[Senate Hearing 117-628]
[From the U.S. Government Publishing Office]
S. Hrg. 117-628
MENTAL HEALTH CARE IN AMERICA:
ADDRESSING ROOT CAUSES AND
IDENTIFYING POLICY SOLUTIONS
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON FINANCE
UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
FIRST SESSION
__________
JUNE 15, 2021
__________
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Finance
__________
U.S. GOVERNMENT PUBLISHING OFFICE
51-591-PDF WASHINGTON : 2023
COMMITTEE ON FINANCE
RON WYDEN, Oregon, Chairman
DEBBIE STABENOW, Michigan MIKE CRAPO, Idaho
MARIA CANTWELL, Washington CHUCK GRASSLEY, Iowa
ROBERT MENENDEZ, New Jersey JOHN CORNYN, Texas
THOMAS R. CARPER, Delaware JOHN THUNE, South Dakota
BENJAMIN L. CARDIN, Maryland RICHARD BURR, North Carolina
SHERROD BROWN, Ohio ROB PORTMAN, Ohio
MICHAEL F. BENNET, Colorado PATRICK J. TOOMEY, Pennsylvania
ROBERT P. CASEY, Jr., Pennsylvania TIM SCOTT, South Carolina
MARK R. WARNER, Virginia BILL CASSIDY, Louisiana
SHELDON WHITEHOUSE, Rhode Island JAMES LANKFORD, Oklahoma
MAGGIE HASSAN, New Hampshire STEVE DAINES, Montana
CATHERINE CORTEZ MASTO, Nevada TODD YOUNG, Indiana
ELIZABETH WARREN, Massachusetts BEN SASSE, Nebraska
JOHN BARRASSO, Wyoming
Joshua Sheinkman, Staff Director
Gregg Richard, Republican Staff Director
(II)
C O N T E N T S
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OPENING STATEMENTS
Page
Wyden, Hon. Ron, a U.S. Senator from Oregon, chairman, Committee
on Finance..................................................... 1
Crapo, Hon. Mike, a U.S. Senator from Idaho...................... 3
Bennet, Hon. Michael F., a U.S. Senator from Colorado............ 4
Warren, Hon. Elizabeth, a U.S. Senator from Massachusetts........ 6
WITNESSES
Miller, Benjamin F., Psy.D., chief strategy officer, Well Being
Trust, Oakland, CA............................................. 7
Jett, Chantay, MA, MFT, executive director, Wallowa Valley Center
for Wellness, Enterprise, OR................................... 8
Durham, Michelle P., M.D., MPH, FAPA, DFAACAP, assistant
professor of psychiatry, Boston University School of Medicine;
and vice chair of education, and psychiatry residency training
director, Department of Psychiatry, Boston Medical Center,
Boston, MA..................................................... 11
Betlach, Thomas, MPA, partner, Speire Healthcare Strategies,
Phoenix, AZ.................................................... 13
ALPHABETICAL LISTING AND APPENDIX MATERIAL
Bennet, Hon. Michael F.:
Opening statement............................................ 4
Betlach, Thomas, MPA:
Testimony.................................................... 13
Prepared statement........................................... 47
Responses to questions from committee members................ 50
Cassidy, Bill:
Submitted letters............................................ 54
Crapo, Hon. Mike:
Opening statement............................................ 3
Prepared statement........................................... 58
Durham, Michelle P., M.D., MPH, FAPA, DFAACAP:
Testimony.................................................... 11
Prepared statement........................................... 58
Responses to questions from committee members................ 60
Jett, Chantay, MA, MFT:
Testimony.................................................... 8
Prepared statement........................................... 65
Responses to questions from committee members................ 67
Miller, Benjamin F., Psy.D.:
Testimony.................................................... 7
Prepared statement........................................... 69
Responses to questions from committee members................ 80
Warren, Hon. Elizabeth:
Opening statement............................................ 6
Wyden, Hon. Ron:
Opening statement............................................ 1
Prepared statement........................................... 90
Communications
American Academy of Family Physicians............................ 93
American Hospital Association.................................... 97
American Psychological Association............................... 99
Association for Behavioral Health and Wellness................... 103
Center for Fiscal Equity......................................... 107
Eating Disorders Coalition for Research, Policy, and Action...... 111
Healthcare Leadership Council.................................... 113
HR Policy Association, American Health Policy Institute, and
National Alliance of Healthcare Purchaser Coalitions........... 115
The Partnership to Amend 42 CFR Part 2........................... 116
Office of the United States Surgeon General...................... 120
MENTAL HEALTH CARE IN AMERICA:
ADDRESSING ROOT CAUSES AND
IDENTIFYING POLICY SOLUTIONS
----------
TUESDAY, JUNE 15, 2021
U.S. Senate,
Committee on Finance,
Washington, DC.
The hearing was convened, pursuant to notice, at 10:10
a.m., via Webex, in Room SD-215, Dirksen Senate Office
Building, Hon. Ron Wyden (chairman of the committee) presiding.
Present: Senators Stabenow, Cantwell, Carper, Cardin,
Bennet, Casey, Warner, Whitehouse, Hassan, Warren, Crapo,
Grassley, Thune, Portman, Cassidy, Daines, Young, and Sasse.
Also present: Democratic staff: Eva DuGoff, Senior Health
Advisor; Marisa Dowling, Health Policy Fellow; and Kristen
Lunde, Health Policy Advisor. Republican staff: Kellie
McConnell, Health Policy Director; Gregg Richard, Staff
Director; and Stuart Portman, Senior Health Policy Advisor.
OPENING STATEMENT OF HON. RON WYDEN, A U.S. SENATOR FROM
OREGON, CHAIRMAN, COMMITTEE ON FINANCE
The Chairman. The Senate Finance Committee will come to
order. The Finance Committee meets this morning to discuss
mental health care in America, and this issue certainly ought
to bring Democrats and Republicans together, starting with a
single, clear lodestar. That lodestar is: every American must
have mental health care when they need it.
The shameful reality is, the United States does not come
close to meeting that bar today. Multiple Federal laws say that
mental health care is supposed to be on a level playing field
with physical health care. In practice, however, the system
still reflects the dangerous, outdated stigma against
recognizing and treating mental illness. And that is why
millions of Americans are now falling between the cracks.
For someone with a mental illness, it can often be nearly
impossible to find a provider who can meet your needs, or one
who accepts insurance, particularly in rural communities or
communities of color. Insurance claims often get denied or cut
off too quickly, particularly for those experiencing
homelessness. The outcome of a mental health crisis is often
incarceration instead of treatment.
Prior to the pandemic, one in five Americans was living
with mental illness. All the evidence suggests that the
pandemic is adding to that crisis. The proportion of Americans
reporting symptoms of anxiety or depression has nearly
quadrupled.
On Friday, the Centers for Disease Control and Prevention
released a new report finding that, over the last year, suicide
attempts among teenaged girls were up more than 50 percent.
Meanwhile, studies that the Government Accountability Office
conducted at our request found that many provider offices
closed or cut staff during the pandemic, and then too many
patients were turned away.
So, there is a lot for this committee to work on on a
bipartisan basis. There are a few key challenges.
First, the country clearly needs a larger mental health
workforce. There simply are not enough providers, whether
psychiatrists or therapists or staff in inpatient facilities.
For example, due to a major staffing shortage, the psychiatric
hospital in my home State of Salem, OR, is currently being
staffed by members of the Oregon National Guard. That is in the
State Capitol where there are people and resources to focus on
the issue. Many other communities have it far worse. More than
one in three Americans lives in an area with a serious shortage
of mental health-care professionals.
Second, insurance companies must not be allowed to cut
corners when it comes to mental health coverage. I hear about
this issue constantly at town hall meetings. People describe
having their claims denied. In other cases, insurance only
covers a portion of the treatment that people need.
Furthermore, it does not make any sense to leave somebody
experiencing a true mental health crisis waiting for a green
light from an insurance company before they can get treated.
Third, clearly the committee has a big challenge to address
racial inequities in mental health care. Black and Latino
Americans are roughly half as likely as white Americans to
receive treatment for mental illness. Suicide rates are much
higher among black kids. There are not enough black, Latino,
and Native American mental health providers. So this is a
question of equity, and we have a long way to go.
Finally, the committee ought to build on recent telehealth.
For example, early in the pandemic this committee led the fight
to get Medicare to cover mental health services via telehealth.
In December, the Congress made that permanent. I believe that
is going to be a game changer, particularly for seniors who
live in rural areas, and it is going to work in traditional
Medicare as well.
My colleagues all know that so many of our reforms have
helped, particularly with Medicare Advantage and other programs
where there is coordinated care, but we have to make sure
traditional Medicare is afforded these benefits as well.
Finally, Senator Stabenow has been a champion of mental
health-care treatment, and I have watched for years as she has
led the effort to bring Certified Community Behavioral Health
Clinics, a program that she battled for and created, to
American communities. These clinics are up and running now in
40 States, including Oregon. It is an approach that works and
meets major needs.
I believe the Congress ought to look at ways to build on
the success that my colleague has led, and we should also note
again the bipartisan route, because I cannot tell Senators how
often I have seen Senator Stabenow and Senator Blunt huddled in
intense discussions about how they are going to expand this.
Finally, the Congress also passed a big down payment for
pioneering a new approach on mental health services and law
enforcement. It is called the CAHOOTS program. It originally
comes from Eugene--Eugene, OR--where I went to law school. But
it is expanding now all over the country.
Essentially what happens with this approach is, you have a
911 call with somebody experiencing a mental health crisis. And
at that point, the mental health-care professionals and the law
enforcement in these communities have essentially teamed up and
figured out a way to actually meet the needs of the patient and
the community.
So, in many instances, these are joint efforts of the
mental health professionals and law enforcement--a team, a
coalition approach. In Oregon, I have talked to the police
officials in Eugene, the mental health professionals in Eugene,
and very often the response--and they both have kind of worked
up a system to do the right thing--is to use mental health
professionals rather than law enforcement. And law enforcement,
to their credit, is saying that they want to do that, and often
the mental health professionals are the right response.
The American Rescue Plan included a billion-dollar payment
to help States build on their own programs, and I think we
ought to look at what else ought to be done.
The last point I will make--and Dr. Cassidy is here, and he
has great expertise in this area. Colleagues, this is an
enormous challenge, and I think it is natural for Democratic
and Republican members of this committee to step up and shape a
major response that we can take to the full Senate. I look
forward to working with all my colleagues.
Senator Crapo?
[The prepared statement of Chairman Wyden appears in the
appendix.]
OPENING STATEMENT OF HON. MIKE CRAPO,
A U.S. SENATOR FROM IDAHO
Senator Crapo. Thank you very much, Mr. Chairman. I
appreciate you holding this hearing, and I agree with your
comments that this is an issue that deeply needs good
solutions, and on which we can build strong bipartisan
solutions that work. And I look forward to working with you,
Senator Stabenow, and all the others that you have mentioned,
on these issues.
Ensuring access to high-quality mental health services has
been and must continue to be a priority. Far too often,
individuals with mental health, addiction, or substance abuse
disorders find themselves isolated from their communities and
separated from their providers. While Congress has taken
decisive steps to address addiction, bolster behavioral health
care, and curb substance abuse disorders, challenges remain.
This committee has the ability to turn the tide. We can begin
by empowering States to craft innovative, targeted solutions.
Medicaid functions most effectively when States have the
flexibilities they need to address patients' unique care needs
and adapt to unforeseen circumstances.
As the Nation's largest payer of mental health and
substance abuse disorder services, Medicaid must support rather
than subvert State efforts to serve communities in need.
Unfortunately, the COVID-19 pandemic has highlighted and
exacerbated the mental and behavioral health challenges we
continue to confront.
Loss of loved ones, increased isolation, and delayed
treatment prompted a spike in anxiety, depression, and other
debilitating conditions. While many are returning to their pre-
pandemic lives, we should not be content to allow our mental
health-care delivery system to revert to its pre-pandemic ways.
Whether for rural communities, urban areas, or tribes,
telehealth has undoubtedly increased access to care. Through
emergency flexibilities and permanent legislation authored by
this committee late last year, we have taken crucial first
steps toward modernizing telehealth coverage. I look forward to
working with you, Mr. Chairman, and the other members of this
committee to build on those efforts in the months ahead.
Further, by partnering with State and local leaders, we can
spur care coordination, strengthen the mental health workforce,
and drive value through delivery system reforms. While there is
no silver bullet here, I am confident we can tackle all of
these challenges while upholding core principles of fiscal
responsibility and program integrity.
Before concluding, it bears emphasizing that we must
continue to make progress in improving understanding of mental
health so that people in need are not afraid or ashamed to seek
treatment. We cannot discount the impact of stigma on
preventing those in need of treatment from receiving care.
I look forward to hearing our witnesses' testimony today,
and I appreciate each of you coming here to share your
expertise and ideas about how we can achieve these objectives.
Thank you very much.
[The prepared statement of Senator Crapo appears in the
appendix.]
The Chairman. Thank you, Senator Crapo.
We have four terrific witnesses. The one who will testify
first--and I think we will do the introductions, because
colleagues are juggling a lot this morning--is Dr. Miller. And
Senator Bennet will give the introduction for Dr. Miller. And
we will introduce all our witnesses, and then we will hear
their testimony.
OPENING STATEMENT OF HON. MICHAEL F. BENNET,
A U.S. SENATOR FROM COLORADO
Senator Bennet. Thank you, Mr. Chairman. I would like to
thank you and Senator Crapo for holding this important hearing.
From the perspective of Colorado, it could not come soon
enough. In my calls with parents and teachers over the past
year, the number one issue has been mental health.
Over the years, the person my office has turned to for
advice on these issues is Dr. Benjamin Miller, one of our
witnesses today. Dr. Miller is one of the country's foremost
experts on mental health. Today he serves as the chief strategy
officer for Well Being Trust, a national foundation dedicated
to advancing a more holistic approach to the health of every
American.
In his early training, which included a doctorate from
Spalding University and post-doctoral roles at the University
of Colorado and the University of Massachusetts, Dr. Miller saw
firsthand how America's inattention to mental health inflicts a
terrible cost on our society, from our schools to our foster
care, health-care, and criminal justice systems.
Dr. Miller has not just studied these issues in the
academy, he has worked on them firsthand in our communities. He
has helped emotionally disturbed children make it through
school, cancer patients cope with difficult diagnoses, and
prisoners plan their reintegration into society. He has also
trained physicians to better handle their patients' mental
health. These issues are not abstractions for him, they are
real people whose lives have directly benefited from greater
attention to their mental health.
I know Dr. Miller from his time at the University of
Colorado, where he led the University's Health Policy Center
for 6 years and was an invaluable resource to my team. During
his time at the Center, Dr. Miller led a breakthrough project
demonstrating the cost savings of integrating mental health
with primary care. That project saved over $1 million for
Medicare and Medicaid beneficiaries in Colorado by
significantly reducing hospitalizations and other medical needs
down the road.
As health-care costs in this country continue to rise, I
think the committee has a lot to learn from Dr. Miller's
experience and expertise. I could spend the next 5 minutes
listing the numerous awards and appointments he has earned over
the years, but let me instead conclude by thanking Dr. Miller
for joining us today, especially since he is supposed to be on
vacation right now with his wife and two daughters. We are
grateful for Dr. Miller's time, and for his service to Colorado
and the country.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Bennet.
The next witness will be from Oregon, Chantay Jett, who is
the executive director of Wallowa Valley Center for Wellness in
Enterprise, OR. It is a small community--I have been there
often--in rural eastern Oregon. And as is the case for so many
people I have the honor to represent, she is the bionic woman.
She is basically everywhere, colleagues.
She has worked in the Wallowa River House, a residential
treatment facility for folks in Oregon afflicted with severe
mental illness. She has been an outpatient mental health
clinician. She is a pillar of the community. I remember
recently--we have sessions in schools called ``Listening to the
Future.'' Chantay was there. And she holds a master's degree in
psychology with a child, couple, and family emphasis; a
bachelor's degree in business administration; and she also
worked with children in the inpatient psychiatric unit at
Children's Hospital.
Chantay, thank you for making the long journey from rural
Oregon. We are so glad you are here. I know the committee is
going to appreciate hearing from you.
Next we will have Dr. Durham, a great advocate for patients
and those facing health challenges. Senator Elizabeth Warren
is, I believe, online and she can introduce Dr. Durham.
Senator Warren, are you out there in cyberspace?
OPENING STATEMENT OF HON. ELIZABETH WARREN,
A U.S. SENATOR FROM MASSACHUSETTS
Senator Warren. I am. Thank you very much, Chairman Wyden,
Ranking Member Crapo. Thank you for having this hearing today.
I have the privilege of introducing Dr. Michelle Durham of
Massachusetts. She has agreed to speak to the committee today
about the importance of expanding access to mental health
services all across our country.
Dr. Durham currently works as a pediatric and adult
psychiatrist at Boston Medical Center. Now, BMC is the largest
safety-net hospital in New England, and it is also an academic
medical center that is located in the heart of Boston. And it
is an amazing place. Most of BMC's patients are low-income or
from underserved populations. About half are covered by
Medicaid. Throughout the COVID-19 pandemic, providers at Boston
Medical Center, including Dr. Durham, have gone above and
beyond to get patients the health-care services that they need.
Our communities owe a great debt to the folks at BMC.
At BMC, Dr. Durham serves as the vice chair of education in
the Department of Psychiatry. She also has a joint appointment
as assistant professor of psychiatry at Boston University
School of Medicine, and she runs the training program for BMC's
general psychiatry residency program.
As you say, Chair Wyden, this is another woman who is
everywhere. Throughout her career, Dr. Durham has been a
tireless advocate of health, equity, and mental health. And she
is the associate director of BMC's Global and Local Center for
Mental Health Disparities. She also co-leads the TEAM UP for
Children initiative at BMC, which works to expand pediatric
mental health care at Federally Qualified Community Health
Centers.
Dr. Durham was an expert on mental health long before the
coronavirus, and she also worked on the front lines of the
pandemic. Her testimony today will offer significant insight
into how Congress should be considering reforming and improving
our mental health system to both build back from the pandemic,
and to fix problems that existed long before that pandemic hit.
So, Dr. Durham, I am deeply grateful for the work you do
for patients, for students, and for the people of the
Commonwealth of Massachusetts. I look forward to having a great
discussion today.
Thank you, Mr. Chairman.
The Chairman. Thank you very much, Senator Warren. Thanks
for your help in assisting us in making sure Dr. Durham could
be with us today.
Our last witness will be Tom Betlach, a partner at Speire
Healthcare Strategies. Prior to joining Speire, Mr. Betlach
served the State of Arizona for 27 years under five different
Governors in three different cabinet positions. For 10 years he
served as Director of the Arizona Health Care Cost Containment
System. That is, as I understand it, Arizona's Medicaid
program. He has a bachelor's and a master's in public
administration from the University of Arizona, and a bachelor
of arts in political science from the University of Wisconsin.
So we are very glad you are here as well.
Let's begin, and we will start with Dr. Miller.
STATEMENT OF BENJAMIN F. MILLER, Psy.D., CHIEF STRATEGY
OFFICER, WELL BEING TRUST, OAKLAND, CA
Dr. Miller. Well, thank you for that wonderful
introduction, Senator Bennet.
Chairman Wyden, Ranking Member Crapo, and members of the
committee, my name is Dr. Benjamin F. Miller, and I am the
chief strategy officer for Well Being Trust, a national
foundation started in 2016 through a gift by the Providence
Health System that is focused on advancing the mental, social,
and spiritual health of the Nation.
I am a clinical psychologist by training and have spent
most of my adult life pursuing strategies that can advance
mental health to a place of priority within our society. This
goal has guided much of my work during my time as the founding
director of the University of Colorado's Farley Health Policy
Center, and is continuing today in my capacity as an adjunct
professor at Stanford School of Medicine and at Well Being
Trust.
It is an honor to be able to speak to you today about an
issue that every American is experiencing, an issue that we
need to aggressively pursue, and which COVID-19 has all but
exacerbated, especially among communities of color and other
marginalized people: their mental health.
Several government reports highlight how broken our mental
health system is. The 2020 DoD Inspector General report found
over 52 percent of service members and their families who
needed mental health care did not receive it. SAMHSA found that
over 56 percent of adults with mental illness did not receive
any treatment in the past year, nor did 35 percent of those
with serious mental illness. And a recent GAO report
highlighted a multitude of issues at multiple levels for mental
health, including ongoing challenges with health insurance,
enforcing laws like mental health parity, and finding the right
clinician who can help. In one survey, almost 30 percent of
people reported not seeking care because they did not know
where to go.
The need to solve these and other existing problems is real
and immediate. Clear pathways do not exist for people seeking
mental health care. There are not obvious doors to enter, and
we have no system that routinely is able to identify and treat
people in a timely manner. This is perhaps our greatest
challenge as we emerge from the devastating COVID-19 pandemic.
With broad majorities of both parties now understanding the
importance of addressing mental health, I believe it is time to
enact immediate fixes for people in need, as well as to begin
to lay the foundation for a reimagined mental health system, a
mental health system that is grounded in community and is an
integral part of a broader health-care infrastructure.
There are three key priorities I believe this committee
should consider as it pursues both short- and long-term reforms
for mental health. First and foremost, we need to bring mental
health care to where people are. This includes schools and even
our work places. But to most immediately meet this moment, the
best place to start is primary care, the largest platform of
health-care delivery. In one poll, 70 percent of adults agreed
that it would be more convenient if their mental health and
substance use services were integrated into their primary care
doctor's office.
To do this, we must create more global and flexible funding
mechanisms for primary care practices that are working to
integrate mental health. Our payment mechanisms often reinforce
a siloed delivery model, and this must change. By first using
existing payment structures like those found in Medicaid
managed care organizations, Medicare Accountable Care
Organizations, and Medicare Advantage Plans to expand mental
health integration work, primary care practices would have the
flexible financial resources to onboard mental health
clinicians as a part of their integrated team.
Second, we must reconsider the design and capabilities of
our workforce. Demand for care has far outpaced the supply of
mental health clinicians, and it is inconceivable to rely upon
clinician recruitment strategies alone to meet our ever-growing
need.
There are two things we can do simultaneously to address
this workforce issue. First, we can map out mental health
utilization gaps to better determine where services are needed,
and for whom. Without this, we run the risk of widening
disparities, or putting money into places or programs that
people are not using for their mental health. Second, we can
invest in our community workforce, those like peer support
specialists, community health workers, or more broadly, lay
people in our communities. We can train them in mental health
skills to help become the first line of mental health support,
complementing our clinical enterprise and enhancing the overall
capacity for communities to address mental health needs.
Finally, we must modernize and connect our Federal programs
and systems to collaboratively solve our common mental health
problems. I realize it is hard to ask committees to work across
jurisdictional boundaries, but so many aspects of our mental
health need to be understood together, and implemented
together, at both the State and community level. Because there
are multiple agencies, funding streams, and programs that
support mental health, performing a landscape analysis can
create a strategy for synergistic efficiencies by breaking down
silos across Federal agencies and departments, and allowing for
a more cohesive plan for mental health.
In closing, I thank this committee again for holding this
hearing on mental health. This is our moment to be bold in what
we can do to boost our Nation's mental health and ultimately
save lives.
Thank you, Mr. Chairman.
[The prepared statement of Dr. Miller appears in the
appendix.]
The Chairman. Thank you very much, Dr. Miller.
Okay, I think next we will go to--Dr. Miller has gotten us
off to a strong start, and now we will hear from Ms. Jett.
[Pause.]
STATEMENT OF CHANTAY JETT, MA, MFT, EXECUTIVE DIRECTOR, WALLOWA
VALLEY CENTER FOR WELLNESS, ENTERPRISE, OR
Ms. Jett. Good morning, Chairman Wyden, Ranking Member
Crapo, and members of the Senate Finance Committee. Thank you
for the opportunity to appear before the committee to discuss
policy solutions to address both the mental health and
substance use crises impacting the United States, and in
particular the rural and frontier areas of our Nation. My name
is Chantay Jett, and I am executive director of Wallowa Valley
Center for Wellness (WVCW), which provides community-based
mental health and substance use treatment services in the most
remote region of the great State of Oregon.
We represent a truly frontier area of our Nation where the
cows outnumber the people and our closest major airport is in
Boise, ID, nearly 4 hours away. We are literally at the end of
the road, where everyone knows everyone, which unfortunately
contributes to the stigma and lack of access for people seeking
treatment services.
I am here to tell you that the Certified Community
Behavioral Health Clinic model has truly made a difference in
our frontier communities. I hope every State in the near future
has an opportunity to use the resources this model has made
available to us to meet the specific needs of our community.
The State of Oregon participates in the 10-State
demonstration of the Excellence in Mental Health and Addiction
Treatment Act that this committee helped to establish in 2014
through the bipartisan leadership of Senators Stabenow and
Blunt. The Center for Wellness is one of 12 CCBHCs that operate
within our State. We provide high-quality integrated community-
based mental health and substance use services to individuals,
while also screening for possible co-morbid conditions like
heart disease, diabetes, HIV, and AIDs.
Among the most important services that CCBHCs provide, both
in Oregon and Nationwide, are immediate access to medication-
assisted treatment services for substance use and 24-hour
psychiatric services. Please permit me to provide some very
brief context of CCBHCs within rural and frontier counties in
the State of Oregon.
According to the Oregon Health Authority, our State reports
higher rates of mental health conditions, including severe and
persistent mental illness and suicidal ideation. The COVID-19
pandemic has only exacerbated an ongoing mental health and
substance use crisis in rural Oregon.
OHA also detailed the lack of access to mental health and
substance use care, especially in frontier communities. To give
you a sense, there is no stop light within this 76-mile radius
of Wallowa County. OHA reports an average wait time of as much
as 6 months Statewide due to a lack of providers. However, we
are the lucky ones, because the CCBHC model helped create an
internal reorganization of service delivery which resulted in
same-day access to care.
Prior to becoming a CCBHC, the Center for Wellness was
heavily reliant upon grants. Grant funding is crucially
important, but it carries limitations. Grants typically end
every 2 to 3 years. They all have different reporting
requirements and different program specifications, which
ultimately result in more time spent filling out paperwork
rather than treating our patients.
By contrast, the CCBHC prospective payment system allows us
to do three major things. First, the Center for Wellness
contracts with more skilled clinicians, including psychiatrists
and medical professionals, to prescribe medication-assisted
treatment for patients with opioid use disorder. This directly
results in decreased wait times and reduced emergency
department visits.
