initiating-
buprenorphine-treatment.
---------------------------------------------------------------------------
Take Home Methadone Dosing
Though methadone initiation requires an in-person visit, patients
have benefited from more flexible take-home policies as a result of the
COVID-19 flexibilities that allow state regulatory authorities to
request blanket exceptions for patients to be able to take home more
medication doses--up to 28 days for ``stable'' patients and up to 14
days for ``less stable'' patients--and receive counseling via
telehealth. This removes a critical barrier to treatment since most
methadone patients must visit an opioid treatment program daily to
receive their medication. \9\
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\9\ Deering, D. E., Sheridan, J., Sellman, J. D., Adamson, S. J.,
Pooley, S., Robertson, R., & Henderson, C. (2011). Consumer and
treatment provider perspectives on reducing barriers to opioid
substitution treatment and improving treatment attractiveness.
Addictive behaviors, 36(6), 636-642.
Recent data shows that these take-home flexibilities are working:
at three North Carolina opioid treatment programs, more than 90 percent
of patients received take-home methadone doses versus 68 percent prior
to the pandemic, and the programs reported that diversion of the
medication was uncommon. \10\ In addition, allowing patients to have a
take-home supply early in treatment has been shown to increase
retention. \11\ Accordingly, SAMHSA has emphasized the importance of
accommodating take-home policies that promote individualized care and
can encourage people to enter into and remain in treatment. \12\
---------------------------------------------------------------------------
\10\ M.C. Figgatt et al., ``Take-Home Dosing Experiences among
Persons Receiving Methadone Maintenance Treatment During COVID-19,''
Journal of Substance Abuse Treatment 123 (2021), https://doi.org/
10.1016/j.jsat.2021.108276.
\11\ Kourounis, G., Richards, B. D. W., Kyprianou, E., Symeonidou,
E., Malliori, M. M., & Samartzis, L. (2016). Opioid substitution
therapy: lowering the treatment thresholds. Drug and alcohol
dependence, 161, 1-8.
\12\ Substance Abuse and Mental Health Services Administration.
Federal Guidelines for Opioid Treatment Programs. HHS Publication No.
(SMA) PEP15-FEDGUIDEOTP. Rockville, MD: Substance Abuse and Mental
Health Services Administration, 2015. https://store.samhsa.gov/sites/
default/files/d7/priv/pep15-fedguideotp.pdf.
To continue this promising new expansion of methadone treatment
post-COVID-19 emergency declaration, Congress should use its oversight
role to encourage SAMHSA to make this flexibility permanent, which the
agency can do through its statutory authority. \13\
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\13\ Dooley, B. C.E. and Stanley, L.E., ``Extending Pandemic
Flexibilities for Opioid Use Disorder Treatment: Unsupervised Use of
Opioid Treatment Medications,'' April 22, 2021, George Washington
University Regulatory Studies Center, https://
regulatorystudies.columbian.gwu.edu/unsupervised-use-opioid-treatment-
medications.
Thank you for your continuing efforts to support expanding access
to OUD treatment and for taking swift action to address the coronavirus
pandemic. As the Committee's work continues on this issue continues,
Pew encourages the Committee to prioritize proposals that increase the
availability of comprehensive and evidence-based treatment for OUD and
improve care provided to vulnerable populations. Pew welcomes the
opportunity to work with you to reduce the human toll related to the
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opioid crisis.
Sincerely,
Elizabeth Connolly,
Director,
Substance Use Prevention and Treatment Initiative.
______
[Whereupon, the hearing was adjourned at 12:14 p.m.]