Secondly, the CCBHC program is designed to expand access to
underserved populations. In our communities, the CCBHC really
opened the door for mental health care to veterans. According
to our local VSO in our county, there are at least 1,000
community members who have donned the uniform out of 7,000
residents. Becoming a CCBHC has allowed us to increase our
services to 23 veterans in our community. This may not seem
significant to you, but it is a 300-percent increase in
services.
Thirdly, consistent CCBHC resources are a fundamental
driver of integrated care. In Oregon, the CCBHC demonstration
financing has made it possible to integrate with a local
Federally Qualified Health Center, allowing primary care and
behavioral health services all under the same roof.
We also share a single electronic health record to permit
immediate care coordination. Patients often tell me that it is
such a relief to not have to retell their stories with every
provider they meet. We are lucky that we have a great neighbor
in the State of Idaho when we have no acute psychiatric beds
available. This component of care coordination in partnership
with primary care in hospitals, even across State lines, is
imperative because patients with severe mental illness and
substance abuse challenges have shockingly high rates of
medical conditions. The CCBHC model allows us to have these
partnerships and get patients the services they deserve in a
timely manner.
In closing, I strongly believe that this model represents
the future of community-based mental health and substance abuse
treatment in the United States. This is why I am asking you to
make this model available to every State Nationwide. As a
Nation, we can do better than first treating mental health and
substance abuse in hospitals, homeless shelters, and our county
jails. Investing in CCBHCs is streamlining services in
efficient ways that drive costs down over the entire continuum
of care.
Despite being from a tiny frontier community at the end of
the road in northeast Oregon, I hope you can see that CCBHCs
make an enormous impact. Again, thank you for the opportunity
to testify, and I am happy to answer any questions.
[The prepared statement of Ms. Jett appears in the
appendix.]
The Chairman. Thank you very much, Ms. Jett. You make
Oregonians proud this morning. I would also note you mentioning
the Idaho-Oregon alliance. Senator Crapo's ears perked up when
he heard that. And on all these incredible efforts, we have
talked about a lot of them. And I just want you to know that it
is a tremendous honor to really be your wing man in some of
these causes, because we have a lot of work to do, and you have
laid out a very powerful case about some of the most important
elements. So thank you. And thank you for making the long trip.
Okay; next will be Dr. Durham.
STATEMENT OF MICHELLE P. DURHAM, M.D., MPH, FAPA, DFAACAP,
ASSISTANT PROFESSOR OF PSYCHIATRY, BOSTON UNIVERSITY SCHOOL OF
MEDICINE; AND VICE CHAIR OF EDUCATION, AND PSYCHIATRY RESIDENCY
TRAINING DIRECTOR, DEPARTMENT OF PSYCHIATRY, BOSTON MEDICAL
CENTER, BOSTON, MA
Dr. Durham. Thank you, Chairman Wyden, Ranking Member
Crapo, and distinguished members of the Senate Committee on
Finance, for holding this hearing and providing me with the
opportunity to speak today about the state of the mental
health-care system in America--where it is working, where it
falls short, and how the Federal Government can play a role in
helping to fill the gaps. Thank you, Senator Warren, for the
kind introduction.
Boston Medical Center is an academic medical center and the
largest safety-net hospital in New England. The patients we
serve are predominantly low-income, with approximately half of
our patients covered by Medicaid or the Children's Health
Insurance Program--the highest percentage of any acute care
hospital in Massachusetts, and one of the highest in the
country.
Mental illnesses are all too common among the patients BMC
treats in our emergency department and across our continuum of
mental health-care services, which include outpatient
integrated mental health care within our pediatric and adult
primary care clinics, and at local community health center
partners. A mental health urgent care clinic, a crisis
stabilization unit, and our Boston Emergency Services Team
(BEST) provide community-based evaluations and a jail-diversion
program. At present, BMC does not own or operate a locked
inpatient psychiatric unit.
The patients we see at BMC who present with mental illness
frequently have co-occurring substance use disorders,
homelessness, malnutrition, and other health-related social
needs linked to poverty. The current COVID-19 pandemic,
structural racism, and economic crisis have further exacerbated
the mental illness and trauma experienced by our patients.
In my 10 years at BMC, I have never seen our mental health-
care services stretched so far beyond their capacity as they
are now. Just the other day we had 25 patients in our
psychiatric emergency department, more than triple its
capacity, presenting with much higher level of acuity, some
waiting for evaluations, and others boarding, awaiting
placement in an inpatient psychiatric unit.
It is widely understood and well documented that America
has a dearth of licensed mental health professionals in
general, and that particular areas of the country, largely
rural and outside of the Northeast, are disproportionately
impacted. Even where I practice in Boston, which has one of the
highest numbers of child and adolescent psychiatrists per
capita in the country, the capacity is insufficient to meet the
mental health needs of the community.
Increased Medicare graduate medical education funding for
psychiatry residency slots can help increase the physician
workforce. Increased funding for loan forgiveness programs for
those who work in underserved areas can help alleviate the over
$250,000 of debt that the average medical student has
accumulated by the time their residency education is completed.
The need to pay off medical school loan burdens is also likely
to cause physicians to pursue practice in more affluent areas,
adversely impacting access to care for low-income populations.
Beyond the shortage of providers, the mental health
workforce is not diverse--for instance, only 2 percent of
psychiatrists identify as black--and not representative or
reflective of the U.S. population. In order to address this, we
must understand that the issue at its root is a pipeline issue
that requires holistic solutions.
Just as we say in medicine that a person's ZIP code is more
influential than their genetic code in determining life
trajectory and long-term health, where a person lives, the
color of their skin, and the language they speak is highly
determinative of quality of education and resources available,
the level of exposure to the mental health field, and the
stigma associated with mental illness.
In terms of access to mental health services, COVID-19 led
to an accelerated adoption of telemedicine. At peak, over 90
percent of our outpatient psychiatric visits were conducted via
telehealth, which enabled BMC to maintain and exceed our pre-
pandemic volume of service. That said, while telehealth is an
important tool for ensuring patient access to mental health
care, it does not work for everyone, due to digital inequities
that exist related to Internet access and digital literacy,
especially among low-income communities.
The social determinants of mental health and structural
vulnerabilities inherently involved with treating low-income
patients require more dedicated time with patients to provide
appropriate care. Insufficient Medicaid reimbursement acts as a
deterrent for providers to see Medicaid patients, producing a
cascade effect in which the more oppressed, marginalized
populations have limited to no access to mental health
professionals.
At BMC, we have developed some innovative models to improve
access to mental health services, which are ripe for
replication and scaling. Transforming and Expanding Access to
Mental Health Care in Urban Pediatrics, otherwise known as TEAM
UP for Children, a pediatric integrated model in Federally
Qualified Health Centers in Massachusetts, builds the capacity
of health centers to deliver high-quality, evidence-informed
care to children and families. The model includes behavioral
health clinicians and community health workers working with
pediatric primary care providers to provide timely mental
health treatment.
The Wellness and Recovery After Psychosis program is
tailored for people experiencing psychotic symptoms using a
team-based approach and providing individual, group, and family
therapy; medication management; case management; and peer
support.
In addition, Massachusetts is home to some other models in
which BMC participates. The Massachusetts Child Psychiatry
Access Program, known as MCPAP, improves access to treatment
for children with behavioral health needs and their families by
making child psychiatry services accessible to primary care
providers across Massachusetts via remote consultation and
education. This model has been expanded to other States such as
Connecticut, where I completed my fellowship. The Metro Boston
Recovery Learning Community offers peer-to-peer services for
people in recovery from mental health and/or substance use
issues through peer support, advocacy, and career coaching.
We are at a pivotal time in our country. Over a year into
the COVID-19 pandemic, every person's mental well-being has
been impacted in some way. The need for a more robust mental
health-care system has never been more clear or pronounced.
Treatment for mental health issues should be accessible, no
matter who you are, where you live, or your ability to pay.
Appropriate investment along the care continuum and for the
mental health workforce can improve access to care and
retention and recruitment of mental health professionals. The
time is now to invest in a 21st-century mental health-care
system in America.
Thank you for your time, and I look forward to the
discussion.
[The prepared statement of Dr. Durham appears in the
appendix.]
The Chairman. Very good, Dr. Durham. I know that we will
have questions for you in just a couple of minutes.
Mr. Betlach, welcome.
STATEMENT OF THOMAS BETLACH, MPA, PARTNER,
SPEIRE HEALTHCARE STRATEGIES, PHOENIX, AZ
Mr. Betlach. Thank you, Chairman Wyden, Ranking Member
Crapo, and members of the Senate Finance Committee. Thank you
for the opportunity to testify today on policy solutions for
addressing mental health.
I had the privilege of serving as the Arizona Medicaid
Director for almost a decade and, for a portion of that time,
as the Mental Health Commissioner. Medicaid serves over 70
million members, offering comprehensive mental health benefits
to some of the country's most complex populations. As you
formulate health policy options, State Medicaid programs should
be a critical component of the discussion. Understanding the
system and the forces prevailing on it should be at the core of
the discussion.
The last year brought to light the extreme fragmentation of
our health-care delivery system at all levels. Our policy and
program structures are in silos. Funding streams to support
these populations follow those siloed program and policy
structures. Providers gravitate towards these funding streams,
creating more complexity at the point of care, and the very
beneficiary the system is designed to serve is forced to
navigate the maze we have created.
Today's environment has challenges, but States and Medicaid
programs now have access to considerable Federal investments to
address these challenges. Examples include the 5-percent set-
aside for mental health block grants used for crisis, 85-
percent enhanced match in Medicaid for the CAHOOTS program, 10-
percent increase in Federal funding for home and community-
based services for the rehab option services, and the expansion
of Certified Community Behavioral Health Clinics.
In February 2021, the National Association of Medicaid
Directors published ``Medicaid Forward: Behavioral Health,''
outlining a series of strategies Medicaid programs are pursuing
to advance mental health services for members. The strategies
vary based on the unique population served by Medicaid. This
report highlighted initiatives such as expanding access and
improving timeliness to care, integrating physical health and
behavioral health, and expanding access for the full continuum
of care, including crisis services.
Further, a March 2021 Bipartisan Policy Council report
concluded that integrating primary and behavioral health care
is necessary and would ensure that individuals with behavioral
health conditions and co-morbid physical health problems
receive high-quality access to care. Arizona provides a strong
example of this. In 2011, we pursued a multiyear strategy to
better integrate services for individuals with serious mental
illness. This strategy was focused on driving integration at
three levels: policy integration, payer integration, provider
integration. In 2018, Mercer consulting conducted an analysis
of the integration efforts. Their final report for individuals
with serious mental illness found that all measures of
ambulatory care, preventative care, and chronic disease
management demonstrated improvement. Just as important, all
indicators of patient experience improved, with 5 of 11
measures exhibiting double-digit increases.
Another opportunity highlighted by NAMD is to strengthen
crisis systems. This issue is front and center with the
implementation of 988. SAMHSA provided extensive thought
leadership with the development of the Crisis Now model to
serve anyone, anywhere, at any time.
The Crisis Now model is based on three critical components:
call center capability, 24-by-7 community mobile response
teams, and 23-hour crisis receiving and stabilization units.
In Arizona, the system has been developed over the past 20
years and serves all Arizonans. The financing for the system
comes from creative multiple funding streams, while leveraging
Medicaid for support. While we have seen improvement, there is
clearly much more to do.
To that end, Congress and the executive branch need to
develop and implement strategies holistically by ensuring
Medicaid and behavioral health collaborate and partner in a
meaningful manner. On several occasions, Congress has leveraged
the mental health expertise of SAMHSA to advance policy
initiatives. However, there do not appear to be sufficient
expectations established by Congress that these important
planning and investment dollars are to be linked to the
Medicaid program. Unfortunately, the dollars often get siloed,
and the opportunity is suboptimal. At the end of the day,
Medicaid beneficiaries may or may not benefit from these
forward-looking investments.
Congress should provide more flexibility with block grant
funds for States to address social determinants of health, as
States look at ways to support these investments. Congress
should look at legislation to establish parity between Medicare
and Medicaid. Where Medicaid has led the way in developing
paraprofessional staff such as peer support services and
systems to support broader populations like Crisis, Medicare
should follow.
Congress should continue to provide financial incentives
for States to modernize mental health infrastructure, like the
investments made in CAHOOTS and CCBHCs. Congress should
continue to evaluate the impact of the IMD 16-bed limit. While
there have been efforts made to allow for some payments in
select instances, some States have not been able to avail
themselves of these opportunities.
Congress should rectify the fact that behavioral health
providers were excluded from the electronic health record
incentive program provided through the HITECH Act. And finally,
as was mentioned by Dr. Durham, Congress should revisit the GME
funding that is made available through Medicare and the 1996
caps.
We are at a critical moment in time to advance the delivery
of mental health services, not only with Medicaid, but for our
entire country. Thank you for your time and interest in these
topics.
[The prepared statement of Mr. Betlach appears in the
appendix.]
The Chairman. Thank you very much, Mr. Betlach.
We will start with you, Ms. Jett. I think what you and your
colleagues are saying is, you cannot expand mental health care
without expanding a trained workforce. And this is especially
true in rural areas. And your eloquent words, I believe, spoke
for a lot of providers from rural areas. And it seems to me you
have a big challenge filling key slots like licensed clinical
social workers who serve Medicare and Medicaid patients, nurses
who do so many things well, starting with health screening and
recovering patients, who play a key role in terms of peer
support. In listening to you over the years, you have convinced
me the professionals are essentially the glue holding the
mental health system together.
Now I would like to get your thoughts with respect to the
workforce, and particularly on the question of having enough
people, and then preventing burnout. Because my understanding
is that the pandemic just made things a lot more treacherous
for so many professionals who just wanted to step up and help
people.
Deaths from opioids are 30 percent higher than last year.
The number of emergency department visits for suicide and drug
overdoses are up more than 25 percent. Three to four times as
many people are identifying as facing depression today than
before the pandemic.
Why don't you tell the committee--because I have heard you
speak to this in the past. It was always a challenge before the
pandemic. Tell us what you think is really happening now with
how the pandemic has made it much harder for you and your
colleagues to do the terrific advocacy you do.
Ms. Jett. Sure. I am happy to speak to that. Crisis burnout
is at an all-time high. Every single one of our crisis
clinicians will--well, clinicians in general that we hire have
to take a crisis rotation. The crisis numbers since the
pandemic started have tripled. And the acuity level of those
crises has gone from a very simple ``I have a lot of anxiety'';
``my cat is stuck in a tree for the past 2 days, and I am not
sure what to do''; ``I am having a panic attack''; to the most
recent crisis call that we had, which was, ``I have a loaded
shotgun, and I intend to use it as soon as we get off this
call.''
I have never, in my 15 years of being part of a mental
health system, ever experienced the acuity level of crises, the
burnout with clinicians, and crisis acuity levels with the
patients that we see now.
The Chairman. Well, thank you for giving us a case example.
I have heard you speak to this challenge of facing cases that
are so much more serious--I guess the technical lingo is the
greater level of acuity--but what a wake-up call, to go from
having lots of calls where people are facing anxiety with cats
in the trees and the like, to people with loaded shotguns
saying that they are prepared to use them. So, thank you very
much for that, and for coming.
Dr. Durham, I want to talk to you about our challenges with
parity. As you know, we got a Government Accountability Office
report documenting all the barriers people face in trying to
get behavioral health. The Federal laws have been on the books.
I remember the day my Dad and I talked about the parity law. We
said, ``This could help Jeff Wyden, a schizophrenic.'' We
rejoiced. And yet, what I hear is that there are still all
kinds of barriers to patients getting the care they need.
And I would like to have you describe what you think is
really going on out there with the parity law. And I gather
your patients are facing a lot of barriers, and you still do
not think the spirit of the law that would treat mental health
like physical health is being honored.
I would like to hear your words.
Dr. Durham. Thank you for the question, Senator Wyden. I
completely agree that we have not made any headway with parity
for mental health and physical health. We have a long way to
go.
A really concrete example is that I work in the psychiatric
emergency room at Boston Medical Center. As I mentioned in my
oral testimony, we have people who--we have like tripled,
quadrupled the capacity during the pandemic. One of the things
that slows the process for us as a team of psychiatrists,
licensed clinical social workers, psychologists, is that we
evaluate the patient, we decide that they need inpatient
psychiatric level of care, and then we start talking to the
insurer.
And that takes a lot of time, where we could be seeing
other patients that are acutely in need of services by us, and
we have to go back and forth faxing paperwork. Then you have to
do a bed search and see what psych unit will accept your
patient. And if it is Medicaid or Medicare, generally they want
to know for Medicare, ``Well, have they met their capacity of
days they can be in a psych unit?'' And then if they have,
total lifetime days, then we are stuck with a patient boarding
with us until we can figure out what else we can do.
And for Medicaid, it is a lot of back and forth for our
folks. And around 50 percent of our patients are on Medicaid.
So that is a huge amount of time when we are in the emergency
room spent going back and forth for, essentially, a prior
authorization.
And I like to use the example that when a patient comes
into the emergency room in acute stroke, or having a heart
attack, the physician in that moment makes a decision that they
need inpatient hospitalization, and they go to the medical
floor without having to go back and forth with an insurer
deciding if that is actually the appropriate level of care.
The Chairman. Thank you. And you know, obviously it was not
the spirit of this bipartisan law from Senator Wellstone and
Senator Domenici, to have patients and providers having to go
into what is almost armed battle to try to navigate just a fair
shake for patients and their providers. So I really appreciate
your being here.
I am over my time.
Senator Crapo?
Senator Crapo. Thank you, Mr. Chairman.
This question is for you, Mr. Betlach. There is bipartisan
interest in expanding opportunities for integration of physical
and mental health services across all payers. While some
approaches prioritize payment, others use co-location services,
or the use of case managers under a medical home model, to
achieve this goal.
What are some of the examples of integration that could be
a road map for Medicare or Medicaid in the near future? And how
could waivers be used in State Medicaid programs to enhance
access to care?
Mr. Betlach. Senator, thank you for the question. I think
there are a lot of different approaches States can take, and
certainly it depends upon the ecosystem of each unique State.
I think the first thing it starts with is, States need a
strategy. What is your integration strategy? So as States think
about this, they should be able to develop a plan in terms of a
multiyear strategy that they are going to be implementing
around integration.
And as I mentioned in my testimony, there are really three
levels to integration. There is how you think about it at the
policy level. And for us in Arizona, it was thinking about some
simple things like, what are the regulations that we have in
place for providers to help build integration? Do we require
some silly things like--we had two separate entryways and
challenges around billing; and so making sure that, as a State,
we were clearing out some of those regulatory burdens that
existed for integration.
States may or may not want to integrate and braid funding
sources like we did in Arizona at the payer level, but States
should certainly have a strategy around maximizing care
coordination between payers. So if you are going to have a
carve-out of behavioral health services, how are you going to
ensure that there is care coordination for individuals who
require both physical health and behavioral health services?
And then finally, States need a strategy in terms of how
they are supporting providers in terms of integration. It may
be opening up things like the collaborative care model codes in
terms of being able to pay for services that are done at the
primary care site, like Dr. Miller talked about. There may be
other incentives.
We leveraged, in Arizona, an 1115 waiver to create provider
payments for milestones that were achieved in terms of
advancing integration strategies like connecting to our health
information exchange and other areas like that.
So States need a plan, and the plan needs to address each
of those three critical areas: policy, pay integration, and
provider support of integration.
Senator Crapo. Thank you.
Ms. Jett, you have very well described the issues that you
face in a rural community in providing the needed services we
are discussing today. Unfortunately, the stigma around
receiving mental health treatment can be even higher in rural
areas.
Can you speak to these challenges? And what approaches has
your clinic taken to combat them?
Ms. Jett. I can. Thank you for the question.
We have been integrated with primary care since 2012
through a series of SAMHSA and HRSA grants. We are partnered,
as I said in my testimony, with a local Federally Qualified
Health Center. And together we have built a 20,000-square-foot
building to provide primary care, dental services, VA services,
and behavioral health, all under one roof.
We are moving in, hopefully in August, and we are hoping
that this destigmatizes your car from being in the parking lot,
because people will not understand why you are there or what
services you are receiving. So this is one way that we thought,
in a frontier community, we could reduce the stigma of people
receiving services.
Senator Crapo. Well, thank you very much.
And, Dr. Durham, one of the positive outcomes of the
pandemic has been, as we have discussed here, the significant
expansion of telehealth, which is an important tool to expand
access.
Have you found any limitations to tele-mental health for
treating your patients, and particularly the younger ones?
Dr. Durham. Thank you for the question. Absolutely, I think
telehealth has been critical to meeting our patients' needs
during this time. But there is a subset of the population where
I think we need more research and understanding of how it is
going to work fundamentally.
I am a child psychiatrist who practices in a child clinic,
and we went to telehealth pretty quickly as well. And I think
it was difficult with some of our families too, because when we
practice, we want a place where someone can speak to us
directly. We want the parents to be separate from the room so
that we can engage with the kid, whether that is a 5-year-old,
or a 12-year-old, or a 16-year old.
And it was very hard for some of the families who are in
low-income communities, who are in multigenerational homes, to
have that private place to have a session. And so that was some
of the difficulty we saw.
I think for little ones, especially kids who have early
intervention services as well, so that 0 to 5 age range, we are
also thinking about how we come back now to the office space
again. And some of those kids we probably will need to see in
person at some point and then maybe go back to telehealth once
we have established a relationship. For the little ones, it is
a little bit more challenging.
And I think for the adult population, some of our folks who
have substance use disorders in particular, and are homeless,
really did not have the technology necessary to always engage
with that support. So throughout the pandemic as well, what we
did was, every day of the week we always had somebody who was
there in person in our clinics to make sure that people could
get the care they needed and did not have to rely on tele-
technology to get the services they wanted.
So I think there is work to do. And I would also say that
the audio-only was critical during this time as well. And so,
any way we can expand that and make sure post-COVID, if you
will, that we still get reimbursement for that, especially in
some of our integrated care models--it was critical to have the
audio-only be reimbursed at the same rate.
Senator Crapo. Thank you. I am out of time.
The Chairman. Thank you, Senator Crapo.
Senator Stabenow?
Senator Stabenow. Well, thank you very much, Mr. Chairman
and Senator Crapo. I really want to thank you for this hearing.
It has been a while since we have had a hearing focus on mental
health and substance abuse services, and I really appreciate
your leadership. And to all of you, you have all raised issues
that are so incredibly important.
I want to speak specifically to what I think is
foundational in the community. And, Ms. Jett, you were talking
about the Certified Community Behavioral Health Clinics that go
to the core of integrating funding and really treating mental
health and substance abuse as part of the health-care system. I
always say we should treat health care above the neck the same
as health care below the neck, and not just through a focus on
grants that stop and start. It needs to be integrated in
Medicaid, and it needs to be prospective payment so we can have
the full opportunity for professionals being funded.
So today I am really pleased to say that Senator Blunt and
I--along with our chairman, Senators Daines, Cortez Masto,
Smith, and Tester--welcome all the members of the committee to
be co-sponsors in the next step. We have 10 States that have
been doing a demonstration of how this can work with high-
quality standards, and today we introduced legislation that
would allow States across the country to be able to do this,
which is incredibly important.
We have, through our startup grants, through the COVID
process, we have been able to bring in dollars, as has been
indicated, to over 300 communities across the country, 40
States plus DC, to do startup grants. But what we need is
comprehensive community care. And this all really started, I
have to say, because Senator Blunt and I worked together on
Federally Qualified Health Centers, which are widely supported
on a bipartisan basis. And the idea, as you said, is quality
standards. If the community clinic can meet the high quality
standards, they get full reimbursement in the health-care
system. And so that is what this is. The idea is to integrate
those payments.
So, Ms. Jett, no surprise, I have a question for you to
expand on CCBHCs. You really were one of the very first in the
country and have done just a marvelous job in showing what can
be done. But I wonder if you could expand more on the issue of
permanent funding.
You know, I have always said to colleagues that it is like
having someone having a heart attack, and they go to the
hospital and they are going to immediately get treated. Right
now, in too many places around the country, if somebody walks
into a mental health center, it is the equivalent of saying,
``I am sorry, the grant ran out, can you come back in a few
months?'' when somebody is in crisis, which obviously is
ridiculous.
So, could you talk a little bit more about the importance
of integrating funding and permanent funding in the mental
health and substance abuse system?
Ms. Jett. Of course. I would like to give a couple of
examples first about how the system is currently funded, which
presents a variety of challenges for us.
For example, on the Medicare side, only licensed clinical
social workers or medical doctors can treat Medicare patients
for mental health services. What this means in a frontier
county is, if we only have one or two licensed clinical social
workers on staff, then the remainder of those services being
delivered to Medicare patients are being written off.
In our CCBHC, we write off upwards of $500,000 a year for
Medicare-delivered services. Our growing population is over 65
and under 17. We have the under-17 covered, but the over-65
population is underserved. And really the reason is, we do not
have the licenses available to treat those people.
So the funding for CCBHCs allows that wrap-around payment
to bridge the gap of services not being currently financed. It
is vital, and it is important that we fund the business of
mental health. People just want to fund the services, but there
is an actual infrastructure that is required to provide this
high level of integrated care.
Senator Stabenow. Thank you so much. And in the limited
time I have left, let me ask you to speak a little bit more to
integrating care. Again, the financing model really is about
integrating primary care for individuals. It is a whole person,
and we segregate them when we are talking about various ways to
provide health care. But could you talk about the delivery of
behavioral health services and what you do in the context of
providing primary care for people?
Ms. Jett. Sure. Well, the CCBHC model in Oregon allows for
20 hours or more of primary care to be delivered, as we say, on
our turf in the behavioral health system. This building, co-
located with our local FQHC, works both sides of that equation,
right? Because we understand that there are many people who
want to access behavioral health services--specifically those
with persistent and severe mental illness--on the behavioral
health side.
Conversely, there are people on the primary care side who
only want to access behavioral health services from their
primary care doc. And so, having both an FQHC and a CCBHC in
one location allows for multiple access to services in the
integration.
Senator Stabenow. Thank you very much. Thank you, Mr.
Chairman.
The Chairman. I thank my colleague.
Senator Crapo and I will be working very closely with you
and Senator Daines as we go forward on these issues in a
bipartisan way.
Let's see. What we are going to do, because I think a
couple of our hearings have been a challenge with so many
Senators having hectic schedules, I am just going to call the
names in order of appearance.
So, Senator Grassley would be next. I am not sure he is
available, but I thought we ought to check. Senator Grassley?
[No response.]
The Chairman. Okay. Senator Cantwell is of course here and
has been a longstanding leader in terms of health-care
advocacy, so let's recognize Senator Cantwell.
Senator Cantwell. Thank you, Mr. Chairman. And thank you
and the ranking member for holding this important hearing, and
my colleague Senator Stabenow for her leadership on this.
Many of you have mentioned--well, a big theme this morning
is the integration of mental and physical health. I appreciate
everybody honing in on what we could do about that. To me, this
is--you know, when I look at 20 to 25 percent of the homeless
population having mental health problems, I think there are
costs. These are just continued costs to the system that we
have not taken care of. And if we had an integrated system, and
I think even better case management, because--who is managing
the situation? If the person has mental health problems, who is
managing the situation? And if no one can talk to any of the
people, how could you possibly integrate the physical and
mental health?
I am sure I am not telling you anything. The drugs that
people are taking for mental health cause a lot of physical
problems. So this has to be fixed.
So what do you think we can do to get our colleagues to
understand that we are losing money that we could save now if
we would just fix this integration? So either Dr. Miller, since
you were very big on this, or Dr. Durham--either one.
Dr. Miller. Well, Senator, thank you for the question. I
will just begin by saying that I think you put your finger
right in the center of the biggest problem that we have, which
is how we have bifurcated, trifurcated, and split apart health.
When you talk about services for the unhoused, or you begin to
look at our children versus adults, we have fragmentation in
almost every level. So to integrate requires us to have really
thoughtful strategies that look at the issue at multiple levels
simultaneously. And I will give you one example of that.
If we simply look at how we clinically integrate care,
without paying attention to how we financially support that
integration, it usually falls apart. If we do not look at the
administrative or operational functions that also provide
oversight, it means that a lot of well-intended folks out there
trying to bring these integration services together usually
fall apart because there is not a structure for them to
ultimately be grabbed by and supported.
So, when we look at health, it is an opportunity to really
think about that integration at multiple levels. So thank you
for the question.
Senator Cantwell. Dr. Durham?
Dr. Durham. Sure. Thank you for that question. I am very
aligned with what you said about case management and those
services needed for families that present with a lot of issues
besides just the mental health issue.
In our model for TEAM UP for Children, which is in FQHCs in
the greater Boston area, we have a community health worker as
part of the model for just that: to do some of that care
coordination not only between the schools, but thinking about
housing insecurity, food insecurity, and what other services
are needed.
I think what happens many times, though, is that the case
management service, the community health worker, or even a peer
coach, are not usually reimbursed by the system. And so it does
end up being a lot of grant funding. And I appreciated what Ms.
Jett said as well, that the grant funding ends and then all
those services that helped support families and patients also
go away.
And so, ways that we can embed that more into the system
from a reimbursement perspective would be fantastic.
Senator Cantwell. Well, I just go back to an example of
the--as the chairman knows, I am a big supporter of affordable
housing too, but hospitals are now helping to finance
affordable housing so you can have a roof over somebody's head
so that they do not keep coming to the emergency room. And
while you are talking about helping families, I am talking
about the cost to the system when people have no support or no
help.
I do not think we have a clue about how much we are running
up the bills that we could do a better job with if we just had
integration and case management for these people. Then we could
make better decisions and lower the costs.
And so, I hope we come to understand this, because a lot of
our--I think what we are seeing in homelessness is people who
just literally fall through the cracks. They do not have
anybody advocating for them. They have bounced in between these
things. They do not have the issue taken care of, and the next
thing you know, they are out on the street.
This is then costing all of us in all sorts of other ways.
So to me, let's understand that this is a task certainly about
helping people, but it is also a task about fixing the system
that is costing us way more than it needs to cost us at this
point.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Cantwell. And as usual,
you go right to the heart of the case, which is, who manages a
lot of these cases? Who is, in effect, in charge? And as I saw
with my late brother, as he suffered from schizophrenia, he got
good care in a number of instances, but too often we could not
figure out who was in charge. And I said to myself continually
through this odyssey, if this is what an elected official who
has tried to specialize in health care faces--and I spent years
and years in those communities playing basketball--what is it
like for the typical person? So, thank you. Thank you for
hitting the question of who is going to manage these cases, and
Senator Cantwell said it so well, as always.
Senator Thune, I believe you are out there on the web.
Senator Thune. Yes, I am.
The Chairman. Are you available?
Senator Thune. Yes, sir. Thank you, Mr. Chairman. And
thanks to our panelists for being with us today.
I think most everyone can agree that telehealth has proven
to be an important tool on our tool belt for increasing access
to mental health services. And once we get past this pandemic,
I have concerns about a policy enacted last year that will
require an in-
person visit for Medicare to pay for tele-mental health.
One of the things I hear everywhere in South Dakota is, it
does not matter what the provider setting is, whether it is
Indian Health Service or the VA or our public hospitals in
South Dakota, our schools, we cannot find, recruit, and retain
providers. And so, as we are talking about the need to increase
access, it seems to me that this arbitrary and inconsistent
barrier does not make sense. In fact, in rural America it
stands to make access even more inequitable.
Ms. Jett, can you share some perspectives on how telehealth
has helped rural patients overcome the stigma of seeking mental
health services and the potential challenge an in-person
requirement can have moving forward?
Ms. Jett. Of course. Thank you for the question. Of course,
there are both pros and cons to receiving telehealth services.
I am happy to say that our clinic provided services nearly
seamlessly through the pandemic because of the use of
telehealth.
However, as Dr. Durham has pointed out, those in
underprivileged or underserved communities often struggle with
technology, as well as appropriate hot spots or Wi-Fi
capability.
And so, what we have done as a community is, we took some
of the FEMA crisis money that we received, and we bought 10
iPads and 10 hot spots to deliver to children and families and
community members who were without Wi-Fi or technology services
that were available to them.
We would often have them drive into the clinic and park in
the parking lot. We would walk out an iPad, and they would hook
up to our system right there in the parking lot and have their
psychiatrist appointment or therapist appointment right there
in the parking lot.
So, telehealth services have certainly expanded the access,
but also have prevented some people from accessing services
too, specifically the population with severe and persistent
mental illness. This has been a great barrier to them,
unfortunately.
It is very difficult to explain to someone with severe and
persistent mental illness that their therapist is on the TV.
That is a little odd. So it has been a bit of a challenge with
that particular population. But overall, I think it has
improved access.
Senator Thune. Well, thank you. And I guess I would direct
this to anybody on the panel. The in-person requirement passed
last year is not consistent with multiple telehealth policies
previously enacted by this committee, like the eTREAT Act for
substance use disorder, and the FAST Act for stroke.
Would you support legislation to remove the face-to-face
requirement for mental health, like Senator Cassidy has
introduced along with Senators Cardin, Smith, and I? And keep
in mind that there is nothing to stop an individual provider
from requiring their patient to have an in-person visit. And to
Ms. Jett's earlier comment, I serve on another committee, the
Commerce, Science, and Transportation Committee, which is
working on the Wi-Fi issue and trying to make those services
available to more people across the country.
But with respect to this issue, this piece of legislation
that Senator Cassidy is leading, and some of us are co-
sponsoring, does anybody want to talk about that particular
legislation, whether or not you think that is something that
you all could support and that makes sense as we look at better
solutions to deal with mental health challenges facing this
country?
Dr. Durham. Yes, I can take that. I think that having a 6-
month in-person provision will really be an unnecessary barrier
to folks getting care. And I think it should be at the
discretion of the clinician or physician seeing the patient
whether or not they need to see them again for an in-person
visit. And I think we would go down this road again of, it is a
parity issue of why, for certain illnesses or disorders you do
not need it, and for mental health you would need it.
So I would be very aligned with not having this provision
and just using the discretion of the clinician on whether or
not they need an in-person evaluation.
Senator Thune. Great. Anybody else?
Ms. Jett. Well, I think the bottom line is, we just have to
be a flexible system that is amenable to serving all people of
all populations at any time they request access for services.
So, requiring these barriers seems sort of silly to me. And
I hope that we can think twice about something like that.
Mr. Betlach. Especially if the beneficiaries have now seen
the value in receiving services through this mode of treatment.
Senator Thune. Okay. Great. My time has expired.
Thank you, Mr. Chairman. Thank you, panel.
The Chairman. Thank you, Senator Thune. And I think you are
making very important points with respect to these various
issues requiring a previous appointment in order to get to
telehealth. We have to work through those issues, and we are
going to do it in a bipartisan way
Senator Grassley would be next.
Senator Grassley. Thank you, Mr. Chairman.
In 2019, I passed the bipartisan ACE Kids Act, with the
help of Senator Bennet, that will align Medicaid rules and
payments to incentivize coordination and improve health
outcomes. This Congress, I am working with Senator Bennet to
build onto the ACE Kids Act with the Accelerating Kids Access
to Care Act. A key aspect of this effort is to enable the
pediatric health home to coordinate care with children,
including the prevention and treatment of mental illness and
substance abuse.
So, for Mr. Betlach and Dr. Durham, you both discussed in
your written testimony the importance of care coordination to
addressing fragmentations in the health-care system. The ACE
Kids Act requires States to ensure mental health-care
coordination is included when establishing a pediatric health
home. What lessons can be learned from both your experience as
a provider and a State Medicaid Director with upcoming
implementation of the ACE Kids Act in 2022?
Dr. Durham. Thank you for the question, Senator Grassley. I
think the more we can coordinate care for kids and families,
the better, at any opportunity. Kids are in many different
systems: school systems, their community, their family network,
and all of their providers, especially as kids have more
complex medical conditions. And so, I would be in great
support--any time we can provide the services to coordinate
care, the better it is. And I think what we have seen in some
of our models that have focused on pediatric and mental health
integration in FQHCs is that, the more members of the team that
are involved with every system that the kid is in, the better
it is for the kid. Their mental health gets better. Their
physical health gets better. And then of course, where they
thrive is at school and at home, ultimately. So, thank you for
that question.
Mr. Betlach. Senator Grassley, what we have seen in Arizona
is that States need to have a strategy around the different
silos that exist in terms of where complex kids may be, whether
it is working with the foster care system, whether it is
working with kids who may be receiving services through a
waiver for individuals with developmental disabilities. Really,
the State needs to be looking at the delivery of behavioral
health services holistically and how it is going to serve those
populations and reduce the fragmentation.
And so, it is leveraging the investments that SAMHSA has
made, for example, with first-episode psychosis to make sure
that Medicaid is plugging into the infrastructure that is being
created, and looking at that. So, if it is using managed care
or fee-for-service, the State needs a plan in terms of how it
is going to take kids with these complex needs and get them the
services that they need.
Senator Grassley. In the last Congress, we made mental
health services via telehealth a permanent benefit of Medicaid.
So, for Dr. Durham and Dr. Miller: as health-care providers,
how best can Congress support this expansion of mental
telehealth while ensuring improved health outcomes for
individuals served by the expansion of access?
Dr. Durham. Access has been greatly improved with
telehealth. We have seen that throughout the pandemic, and with
our patients. You know, as we discussed previously, I do think
there are certain populations where it is more difficult.
And so, audio-only has been very helpful throughout the
pandemic. We have seen that a lot in some of our integrated
care settings, whether that is pediatric integrated care, or
internal medicine integrated care for primary care--at least at
Boston Medical Center.
And so, I hope that the provision would still continue to
allow audio-only visits at the same reimbursement rates,
because it has significantly impacted and helped many of the
homeless population, folks who do not always have access to the
technology.
Dr. Miller. I agree with Dr. Durham. And, Senator Grassley,
thank you for the question.
The uptick in telehealth utilization for mental health has
been a very helpful sign. The people like it when care is able
to come to them. And if we are really going to put the patients
and families first, we do have to consider policies like the
in-person requirement we just discussed and consider whether or
not these things are good or bad for people. Does it restrict
their access? Does it restrict where they are going to be able
to ultimately use these services?
So, making permanent the audio-only, having payment parity,
and allowing this for all forms of outpatient care, is a
tremendous benefit for so many people across our country.
Senator Grassley. I will yield.
The Chairman. Thank you, Senator Grassley.
Next would be Senator Carper. Is he available on the web?
Senator Carper. Senator Carper is right here.
The Chairman. Okay, and we can hear you. Go ahead.
Senator Carper. Thank you, sir. I welcome each of our
witnesses today.
My staff and I have heard from pediatricians from across
the country, including in the Nemours Children's Hospital, the
fabled children's hospital that we are very proud of. And we
hear from any number of sources that our country is
experiencing a mental health crisis among our children. And I
do not think it is just in Delaware, I think it is throughout
our country.
But during the pandemic, children have experienced major
disruptions as a result of public health safety measures,
including school closures, social isolation, financial
hardships, and gaps in health-care access. It has become clear
that COVID-19 has significantly exacerbated the health stress
on our children and youth, highlighting our Nation's acute
shortage of mental health services and the need to reinforce
and expand the pediatric mental health delivery systems and
infrastructure.
A question for Dr. Durham, if I could. Dr. Durham, what
more can those of us in the Congress do to address root causes
and support effective approaches to prevention and early
identification of mental and behavioral health issues? Dr.
Durham?
Dr. Durham. Thank you very much for that question. As you
mentioned, many of our kids have experienced a lot of loss. And
when we think of loss, it is not only death within their
family, but also thinking of not being able to see their
friends or do the social activities and other things that
fulfill and support their livelihood.
I do think one thing that we need to think through from a
prevention/promotion standpoint is that many of our schools,
even in the Boston area, do not have school therapists that
they have access to. So, we do not want people to always get
treatment once there is a severe level of illness and they need
to be in a hospital or an emergency room, but how can we start
thinking in a prevention and promotion framework of just
touches, if you will? So, meaning that something is going on. A
teacher notes it, or a principal, or someone in the school or
the family, and they have the services right there within the
school system before we get to the point where you are calling
the emergency services or a crisis line.
There are not enough supports within the school system to
do any of that sort of prevention and promotion framework.
Teachers are doing a lot. They are doing their job. But we do
not have therapists embedded in many of our schools, even when
we think about a resource-rich place like Massachusetts. And
so, I think it is critical that we think about it in that
framework.
I do think pediatric integrated care is another way to
think more about prevention and promotion; so, seeing children
and families at their well-child visit, which we do in
Massachusetts, and start thinking and asking those questions
about what stresses are happening in their lives and getting
care for immediate needs--whether it is a mild behavioral
health need, depression or anxiety that is not to the point
where maybe they are thinking about harming themselves or
harming anyone else.
So, using that framework of prevention and promotion, I
think, is critical. And sometimes that is not necessarily
reimbursable from a mental health standpoint as it is for
physical health. Kids are supposed to go get their visits quite
early in life for a check-in. And the more we can think about
even like a mental health check-in with their primary care
provider or therapist in the school, I think the better we
would all be in the long run.
Senator Carper. Thanks.
A question for the record, if I could, for all of our
witnesses. Several months ago I was in the Bay Area in
California visiting a number of promising technology companies.
One was called Ginger, G-i-n-g-e-r, in the Bay Area. And they
focus on coverage for--or they focus on mental health
screenings, and behavioral health coaching. And I have a
question regarding the coverage for those screenings and
coaching. And I would just ask you if any of you find virtual
behavioral health coaching to be an efficient means of
preventing serious mental illness? And if so, should Congress
consider mandating coverage for virtual mental health
screenings and behavioral health coaching in plans offered on
the health insurance marketplace? That is a question for the
record for each of you.
Thank you, very much. Thank you, Mr. Chairman and Ranking
Member.
The Chairman. Thank you, Senator Carper.
So, colleagues, we are going to keep this going. Our guests
will, I am sure, find this somewhat entertaining, because we
have all these votes, and Senators are coming in and going, but
we are going to keep it going.
The next four questioners from the committee will be
Senator Cardin, Senator Cassidy, Senator Bennet, and Senator
Daines.
So, Senator Cardin, if he is available on the web, would be
next. And as I say, we are just going to keep this going.
Senator Cardin, are you out there in cyberspace?
[No response.]
The Chairman. Okay. Senator Cassidy has been sitting here
all morning.
Senator Cassidy. Thank you, Mr. Chairman.
Dr. Durham, I think I may have given you a lecture in
medical school.
Dr. Durham. I think you may have. [Laughter.]
Senator Cassidy. You may recall, it was on diarrhea and
hepatitis. I was famous on those lectures. There will be a quiz
as to hepatitis A and how it is transmitted, but we will do
that off the record. Thank you, very much.
It is incredibly gratifying to me to see you and how your
career has gone.
Dr. Durham. Thank you very much.
Senator Cassidy. Let me echo Senator Thune's endorsement of
the bill that we have introduced as regards telehealth, tele-
mental health. And, Mr. Chair, I would like to submit two
letters which support this legislation that we are putting
forward with Senator Thune, as you mentioned, but also Senators
Smith and Cardin--and I have lost the list. And so this letter
is from the American Telemedicine Association, and this is a
group of folks with the Health Innovation Alliance of the
American Telemedicine Association.
The Chairman. Without objection, so ordered, Senator
Cassidy. And Senator Crapo and I will be working very closely
with you and the coalition on this very important idea.
[The letters appear in the appendix on p. 54.]
Senator Cassidy. Thank you.
Mr. Betlach, good to see you.
Mr. Betlach. Senator Cassidy, good to see you, sir.
Senator Cassidy. Your hair is a little longer----
[Laughter.]
Listen, several questions for you. You and I both know, in
fact we all know, dual-eligibles are just a terrible mess, very
expensive to care for, with terrible outcomes. We are spending
incredible amounts of money to get terrible outcomes. It is the
worst of all.
Now SAMHSA has a lot of grants out there in order to
address the issues of the mentally ill, as well as those who
have substance abuse, and yet there seems to be poor
coordination with Medicaid. You have experience. Can you give
some ideas as to how we could better coordinate those programs?
Mr. Betlach. Sure, Senator Cassidy. That is an incredibly
important question. In Arizona, roughly 40 percent of the
population of individuals with serious mental illness are dual-
eligible members, which actually leads to incredible
fragmentation, as you described.
When I first became the Medicaid Director, if you were an
individual with a serious mental illness, you had a plan for
physical health for Medicaid, a plan for behavioral health for
Medicaid, Medicare fee-for-service, Medicare Part D--four
different organizations that were potentially involved in
paying for your services, none of them coordinated.
As you said, it has led to just terrible results. On
average, an individual with serious mental illness dies 25
years younger than peers, and oftentimes it is from untreated
chronic diseases.
And so in Arizona, it all comes back to the system design
issue. Who is accountable in this? And it is very challenging
with dual-eligible members. But we created and built off some
of the Federal regulations that exist that said the managed
care organization that was responsible for providing services
for individuals with serious mental illness not only had to
deliver Medicaid services but Arizona Medicaid programs, the
third largest housing authority, so there were rental subsidies
that were flowing through the Medicaid program--employment
support services. Very importantly, the plan had to be a dual
special needs plan, which meant that it offered the Medicare
services, which meant it was then accountable for delivering
Medicare services to that population.
Senator Cassidy. Let me stop you.
Mr. Betlach. Yes.
Senator Cassidy. Great ideas: aligning incentives, a point
of authority, everything that checks the boxes. What were your
outcomes? Were you able to improve outcome for the duals?
Mr. Betlach. Yes. In the independent third-party study that
was done by Mercer, we saw an increase in terms of all the
HEDIS scores for ambulatory and chronic management, and an
increase in all of the CAHPS scores.
Senator Cassidy. Now let me ask, because sometimes those
are process-oriented as opposed to outcomes-oriented----
Mr. Betlach. Right.
Senator Cassidy. And so, to what degree did you see
emergency room visits decrease? Return to workforce? Longer
life span, et cetera?
Mr. Betlach. We do not have the indicator yet on longer
lifespan. We are only a few years into this, right? So that is
going to be a lagging measure as we look at the different
indicators. But we did see a decrease in emergency department
utilization and an increased use of primary care. Again, not
necessarily outcome measures, right, but it is a start.
Senator Cassidy. Well, let me ask, then--because I am
almost out of time--specifically, integrating SAMHSA grants in
there, were you able to do that as well?
Mr. Betlach. We did. We flowed all of the SAMHSA block
grant dollars to that organization. They were responsible for
those as well. So again, a single accountable organization that
had all those dollars braided in it.
Senator Cassidy. Gotcha. I thank you all for your good
work. I really appreciate it.
And again, Dr. Durham, it is great to see your success.
Dr. Durham. Thank you.
Senator Cassidy. And I yield back.
The Chairman. Thank you, Senator Cassidy. We are going to
be working very closely with you as we go forward on this
committee effort.
Senator Bennet is next.
Senator Bennet. Thank you, Mr. Chairman. And again, thank
you very much for holding this hearing. I hope that it is only
the start of a larger effort to address the mental health
issues in our country. I, like my colleagues, am deeply
concerned about the issue of parity and how insurance companies
and providers often erect barriers to adequate mental health
coverage.
Senator Kaine and I were working on developing our
Medicare-X Choice Act to create a public option, and mental
health access was at the top of our mind. We viewed this as an
opportunity to improve access to people, especially in rural
areas. And a key provision in this proposal provides primary
care to patients with a public option without cost sharing--and
this should absolutely include mental health care.
Dr. Miller--and anybody else on the panel who would like to
answer--can you speak to how a public option could be designed
to integrate mental health and primary care? How should this
elevate the standards on parity that currently do not exist in
the private health insurance market?
Dr. Miller. Thank you for the question, Senator Bennet, and
thanks for your ongoing leadership in this space.
First, from a coverage perspective, any public option
should incorporate some of the key lessons that we are learning
from landmark Federal cases like Wit vs. United Behavioral
Health. This includes things like requiring coverage to be
consistent with generally accepted standards of care that
ensure the inclusion of civil enforcement provisions.
Second, a public option can actually create a standard for
integrating care. A public option can determine the scope of
services, and it can actually raise the bar on expectations for
integrated practices. This is needed, and overnight it could
create a new mechanism to support integrated primary care.
And then finally, a public option could expand the scope of
services and the range of providers to make sure that it pays
for critical services that augment the onsite delivery, like
peer support specialists. Hence really, if you bake it into a
public option, you are beginning to change the game from how
people have experienced mental health and primary care on the
ground.
Senator Bennet. Anybody else?
[No response.]
Senator Bennet. I am deeply concerned with the increased
rates of mental illness that young people are experiencing,
leading to death by suicide, substance use, or other mental and
behavioral health challenges.
In Colorado, it has been 5 years since suicide became the
leading cause of death for kids aged 10 and older. And at the
same time, we have seen a reduction in beds for youth suffering
from mental illness. We have seen that decreased by 1,000 in
the past decade.
A few weeks ago, our children's hospital declared, quote,
``a pediatric mental health state of emergency,'' as emergency
mental health visits were up 90 percent in April of 2021
compared to April 2019.
What gaps exist in the tools needed to address the mental
health challenges facing our children and young adults across
the continuum of mental health care, particularly for the
Medicaid population? I know a lot of our colleagues are working
on improving home and community-based services. How can we
ensure that kids and families are receiving mental health
services at home or in their communities? I don't know, Dr.
Durham, whether you might want to get us started?
Dr. Durham. Sure, I can get us started. I think it is a
fantastic and great question, so I appreciate it. I think it
also has a lot to do with the care continuum. I think what we
have seen is, everything has been exacerbated. What we knew
pre-pandemic was that we do not have enough services for kids.
I think a State like Massachusetts has done a good job. Senator
Cassidy is from Louisiana, which is my home State, which is
very different. And my family and friends are still there, and
I can compare Massachusetts and Louisiana.
And so we do have a continuum for care. We have in-home
services for kids on State Medicaid in Massachusetts with
different language capacities. And I think that model should be
replicated in other States similar to the State of Louisiana,
where I come from, where there are very limited resources for
kids on the State Medicaid.
And that care continuum has day programs in Massachusetts.
We have crisis units for kids so we do not have to go all the
way to the highest level of care, which is a locked psychiatric
unit for kids. And you know, as previously stated, I do think
we need to do something to expand school-based therapists at
schools.
We do not have enough. That is where kids are most of the
day. That is what gets noticed quickly by teachers and other
people who see them day in and day out. And so these are ways
that we can work from a prevention and promotion framework.
Kids as young as 12, 13, and 14 will tell you when they are in
their early 20s, ``I knew when I was 12 that something was
going on.'' And either maybe a parent or a caregiver did not
recognize, but also there was no one to go to.
So, the more that we can invest in that, all the way from
prevention and promotion along the care continuum, I think the
better for all of our kids.
Senator Bennet. Thank you, Mr. Chairman.
I am out of time, but I appreciate that answer very much.
Senator Crapo [presiding]. Thank you, Senator Bennet. The
chairman has gone over to vote. I don't know if it has been
explained that we have two votes going right now, so we are
kind of rotating back and forth. Plus, we have a lot of members
who may or may not be available because of that. But I am just
going to go down the list.
I am told that Senator Daines is on his way here, but let
me just ask. Is Senator Daines on the Internet?
[No response.]
Senator Crapo. All right. I am just going to call out some
names, and if nobody answers, I am going to--did I just hear
somebody? If nobody answers, I will ask a few of my own
additional questions.
Senator Casey?
[No response.]
Senator Crapo. Senator Young?
[No response.]
Senator Crapo. Senator Warner?
[No response.]
Senator Crapo. Senator Whitehouse?
[No response.]
Senator Crapo. Senator Hassan?
Here is Senator Daines. You are up.
[Pause.]
Senator Daines. Mr. Chairman, thank you. And truly, I am
very glad that we are holding this hearing today on such an
important topic.
Last month, Senator Stabenow and I hosted our first Finance
Health Care Subcommittee hearing of the year, since May was
mental health month. We focused on the importance of improving
access to mental health services and how the COVID crisis has
impacted patients as well as providers.
We were fortunate to have Lenette Kosovich as our Montana
witness. She is the CEO of the largest behavioral health
organization in Montana, and she was able to highlight the
challenges our rural communities face when it comes to
accessing mental health care. She also discussed the benefits
of the Certified Community Behavioral Health Clinic model,
known as the CCBHC model, which brings the reimbursement for
behavioral health services on par with that for physical
health-care services.
In fact, following that hearing, Senator Stabenow and I
decided to team up in this legislation to allow States,
including Montana, to adopt the CCBHC model. In fact, we are
introducing it today. Our bipartisan bill will integrate the
physical and the mental health care and provide patients with
access to treatment more quickly.
Ms. Jett, how can the CCBHC model help rural communities
like those in Montana that face access challenges and have a
shortage of mental health professionals?
Ms. Jett. Thank you for your question. We really believe in
the CCBHC model. In fact, we have been one of the first to
adopt it and have been using the model for about 4 years now.
We find that integrating the services, or creating what we
like to call the neck in between the head and the body, really
helps improve outcomes for patients that we serve. It also
improves access to underserved populations, specifically
veterans in our community who have really benefited from us
becoming a CCBHC, primarily because Oregon wrote a waiver with
the CCBHC model that would allow veterans to access care from
non-veteran clinics.
So where we live in northeast Oregon is about a 2-hour
drive for any veteran receiving any sort of services, medical
or mental health services. And so by becoming a CCBHC, and
along with that Oregon waiver, we are able to treat local
veterans for behavioral health issues. It has been really
powerful.
Senator Daines. As the son of a veteran, thank you.
I recently introduced legislation with Senator Cortez Masto
to make permanent a CARES Act policy that I championed allowing
first-dollar coverage of virtual care under these high-
deductible health plans. Our bipartisan bill would allow
Montanans and Americans across our country to continue
accessing essential care like mental health and primary care
services, without the burden of first meeting a deductible.
With more than 50 percent of American workers now receiving
their health-care coverage through the high-deductible health-
care plans, I believe this policy should be made permanent.
A question for Dr. Miller. Do you agree that limiting
barriers to telehealth services, after the public health
emergency, would benefit patients seeking mental health
services?
Dr. Miller. Senator Daines, thank you for the question. As
we have discussed today, there is such power in being flexible
with how we are able to deliver services to where people are.
And so what we need to do is continue to explore how these
services have added value to people's lives, and how they have
improved outcomes.
Many of the changes that we have seen through the emergency
order have made a difference in countless lives. And I think to
take that away would not only be to the detriment of those
families that have become dependent on it, it would also hurt
our Nation's overall health.
And so, we have to be very thoughtful and very considerate
when it comes to these issues of telehealth. I would recommend
that this group, this committee and this Congress, really
consider ways to either make some of these changes permanent,
or to consider an extension that goes on for the next year to 2
years to allow for us to continue to maximize on what many
folks have benefited from.
Senator Daines. Thank you.
I want to shift gears and talk about a problem we are
facing in Montana, and that is meth. In Montana, meth is taking
a devastating toll on our families and our communities. I had a
briefing with our Guard in Montana on Friday, their Counter-
Drug Task Force, and we were talking about significant
increases year over year in 2020 versus 2019 on drug seizures
in our State--meth and heroin.
In fact, in 2020 drug overdose deaths hit a record high. We
are now looking at a disturbing increase in meth-related
violent crime. While medications can be effective in treating
some substance use disorders, there are currently no FDA-
approved medications to help meth addiction.
According to the National Institute of Drug Abuse,
contingency management, which involves giving patients
incentives to not use drugs, is an effective treatment for some
individuals suffering with addiction. Mr. Betlach, in your
experience, are there any Federal barriers that prevent States
from implementing effective contingency management?
Mr. Betlach. Senator, thank you for the question. I would
say, I am not aware of any, but we can do some further research
and get back to you.
Senator Daines. Okay. Thank you.
Thanks, Mr. Chairman.
Senator Crapo. Thank you very much.
And I do understand that Senator Young is on the web.
Senator Young, are you there?
Senator Young. I am, Mr. Chairman. Thank you so much for
holding this hearing. I think this is a really important topic.
The coronavirus outbreak has created an unprecedented
mental health challenge for our country. I know it has
certainly created challenges back home for many of my Hoosier
constituents. While we do not yet know the full impact of the
coronavirus pandemic on mental health, we do know it has forced
Americans to isolate from their loved ones and other support
systems, causing a troubling spike in mental health and
substance abuse problems.
A Kaiser Family Foundation poll found that 45 percent of
adults say that the outbreak has affected their mental health,
almost half of adults. Among adults in Indiana who reported
experiencing symptoms of anxiety or depressive disorder, almost
20 percent, one out of five, reported needing counseling or
therapy but not receiving it, in the past 4 weeks.
I have a few questions related to this directed towards Dr.
Durham. Dr. Durham, access has long been a barrier to adequate
behavioral health care. The public health emergency is only
exacerbating the existing challenges and increasing the need
for providers and treatment.
How are providers responding to this increased need?
Dr. Durham. Thank you for the question. I think that you
are absolutely correct that we have seen a lot of people, and a
lot of uptake in services because of what we have all, I think,
noted today, which is that there has been an increase in
flexibility when we have added audio and video telehealth
capability to all of our clinics throughout the country.
And like most have said previously, I do not think we
should change that moving forward. We need to meet people where
they are and whenever they can access the technology without
having to necessarily come and drive in to appointments, or if
you are in a rural community where you may not have access in
your community to a mental health provider.
So, what has happened is that our clinics are full. We are
seeing people back to back with telemedicine and our audio
appointments. And what it leads to is that, you know, we have a
workforce issue. And we need to figure out ways that we can
expand on who is able to provide care, as Ms. Jett mentioned
earlier. There are certain insurers that do not allow for
certain services to be provided. And so we need to look at that
more deeply, the issue of who can provide services and be
reimbursed for the services.
I am a firm believer that whatever you trained for and went
to school for, you should be able to practice and get
reimbursed appropriately for it. So I think that telehealth has
expanded so much for our communities, and I think there is more
research to be done as well about which patient populations it
works for and how we need to pivot in some other ways to make
sure it is accessible for them too, due to other digital
inequities, and maybe a lack of digital literacy as well. But
it has definitely aided that process of engaging and reducing
stigma, I think, in mental health. Not having to physically
come in to see a mental health provider, I think, has helped
substantially.
Senator Young. Well, I agree that these additional
flexibilities, based on my consultation with providers back
home, have just been essential. So I think it is really
important that we continue to maintain these flexibilities.
If time remains, I will briefly touch on social
determinants of health. Because we know that these are the
economic and social conditions in which people live and learn
and work and play. And they also impact one's ability to access
transportation and stable housing. And by extension, these
factors can positively impact the health and well-being of the
most vulnerable Americans.
So, Dr. Durham, once again, just briefly, how might we
better leverage existing programs and address the barriers to
coordination between mental health and some of these social
service programs that I alluded to? Is there anything that
comes to mind that you see as a real opportunity for us in
Congress?
Dr. Durham. So, I can talk based on my experience, just as
a clinician and as someone who works in outpatient child
psychiatry. We have folks at Boston Medical Center with exactly
what you mentioned. They are struggling with food insecurity,
housing insecurity, transportation issues--all of the social
determinants. But what is lacking, most times from a Medicaid
perspective, is we are not necessarily reimbursed for that time
that we take to coordinate the care. It is very difficult to
get case management as a psychiatrist, or as a social worker in
our clinic, or we have LMHCs in our clinic--the time dedicated
to coordinate all of those services that family may need from a
case management standpoint are not necessarily reimbursed.
And so that happens but is carved out at other times during
the day when maybe we have a gap, if you will, in our
schedules. And I wholeheartedly agree that a person's mental
health is affected by all of those social determinants. And the
more that we can think about how we provide care and get
reimbursed so that we can talk about all the social
determinants, get them the services they need and also, as a
provider, focus on their mental health, I think the better, you
are right, our families would be. And then the communities
would be as well, ultimately.
So many times that mechanism is funded by grants, and
grants go away. And then we are stuck with, how do we help our
families with all of the needs that they need in order to focus
on the mental health issue at hand?
Senator Young. Thank you so much. Yes, sustainable
reimbursement for transportation to a primary care provider,
and in under-served populations, so that we do not end up
paying, as taxpayers, for something that becomes far more
costly in the longer term, and certainly costly to that
person's health, reimbursement to replace an air conditioning
unit--or a heater--so that somebody does not become incredibly
ill. It is the whole ounce of prevention notion. And we have
just got to get better at that.
So thank you so much.
Senator Crapo. We will have to move on to the next Senator,
which is Senator Casey, who I understand is on the web.
Senator Casey. Thank you, Senator Crapo. Thanks very much.
I just have one question, and I know this may be plowing
ground that has been plowed during the hearing, but I want to
reiterate some of it.
I will direct my question to Dr. Durham and Dr. Miller. We
know that, even before the COVID-19 pandemic, children were
facing both behavioral and mental health crises all across the
country. This need obviously is much greater because of the
pandemic. And now kids are waiting weeks to months to get
mental health care, both in the evaluation and the treatment.
So it is highly unlikely to get markedly better even as the
pandemic is receding.
We have heard a lot today about telemedicine and the
benefit it provides. But used alone, it does not help us with
the question of increasing the number of trained professionals
who can help both children and teens access the mental and
behavioral health care that they need.
Primary care docs and nurses are often the first point of
contact for kids, and for teens and their families, whether
they are struggling with anxiety or depression or substance use
disorder issues. Yet too often, many of these primary care
providers believe they are not prepared to respond
appropriately.
So there is not a lot in the way of incentives to provide
to child health providers to either engage in or expand their
provision of mental or behavioral health care. So we know that
that lack of incentives can contribute to both racial and
ethnic health-care disparities, both in terms of care and
outcomes.
So to both Doctors, Dr. Miller and Dr. Durham, how do we
better support or incentivize health-care providers, advanced
practitioners, and other therapists to increase or enhance
their ability to respond to these mental health needs?
Dr. Miller. Thank you for the question, Senator Casey. And
I will just begin by briefly saying that I think you have your
finger right at the center of this issue, which is that people,
families, children, have to work too hard to get access to
care. So how do we incentivize the places where the kids show
up to make sure that they are providing adequate onsite mental
health care?
And I think it begins with the flexibility of funding. One
of the most profound barriers as to why people do not adopt
integrated mental health care is because of the up-front
startup costs. If they had flexible funding, what they could do
is be a little more creative with how they were able to onboard
a clinician to make sure that they were there in that pediatric
setting to help that family and that child.
The second thing is that we have to provide some level of
technical assistance. Integrating care, as powerful and potent
as it is, can be difficult. And so an added incentive beyond
just the flexible funding is helping practices make that
change, make that transformation. Without that, sometimes we
see people start and stop because of the difficulty of it.
Senator Casey. Thanks.
Dr. Durham?
Dr. Durham. Yes, thank you for the question. I will echo
everything Dr. Miller said, and I will just add to it in that
our TEAM UP for Children model, which is at FQHCs in Boston,
the greater Boston area, did exactly that. You have to have
some funding in order for those health centers to start doing
some of that work. And so that is what some of the grant
initiatives did.
But then on top of that, I would say that what we have also
added to that care team--and make sure that it is a true team--
is that the pediatrician or the pediatric primary care provider
does not feel alone, that there is a behavioral health
clinician and community health worker as a part of that model
to get at kids that have the most needs--these are kids on our
State Medicaid--to make sure, as the previous Senator
mentioned, that we are tucking away housing, and food
insecurity, and all of those other things so that we are not
continuing to cost the system, but helping with that as well.
But I do think that that team effort, so that the pediatric
primary care doc does not go at it alone, we have also
integrated training within that, so they learn more about
mental health conditions at the primary care level, which has
been instrumental. And then also clinical work flows, because
it is different, when we decide to start shifting from just
physical health to both mental and physical health, that they
have to shift their practice in some way. So the technical
assistance aspect, I think, is also very key.
Senator Casey. Thanks very much.
Thanks, Senator Crapo.
Senator Crapo. Thank you.
And I understand Senator Warner is now with us. Senator
Warner?
Senator Warner. Thank you, Senator Crapo. And I thank the
panel and the chairman for holding this hearing.
I know we have been talking about a variety of mental
health issues. I want to talk about one that is quite close to
home with me in terms of my own family, and that is some of the
challenges around eating disorders.
We have seen from the Journal of Eating Disorders that
about 62 percent of the individuals with eating disorders have
seen an increase in stress due to COVID-19. We have seen a
dramatic increase in binge eating as well.
I have seen around Virginia--again both on a personal basis
and on a more global basis--how this disease can really
challenge not only the afflicted, but whole families. As a
matter of fact, eating disorders have the highest incidence of
mortality of any mental health issue.
Dr. Durham, given your experiences as a physician
specializing in pediatric and adult psychiatry, what do you
think, both COVID-related and non-COVID-related, we can do to
get ahead of this issue around eating disorders, from anorexia
to bulimia to a host of other kinds of manifestations of this
challenge?
Dr. Durham. Thank you for the question. This is not
necessarily my area of expertise, but what I will say is that I
understand, and can understand how eating disorders, among many
other disorders that we treat during the pandemic, are on the
rise. I think what happens when you are in a position of high
stress, social isolation, lots of loss, is that you do not have
all those reserves, those emotional reserves, that you had
prior to the pandemic, and lack all the social connectedness
that we all want and strive for.
And so, I think that is why we have seen rates rising in
depression, anxiety, and folks maybe going back to some
restrictive or binge-eating behavior. And we have also seen
that for folks with substance use disorders, who had a period
of sobriety for maybe years and now unfortunately have relapsed
during this time because it has been stressful for everyone,
and you sort of fall back to maybe things that felt more
comfortable, or that were habit-forming at some point.
And so now, we have talked a lot too today about thinking
about this critical time. But I do not think we have seen--you
know, we need that year or two to see the devastating
consequences of this pandemic, because I think it is going to
take time for people to get back to their normal level of
functioning, if you will, and to their own baseline.
And so whatever we can do to extend services for telehealth
and other services, and increase that flexibility, I think will
be key moving forward.
Senator Warner. I agree with you. I do think it is going to
take us that time. What is the new baseline going to be? I
mean, Dr. Miller, in your testimony you noted the need to
integrate mental health within the primary care field and to
modernize the workforce. The National Center of Excellence for
Eating Disorders trained primary care practitioners on
screening, brief intervention, and referral to treatment called
SBIRT.
Do you view these cyber-trainings for primary care
practitioners as helpful in addressing some of these workforce
issues around mental health; not just eating disorders but more
broadly?
Dr. Miller. Yes. Thank you for the question, Senator
Warner. And I think any time we do not ask, we do not know. So
we have to be able to screen to detect if there are issues that
are under the surface that our patients and families are not
necessarily raising on their own.
So I think it is a positive thing to screen. However, I
have to point out that screening alone without treatment is
insufficient. We need to be providing incentives, as we have
discussed today, to onboard experts, clinicians who can help
when those individuals do come forward with a positive
screening, if it is an eating disorder, if it is anxiety, and
if it is depression. This is a very positive thing for us. It
not only normalizes how people begin to talk about issues like
eating disorders, but it also creates a team-based environment
so that we can provide the most comprehensive care necessary
for that patient.
Senator Warner. Well, this is an area--I wish, Mr.
Chairman, I was not as much of an expert as I have become over
the last 12 or 14 years, but I appreciate the comments.
I want to go to Dr. Durham again. You know, when we are
talking about practitioners, we had an enormous tragedy with
Dr. Lorna Breen in Charlottesville, VA, who was a solo
practitioner. In many ways the stress and overwhelming nature
of COVID-19 unfortunately led her to, with the level of
depression--she took her own life. Along with Senator Kaine and
others in Congress, we introduced the Lorna Breen Health Care
Provider Protection Act that would address professionals in
terms of trying to make sure that we train folks on how to deal
with these high-stress circumstances.
Dr. Durham, I know we are down to the last couple of
seconds. Do you want to comment on how we make sure that we
take care of patients, but also our providers?
Dr. Durham. Yes, in the last couple of seconds, I
appreciate that. And I appreciate that that is happening,
because we do need to take care of all of our providers. It has
been an equally stressful time for all of us, no matter if you
are a physician or a social worker, an LMHC, nurses; we have
been working really hard. And I think that at a place like BMC,
a lot of things have happened where they were even just doing
wellness check-ins for all of our staff, from people that
deliver food to patient rooms, to physicians, to the nurses.
And I think that that is important.
And any time we can integrate more initiatives for the
workforce, I think the better. We are going through this
equally, as all of our patients are.
Senator Warner. Thank you, Mr. Chairman. Thank you, Dr.
Durham.
The Chairman. Thank you, Senator Warner.
Our next three are Senator Whitehouse, Senator Hassan, and
Senator Warren.
Senator Whitehouse, are you out there?
Senator Whitehouse. Thanks, Mr. Chairman. I am out here. I
appreciate this hearing very much.
First, one of the things that I have gotten for feedback
from my mental health community in Rhode Island is that the
increase in telehealth during COVID had kind of a hidden
benefit, very hard to quantify, but I heard it repeatedly, and
that was the sense from practitioners that the qualitative
input that they were getting through telehealth was actually
better, more meaningful, than beforehand when people had to
find their way across town, wait in the waiting room, fill out
the stupid clipboard, go into an unfamiliar room, and then have
a chat with the practitioner. To be able to do it from a place
of safety at home seemed to bring out better interaction,
better substantive qualitative interaction.
And I am wondering if any of you have had that experience,
or if you have seen any--I know it is hard to quantify, but has
anybody tried to quantify it in any way?
Mr. Betlach. Thank you for the question, Senator. The only
thing I would add to that is that, in talking with providers,
not only have they heard that from an impact, but also a lower
notional rate. So, definitely----
Senator Whitehouse. Yes, definitely a lower notional rate.
Mr. Betlach. So, in addition to being able to have a better
impact, you also have people showing up more for appointments.
They have not had conflicts. They have not had transportation
issues. So a number of those factors have been taken out of the
equation, and as a result, more people have accessed services.
Senator Whitehouse. So let me leave it at that. And if
anybody else wants to expand on that for the record, please let
me know. But I am going to take it as the agreement of the
panel that there were those two improvements, both in showing
up and in being engaged and getting better engagement as a
result of telehealth.
The other topic I wanted to go into was the interface
between law enforcement and mental health, which plays out
first directly on the street with law enforcement and then,
depending on how the individual engaged with law enforcement,
maybe at the local police station or jail; and if not, then
usually a ride over to the emergency room, where they get
dropped on the unhappy ER docs to cope with.
So, Senator Cornyn and I are working on a bill to improve
the engagement of law enforcement in this space so that there
is an accredited curriculum and training programs for people so
that they know they are getting the real deal in terms of
training to improve crisis intervention teams and their
engagement with law enforcement, to figure out how to improve
the referrals to community-based mental and behavioral health
service folks, and to improve de-escalation tactics. All of
this, I think, is pretty important.
And I just wanted to get your sense--anybody who would care
to respond--on the extent to which law enforcement today is the
entry point for people who are in need of and have not received
adequate mental health and behavioral health services and the
extent to which it is a successful entry point.
Mr. Betlach. Senator, thank you for the comments. In terms
of the interaction between the mental health delivery system
and law enforcement, I guess I would invite you to come out to
Arizona and see what is going on with regards to the crisis
system in our State in which, not only do we have robust mobile
response teams but also crisis stabilization facilities to be
able to work with law enforcement. There are thousands of drop-
offs that occur annually within a 5-minute time span
oftentimes.
There is also a lot of training in terms of the CIT model
that you mentioned. So clearly there is a role, from my
perspective, that Medicaid should be playing in helping to
support the interaction and support of law enforcement, mental
health providers, through a stabilization crisis
infrastructure. And really, there has been a lot of discussion
and a lot of new resources for States to be able to establish
more robust systems.
There is also going to be an expectation from individuals
as they dial 988 in the future in terms of what types of
infrastructure will be available for individuals.
Senator Whitehouse. Thanks. And I think my time is running
out. So, if anybody else has best practices or really good
local examples that you would like to share with us, if you
could please get that information into the committee, both
Senator Cornyn and I would be very grateful.
Thanks, all, for your terrific work and for helping get us
through the COVID situation.
The Chairman. Thank you, Senator Whitehouse.
Senator Hassan, and then Senator Warren.
Senator Hassan. Well, thank you, Chair Wyden and Ranking
Member Crapo, for this hearing. And to all of our witnesses,
thank you so much for taking the time to be with us today.
Dr. Miller, I want to start with a couple of questions to
you, and then I will move on to the other panelists. The demand
for mental health and substance use disorder treatment and
services skyrocketed during the COVID-19 pandemic, as millions
of Americans grappled with grief, isolation, and economic
uncertainty. We have helped meet that demand by providing new
means to access mental and behavioral services such as
telehealth, and there has been a lot of discussion about that
this morning. Unfortunately, even as we move to make it easier
to access some services, the stigma still associated with
substance misuse prevents too many people from getting the
behavioral health services they need.
Dr. Miller, how does the stigmatization of substance use
disorder impact access to treatment and services, and what
steps can Congress take to better integrate substance use
disorder treatment into primary care settings?
Dr. Miller. Well, thank you for your question, Senator, and
thank you for your ongoing passion and views in this space.
You know, to your point on stigma, we know that only about
10 percent of individuals with substance use disorders receive
care. And that tells me a lot about stigma. It says both
socially that we do not talk about it as much as we should but,
more importantly however, structurally we have these fragmented
ways of individuals being able to get access to care.
One of the views that I think you are very familiar with,
and that we have discussed today, is that we need to make it
easier for individuals who are identified with a substance use
disorder to be able to get access to care. That means bringing
that care to where people are.
We have to train up our providers to identify it, and we
have to train up our clinicians to treat it, and we have to
recognize that undergirding all of the substance use disorders
is also mental health. The reasons that we provide gold
standard treatment for things like substance use disorders is
because we need to provide counseling at the same time. This is
how we begin to destigmatize substance use disorders and,
hopefully, encourage more people to seek care.
Senator Hassan. Thank you. I am also continuing to work on
trying to change the X-waiver requirement as we move forward,
because I think that stigmatizes the provision of treatment for
some health-care providers too.
Dr. Miller, I want to turn to another devastating public
health crisis that we have to work on, which is the issue of
suicides. A report published yesterday--and Senator Wyden
mentioned it earlier--by the CDC found that, earlier this year,
emergency department visits for suicide attempts by adolescent
girls increased 51 percent on average when compared to 2019.
And I have heard directly from New Hampshire students about
the mental health concerns that they have. That is why I have
introduced the bipartisan STANDUP Act with my colleague,
Senator Ernst, that is going to encourage the implementation of
evidence-based policies and training in schools and communities
across the country that will help to prevent suicide.
Dr. Miller, 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. Miller. Thank you again for the question, Senator. As
the father of two children, I can tell you this is the one that
I really want to make sure that we get right. We teach our
youth, our kids, all about aspects of physical health. We even
teach them things like how to drive a car, and even how to save
someone's life with CPR. And so, yes, we have to be able to
equip our youth and our schools, frankly, where our youth are
basically a lot, with the ways to identify issues related to
suicide.
In fact, there was one survey that came out from Mental
Health America that showed how youth are talking more to each
other around the issues of mental health, which includes
suicide, rather than their parents.
So, because our youth are the front lines, we need to equip
them with those skills necessary to know how to be there for
one another. This could be the way to augment the workforce
that we have discussed today. If we simply depend on our
clinical workforce to address the demand, especially with our
youth, we will fail.
We have to be more creative, more thoughtful, and most
importantly, we have to have the youth at the table and with us
as we design the solution to work with them on ways that they
can better help each other.
Senator Hassan. Thank you.
Mr. Betlach, I want to move on with a question for you. We
increased Federal funding for home and community-based Medicaid
services under the American Rescue Plan. This funding helps
ensure that older adults and individuals with disabilities,
including those with mental health conditions such as bipolar
disorder and schizophrenia, can access mental health services
outside of institutional settings.
Can you, from your experiences as Director at the Arizona
Medicaid program, speak to the important role that home and
community-based mental health professionals play in delivering
care for individuals who experience severe mental health
disabilities? And what can we do in Congress to expand access
to home and community-based care for those struggling with
mental health conditions?
Mr. Betlach. Senator, the investment that you have made is
really a once-in-a-generation investment in terms of where
States are at in the ability to leverage that 10-percent home
and
community-based bump. And it is really broader, I think, than a
lot of people appreciate. It is also on behavioral health
services that States deliver through the rehab option as well.
And those are incredibly important.
So States are right now developing their plans. I am
working with a number of States, and they are generating their
options that they want to invest in. So it is an exciting time
for States. But States are feeling like there is a very
significant time crunch here in terms of being able to
establish this investment and do it in the right way.
So I think those plans will be evolving. But there is
clearly a unique opportunity, and these services are so
important to be able to deliver services in the communities
that serve these populations.
So it is an exciting time for States to have these
resources to be looking at workforce issues, to be looking at
being able to deliver more services in the community.
Senator Hassan. Thank you.
And thank you, Mr. Chair.
The Chairman. I thank my colleague.
Senator Warren?
Senator Warren. Thank you, Mr. Chairman.
COVID-19 is the worst public health crisis that our Nation
has tackled in over a century, but it does not exist in a
vacuum. The pandemic has exacerbated every preexisting public
health problem facing our Nation. And that is especially true
for substance use disorder, which often co-occurs with other
mental health conditions.
Dr. Durham, I am sure that you are familiar with the data.
Did substance use disorder and drug overdoses increase or
decrease during the pandemic?
Dr. Durham. Thank you, Senator Warren. They definitely
increased during the pandemic. I think DPH in Massachusetts
reported, for black Americans in particular, a 69-percent
increase over the pandemic----
Senator Warren. Sixty-nine percent increase?
Dr. Durham. Yes, in Massachusetts, specifically. That could
have been from various, you know--this is usually fentanyl-
laced substances. Many times, cocaine use disorder is pretty
prevalent in some of the black patients that we see,
specifically at BMC. And so we can think of lots of things that
happened during this period. What happened to everyone happened
also to the folks we see with substance use disorders: job
loss, economic insecurity, housing insecurity, the loss of
social supports. You know, substance use disorders are a
remitting and relapsing disease. People sort of think of one
moment in time you are sober, and then that's it. But it is
not. And so, it is a chronic medical condition, and we should
treat it as such.
Senator Warren. So let me just push on this a little bit
and let that sink in a little bit, that we saw a 69-percent
increase in opioid deaths in Massachusetts.
You know, we were already, Nationwide, losing tens of
thousands of Americans to drug overdoses. And the problem has
only gotten worse. And I think this is where you were headed.
It has gotten worse--differently in different communities.
So you were serving on the front lines of this pandemic at
Boston Medical Center, which serves many low-income patients
and communities of color. As the coronavirus spread through
Massachusetts and substance use disorder worsened, what
patterns did you see in terms of the types of patients you saw
at BMC, the types of communities that were affected? Can you
just say a little more about that? I think that is where you
were headed.
Dr. Durham. Yes, sure. Well, we predominantly serve about
70 percent black and Latinx at BMC, people who identify as
black and Latinx, and about 30 percent do not speak English as
their first language.
Just like many, I think many people were scared to come
into the hospital at the beginning of the pandemic. And so I
think what happened, though, is that we got high acuity as we
hit December and January, where people were coming in with
severe--whether that be mental illness, but also severe relapse
on whatever substance that they may have been previously using
and maybe had stopped. I think poverty and job loss, like I
mentioned earlier--you know, health, access to health care in
general, there was a change in that. We have talked a lot about
telehealth, but it does not work for everybody.
And so this is the particular population where I do not
think it worked well. You needed to be on a Zoom link with your
recovery coach. Did you have access to a computer and to get
the Zoom link, and then have a smartphone? So I will pause
there.
Senator Warren. That is very helpful. So you have told us
about the scope of the problem. You have told us about how it
hits different communities differently. Let's talk a little bit
about the solution.
In recent years, Congress has taken some steps, like
passing the SUPPORT Act, to expand access to addiction
treatment services. But it is clear that more resources are
needed.
So let me ask you. Boston Medical Center is a national
leader in addiction and substance use disorder treatment,
research, and training. Would a significant Federal investment
in substance use disorder prevention help lower overall deaths,
reduce these disparities, and help support providers like BMC?
Dr. Durham. Absolutely. I think that we need parity in
mental health and substance use treatment. I think we also silo
substance use disorders from mental health disorders from
physical health. The more we can combine all of that, because
it is one person that presents, the better we will all be.
I do think that we need to start early with community
outreach and more investment in the community. I think when we
speak about black and Latinx communities in particular, we need
more research that allows us to partner with community-based
services to do some of that research, because we are not
targeting that population well, and we need to invest dollars
to do that.
Senator Warren. Well, I really appreciate it. You know, we
have an opportunity here not just to build back to where we
were before the pandemic, but to drastically improve our public
health infrastructure.
I was very happy to see President Biden's commitment back
as a candidate to invest $125 billion over 10 years in
substance use disorder and the opioid crisis. And that is why,
in the coming weeks, I will be reintroducing my Comprehensive
Addiction Resources Emergency Act, or the CARE Act. This
legislation would provide State and local governments the
resources to combat substance use; to invest in biomedical
research, public health surveillance, and professional
training; and to expand access to naloxone.
I am looking forward to working with my colleagues to get
this done. I appreciate all the work that all of you are doing.
I hope you can get better support from Washington to continue
to do it.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Warren. And I believe what
you and Dr. Durham have just done in terms of laying out the
69-percent increase in substance abuse in your State really
conveys the urgency of what this committee has to do. So I
thank you very much, and I thank you, Dr. Durham, because that
is what this is all about.
Senator Warren and I talk about this all the time. The
committee has a lot of stuff we have to deal with. We have all
kinds of issues. But when you hear about a 69-percent increase
in substance abuse, you say, ``This is something that cannot
wait.'' So I really thank you, Senator Warren.
And I am just going to wrap up with a couple of comments. I
want to thank our witnesses. You all have been terrific. And I
think you have seen from the Senators the very strong feelings
about how important it is that we work on this, and we do it
coming together in a very polarized political environment.
I do not know if any of you are aware of the Wyden story.
My father wrote a book called ``Conquering Schizophrenia.'' It
was about my late brother. And for years and years on end, my
brother had schizophrenia and would be out on the streets in
California, and the Wyden family went to bed at night worried
that he was going to hurt himself or somebody else. And I think
that is pretty typical of what families are facing when they
are dealing with mental illness. And you all have described how
many people fall between the cracks--the incredible stigma of
this.
Chantay, thank you so much for describing what you are
trying to do in rural Oregon, the part of the State I love so
much, to try to reduce the stigma. And you all have laid out a
lot of solutions here. You have laid out a lot of solutions,
and I have been talking with Senator Crapo. We think that this
is an issue where the committee can come together and do
better.
We have currently reviewed the committee records. This is
the second-ever hearing of the Senate Finance Committee on the
issue of mental health care in our over 100-year history.
Senator Stabenow and Senator Daines are doing good work in the
subcommittee, and I think now both Democrats and Republicans
understand that we have to bring a greater sense of urgency and
commitment and resources into this issue so that mental health
is really in line with physical health, which of course was the
dream of Senators Wellstone and Domenici,
And I think I touched on it. I remember opening up the
paper the next day, and I said to myself, ``Hallelujah; there
is hope for Jeff Wyden and all the families who have
suffered.'' And as you said very eloquently, Dr. Durham, in a
lot of instances, the commitment to parity is honored more in
the breach than in the observance.
So I thank you all very much for your excellent testimony.
It is a great kickoff to the committee's work in this area. I
think you have heard from my Republican colleagues--they were
raising important issues. I looked at the comments made by my
Republican colleagues and my Democratic colleagues, and there
was not an off-base idea in the house today. You can literally
go up and down both sides of the dais and see Senators with
great sincerity offering concrete ideas.
So we are going to wrap up for today. But for all of you
and your colleagues who are out there on the web, we are
wrapping up for today, but make no mistake about it: we are
going to be consulting with you. This is a ``to be continued''
discussion.
Members know that questions have to be produced, what we
call QFRs, within a week. And I want to thank our witnesses
again.
And with that, the Senate Finance Committee is adjourned.
[Whereupon, at 12:30 p.m., the hearing was concluded.]
A P P E N D I X
Additional Material Submitted for the Record
----------
Prepared Statement of Thomas Betlach, MPA,
Partner, Speire Healthcare Strategies
Chairman Wyden, Ranking Member Crapo, and members of the Senate
Finance Committee, thank you for the opportunity to testify today on
policy solutions for addressing mental health. I had the privilege of
serving as the Arizona Medicaid Director for almost a decade and for a
portion of the time, as the Mental Health Commissioner.
Medicaid serves over 70 million members, offering comprehensive
mental health benefits to some of our country's most complex
populations. In 2020, the Medicaid and CHIP Payment and Access
Commission (MACPAC) published mental health statistics that showed, for
non-institutionalized adults, 27.6 percent of the Medicaid population
had an indicator of mental illness compared to 18.7 percent of the
commercially insured population. And for individuals with Serious
Mental Illness, the numbers were 8.2 percent for Medicaid, and 4.3
percent for commercial populations.\1\
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\1\ Behavioral Health in Medicaid Presentation, MACPAC, September
2020.
As you formulate health policy options, State Medicaid programs
should be a critical component of the discussion. Understanding the
system and the forces prevailing on it should be at the core of
---------------------------------------------------------------------------
discussion.
The last year brought to light the extreme fragmentation of our
healthcare delivery system at all levels. Our policy and program
structures are in silos. Funding streams to support these populations
follow those siloed program and policy structures. Providers gravitate
towards these funding streams creating more complexity at the point of
care. The very beneficiary the system is designed to serve is forced
navigate the maze we created.
Fragmentation is often discussed, so I would like to explain how
that fragmentation manifests in our system. When I became Medicaid
director, individuals with serious mental illness had up to four
different payers to navigate. Forty percent of that population were
Medicaid and Medicare dual-eligible members. An individual had a
Medicaid plan for physical health, a Medicaid plan for behavioral
health, traditional Medicare and a Part D plan or a Medicare Advantage
plan. Unfortunately, this level of fragmentation is common. The result
is misaligned incentives and the bureaucracies of Medicare and Medicaid
spending considerable time and resources creating payment rules and
refereeing rather than focusing on improving care for our populations.
Now, in addition to fragmentation, Medicaid leaders are contending
with the impact that the pandemic has had on an individual's mental
health. It has been well documented that the pandemic has had a more
negative impact on individuals with less means, both in terms of health
and financial stress.
This last year has brought important issues such as social justice
and health equity to the surface and at the same time there was rapid
innovation. For example, the use of telehealth and the deployment of
the 988 crisis hotline. Both will require much work ahead to ensure
long-term success.
Today's environment has challenges. But States and Medicaid
programs now have access to considerable investment resources to
address these challenges and advance the delivery of mental health
services.
1. Congress has authorized a 5-percent set-aside funding from
the Mental Health Block Grant to be used for Crisis Systems.
2. Congress has authorized an 85-percent enhanced match in
Medicaid for community mobile response teams.
3. Additional resources are now available for States that use
the rehabilitation option to cover behavioral health services, which
was included in the 10-
percent increased Federal funding for home and community-based
services.
4. Finally, additional resources are available for expanding
Certified Community Behavioral Health Clinics.
In February 2021, The National Association of Medicaid Directors
(NAMD) published ``Medicaid Forward: Behavioral Health,'' outlining a
series of strategies Medicaid programs are pursuing to advance mental
health services for members. The strategies varied based on the unique
populations served by Medicaid. This report highlighted initiatives
such as, expanding access and improving timeliness to care, integrating
physical health and behavioral health, and expanding access for the
full continuum of care including crisis services.
Populations identified included children with complex needs,
individuals experiencing homelessness, older adults, individuals with
intellectual and developmental disabilities, and individuals involved
in criminal justice.
The NAMD report provided proof that when implemented, the
highlighted strategies make a difference.
Further, a March 2021 Bipartisan Policy Council report concluded
that ``integrating primary and behavioral health care is necessary and
would ensure that individuals with behavioral health conditions and
comorbid physical health problems receive high-quality access to care.
Comorbid behavioral and physical health diagnoses are common.
Addressing them together through integration can provide a patient-
centered approach that can be cost-effective for payers and providers,
reduce health disparities, and improve patient outcomes.''\2\
---------------------------------------------------------------------------
\2\ Tackling America's Mental Health and Addiction Crisis Through
Primary Care Integration. Bipartisan Policy Council, March 2021, page
8.
Arizona provides a strong example of this, in 2011, we pursued a
strategy to better integrate services for individuals with serious
mental illness. This strategy was focused on driving integration at
---------------------------------------------------------------------------
three levels.
1. Policy integration--Arizona merged behavioral health policy
expertise into the Medicaid program and reviewed all policies that
limited integrated services.
2. Payer integration--Arizona braided multiple funding streams
including Medicaid, SAMHSA block grants, and local dollars to support
housing and other non-Medicaid compensable services.
3. Provider integration--Arizona created new incentives and
supported providers in developing more coordination and integration at
a provider level. This included opening up new codes to support the
collaborative care model. This model has been shown to improve clinical
outcomes and reduce costs by further integrating care at the primary
care provider.
In 2018, Mercer consulting conducted an analysis of the integration
efforts. Their final report for individuals with serious mental illness
found that all measures of ambulatory care, preventive care, and
chronic disease management demonstrated improvement. For example,
Medication management for people with asthma (75-percent compliance)
increased 35 percent. Just as important, all indicators of patient
experience improved, with five of the 11 measures exhibiting double-
digit increases. For example, shared decision-making improved 61
percent.\3\
---------------------------------------------------------------------------
\3\ Independent Evaluation of Arizona's Medicaid Integration
Efforts, Mercer, 2018.
Another opportunity highlighted by NAMD is to strengthen crisis
systems. This issue is front and center with the implementation of 988.
SAMHSA provided extensive thought leadership with the development of
the Crisis Now model and the publication of the National Guidelines for
Behavioral Health Crisis Care Best Practice Toolkit. This document
provides the details on how to establish a system to serve anyone,
---------------------------------------------------------------------------
anywhere at any time.
The Crisis Now model is based on three critical components.
1. Call center capability.
2. Twenty-four by seven Community Mobile Response Teams.
3. Twenty-three hour crisis receiving and stabilization units.
In Arizona, this system was developed over 20 years and serves all
Arizonans. The call centers answer thousands of calls every month,
meeting the State's expectations of three rings or less. Mobile
response teams located throughout the State serve individuals in the
community. Stabilization facilities provide services for individuals
experiencing severe crisis episodes and offer continuous support for
law enforcement to drop off individuals and to return to the field
within 5 minutes. The financing for this system comes from creatively
braiding multiple funding streams while leveraging Medicaid for
support.
While we have seen improvement, there is clearly much more to do.
We stand today at a unique moment with the power to address complex
issues and continue the momentum of innovation by making strategic
policy changes. To that end:
1. Congress and the executive branch need to develop and
implement strategies holistically by ensuring Medicaid and behavioral
health collaborate and partner in a meaningful manner. On several
occasions Congress has leveraged the mental health expertise that lives
at the Substance Abuse and Mental Health Services Administration
(SAMHSA) to advance policy initiatives. This includes set-aside funding
for first episode psychosis and crisis system planning. However, there
does not appear to be sufficient expectations established by Congress
that these important planning and investment dollars are to be linked
to the Medicaid program. Unfortunately, the dollars often get siloed
and the opportunity is suboptimal. SAMHSA traditionally works directly
with its network of mental health commissioners, and Medicaid programs
sometimes lack the expertise or bandwidth to leverage these
opportunities. At the end of the day, Medicaid beneficiaries may or may
not benefit from these forward-looking investments.
2. Congress should provide more flexibility with block grant
funds for States to address social determinants of health as States
look at ways to support these investments. As coverage has expanded,
there may be opportunities for States to leverage block grants to
support select social determinants for specific populations and improve
outcomes.
3. Congress needs to legislate to establish payment parity
between Medicare and Medicaid. Where Medicaid has led the way in
developing paraprofessional staff such as peer support services and
systems to support broader populations like Crisis, Medicare should
follow. To achieve parity, Congress must act to have Medicare cover
these and similar services.
4. Congress should continue to provide financial incentives for
States to modernize the mental health infrastructure. Programs like
Money Follows the Person worked well for home and community-based
services. I am excited to see Congress using similar approaches for
behavioral health services like community mobile response teams and
CCBHCs. Congress should consider lending financial support towards
models that improve care and access. This approach should also be
expanded to dual eligible members as well.
5. Congress should continue to evaluate the impact of the IMD
16-bed limits. While there have been efforts made to allow for some
payments in select instances, some States have not been able to avail
themselves of these opportunities. A good place to start the policy
discussion is looking at select settings like crisis stabilization.
6. Congress should rectify the fact that behavioral health
providers were excluded from the electronic health records incentive
program provided through the HITECH Act. Data aggregation and analytics
are an important component of improved care coordination. This is an
investment that should be made to advance integration.
7. Finally, Congress should evaluate how graduate medical
education financing policies negatively impact the ability to attract
specialists, such as child psychiatrists, to meet the needs of the
Medicaid population. Many States, like Arizona, are punished as a
result of the Medicare formulas that are locked in at 1996 allocations.
We are at a critical moment in time to advance the delivery of
mental health services, not only within Medicaid but for our entire
country. Thank you for your time and interest in these topics.
______
Questions Submitted for the Record to Thomas Betlach, MPA
Questions Submitted by Hon. Catherine Cortez Masto
Question. Arizona has been a leader in behavioral health crisis
services as the State's crisis now model has been incredibly successful
in supporting individuals experiencing crisis, and creating a safety
net for folks who have slipped through the cracks of our mental health
system for far too long. Senator Cornyn and I have introduced
legislation that seeks to empower communities across the country to
build crisis services. The crux of our bill is insurance coverage--
these are services that should be covered, no matter where people get
their insurance.
What kind of difference would insurance coverage make as States
look to build crisis services similar to the Arizona model?
Answer. Having all insurers provide coverage for crisis services
would greatly benefit States. True parity would enable additional
resources to be made available to support important crisis
infrastructure. If all plans (e.g., commercial insurers and Medicare)
covered a broad continuum of behavioral health services, it would
reduce stigma, educate consumers on the importance, and improve access
to behavioral health resources.
Question. What else can Congress do to facilitate the delivery of
crisis services across the country?
Answer. Congress can continue to provide financial incentives like
the block grant set-aside funding for crisis services and the
additional funding for mobile response teams. Additionally, Congress
can work closely with the administration to ensure appropriate
coordination is occurring at the Federal level to maximize
collaboration between agencies, including SAMHSA and Medicaid.
Question. In your testimony you also highlighted a recent report
from the Bipartisan Policy Center on behavioral health integration.
What does that look like in practice and how easy or difficult
would it be to implement this kind of integration into risk-based
payment models such as Accountable Care Organizations, Medicaid Managed
Care Organizations, and Medicare Advantage?
Answer. It is challenging to implement integration well with
managed care. States should be thoughtful purchasers and make sure that
appropriate contracts and policies are in place to support payer and
provider integration. However, as more States have adopted integrated
purchasing models, lessons learned and best practices are available to
other States to enable them to successfully design and implement
structures. State experience tells us that while it is challenging, if
done correctly there are positive impacts associated with payer
integration.
Question. What difference would that make in boosting access to
services?
Answer. The Arizona experience shows that for individuals with
serious mental illness there has been an increase in access when
measured based on HEDIS scores. When done appropriately, integration
results in additional providers being able to deliver behavioral health
services.
______
Questions Submitted by Hon. John Barasso
Question. The health-care professionals, along with all front-line
workers, deserve our gratitude and appreciation. Their dedication to
our communities during this pandemic is something we must recognize and
never forget.
A top concern of Wyoming mental health facilities is making sure
there are enough staff to care for their patients. It is especially
challenging to attract and keep health-care providers in rural
communities. Can you discuss solutions related to workforce development
you believe will improve the ability of mental health facilities to
attract and maintain staff in rural areas?
Answer. Medicaid has done some excellent work expanding the
behavioral health workforce through the use of peer supports. By
leveraging individuals with lived experience, Medicaid has been able to
expand access and better engage patients. Medicaid (and other payers)
need to continue to expand the use of peer and family supports for
behavioral health. In addition, the significant growth of telehealth,
in response to COVID, expanded access and should continue to improve
workforce capacity particularly in rural areas.
Question. Can you specifically discuss changes to GME policy you
believe would improve the pipeline of mental health physicians?
Answer. There are a range of policy changes that Congress should
consider with regards to GME. Three GME policy changes that would have
a strong positive impact and improve capacity are:
Change the Medicare formula to recognize the growth that has
occurred especially in States like Arizona that are at an extreme
disadvantage based on the Medicare formula being frozen for the past 25
years.
Provide incentives for GME programs that specialize in
behavioral health training.
Increase expectations and create incentives so that more
training can be done in outpatient clinics and in rural settings.
Question. As a doctor, I strongly support increasing access to
mental health services, especially in rural communities. Senator
Stabenow and I have previously introduced legislation for many years
that would allow mental health counselors and marriage and family
therapists to receive reimbursement from Medicare.
Can you discuss how the Department of Health and Human Services can
improve access for mental health services, especially for those on
Medicare?
Answer. Access will be improved when Medicare improves the overall
benefits for behavioral health by expanding who can deliver services
and where those services may be delivered.
Question. In particular, can you comment on the merits of allowing
licensed professional counselors and marriage and family therapists to
receive reimbursements from Medicare?
Answer. Some State Medicaid programs have determined that covering
these codes are valuable in increasing access for members. Given the
limited benefits within Medicare today for behavioral health services,
especially in comparison to the robust Medicaid benefits, this is an
important area for Congress to evaluate.
______
Questions Submitted by Hon. Tim Scott
Question. The toll that union-sponsored excuses for ``virtual
learning'' has taken on actual kids is extraordinarily sad, especially
for our Nation's most vulnerable children. In October 2020, a survey
conducted by the Jed Foundation showed that 31 percent of parents said
their child's mental or emotional health was worse than before the
pandemic. Private insurance data also shows that while all health care
claims for adolescents ages 13-18 were down in 2020 compared to 2019,
mental health-related claims for this age group increased sharply.
Additionally, the Centers for Disease Control and Prevention (CDC)
reports 25 percent of parents whose children attended school virtually
were more likely to report an overall worsened mental or emotional
health compared to only 16 percent of parents of children attending
school in-person.
What strategies and collaboration efforts would you recommend to
encourage the infrastructural changes and technical assistance
necessary to promote school safety and proactive approaches to mental
health challenges?
Answer. We need to continue our efforts to train and support
parents, teachers, staff, and students about the importance of
behavioral health. Programs like mental health first aid have shown
benefits towards reducing stigma and providing individuals with
important tools on how to have challenging conversations.
Question. What programs within the Department of Health and Human
Services' (HHS) purview are best poised to support children and schools
as they return to complete in-person learning?
Answer. See above.
Question. How can we integrate more telehealth opportunities to
expand access to mental health services in schools?
Answer. Medicaid and other purchasers should work with insurers and
schools to leverage telehealth and other mobile technologies to engage
students. These opportunities extend beyond just K-12 into higher
education. Some States are evaluating policies that will expand the
capacity to use schools as sites for delivering telehealth services.
Question. Telehealth has expanded rapidly as a result of the COVID-
19 pandemic. Numerous studies have demonstrated the effectiveness of
telehealth for behavioral health services. As telehealth becomes more
common among health-care providers, what can Congress do to ensure that
patients do not suffer from unnecessary bureaucratic delays?
Answer. States with support from the Federal Government greatly
expanded access to telehealth services for programs like Medicaid.
Post-COVID, States will need to monitor access to ensure that
inappropriate barriers are not being placed on the delivery of
services. Access to care and the quality of the services being
delivered are ultimately what Congress may want to consider evaluating
as the telehealth evolution moves forward.
Question. There is a well-researched connection between
unemployment and mental health. As recently as April 2021, despite
billions of dollars of COVID-19 stimulus, aggregate employment remained
7.9 million jobs below its pre-recession level.
What impact will this failure to get people back to work have on
mental health?
Answer. Recent surveys and studies indicated that individual stress
levels are higher today than pre-COVID. There are many factors in place
that have resulted in increased stress, including employment status.
There will need to be continued efforts to provide education to
individuals and families on the importance of mental health along with
information on how individuals may access care in a timely matter.
Question. Last November, an article published in the Journal of the
American Medical Association noted that multiple studies indicated that
older adults may be less negatively affected by certain mental health
outcomes than other age groups. Are these study outcomes consistent
with your own professional experiences working with older adults?
Answer. This in not my area of expertise, and I do not feel
comfortable commenting on this.
Question. Current network adequacy standards often allow networks
of specialists who aren't taking new patients or who have long waiting
lists. That means that many people needing treatment must go out of
network to get care, and only those who can afford the high cost get
it. One of the biggest challenges to access to behavioral health care
services is that many behavioral health specialists don't participate
in health plan networks.
Why is that, and how can we change that?
Answer. Market dynamics often drive provider utilization. It is
clear that the country needs more specialists and a broader workforce
to meet the increased demand. Congress should evaluate the impact of
Graduate Medical Education funding and how that has resulted in
constraints in behavioral health specialists. Medicaid has overcome
some of the constraints by establishing a para-professional workforce
of Peer supports.
Question. Outside of the public health emergency, telehealth
services are restricted to certain geographic and clinical settings.
Beneficiaries must live in a rural area and have an initial face-to-
face visit with the distant-site provider. Once a relationship has been
established, periodic in-person visits are also required. With few
exceptions, patients must be located in a clinical setting and may not
receive care from their homes. In addition, the distant- site provider
cannot be located in a rural health clinic or FQHC.
Telehealth has been used broadly during the pandemic to expand
health-care access to individuals throughout the country. During the
pandemic, Medicare significantly expanded the coverage of telehealth
services. A recent Bipartisan Policy Center poll suggests that people
receiving mental health and substance use services want a combination
of in-person, video, and telephone services even after the pandemic has
passed.
What telehealth expansions should remain after the pandemic?
Answer. I believe that consumers will expect all telehealth
expansions to remain in place after the pandemic and purchasers and
payers will need to ensure appropriate oversight is in place to drive
the level of quality required from this platform.
______
Questions Submitted by Hon. John Cornyn
Question. Could you please explain why utilizing the primary care
physician as the coordinator for a patient's mental health will result
in better access to care and, ultimately, better patient outcomes?
Answer. Primary care physicians in many instances can serve as an
initial access point for individuals with behavioral health needs. Like
other acute or chronic issues, more serious cases may require a
referral to specialists. However, a primary care provider may in fact
be well-positioned to deal with the behavioral health needs of the
patient in that moment. For many patients, the relationship with the
primary care provider is already established and there will be more
interactions. There also may be an ability to deal with stigma and
educational issues around behavioral health diagnosis. Like many other
cases that are more complex, primary care providers may not ultimately
be the only provider involved with a patient but we need to do more to
leverage and incentivize our primary care providers to meet the
behavioral health needs of patients.
Question. Do you foresee any differences in integrating care with
pediatricians and perhaps geriatricians as well?
Answer. Yes. Integration will look different for subsets of
populations. Pediatricians need support for certain diagnosis and
subpopulations. For example, children with more severe cases of autism
may need to be referred to other providers for specialty services. More
complex cases like children involved with the foster care system may
require additional behavioral health supports. Populations served by
geriatricians may require more robust specialty home and community-
based services. Coordination between providers, patients and families
are critical and pediatricians and geriatricians should be able to lean
on insurers and managed care organizations to support and enhance
service coordination.
Question. As COVID-19 closed down our society, health-care
providers still cared for patients. And with the pandemic came
increased isolation, loneliness, anxiety, and depression.
Sadly, nearly 40 percent of American adults reported struggling
with mental health or substance use. Anxiety and depression rose by 31
percent and serious suicidal ideation increased by 11 percent.
Points of access for those in crisis is a high priority for me.
Last Congress I, alongside my colleague Senator Bennet, introduced the
Suicide and Crisis Outreach Prevention Enhancement Act. This bill would
reauthorize the National Suicide Prevention Lifeline for 5 years and
collect more data on outcomes, providing a feedback loop of perfecting
best practices. We think this legislation could save lives and help
breakdown the stigma of seeking mental health care.
Can you describe the impact that you see this pandemic having on
the need for access to mental and behavioral health services?
Answer. The pandemic has resulted in an increased need for
behavioral health services. It has also increased expectations that
these services be delivered through a full continuum of platforms
including in-person, telehealth, and the ability to have individuals
receive services in-home.
Question. What gaps do you continue to see in access to mental and
behavioral health care?
Answer. Consistent with my testimony, we need to continue to
support integration so that more patients can access behavioral health
services in more settings. We need to continue to create incentives for
a full continuum of services. The Lifeline program is a great start,
but there is significant work to be done to enable success.
With the advent of 988, we need to make sure States are creating
the infrastructure to respond to the expected increased demand. We also
need a full continuum of crisis services. While Lifeline call center
capacity is critical so are community services like mobile response
teams and stabilization centers who handle more complex cases that
cannot be resolved by call center teams. We need to create alternatives
to emergency department boarding and short-term incarceration for those
in crisis. We need to have Medicare and commercial carriers provide
more financial support for behavioral health services and follow the
lead Medicaid has established with broader services and provider
access. We need to incentivize GME programs to create more specialists
to support the behavioral health needs of patients.
Question. You mention in your testimony the National Association of
Medicaid Director's recommendation of Crisis Systems. These are teams
that are mobile, in the community and respond to individuals who may be
experiencing a mental health crisis.
I am honored to work with my colleague from Nevada, Senator Cortez
Masto, on the Behavioral Health Crisis Services Expansion Act. This
bill would help communities establish a continuum of care for those
undergoing a mental health crisis and support first responders and care
providers by making such services reimbursable under Medicare and
Medicaid.
This model would transform the way communities care for individuals
in crisis and, in turn, it would help those who are most in need. I
know you outlined the Crisis Now model in your testimony, but could you
reemphasize the potential impact of such a crisis care system?
Answer. In Arizona, the Crisis Now model has been a critical part
of the behavioral health continuum. It has provided robust call center
teams that support individuals experiencing behavioral health crisis.
Consistently, Arizona has one of the highest answer rates of any State
for calls made to the Lifeline that originate from Arizona area codes.
These call centers are able to support those in crisis by activating
robust mobile response teams that serve all Arizonans (not just
Medicaid members) in both urban and rural parts of the State. For the
most complex cases, individuals may be served by short-term
stabilization units. These stabilization units have also supported tens
of thousands of law enforcement drop-offs that often occur in under 5
minutes. A robust crisis system can serve anyone anywhere at any time.
Unfortunately, Arizona is somewhat unique in having this level of
infrastructure. The overall impact is that people experiencing a
behavioral health crisis are served in their time of need by
individuals trained to deal with those in need. Crisis Now offers an
appropriate array of vital services as an alternative to how people
were treated previously through Emergency Department bed holds and
incarceration.
Question. Do you see these teams as part of a larger strategy for
addressing mental health?
Answer. Yes. The Crisis Now model serves individuals experiencing a
crisis. We need to continue to expand access to prevent individuals
from moving into crisis. We need to expand educational efforts around
the importance of behavioral health and reduce stigma. We need to look
at creative ways to deliver engaging behavioral health services through
various platforms. We need to continue to improve culturally
appropriate services and expand behavioral health access to address
health equity issues. Crisis is an important step for improving
behavioral health services but it is not the only policy focus that
needs to be addressed to meet the needs of our country.
______
Submitted by Hon. Bill Cassidy, a U.S. Senator From Louisiana
American Telemedicine Association
901 N. Glebe Road, Suite 850
Arlington, VA 22203
T 703-373-9600
June 15, 2021
The Honorable Ron Wyden
Chair
U.S. Senate
Committee on Finance
Washington, DC 20510
The Honorable Mike Crapo
Ranking Member
U.S. Senate
Committee on Finance
Washington, DC 20510
Dear Chairman Wyden and Ranking Member Crapo:
On behalf of the American Telemedicine Association (ATA), I commend you
for holding an important and timely hearing entitled, ``Mental Health
Care in America: Addressing Root Causes and Identifying Policy
Solutions.'' This hearing presents an excellent opportunity for members
of your committee to thoughtfully consider the future of mental health
care and how Congress can act to expand access to quality care for
patients across the country. One such way you can accomplish this goal
is to support the Telemental Health Care Access Act of 2021, bipartisan
legislation championed by Senators Cassidy (R-LA), Smith (D-MN), Cardin
(D-MD), and Thune (R-SD). The ATA enthusiastically endorses this
important legislation and asks that you give it every possible
consideration as you work together to identify policy solutions to
improve mental health services.
As the only organization exclusively dedicated to expanding access to
care through telehealth, the ATA appreciates and commends your
committee's continued work to thoughtfully consider sound health care
policies, including those impacting Medicare beneficiaries' access to
telehealth services. Telehealth allows patients to receive safe,
affordable, and quality care where and when they need it and has been a
lifeline for millions of Americans during the COVID-19 pandemic. Before
COVID-19, 65% of patients felt hesitant about telehealth, but now 87%
want to continue using telehealth services post-pandemic.\1\ Behavioral
health services lend themselves particularly well to remote care, both
because physical presence is not always clinically necessary for care
and because of the great need for more access to mental health
services.
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\1\ How Americans Feel About Telehealth: One Year Later, SYKES'
2021 Telehealth Survey Report, April 9, 2021.
We appreciate Congress's acting swiftly at the beginning of the COVID-
19 Public Health Emergency (PHE) to ensure patients could safely access
health care services from their homes. As you know, should Congress
fail to act before the end of the current PHE, millions of Medicare
beneficiaries will lose the choice to use these telehealth services. We
look forward to continuing to work with you and your dedicated staff on
policies that ensure these beneficiaries are not pushed off the
telehealth cliff. Further, we commend you for already recognizing this
looming cliff by including in the Consolidated Appropriations Act,
2021, Pub. L. 116-260, a provision to ensure Medicare beneficiaries can
access telemental services moving forward. However, one well-
intentioned part of this policy provision, the in-person requirement,
could have unintended negative consequences on Medicare beneficiaries.
In-Person Requirements for Telehealth Are Clinically Inappropriate
There is no clinical evidence for an arbitrary in-person requirement
before a patient can access telehealth services. In fact, evidence has
demonstrated that telemental services like telepsychology are just as
effective as in-person visits.\2\ Further, there is clear consensus
that a provider can establish a relationship with a patient via a
telehealth visit. The association of state regulators who oversee
standards of medical care, the Federation of State Medical Boards,
states that ``. . . the relationship is clearly established when the
physician agrees to undertake diagnosis and treatment of the patient,
and the patient agrees to be treated, whether or not there has been an
encounter in person between the physician (or other appropriately
supervised health care practitioner) and patient.''
---------------------------------------------------------------------------
\2\ How well is telepsychology working?, American Psychological
Association, July 1, 2020.
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In-Person Requirements Exacerbate Provider Shortages
The United States has a deficit of 6,000 mental health providers, and
this shortage is expected to grow to a quarter of a million by 2030.\3\
As we saw in 2020 and 2021, telehealth increases the capacity of the
providers we do have to see more patients by removing geographic and
other physical barriers. We must work together to increase the number
of mental health providers to ensure all Americans get the care they
need. However, explicitly denying a patient's access to mental health
services based on his or her inability to find a scarce mental health
provider is simply unreasonable.
---------------------------------------------------------------------------
\3\ Triple-Tree: A New Era of Virtual Health Q2, 2021.
---------------------------------------------------------------------------
In-Person Requirements Increase Barriers and Worsen Health Inequities
The ATA strongly opposes statutory in-person requirements as they
create arbitrary and clinically unsupported barriers to accessing
affordable, quality health care. Requirements such as these could
negatively impact those in underserved communities who may not be able
to have an in-person exam due to provider shortages, work, lack of
childcare, and/or other resources. Recent CDC data demonstrate that 23%
of American adults do not have an existing relationship with a health
care provider, and that statistic is alarmingly high in minority
populations.\4\ We cannot ignore the importance of providing all
Americans, regardless of whether they have an established relationship
with a medical provider, the opportunity to access life-saving health
care.
---------------------------------------------------------------------------
\4\ Adults Who Report Not Having a Personal Doctor/Health Care
Provider by Race/Ethnicity, KFF, Accessed June 8, 2021.
---------------------------------------------------------------------------
Federal In-Person Requirements Unnecessarily Preempt State Laws
The in-person requirement for telehealth services is at odds with the
direction telehealth policy has moved over the last decade. It disrupts
Medicare's historical approach, which is to remain deferential to state
laws on professional practice requirements and clinical standards of
care. Today, no state practice of medicine law in the U.S. requires a
prior in-person visit. The ATA urges Congress to ensure telemental
health services continue post-pandemic but to recognize federal laws
restricting these services are inappropriate. Instead, Congress should
defer to states and individual payers to determine telehealth
prerequisites. For the Medicare program, instead of codifying service-
specific restrictions in statute, Congress should work with HHS to
ensure the Secretary has the authority at the regulatory level to
implement any appropriate health care requirements. By explicitly
limiting care in statute, legislators will unnecessarily stifle
innovation and tie the hands of regulators, providers, and patients.
For each of the reasons listed above, the ATA is proud to strongly
support the Telemental Health Care Access Act and applauds the
leadership of Senators Cassidy, Smith, Thune, and Cardin in introducing
this essential legislation. We ask that you, too, consider the
importance of this legislation and how we can work together to identify
commonsense policies to not only expand access to care but also ensure
beneficiaries and federal taxpayers are protected. Thank you for your
consideration, and please feel free to contact the ATA policy director
Kyle Zebley should you have any questions about our support for
thislegislation or ATA's broader federal policies.
Kind regards,
Ann Mond Johnson
CEO
American Telemedicine Association
CC: The Honorable Bill Cassidy
The Honorable Tina Smith
The Honorable John Thune
The Honorable Ben Cardin
______
Health Innovation Alliance et al.
June 22, 2021
Senator Bill Cassidy Senator Tina Smith
520 Hart Senate Office Building 720 Hart Senate Office Building
Washington, DC 20510 Washington, DC 20510
Senator Ben Cardin Senator John Thune
509 Hart Senate Office Building 511 Dirksen Senate Office Building
Washington, DC 20510 Washington, DC 20510
Dear Senators Cassidy, Smith, Cardin, and Thune:
We write to thank you for your support of patients and providers in the
mental health community by introducing the Telemental Health Care
Access Act. We endorse your bill and applaud your efforts to ensure
consistent coverage of mental health services furnished through
telehealth.
Congress and the Administration have done much to utilize telehealth in
response to COVID-19, and the results have been impressive. Prior to
the pandemic just one percent of primary care visits were delivered via
telehealth. Immediately after COVID-19 came ashore, primary care visits
were delivered via telehealth more than 40 percent of the time.
Telehealth improved access to care without generating cost increases
for many, and at the exact time it was needed to help safeguard
patients and prevent additional infections. It is a solid investment.
We were glad to see language pass through the Consolidated
Appropriations Act of 2021 to remove Medicare restrictions on the
mental health services delivered through virtual means, but we believe
the inclusion of the in-person requirement every six months was
unnecessary and a step in the wrong direction. Your legislation seeks
to rectify that issue and we appreciate your leadership. Over the past
10 years, all 50 states and the District of Columbia have removed in-
person requirements as a prerequisite to treatment through telehealth.
In-person requirements on telehealth services create unnecessary
barriers to care and can be especially harmful for those seeking mental
and behavioral health services. The Health Resources and Services
Administration reports a shortage of over 6,500 providers in the mental
and behavioral health specialty. The scarcity of providers,
particularly in rural and underserved areas makes lifting the in-person
requirement even more critical. Those seeking care should not, and in
many instances cannot, travel for hours to see an in-person provider.
By removing the automatic application of an in-person requirement for
telemental health services in Medicare, Congress can improve health and
lower costs while increasing access and utilization. This is where
health care must head to become
consumer-focused and responsive in the 21st century. We strongly urge
Congress to pass the Telemental Health Care Access Act and continue
increasing patient access to convenient at-home telehealth services.
Thank you for considering our comments and for your leadership on this
important issue.
Sincerely,
Health Innovation Alliance
American Telemedicine Association
STCHealth
CoverMyMeds
HIMSS
PCHAlliance
National Council for Mental Wellbeing
athenahealth
Alliance for Connected Care
eHealth Initiative
Doctor On Demand
Hims & Hers
Association for Behavioral Health and Wellness
GO2 Foundation for Lung Cancer
Partnership to Advance Virtual Care
Teladoc Health
Centerstone
American Psychiatric Association
3M Health Information Systems
American Foundation for Suicide Prevention
American Psychological Association
The Michael J. Fox Foundation for Parkinson's Research
American Medical Association
College of Healthcare Information Management Executives
Connected Health Initiative
American College of Physicians
Federation of American Hospitals
American Heart Association
Greenway Health
Marshfield Clinic Health System
Association of American Medical Colleges
American Medical Group Association
Vanderbilt University Medical Center
______
Prepared Statement of Hon. Mike Crapo,
a U.S. Senator From Idaho
Thank you, Mr. Chairman. Ensuring access to high-quality mental
health services has been--and must continue to be--a priority.
Far too often, individuals with mental health, addiction, or
substance use disorders find themselves isolated from their communities
and separated from their providers. While Congress has taken decisive
steps to address addiction, bolster behavioral health care, and curb
substance use disorders, challenges remain. This committee has the
ability to turn the tide.
We can begin by empowering States to craft innovative, targeted
solutions. Medicaid functions most effectively when States have the
flexibilities they need to address patients' unique care needs and
adapt to unforeseen crises. As the Nation's largest payer of mental
health and substance use disorder services, Medicaid must support,
rather than subvert, State efforts to serve communities in need.
Unfortunately, the COVID-19 pandemic has highlighted--and
exacerbated--the mental and behavioral health challenges we continue to
confront. Loss of loved ones, increased isolation, and delayed
treatment prompted a spike in anxiety, depression, and other
debilitating conditions.
While many are returning to their pre-pandemic lives, we should not
be content to allow our mental health-care delivery system to revert to
its pre-pandemic ways. Whether for rural communities, urban areas, or
tribes, telehealth has undoubtedly increased access to care. Through
emergency flexibilities and permanent legislation authored by this
committee late last year, we have taken crucial first steps toward
modernizing telehealth coverage.
I look forward to working with you, Mr. Chairman, and with other
members of this committee to build on those efforts in the months
ahead. Further, by partnering with State and local leaders, we can spur
care coordination, strengthen the mental health workforce, and drive
value through delivery system reforms.
While there is no silver bullet here, I am confident we can tackle
all of these challenges while upholding core principles of fiscal
responsibility and program integrity.
Before concluding, it bares emphasizing that we must continue to
make progress in improving understanding of mental health so that
people in need are not afraid or ashamed to seek treatment. We cannot
discount the impact of stigma on preventing those in need of treatment
from receiving care. I look forward to hearing our witness testimony
today to learn more about the solutions they have identified.
______
Prepared Statement of Michelle P. Durham, M.D., MPH, FAPA, DFAACAP,
Assistant Professor of Psychiatry, Boston University School of
Medicine; and Vice Chair of Education, and Psychiatry Residency
Training Director, Department of Psychiatry, Boston Medical Center
Thank you, Chairman Wyden, Ranking Member Crapo, and distinguished
members of the Senate Committee on Finance, for holding this hearing
and providing me with the opportunity to speak today about the state of
the mental health-care system in America--where it's working, where it
falls short, and how the Federal Government can play a role in helping
to fill the gaps.
My name is Dr. Michelle Durham. I am a pediatric and adult
psychiatrist at Boston Medical Center, and vice chair of education in
the Department of Psychiatry, where I also trained for my residency,
and now have the distinct honor of serving as the psychiatry residency
training director. I hold a joint appointment at the Boston University
School of Medicine as an assistant professor of psychiatry. Boston
Medical Center (BMC) is an academic medical center and the largest
safety-net hospital in New England. The patients we serve are
predominantly low-income, with approximately half of our patients
covered by Medicaid or the Children's Health Insurance Program (CHIP)--
the highest percentage of any acute care hospital in Massachusetts.
The BMC emergency department, which includes 8 adult psychiatric
emergency beds, is among the top ten busiest in the country. Mental
illnesses are all too common among the patients BMC treats in our
emergency department and across our continuum of mental health care
services, which include outpatient integrated mental health care within
our pediatric and adult primary care clinics and at local community
health center partners, a mental health urgent care clinic, a crisis
stabilization unit, and our Boston Emergency Services Team (BEST)
provides community-based evaluations and a jail diversion program. At
present, BMC does not own or operate a locked inpatient psychiatric
unit.
To give you a sense of who BMC serves, 70 percent of our patients
identify as black or Latinx, approximately one in three (32 percent)
speak a language other than English as their primary language, and over
half live at or below the Federal poverty level. The patients we see at
BMC who present with mental illness frequently have co-occurring
substance use disorders, homelessness, malnutrition, and other health-
related social needs linked to poverty. The current COVID-19 pandemic,
structural racism, and economic crisis has further exacerbated the
mental illness and trauma experienced by our patients. In my 10 years
at BMC, I have never seen our mental health-care services stretched so
far beyond their capacity as they are now. Just the other day, we had
25 patients in our psychiatric emergency department--more than triple
its capacity--presenting with a much higher level of acuity, some
waiting for evaluation and others boarding awaiting placement in an
inpatient psychiatric unit.
A severe lack of capacity in our country's mental health-care
system existed long before the COVID-19 pandemic. The reasons for this
are multifactorial; however, for the sake of my remarks today I will
broadly categorize them into issues related to the mental health-care
workforce and patient access to care.
It is widely understood and well-documented that America has a
dearth of licensed mental health professionals, in general, and that
particular areas of the country--largely rural and outside of the
Northeast--are disproportionately impacted.\1\ Even where I practice in
Boston, which has one of the highest number of child and adolescent
psychiatrists per capita in the country, the capacity is insufficient
to meet the mental health needs of the community.\2\ Increased Medicare
graduate medical education (GME) funding for psychiatry residency slots
can help increase the physician workforce. Increased funding for loan
forgiveness programs for those who work in underserved areas can help
alleviate the $250,000 of debt that the average medical student has
accumulated by the time their residency education is completed. The
need to pay off medical school loan burden is also likely to cause
physicians to pursue practice in more affluent areas, adversely
impacting access to care for lower-income populations.\3\
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\1\ U.S. Health Resources and Services Administration. Health
Professional Shortage Areas Data Dashboard. Last Updated: June 10,
2021. https://data.hrsa.gov/topics/health-workforce/shortage-areas.
\2\ American Academy of Child and Adolescent Psychiatry. Practicing
Child and Adolescent Psychiatrists Workforce Maps by State. Last
Updated: March 2018. https://aacap.org/AACAP/Advocacy/
Federal_and_State_Initiatives/Workforce_Maps/Home.aspx.
\3\ Zimmerschied C. How med student loan burdens can deepen health
disparities. American Medical Association. April 27, 2017. https://ama-
assn.org/education/medical-school-diversity/how-med-student-loan-
burdens-can-deepen-health-disparities.
Beyond the shortage of providers, the mental health workforce is
not diverse--for instance, only 2 percent of psychiatrists identify as
black--and not representative or reflective of the U.S.
population.\4\, \5\ In order to address this, we must
understand that the issue at its root is a pipeline issue that requires
holistic solutions. Just as we say in medicine, that a person's ZIP
code is more influential than their genetic code in determining life
trajectory and long-term health, where a person lives, the color of
their skin, and language they speak is highly determinative of the
quality of education and resources available, the level of exposure to
the mental health field, and stigma associated with mental illness.
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\4\ Lin L, Stamm K, Christidis P. How diverse is the psychology
workforce? American Psychological Association. 2018; 49(2). https://
apa.org/monitor/2018/02/datapoint.
\5\ American Hospital Association (2016). The State of the
Behavioral Health Workforce: A Literature Review. https://aha.org/
system/files/hpoe/Reports-HPOE/2016/aha_Behavioral_
FINAL.pdf.
In terms of access to mental health services, COVID-19 led to an
accelerated adoption of telemedicine. At peak, over 90 percent of our
outpatient psychiatric visits were conducted via telehealth, which
enabled BMC to maintain and exceed our pre-pandemic volume of service.
That said, while telehealth is an important tool for ensuring patient
access to mental health care, it does not work for everyone due to
digital inequities that exist related to Internet access and digital
---------------------------------------------------------------------------
literacy, especially among low-income communities.
Additional barriers to care exist as a result of disparate
insurance coverage, lack of mental health parity, and insufficient
insurance uptake by licensed mental health providers (especially for
Medicaid). The social determinants of mental health and structural
vulnerabilities inherently involved with treating low-income patients
require more dedicated time with patients to provide appropriate care.
Insufficient Medicaid reimbursement acts as a deterrent for providers
to see Medicaid patients, producing a cascade effect in which the more
oppressed, marginalized populations have limited to no access to mental
health professionals.
I welcome the Senate Finance Committee's involvement in exploring
ways for Federal policy to improve mental health care across various
settings, as well as incentivize and seed the development and scaling
up of innovative models of mental health care delivery in order to
improve access. A few such examples include:
Transforming and Expanding Access to Mental Health Care in
Urban Pediatrics (TEAM UP) for Children, a pediatric integrated model
in Federally Qualified Health Centers in Massachusetts, builds capacity
of health centers to deliver high-quality, evidence-informed care to
children and families. The model includes behavioral health clinicians
and community health workers working with pediatric primary care
providers to provide timely mental health treatment.
The Massachusetts Child Psychiatry Access Program (MCPAP)
improves access to treatment for children with behavioral health needs
and their families by making child psychiatry services accessible to
primary care providers across Massachusetts via remote consultation and
education. This model has been expanded to other States such as
Connecticut where I completed my fellowship.
The Wellness and Recovery After Psychosis (WRAP) Program is
tailored for people experiencing psychotic symptoms using a team-based
approach and providing individual, group and family therapy, medication
management, case management, and peer support.
The Metro Boston Recovery Learning Community (MBRLC) offers
peer-to-peer services for people in recovery from mental health and/or
substance use issues through peer support, advocacy, and career
coaching.
We are at a pivotal time in our country. Over a year into the
COVID-19 pandemic, every person's mental well-being has been impacted
in some way. The need for a more robust mental health care system has
never been more clear or pronounced. Treatment for mental health issues
should be accessible--no matter who you are, where you live or your
ability to pay. Appropriate investment along the care continuum and for
the mental health workforce can improve access to care and retention
and recruitment of mental health professionals.
Mental health is health and should not be thought of or managed
separate or apart from physical health in the ways it historically has
been. The time is now to invest in a 21st-century mental health-care
system in America.
Thank you for your time. I look forward to the discussion.
______
Questions Submitted for the Record to Michelle P. Durham,
M.D., MPH, FAPA, DFAACAP
Questions Submitted by Hon. Elizabeth Warren
Question. During your testimony and conversations with my staff,
you mentioned that telehealth flexibilities were not enough to fully
capture people with substance use disorder that encountered BMC
providers (for example, it was harder to connect individuals that
entered the emergency room with SUD services that were online, as
opposed to available in person and in the moment). Congress should take
steps to expand telehealth flexibilities beyond the pandemic, but it
should also identify and seek to mitigate gaps that emerge when
telehealth is the default.
What additional barriers, if any, did virtual telehealth services
pose to patients in need of SUD services, and what specific steps
should Congress take to address those barriers in advance of future
pandemics?
Answer. Telehealth video was difficult for patients who didn't have
reliable access to the needed technology (phones with video, computers,
Internet, etc.) and a confidential place to have an appointment.
Patients who need certain medications still were required to come into
the clinic (e.g., methadone and injections for naltrexone or extended-
release buprenorphine). Reimbursement for audio-only appointments
allowed clinicians to connect with folks who did not have access to
technology with video capabilities and should be continued beyond the
pandemic. Expanding mobile services for methadone and injectable
medications would also help to reduce barriers to treatment. The
infrastructure proposals before Congress that seek to expand broadband
access would also be beneficial to enable more of the population to
reliably access telehealth services. In addition, the Federal
Government could work with local communities to establish centralized
locations in the community where people can attend telehealth
appointments.
Question. During your testimony, you raised the alarming statistic
that black men in Massachusetts saw a 69-percent increase in overdoses
and overdose deaths during the pandemic.
As Congress seeks to develop future legislation that responds to
overdoses and overdose deaths through a health equity lens, what types
of questions should members ask to ensure they are identifying
challenges facing communities of color in SUD policy development?
Answer. I really appreciate this question. I think it's important
for members of Congress to ask, ``Who is not at the table?'' It is
important to include people with lived experience with addiction,
including persons of color, in the conversation as they are so often
left out, and ask them directly, ``What are the challenges you
personally faced in getting the care you needed to get better?'' In
addition, using a health equity lens, Congress could ask, ``How does
SUD treatment offered to white patients differ from what is offered to
persons of color, in terms of where services are offered, how they are
advertised, and what specific treatment are offered to individuals?
Data suggest that racial disparities exist in each of these arenas.
It is also important to acknowledge that stigma related to
addiction and mental health is very real and differs by community and
culture. Stigma is a challenge for ensuring access to care and stigma
is a challenge for policymaking. Members of Congress can help reduce
stigma by validating the experiences of persons of color with substance
use disorders by inviting them to have a seat at the table in the
development of SUD policy. Congress could seek to learn more about why
stigma exists against seeking help, including the particular stigma
associated with receiving medications for addiction, and what added
stigma exists for persons of color who use drugs.
The Federal response to addiction should not focus on a specific
class of substances like opioids at the exclusion of others as use
patterns oftentimes cuts across racial/ethnic lines. In addition, use
of more than one substance (or polysubstance use) is common and
government policies and funding would do better to reflect that
reality. As members of Congress are likely well aware, fentanyl is
increasingly being mixed into other substances like cocaine, which
users may ingest unknowingly, and may influence overdose and overdose
death rates. The Congress could inquire, ``How does the availability of
drugs and presence of fentanyl in the drug supply create further
disparities in overdoses and overdose deaths for persons of color?''
There are numerous historical policies related to drug use that
have resulted in the systematic exclusion of people of color from
addiction treatment services. Reviewing past policies through a health
equity lens can help to correct past inequities in order to create a
more equitable and accessible SUD treatment system for persons of
color. In particular, decriminalizing drug possession can help
individuals get the treatment they need and avoid incarceration where
comprehensive addiction services, including medications for addiction
treatment, are rarely available. Additionally, a health equity lens
should be applied to examining racial disparities in access to
different medications for opioid use disorder, like methadone, which is
more commonly prescribed to persons of color, and buprenorphine, which
is more commonly prescribed to white patients, as well as the disparate
regulations pertinent to these treatments. Research is necessary to
better characterize the needs of people of color and to design
addiction treatment programs that may be more responsive to their goals
and expectations--the Federal Government can play a role in catalyzing
and seeding this research. Additionally, Congress can create
sustainable funding and additional incentives for integrated mental
health and primary care services, which especially for low-income
populations, like those served at BMC, should incorporate the capacity
to address social determinants of health.
Question. In your experience as a provider, how do you see these
communities left out of SUD conversations, and what preemptive steps
should policymakers take to center these communities in policy
discussions?
Answer. The one-size-fits-all approach of the American health care
system does not work for all communities--i.e., expecting patients to
show up to clinic to get care, instead of bringing care to places and
people that communities trust. For example, care provided in houses of
worship, community centers or home visits. In general, there's not a
lot of focus on prevention and promotion in our addiction and mental
health-care system. Greater investment in community-based organizations
and support services, such as case management focused on psychosocial
needs, would help reach more people that the current system fails to
catch. It also could help to create a seat at the table in SUD policy
discussions for community health workers (CHWs) and recovery coaches.
______
Questions Submitted by Hon. Catherine Cortez Masto
Question. In your testimony you touched on the continuum of crisis
services that are provided by Boston Medical Center.
If you were to be able to expand the capacity of programs like the
behavioral health urgent care clinic or the crisis stabilization unit,
would you expect to see changes in ER volume or even hospital
readmissions?
Answer. Expanding the continuum of crisis services at Boston
Medical Center (BMC) would probably not realistically impact the volume
of patients we see presenting with behavioral health issues in the
emergency room (ER) or inpatient setting. A regional approach to expand
the full continuum of care services, not just crisis services,
including an emphasis on prevention and moving upstream to address
health-related social needs, behavioral health integration in primary
care settings, and other means of enabling individuals to access
outpatient mental health services when they need it, would be more
likely to reduce reliance on ER and inpatient mental health services.
Timely response is key and can potentially avoid requiring ER or
inpatient-level care.
Question. You spoke about the workforce challenges that we're
seeing across the country, and the lack of diversity among providers
that seems to exacerbate access issues among LGBT populations,
communities of color and underserved communities.
Do you think expanding the types of clinicians who can practice
behavioral health services would help to build the pipelines of
providers who can meet the needs of diverse communities?
Answer. Increased use of behavioral integration in primary care and
allowing mental health professionals to work to the full extent of
their license within scope of practice could help address workforce
shortages and improve access to behavioral health care. Including CHWs
and peer support in care models, and reimbursing them for their time is
crucial to better serving the needs of diverse communities.
Question. How else can Congress develop a provider workforce that
is able to serve diverse communities most effectively?
Answer. As I mentioned in my testimony, I see the provider
workforce shortage as a pipeline issue. Additional education and
training opportunities writ large and for communities of color in
particular would go a long way. Increased resources should be targeted
to historically disinvested communities. Barriers to education and
training can be addressed with additional funding for scholarships for
people of color and individuals from low-income communities to complete
their primary education and higher education, as well as loan repayment
programs to reduce the financial burden/barriers to getting people into
the field. Addressing stigma in the community--what it means to work in
the mental health profession, and what it means to get mental health
care--is imperative as well. In terms of legislation before Congress,
the Pursuing Equity in Mental Health Act (S. 1795)--which you've
cosponsored and has passed the House as H.R. 1475--if passed by the
Senate would help provide additional resources to recruit and sustain a
diverse mental health workforce. BMC is very much in support of S.
1795/H.R. 1475.
______
Questions Submitted by Hon. John Barasso
Question. The health-care professionals, along with all front-line
workers, deserve our gratitude and appreciation. Their dedication to
our communities during this pandemic is something we must recognize and
never forget.
A top concern of Wyoming mental health facilities is making sure
there are enough staff to care for their patients. It is especially
challenging to attract and keep health-care providers in rural
communities.
Can you discuss solutions related to workforce development you
believe will improve the ability of mental health facilities to attract
and maintain staff in rural areas?
Answer. The mental health burden in some communities, rural, urban,
and suburban, is tremendous, and requires significantly more resources
to adequately support the mental health workforce and address the need.
Overtaxing the limited mental health resources that exist in high need
areas contributes to high churn among mental health professionals. A
model like the Massachusetts Child Psychiatry Access Program (MCPAP),
which I referenced in my testimony, is one way to stretch existing
resources and increase access to psychiatric consults for primary care
providers in rural areas.
Question. Can you specifically discuss changes to GME policy you
believe would improve the pipeline of mental health physicians?
Answer. Increased funding for GME slots in general, as proposed in
the Resident Physician Shortage Reduction Act (S. 834/H.R. 2256), and
targeted to a particular specialty, such as addiction medicine and
addiction psychiatry, as proposed in the Opioid/SUD Workforce Act (S.
1438/H.R. 3441), would help significantly improve the pipeline of
mental health physicians.
Question. As a doctor, I strongly support increasing access to
mental health services, especially in rural communities. Senator
Stabenow and I have previously introduced legislation for many years
that would allow mental health counselors and marriage and family
therapists to receive reimbursement from Medicare.
Can you discuss how the Department of Health and Human Services can
improve access for mental health services, especially for those on
Medicare?
Answer. One way HHS could help improve access to mental health
services is by removing the Medicare cap on the number of inpatient
psychiatric days a beneficiary can have in their lifetime--this is a
lack of parity with physical health care. People under age 65 who are
chronically or severely mentally ill and on Medicare, who need
inpatient mental health care, end up stuck in the hospital emergency
department because of this restriction.
Question. In particular, can you comment on the merits of allowing
licensed professional counselors and marriage and family therapists to
receive reimbursements from Medicare?
Answer. People should get reimbursed for what is in their scope of
practice, so I don't see any reason why licensed professional
counselors (LPCs) or marriage and family therapists (MFTs) should not
receive reimbursement from Medicare for the services they are trained
to provide.
______
Questions Submitted by Hon. Tim Scott
Question. The toll that union-sponsored excuses for ``virtual
learning'' has taken on actual kids is extraordinarily sad, especially
for our Nation's most vulnerable children. In October 2020, a survey
conducted by the Jed Foundation showed that 31 percent of parents said
their child's mental or emotional health was worse than before the
pandemic. Private insurance data also shows that while all health care
claims for adolescents ages 13-18 were down in 2020 compared to 2019,
mental health-related claims for this age group increased sharply.
Additionally, the Centers for Disease Control and Prevention (CDC)
reports 25 percent of parents whose children attended school virtually
were more likely to report an overall worsened mental or emotional
health compared to only 16 percent of parents of children attending
school in-person.
What programs within the Department of Health and Human Services'
(HHS) purview are best poised to support children and schools as they
return to complete in-person learning?
Answer. I'm not sure of the particular programs within HHS that may
best support children and schools as they return to in-person learning,
but either way more therapists are needed in schools. Kids spend most
of their waking hours in school so it is best to make mental health
services and supports available to them there. In addition, mental
health support for school teachers, staff, administrators, and parents
of school-aged children will be vitally important as kids look to
adults for modeling especially during times of transition and
uncertainty. The Federal Government can and should play a role in
helping to facilitate connections to care within the community in
instances when it is beyond the capacity of school (e.g., funding and
supporting crisis management services in the community). All of this
should be integrated into a prevention and promotion framework, which
includes psychoeducation and group intervention, in order to help kids
and adults connect the dots of what they have experienced and identify
how trauma may manifest and when to ask for help.
Question. How can we integrate more telehealth opportunities to
expand access to mental health services in schools?
Answer. I think it would be very impactful if students could access
telehealth in schools. Schools or community health center partners
should be outfitted with the technology to enable access for kids who
may not have the necessary technology or private space at home,
assuming the location of the child is no longer relevant for
reimbursement. Parents will have to be involved to a certain extent
with the care of minors, particularly with respect to prescribing
medication, so it will be important for schools and communities to set
up systems and processes to engage parents without creating additional
barriers.
Question. Telehealth has expanded rapidly as a result of the COVID-
19 pandemic. Numerous studies have demonstrated the effectiveness of
telehealth for behavioral health services.
As telehealth becomes more common among health care providers, what
can Congress do to ensure that patients do not suffer from unnecessary
bureaucratic delays?
Answer. Congress can help to ensure parity for mental health
services with physical health services. In my experience, prior
authorization for behavioral health services is not level with physical
health and should be addressed to reduce unnecessary barriers to care.
Question. There is a well-researched connection between
unemployment and mental health. As recently as April 2021, despite
billions of dollars of COVID-19 stimulus, aggregate employment remained
7.9 million jobs below its pre-recession level.
What impact will this failure to get people back to work have on
mental health?
Answer. Engaging people with meaningful work, financial security,
and structure is helpful for maintaining and supporting mental health.
In places where insurance is more closely tied to work, rising or
stagnant unemployment could reduce access to health care for people
facing unemployment.
Question. Last November, an article published in the Journal of the
American Medical Association noted that multiple studies indicated that
older adults may be less negatively affected by certain mental health
outcomes than other age groups.
Are these study outcomes consistent with your own professional
experiences working with older adults?
Answer. N/A.
Question. Current network adequacy standards often allow networks
of specialists who aren't taking new patients or who have long waiting
lists. That means that many people needing treatment must go out of
network to get care, and only those who can afford the high cost get
it. One of the biggest challenges to access to behavioral health care
services is that many behavioral health specialists don't participate
in health plan networks.
Why is that, and how can we change that?
Answer. Low reimbursement and administrative burden, including
dealing with prior authorization, act as deterrents to providers
accepting health insurance. Improving reimbursement and expanding team-
based care models that support integration of behavioral health into
primary care settings could help.
Question. Outside of the public health emergency, telehealth
services are restricted to certain geographic and clinical settings.
Beneficiaries must live in a rural area and have an initial face-to-
face visit with the distant-site provider. Once a relationship has been
established, periodic in-person visits are also required. With few
exceptions, patients must be located in a clinical setting and may not
receive care from their homes. In addition, the distant-site provider
cannot be located in a rural health clinic or FQHC.
Telehealth has been used broadly during the pandemic to expand
health care access to individuals throughout the country. During the
pandemic, Medicare significantly expanded the coverage of telehealth
services. A recent Bipartisan Policy Center poll suggests that people
receiving mental health and substance use services want a combination
of in-person, video, and telephone services even after the pandemic has
passed.
What telehealth expansions should remain after the pandemic?
Answer. Particularly for the patients that I see at Boston Medical
Center, a majority of whom are low-income, maintaining coverage and
reimbursement for audio-only telehealth is essential. Insurers should
also not require an in-person visit for mental health visits in order
to permit continued telehealth use (e.g., requiring one in-person visit
within 6 months of the first telehealth appointment). The decision of
whether to see a patient in person or virtually should instead be up to
the discretion of the clinician.
______
Questions Submitted by Hon. John Cornyn
Question. Your testimony outlines the collaborative care model and
integrated care. I can appreciate the benefit of this collaboration
between practitioners, and I too am concerned about the education and
support our primary care physicians receive for addressing mental
health.
The Massachusetts Child Psychiatry Access Program, as you claim,
``improves access to treatment for children with behavioral health
needs and their families . . . via remote consultation and education.''
Telehealth is a tool that delivered positive results during the
pandemic and is largely here to stay. And I look forward to working
with my colleagues on ensuring patients have access to care through
telehealth, including mental health care.
What type of education regarding mental health is offered to
primary care physicians in collaborative care models?
What about outside of those care models?
Do you have any recommendations for Congress to consider regarding
disseminating mental health best practices or education items to
primary care physicians?
Answer. Congress could play a role in funding a national technical
assistance program for collaborative care models, including access to
start-up capital to get behavioral health clinicians, managers, and
systems in place. Training and education works best when built into
clinicians' workflow/time. Additional research funding is needed in
order to learn more about the best forms of integrated care for
different patient populations.
______
Prepared Statement of Chantay Jett, MA, MFT,
Executive Director, Wallowa Valley Center for Wellness
introduction/background
Good morning, Chairman Wyden, Ranking Member Crapo, and members of
the Senate Finance Committee. Thank for you for the opportunity to
appear before the committee to discuss policy solutions to address both
the mental health and substance use crises impacting the United States
and in particular the rural and frontier areas of our percent. My name
is Chantay Jett, and I am executive director of Wallowa Valley Center
for Wellness (WVCW), which provides community-based mental health and
substance use treatment services in the most remote region of the great
State of Oregon.
We represent a truly frontier area of our Nation where the cows
outnumber the people and our closest major airport is in Boise, ID--
nearly 4 hours away. We are literally at the end of the road where
everybody knows everybody, which unfortunately contributes to both
stigma and lack of access for people seeking treatment services. I am
here to tell you that the Certified Community Behavioral Health Clinic
(or CCBHC) model has truly made a difference in our frontier community.
I hope every State in the near future has the opportunity to use the
resources this model has made available to us to meet the specific
needs of our wonderful community.
The State of Oregon participates in a 10-State demonstration of the
Excellence in Mental Health and Addiction Treatment Act that this
committee helped to establish in 2014 through the bipartisan leadership
of Senators Stabenow and Blunt. The Center for Wellness is one of 12
CCBHCs that operate in our State. We provide high-quality, integrated,
community-based mental health and substance use services to
individuals, while also screening for possible co-morbid conditions
like heart disease, diabetes, and HIV/AIDS. Among the most important
services that CCBHCs provide--both in Oregon and nationwide--are
immediate access to Medication Assisted Treatment (MAT) for substance
use and 24-hour emergency psychiatric care.
prevalence of behavioral health conditions in oregon/
mental health professional shortages
Please permit me to provide some very brief context of CCBHCs
within rural and frontier counties in the State of Oregon. According to
the Oregon Health Authority (OHA), our State reports higher rates of
mental health conditions, including severe and persistent mental
illness and suicidal ideation. The COVID-19 pandemic has only
exacerbated an ongoing mental health and substance use crisis in rural
Oregon.
OHA also details a lack of access to mental health and substance
use care, especially in frontier communities which face greater
distances for referral to outpatient and inpatient services. To give
you a sense, there is no stoplight within a 76-mile radius of Wallowa
County. The OHA reports average wait times of as much as 6 months
Statewide due to a lack of providers. However, we are the lucky ones,
because the CCBHC model helped created an internal reorganization of
service delivery which resulted in same day access to care.
wallowa valley center for wellness: the ccbhc experience
Prior to becoming a CCBHC, The Center for Wellness was heavily
reliant upon grants. Grant funding is crucially important, but it
carries limitations. Grants typically end every 2 to 3 years; they all
have different reporting requirements and different program
specifications, which unfortunately results in more time spent filling
out paperwork, rather than treating our patients.
By contrast, the CCBHC prospective payment system permits us to do
three big things. First, The Center for Wellness is able to contract
with more skilled clinicians--including psychiatrists and medical
professionals to prescribe Medication Assisted Treatment for patients
with opioid use disorder. This directly results in decreased wait times
and reduced emergency department utilization.
Secondly, the CCBHC program is designed to expand access to
underserved populations. In our case, becoming a CCBHC really opened
the door for mental health care to veterans as it requires the staffing
of services specifically for veterans. According to the Veterans
Service Organizations (VSO) in our county, there are at least 1,000
community members who have donned the uniform out of 7,000 residents.
One of our CCBHC funded clinicians has been invited to the weekly PTSD
groups at the Veterans of Foreign Wars (VFW) for veterans and their
families. Becoming a CCBHC has allowed us to increase our services to
23 veterans in our community. This may not seem significant to you, but
it's an increase of 300 percent--a big deal for us here in rural
Oregon.
Thirdly, consistent CCBHC resources are a fundamental driver of
integrated care. In Oregon, the CCBHC demonstration financing has made
it possible to integrate with a local Federally Qualified Health Center
(FQHC) allowing primary care, specialty medical services, and
behavioral health services to be accessible under the same roof. We
also share a single Electronic Health Record with our partner FQHC and
local critical access hospital to permit immediate care coordination.
Patients tell me that it is such a relief to not have to retell their
story with every multidisciplinary provider they see. I will add that
if there is no open acute psychiatric bed in our hospital or an acute
bed is too distant in time traveled, we are lucky to have a great
neighbor and partner across the State line in Idaho to access acute
care psychiatric hospitalization. This component of care coordination
and partnership with primary care and hospitals even across State lines
is imperative because patients with severe mental illness and substance
use challenges have shockingly high rates of chronic conditions,
encompassing everything from cirrhosis to emphysema to heart disease.
The CCBHC model allows us to have these partnerships and get patients
the services they deserve in a timely manner.
In closing, I strongly believe that this model represents the
future of community-based mental health care and substance use
treatment in the United States. This is why I am asking you to make
this model available to every State nationwide. As a percent, we can do
better than first treating mental health and substance use in hospital
emergency departments, homeless shelters, and the county jails.
Investing in CCBHC's is streamlining services in efficient ways that
drive costs down over the entire continuum of care. Despite being from
a tiny frontier community at the end of the road in northeastern
Oregon, I hope you see that CCBHCs make an enormous impact.
Again, thank you for the opportunity to testify, I am happy to
answer any questions you may have.
______
Questions Submitted for the Record to Chantay Jett, MA, MFT
Question Submitted by Hon. Ron Wyden
Question. I understand you employ a range of physician and non-
physician providers.
Can you tell the committee more about the clinical staff you employ
who can and cannot receive Medicare reimbursement? In rural and
frontier counties it is very difficult to find licensed providers in
this workforce shortage landscape.
Answer. Many of the service providers, such as peer support, case
management, skills training, Supported Employment, Early Assessment
Support Alliance (EASA), Assertive Community Treatment Team (ACT), med
management, and Substance Use Providers (SUD) are not compensated at
all by Medicare. The Licensed Clinical Social Workers we employ along
with psychiatrists are compensated less than the value of the service
they provide.
Question. In a typical year, about how much does Medicare's
provider policy cost your clinic?
Answer. Wallowa Valley Center for Wellness writes off more than
$500,000 per year in uncovered Medicare services.
______
Questions Submitted by Hon. John Barasso
Question. The health-care professionals, along with all front-line
workers, deserve our gratitude and appreciation. Their dedication to
our communities during this pandemic is something we must recognize and
never forget.
A top concern of Wyoming mental health facilities is making sure
there are enough staff to care for their patients. It is especially
challenging to attract and keep health-care providers in rural
communities.
Can you discuss solutions related to workforce development you
believe will improve the ability of mental health facilities to attract
and maintain staff in rural areas?
Answer. Attracting and retaining a highly qualified workforce
requires easier loan repayment programs and equalizing the requirements
for school BH, primary care BH and community BH. We currently see the
other sectors being able to pay more for less requirements and we
cannot compete with this. The solution is to create an environment of
equal parity in base salary for behavioral health workers as well as
parity with the paperwork administrative burden placed only on the
community mental health programs, as well as primary care providers
sharing the risk for acute care hospital placements. I believe these
three practices would remove a significant barrier to workforce
development and the inability to offer competitive employment for a
spouse/partner of a master's level clinician.
Question. Can you specifically discuss changes to GME policy you
believe would improve the pipeline of mental health physicians?
Answer. As a community mental health program, we do not deal
specifically with the guidelines and policies related to GME programs
on the primary health-care side. I do not feel like I could offer an
educated answer to your question.
Question. As a doctor, I strongly support increasing access to
mental health services, especially in rural communities. Senator
Stabenow and I have previously introduced legislation for many years
that would allow mental health counselors and marriage and family
therapists to receive reimbursement from Medicare.
Can you discuss how the Department of Health and Human Services can
improve access for mental health services, especially for those on
Medicare?
Answer. Medicare reimbursement for Licensed Professional Counselors
(LPCs) and Licensed Marriage and Family Therapists (LMFTs) would vastly
improve access to care. Currently, a consumer has to either wait for an
available (and scarce) LCSW or pay full fee for services, both of which
are unacceptable. The ability to conduct telephonic and video sessions
has addressed some barriers to care and these services must continue to
be reimbursed/billable regardless of the status of COVID.
Question. LMFTs and LPCs are as qualified or more to serve our
community members, and the alliance between Medicare and LCSWs is
purely an outcome of effective lobbying not good practice. In
particular, can you comment on the merits of allowing licensed
professional counselors and marriage and family therapists to receive
reimbursements from Medicare?
Answer. Please see above.
______
Questions Submitted by Hon. Tim Scott
Question. The toll that union-sponsored excuses for ``virtual
learning'' has taken on actual kids is extraordinarily sad, especially
for our Nation's most vulnerable children. In October 2020, a survey
conducted by the Jed Foundation showed that 31 percent of parents said
their child's mental or emotional health was worse than before the
pandemic. Private insurance data also shows that while all health care
claims for adolescents ages 13-18 were down in 2020 compared to 2019,
mental health-related claims for this age group increased sharply.
Additionally, the Centers for Disease Control and Prevention (CDC)
reports 25 percent of parents whose children attended school virtually
were more likely to report an overall worsened mental or emotional
health compared to only 16 percent of parents of children attending
school in-person.
What programs within the Department of Health and Human Services'
(HHS) purview are best poised to support children and schools as they
return to complete in-person learning?
Answer. Regardless of the location of the instruction, a global
event like COVID impacts the mental health of students. DOE and HHS
need to partner on grasping the impact of collective trauma. Educators
and school-based counselors need to recognize and support the lasting
effects that COVID has had on our Nation and world and help students
gain an understanding and normalize the emotional response to a life
changing event.
Question. How can we integrate more telehealth opportunities to
expand access to mental health services in schools?
Answer. A barrier to tele-health BH services is ensuring IT systems
have the necessary permissions to ``talk'' to teach other. Our
experience is that the school's Internet blocks our access.
Question. Telehealth has expanded rapidly as a result of the COVID-
19 pandemic. Numerous studies have demonstrated the effectiveness of
telehealth for behavioral health services.
As telehealth becomes more common among health care providers, what
can Congress do to ensure that patients do not suffer from unnecessary
bureaucratic delays?
Answer. Unnecessary bureaucratic delays are often due to the
payment structure and how Medicare and private insurance will not pay
for less expensive evidence-based services such as IPS-supported
employment, case management, skills training, etc.
Question. There is a well-researched connection between
unemployment and mental health. As recently as April 2021, despite
billions of dollars of COVID-19 stimulus, aggregate employment remained
7.9 million jobs below its pre-recession level.
What impact will this failure to get people back to work have on
mental health?
Answer. Like students, the entire Nation has experienced collective
trauma, and employers need to recognize that status quo employment
practices and some of the barriers to things like affordable housing
and child care have a ripple effect across the employment rate.
Question. Last November, an article published in the Journal of the
American Medical Association noted that multiple studies indicated that
older adults may be less negatively affected by certain mental health
outcomes than other age groups.
Are these study outcomes consistent with your own professional
experiences working with older adults?
Answer. Actually, older adults identify ``not needing'' MH support
but that does not correlate with overall health outcomes and behaviors
(such as obesity, smoking, gambling, alcohol abuse, and suicide). Our
older community members cite stigma and rugged individualism as factors
in avoiding MH services. This is also relevant to accessing/pursuing
preventative medical care. ``I'm not sick, so why should I see a
doctor?''
Question. Current network adequacy standards often allow networks
of specialists who aren't taking new patients or who have long waiting
lists. That means that many people needing treatment must go out of
network to get care, and only those who can afford the high cost get
it. One of the biggest challenges to access to behavioral health care
services is that many behavioral health specialists don't participate
in health plan networks.
Why is that, and how can we change that?
Answer. In my opinion, this problem is specific to the failure of
health plan networks. The most common feedback I hear is that ``the
network is full and not accepting any new providers.'' This is
something providers in private practice face; this is not generally an
issue in a community mental health program which employs a wide range
of behavioral health specialists within their own programs.
Question. Outside of the public health emergency, telehealth
services are restricted to certain geographic and clinical settings.
Beneficiaries must live in a rural area and have an initial face-to-
face visit with the distant-site provider. Once a relationship has been
established, periodic in-person visits are also required. With few
exceptions, patients must be located in a clinical setting and may not
receive care from their homes. In addition, the distant-site provider
cannot be located in a rural health clinic or FQHC.
Telehealth has been used broadly during the pandemic to expand
health care access to individuals throughout the country. During the
pandemic, Medicare significantly expanded the coverage of telehealth
services. A recent Bipartisan Policy Center poll suggests that people
receiving mental health and substance use services want a combination
of in-person, video, and telephone services even after the pandemic has
passed.
What telehealth expansions should remain after the pandemic?
Answer. All of them! We are finding greater engagement to care by
being offering an array of access points for folks. Even in the
pandemic our yearly hours of service only fluctuated by about 60 hours
from the previous year. However, the number of visits nearly doubled
due to shorter encounters made possible through a variety of video,
telephonic and in-person visits.
______
Prepared Statement of Benjamin F. Miller, Psy.D.,
Chief Strategy Officer, Well Being Trust
Chairman Wyden, Ranking Member Crapo, and members of the committee,
my name is Dr. Benjamin F. Miller, and I am the chief strategy officer
for Well Being Trust, a national foundation started in 2016 through a
gift by the Providence Health System that is focused on advancing the
mental, social, and spiritual health of the Nation.
I am a clinical psychologist by training and have spent most of my
adult life pursuing strategies that can advance mental health to a
place of priority within our society. This goal has guided much of my
work during my time as the founding director of the University of
Colorado's Farley Health Policy Center and continuing today in my
capacity as an adjunct professor at Stanford School of Medicine and at
Well Being Trust.
It is an honor to be able to speak to you today about an issue that
every American is experiencing--an issue that we need to aggressively
pursue, and which COVID-19 has all but exacerbated especially among
communities of color and other marginalized people: our mental health.
Several government reports highlight how broken our mental health
system is. The 2020 DoD Inspector General report that found over 50
percent of service members and their families who needed mental health
care did not receive it.\1\ SAMHSA found that over 56 percent of adults
with mental illness did not receive any treatment in the past year, nor
did 35 percent of those with serious mental illness.\2\ And a recent
GAO report highlighted a multitude of issues at multiple levels for
mental health, including ongoing challenges with health insurance,
enforcing laws like mental health parity, and finding the right
clinician who can help.\3\ In one survey, almost 30 percent of people
reported not seeking care because they did not know where to go.\4\
---------------------------------------------------------------------------
\1\ https://www.dodig.mil/reports.html/Article/2309785/evaluation-
of-access-to-mental-health-care-in-the-department-of-defense-dodig-2/.
\2\ https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/
NSDUHDetailedTabs2018
R2/NSDUHDetTabsSect10pe2018.htm.
\3\ https://www.gao.gov/products/gao-21-437r.
\4\ https://www.thenationalcouncil.org/press-releases/new-study-
reveals-lack-of-access-as-root-cause-for-mental-health-crisis-in-
america/.
The need to solve for these and other existing problems is real and
immediate. Clear pathways do not exist for people seeking mental health
care--there are not obvious doors to enter, and we have no system that
routinely is able to identify and treat people in a timely manner. This
is perhaps our greatest challenge as we emerge from the devastating
---------------------------------------------------------------------------
COVID-19 pandemic.
With broad majorities in both parties now understanding the
importance of addressing mental health, I believe it is the time to
enact immediate fixes for people in need, as well as begin to lay the
foundation for a reimagined mental health system--a mental health
system that is grounded in community and an integral part of our
broader health-care infrastructure.
There are three key priorities I believe this committee should
consider as it pursues both short- and long-term reforms for mental
health.
First and foremost, we need to bring mental health care to where
people are. This includes schools, and even our workplaces, but to most
immediately meet this moment, the best place to start is in primary
care, the largest platform of health-care delivery. In one poll, 70
percent of adults agreed that it would be more convenient if their
mental health and substance use services were integrated into their
primary care doctor's office.\5\
---------------------------------------------------------------------------
\5\ https://bipartisanpolicy.org/download/?file=/wp-content/
uploads/2021/03/BPC-MC-FINAL-Slide-deck-on-Mental-Health-Analysis-
Poll.pdf.
To do this, we must create more global and flexible funding
mechanisms for primary care practices who are working to integrate
mental health. Our payment mechanisms often reinforce a siloed delivery
---------------------------------------------------------------------------
model, and this must change.
By first using existing payment structures like those found in
Medicaid Managed Care Organizations, Medicare Accountable Care
Organizations, and Medicare Advantage plans to expand mental health
integration work, primary care practices would have the flexible
financial resources to onboard mental health clinicians as a part of
their integrated care team.
Second, we must reconsider the design and capabilities of our
workforce. Demand for care has far outpaced the supply of mental health
clinicians, and it is inconceivable to rely upon clinician recruitment
strategies alone to meet our ever-growing need. There are two things we
can do simultaneously to address this workforce issue.
First, we can map out mental health utilization and gaps to better
determine where services are needed and for whom.\6\ Without this we
run the risk of widening disparities or putting money into places or
programs people are not using for their mental health.
---------------------------------------------------------------------------
\6\ https://www.thelancet.com/journals/lanpsy/article/PIIS2215-
0366(21)00073-0/fulltext.
Second, we invest in our community workforce--those like peer
support specialists, community health workers, or more broadly, lay
people in our communities. We train them in mental health skills to
help become the first line of mental health support, complementing our
clinical enterprise and enhancing the overall capacity for communities
to address mental health needs.\7\
---------------------------------------------------------------------------
\7\ https://onlinelibrary.wiley.com/doi/abs/10.1111/jrh.12229.
Finally, we must modernize and connect our Federal programs and
systems to collaboratively solve for common mental health problems. I
realize it is hard to ask committees to work across jurisdictional
boundaries, but so many aspects of our mental health need to be
understood together and implemented together--at the State and
community level. Because there are multiple agencies, funding streams,
and programs that support mental health, performing a landscape
analysis can create a strategy for synergistic efficiencies by breaking
down silos across Federal agencies and departments and allow for a more
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cohesive plan for mental health.
In closing, I thank the committee again for holding a hearing on
mental health. This is our moment to be bold in what we can do to boost
our Nation's well-being, and ultimately save lives.
context
In 2019, 156,242 Americans were lost to alcohol, drugs, or
suicide--one person every 3\1/2\ minutes. 39,043 of those deaths were
tied to alcohol misuse--a 4-percent increase over 2018--and drug-
induced deaths in 2019 increased by 5 percent to account for 74,511 of
the totals.\8\
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\8\ https://wellbeingtrust.org/news/pain-in-the-nation-annual-
deaths-due-to-alcohol-drugs-or-suicide-exceeded-156000/.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
A few things to note. First, this data represents societal
behaviors before COVID-19. While we do not have all the data from 2020
yet, preliminary CDC data suggests a 27-percent increase over 2019 in
drug overdose deaths offering a glimpse into how much worse it could
be.\9\ In addition, between 2003 and 2018, the age-adjusted suicide
rate reported by the CDC increased by more than 30 percent--and early
data indicates that this number will continue to grow in the face of
COVID-19.\10\
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\9\ https://www.cdc.gov/media/releases/2020/p1218-overdose-deaths-
covid-19.html.
\10\ https://stacks.cdc.gov/view/cdc/100479.
Second, the data highlight our ongoing problems with health
disparities. In these data, we saw a 2-percent increase in drug
overdose deaths in whites but a 15-
percent increase in blacks and Latinos, an 11-percent increase in
American Indians, and a 10-percent increase in people of Asian descent.
These are statistically significant differences that highlight how even
dominant legislative responses to major issues like our opioid crisis
can work well with some populations but not all. These ongoing
disparities require a level of attention in system design that is
currently missing. Simply decreasing the supply of opioids overall
without addressing the demand and its underlying causes leaves us in a
place where unintended consequences are likely to occur, such as
increases in deaths from synthetic opioids or some subpopulations
failing to sufficiently benefit from even the most well-intentioned
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reforms.
Finally, it's important to see these data points for what they
are--a macro trend line going in the wrong direction. While the
calculations are ongoing, the projections informed by the CDC data and
others suggest that our problems are only getting worse and are
overwhelming communities. We must stop trying to see substance us
disorder and mental, physical and behavioral health as separate
issues--they are all interconnected. Assessing and addressing all is
essential to achieve the outcomes and well-being we want for
individuals and society as a whole. But in order for us to do this, and
do this well, we need a system that can take care of all aspects of our
health and not just the pieces. In fact, COVID-19 has given our Nation
an opportunity to see mental health for what it is--a foundation to our
overall health and well-being.
As seen below, Kaiser Family Foundation has tracked the mental
health impact of COVID-19 throughout the pandemic. This is truly an
issue that impacts us all.
In early 2020, the number of adults who said worry and stress
related to the coronavirus was having a negative impact on their mental
health increased from about one-third (32 percent) in March 2020 to
roughly half (53 percent) in July 2020.\11\ While the impact appears to
have normalized, data from March 2021 finds thatalmost half of adults
report negative mental health impacts due to COVID-19.
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\11\ https://www.kff.org/coronavirus-covid-19/poll-finding/mental-
health-impact-of-the-covid-19-pandemic/.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
In another survey conducted in the fall of 2020, almost 80
percent of surveyed registered voters described how COVID-19 had
impacted their mental health. In the same survey, 9 out of 10 people
believed that elected officials should be doing more for mental
health.\12\ And when compared to the rest of the world, the U.S. has a
much higher mental health burden from COVID-19 than other high-income
countries.\13\
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\12\ https://wellbeingtrust.org/news/viacomcbs-well-being-trust-
2020-mental-health-survey/.
\13\ https://www.commonwealthfund.org/publications/issue-briefs/
2020/may/mental-health-conditions-substance-use-comparing-us-other-
countries.
Perhaps most concerning is the impact that COVID-19 has had on our
kids and younger adults. Thirty-one percent of 18-29-year-olds report
stress has had a major impact on their mental health. Schools are
overwhelmed by the mental health needs of students but must make
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difficult decisions on where to invest their limited resources.
Some of these issues are the expected result of a national health
emergency; however, our Nation's fragmented approach to mental health
and addiction impedes treatment and has exacerbated these problems. In
addition, some facets of society, like our Nation's jails and prisons,
are full of people with mental health and addiction needs. Many of
these people had significant unmet need for mental health and addiction
services before they were incarcerated. And too often, these needs
unaddressed by the time they move back into community settings--further
stressing the ability of local systems to adequately respond.\14\ These
national problems and others are a constant threat against the well-
being of our communities until comprehensive reforms are embraced.
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\14\ https://www.mhanational.org/issues/access-mental-health-care-
and-incarceration.
It should be no surprise that when people don't have any place to
go, they show up in the emergency department--but these are often some
of the worst places for people to go who are in a mental health crisis
as they are often ill-equipped to manage acute psychiatric crises
potentially exacerbating an already existing problem. Data from the CDC
found that compared with 2019, the proportion of mental health-related
visits to emergency departments for children aged 5-11 and 12-17 years
old in 2020 increased approximately 24 percent and 31 percent,
respectively.\15\
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\15\ https://www.cdc.gov/mmwr/volumes/69/wr/mm6945a3.htm.
To make this crisis even more challenging, two commercial payers
\16\,\17\ have stated that they will retroactively review
why a person went to the ED, and if they determine it wasn't warranted,
they can restrict or deny these Americans coverage. Imagine showing up
thinking you are having a heart attack only to be told it's a panic
attack, and then have to pay out of pocket after the cause of the
emergency was diagnosed. This could further discourage American
families from seeking out help, and while one payer has temporarily
walked back this policy,\18\ it remains something that could reemerge.
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\16\ https://www.uhcprovider.com/en/resource-library/news/2021-
network-bulletin-featured-articles/0621-ed-facility-commercial-
claims.html.
\17\ http://file.anthem.com.s3-website-us-east-1.amazonaws.com/
04591CAEENABC.pdf.
\18\ https://www.nytimes.com/2021/06/10/health/united-health-
insurance-emergency-care.html.
In summary, unaddressed mental health and addiction needs will
negatively impact the collective spirit and well-being of individuals,
families, and communities. The 116th Congress passed landmark
legislation establishing streamlined crisis hotlines (988 crisis
hotlines), which could very well overwhelm an already fragile system
without support. I am hopeful that this committee might take the
opportunity afforded by this legislative effort to begin laying the
foundation for a truly modern system of care that works to integrate
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mental health through delivery, financing, and policy.
Below I outline the three areas that I believe hold the most
promise for mental health.
1. Reimagine Care Delivery
Mental health is local. We need to consider all the places that
people show up with need and be prepared with a mental health response.
From community settings like schools, and workplaces to health delivery
settings like primary care, one of the best ways we can begin to
enhance access and more proactively address mental health needs is to
integrate mental health.
What does this look like? At a high level it means that the
location--whether it's a primary care office or a school--has the
resources to have an onsite mental health professional who can help
identify, treat, and coordinate. This approach helps us begin to better
distribute mental health services throughout the community in an effort
to better be responsive to needs. Below I outline a few specific policy
ideas that can support this reimagined approach to mental health.
Primary Care
Care for those seeking mental health services is fragmented in many
of today's local systems, leaving even the most connected of people
waiting for help. The issues that contribute to the problems in our
current care delivery systems include: (1) unnecessary care limitations
restricting where and how a person can get access to care; (2)
referrals being the dominant intervention for mental health in most
health-care settings; and (3) care approaches remain fragmented with
team-based interventions remaining an aspirational goal in most
settings. Integrating mental health into primary care addresses all
three of these issues head on.
The Bipartisan Policy Center's report on mental health and primary
care integration offers several key recommendations for this committee
to consider.\19\ And rather than list all of those recommendations
here, I would encourage the committee and staff to look into the report
at the three major areas the report covers: transforming payment and
delivery to advance value-based integrated care, expanding and training
the integrated workforce, and promoting technology and telehealth to
support integrated care.
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\19\ https://bipartisanpolicy.org/download/?file=/wp-content/
uploads/2021/03/BPC_
Behavioral-Health-Integration-report_R02.pdf.
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Additional integration recommendations include:
Creating a definition for mental health and primary care
integration. The definition should allow for local adaptation and
flexibility in how practices implement an integrated model of care.
There are operational definitions that have been created, which may
prove useful in this process.\20\ The evidence for integration is that
patients like it, clinicians like it, it saves money from total costs,
the costs are currently borne by practices and are
unsustainable.\21\, \22\ The National Academies' report on
Implementing High Quality Primary Care published last month with
support from four Federal health agencies, points to mental health
integration in primary are as the team-based intervention most
supported by evidence.
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\20\ https://integrationacademy.ahrq.gov/products/lexicon.
\21\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5698230/.
\22\ https://jamanetwork.com/journals/jama/fullarticle/2545685.
Fixing the financing of integrated mental health in primary
care because practices typically bear the cost, one size will not fit
all, and flexible financing options will allow for practices to create
a model of care that works best for their community. I have offered an
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example below from Colorado.
Western Colorado's Rocky Mountain Health Plans (RMHP) has
pursued a comprehensive approach to mental health integration and found
the model necessary to meet the needs of their members, wherever they
choose to access care. Specifically, they have implemented enhanced,
non-volume-based payment models to promote and sustain integrated
mental health clinicians in advanced primary care sites. Their payment
models sustain services that are often not recognized in conventional
private payer or State programs, such as health and behavioral
encounters or care coordination services. These embedded mental health
clinicians provide immediate support for the emotional well-being of
patients and families and improve the overall capacity of scarce
primary care providers to serve the population.
Additionally, when extended or specialty therapy is necessary,
primary care-based providers receive reimbursement for care alongside
other provider options in the inclusive network. They admit all willing
and qualified providers promptly to their mental health provider
network, credentialing over 90 percent of all complete applications
within 45 days, often a major rate limiting factor in expanding our
workforce.
Patrick Gordon, RMHP's CEO, attributes the positive performance
of their health plans to comprehensive primary care and integrated
mental health. They routinely exceed quality benchmarks set by the
State of Colorado in their year-to-year agreements and have achieved
Commendable accreditation distinction from the National Committee for
Quality Assurance, as well as statutory and contractual financial
performance requirements that require an annual return of 2 percent
savings to taxpayers.
The key? They have embraced a new model of care that pays for
mental health differently in primary care settings. This model begins
to take us away from traditional fee-for-service codes and embraces the
power of what can happen when we push for flexibility in our financing
that supports the concept of a team working in concert to improve
health. A recent report from the National Academies reinforces this by
recommending paying for primary care teams to care for people, not
doctors to deliver services.\23\ A forceful charge to move away from
volume-driven payment mechanisms that may reinforce a siloed approach
to mental health.
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\23\ https://www.nationalacademies.org/our-work/implementing-high-
quality-primary-care.
Future Accountable Care Organization efforts and primary care
value-based payment models should include specific incentives to
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promote mental health integration.
In addition, as States move away from carved-out financial
models for mental health, new arrangements emerge that better support
integrating care. Each decision of how mental health is financed can
have an impact on how care is delivered on the ground.\24\ We should
continue to promote payment models that reinforce the concept of a team
and facilitate easier access for mental health services in primary
care.
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\24\ https://www.ohsu.edu/sites/default/files/2021-05/
McConnell%20et%20al.%20Financial%
20Integration%20of%20Behavioral%20Health%20in%20Medicaid.pdf.
Assuring that our mental health workforce is trained and
prepared to work in integrated settings.
Most mental health clinicians are trained to work in specialty
mental health settings. While some training programs have recognized
the importance of training their mental health clinicians to work in
places like primary care, without proper training, many mental health
clinicians may not adapt to a primary care culture, making it difficult
to sustain integrated efforts.
To this end, the Federal Government could consider:
Expanding financial support for continuing education
programs that prepare providers to work in integrated settings;
Increasing financial support for programs that recruit
diverse students into primary care and mental health professions and
improve access to and affordability of health-care education;
Creating learning collaboratives for integrated
programs and increasing preference for integration as a quality
improvement activity under programs like MIPS; and
Funding the incubation of new models of integrated
training for primary care and mental health professionals in medical
schools/other training institutions.
Providing technical assistance to primary care practices
looking to integrate mental health.
Integrating care requires a change in workflow and overall
practice culture. It becomes about the team and not just the individual
clinician. Practices could benefit greatly from having some form of
technical assistance to help them with this transformation. Recent
evidence from the Agency for Healthcare Research and Quality
demonstrates that this facilitation is key to enabling transformation
and for speeding it up.\25\, \26\ There are two immediate
options to help here:
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\25\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8118489/.
\26\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6827672/.
Provide appropriate funding for the Primary Care
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Extension Program; and
Establish grant funding for technical assistance for
implementation and the ongoing delivery of integrated care.
Schools
Federal policies, initiatives, regulations, and guidance are
important tools for the promotion and widespread adaption of
comprehensive school mental health systems. In addition to Federal
agencies with responsibility over the well-being of children and youth
such as the Department of Education (DOE) and the Department of Health
and Human Services (HHS), congressional champions are increasingly
leaning into their role in this space.
We have a patchwork of grants at SAMHSA, and elsewhere that either
promote school climate or integrate mental health services, and ESSA
allows flexibility, but we need an ambitious goal of making sure that
our initiatives reach every school and that they're equipped to engage
all of the school staff in promoting the mental well-being of the
students and addressing the needs of those with mental health
conditions.
Before the pandemic, clinicians were seeing alarming trends in
adolescent mental health, with increased reporting of depression,
anxiety, and suicidal ideation. Unfortunately, those trends were
accelerated by the pandemic. Emergency room visits for mental health
for adolescents 12-17 rose by 30 percent last year. To put it simply,
America's children are in trouble.
The good news is that we know what can be done to help alleviate
this mental health crisis in our youth. We want to see strong community
and family supports, and importantly we know that one of the best
chances we have to get children the mental health care they need is
actually in the one place they all have to go every day, and that's in
our school systems. The adoption of comprehensive mental health systems
in our school systems will help make sure that every child has the
opportunity to thrive, while also making sure we offer immediate help
to those who might be falling through the cracks.
Congress has a significant role to play in promoting school mental
health. Federal policies, initiatives, regulations, and guidance are
important and necessary tools for the widespread adaption of
comprehensive school mental health systems.
Congress can provide three major lanes of support to comprehensive
school mental health programs: providing funding via appropriations,
grants, and initiatives; setting up sustainable funding mechanisms and
incentives such as increasing the Federal Medicaid matching rate for
school-based health services and working with schools to support their
ability to bill Medicaid; and scaling up technical assistance centers
and programs to provide ongoing support for implementation at the
district and school levels.
However, and important to note, promoting school-wide mental health
is not a one-and-done program--it's a process of engaging staff,
students, and parents to identify needs and continuously improve. And
to accomplish this, schools need support.
Making concrete investments in school mental health won't just
address the current crisis we find ourselves in, it will pay dividends
for generations, giving all children the chance to thrive, and building
a next generation resilient and prepared workforce.
2. Reconsider the Design and Capabilities of our Workforce
To make it easier for people to access and pay for mental health
care, we need a different way of thinking about workforce--one that
helps us respond to mental health needs in a timely manner and do so in
a high quality and effective way. Solving these problems goes beyond
simply adding more clinicians.
The existing mental health workforce access challenges within our
communities are well understood. They result in the following
statistics:
Thirty-three percent of those seeking care wait more than a
week to access a mental health clinician;
Fifty percent drive more than one-hour round trip to mental
health treatment locations;
Fifty percent of counties in the U.S. have no psychiatrist;
And only 16 percent of active psychologists are from minority
populations despite comprising 40 percent of the U.S. population;\27\
and
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\27\ American Psychological Association. Demographics of the U.S.
psychology workforce: Findings from the American Community Survey.
Washington, DC, 2015.
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Only 10 percent of practicing psychiatrists are from
underrepresented minorities.\28\
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\28\ Wyse R., Hwang W.-T., Ahmed A.A., Richards E., Deville C.
Diversity by Race, Ethnicity, and Sex Within the U.S. Psychiatry
Physician Workforce. Acad Psychiatry. 2020;44(5):523-530.
There are two immediate steps we can take to best begin to address
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our workforce shortage problem.
First, we can map out mental health utilization and gaps to better
determine where services are needed and for whom.\29\ We should look at
where people are showing up for care and who is available to help.
Without this important foundational step, we run the risk of widening
disparities or putting money into places or programs people are not
using.
---------------------------------------------------------------------------
\29\ https://www.thelancet.com/journals/lanpsy/article/PIIS2215-
0366(21)00073-0/fulltext.
Second, we need to invest in our community workforce--those like
peer support specialists, community health workers, or more broadly,
lay people in our communities with no formal role or title. We train
them in mental health skills to help become the first line of mental
health support, complementing our clinical enterprise and enhancing the
overall capacity for communities to address mental health needs.\30\
Frameworks have been proposed that offer guidance on how best to
enhance our mental health workforce, and much of it begins with
strengthening our unlicensed and community-based workforce.\31\
Solutions for the mental health workforce can be broken down further
into three distinct buckets of improving our current workforce,
enhancing the pipeline for the future workforce, and creating a new
community workforce.
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\30\ https://onlinelibrary.wiley.com/doi/abs/10.1111/jrh.12229.
\31\ https://thinkbiggerdogood.org/enhancing-the-capacity-of-the-
mental-health-and-addiction-workforce-a-framework/.
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Current Workforce
We should take the clinicians we have out there in the field and
retrain or prepare them to work in new settings. For mental health
clinicians, this might be primary care or schools. We should also look
to our unlicensed workforce--peer support specialists and community
health workers and seek ways to support, finance, and scale their work.
The education, training, and development of new generations of
health professionals will be needed to address existing and expected
unmet needs in areas such as crisis care and maternal and childhood
mental health. The following steps should be taken in the short-term to
address immediate areas of unmet medical need and prepare for expected
increases in service requests once the 988 community crisis hotlines
come online in the near future.
Increase funding for Medicare residency slots. Without this,
it's nearly impossible to increase the number of clinicians like
psychiatrists. Of note, parity implementation and enforcement may also
help here considering that some clinicians eligible to bill for
services may be under-reimbursed making it less desirable to fill a
residency slot.
Make permanent 1135 waiver allowing Medicaid providers in
another State to provide Medicaid services (though State licensing laws
still apply).
Promote telehealth and other digital service options to expand
the service reach of our existing medical professionals.
Incentivize providers to take additional Continuing Medical
Education (CME) classes on current mental health best practices.\1\
Focus existing federally funded quality improvement
organizations on mental health integration across diverse primary care
practices and for serving diverse populations, and finance additional
learning collaboratives as necessary.
Future Workforce
We should provide prospective health-care professionals with the
appropriate training by making mental health a core curricular
component of medical school education. In addition, we should train our
future clinicians to understand what it's like to work within a team-
based, multidisciplinary setting and provide incentives to higher
education institutions to offer training in integrated mental health
care, through graduate medical education (GME), graduate nursing
education (GNE), and other programs.
While increasing our future workforce is necessary, it alone cannot
solve our workforce problem. The time and resources needed will always
present limitations to the numbers of new mental health and medical
professionals our Nation can train at any one time. Therefore, steps
should be taken to expand workforce capabilities in new ways to address
current and expected service needs.
Policymakers should consider the following reforms to help local
systems begin to update their local workforce capabilities:
Develop non-medical multi-discipline community workforces to
help address service requests that do not require a medical license to
satisfy. Offering up payment mechanisms like Medicare to support
critical services like peer support specialists would go a long way in
strengthening this approach.
Promote the use of innovative technologies like automated
testing and screening platforms to reduce the requirements on medical
professionals.
Develop innovating payment methods and coverage designs like
global payments to promote additional testing services from non-medical
and technology platforms to better identify and improve access to the
right care at the right time.
Community Workforce
We should empower everyone to perform tasks that traditionally
clinicians would. There's robust literature out there on it, and it
seems to solve several problems at once.\32\
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\32\ https://pubmed.ncbi.nlm.nih.gov/29914185/.
We must also recognize that there are never going to be enough
clinicians to meet service demands. Even as we reform Medicare and
Medicaid to help primary care better integrate mental health, we will
still run into the issue of finding time to undergo trainings and
recruit mental health professionals to join their practice in the short
term. And in truth, many mental health needs people have are not going
to be solved solely at a clinical level, e.g., housing, employment,
etc. Of course we will need people to be able to diagnose and
prescribe, but we also need many more people to be able to teach
important skills for navigating recovery or building a sense of
community that supports people in times of crisis. Ideally, these
skills would be spread out across many people and can mutually
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reinforce one another.
In the long term, we are likely to never have enough clinicians to
meet the community's demand without additional effort to increase the
pipeline. Like what we've seen successfully work in other countries, we
need to tap into our unlicensed yet credentialed workforce--such as
peer support specialists and community health workers--and also adopt
models that empower everyone to take on mental health at a local level.
Innovative technologies such as digital therapeutics and telehealth can
open up new access opportunities to train communities as well as reach
individuals in need.
Congress and this committee could consider grants or financing
mechanism to States to help them sort out the regulatory and multipayer
financing issues that often stymie creative and innovative ideas for
mental health.
3. Modernize Federal Programming and Operations Strategies
We must modernize and connect our Federal programs and operational
systems to collaboratively solve for common goals within communities,
and to better bring mental health into the national mainstream. Like
when corporations merge, we should do a landscape analysis and create a
national strategy for synergistic efficiencies among the 55 or more
payment systems and thousands of programs that support mental health
care in our communities today. Such a step can also help identify
redundancies and inefficiencies by allowing for modern programming
strategies to break down these silos across all Federal departments and
agencies to allow for a more cohesive system for the future. For
example, modern Federal funding and programming strategies might allow
families and individuals to access a host of different Federal health
care, workforce and educational services from multiple different
Federal agencies, departments and programs through community and health
system access routes.
There are a host of additional steps we can take such as doing a
better job of enforcing and expanding existing mental health parity
laws that equate mental health and physical or improving care
coordination for physical, mental, and behavioral care. In addition,
public and private means of coverage.
Communities and local health systems are on the front lines of
managing services critical to the mental health and well-being of all
Americans. Traditionally, the Federal Government's role has been to
provide funding and other resources to these communities to help them
manage their service needs. There are dozens of programs, funding
streams, and other Federal resources available to communities and local
health systems to support the provision of mental health services.
However, allowing local communities greater flexibility to plan,
program, and allocate these resources would allow programs the
opportunity to manage their service needs while investing in local
system innovations.
Policymakers should consider reforms to key Federal financing
authorities as a means of promoting greater local control over how
resources are programmed. At the same time, policymakers can improve
how the Federal Government plans for and allocates funds to communities
to help maximize on these critical investments and better justify new
expenditures that might be required in the future.
Policymakers should consider:
Establishing a national strategy for how the Federal
Government can establish ``smart'' or collaborative financing
strategies to improve the efficiency of Federal spending, leverage new
uses of existing funds, and create better budgetary certainty for local
communities. The 21st Century Cures Act, which became law, contained
provisions intended to establish such a strategy. Policymakers might
consider steps already taken by the agency in response to the act to
establish such a national strategy more quickly.
In 2016, there was a Community Solutions Task Force that had a
focus on solving major challenges facing communities.\33\ Congress
could use this as a model for mental health and ensure that in each
policy it works on it specifically enables cross-agency and community-
level collaboration.
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\33\ https://obamawhitehouse.archives.gov/the-press-office/2016/11/
16/fact-sheet-establishing-council-community-solutions-align-federal.
Repositioning the Family First Prevention Services Act (FFPSA)
and Community Mental Health Services Block Grant (CMHSBG) to act as
lead funding authorities for the various acts with overall
responsibility for managing and verifying performance aspects related
to Federal funds and other resource allocations meant to support the
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provision of mental health services within local communities.
Requiring the Federal Government to regularly update the
Committees of Jurisdiction in the House and Senate on the goals of the
reformed financing process including progress against those goals.
While the resources provided for by the Federal Government are
substantial, overly prescriptive Federal requirements and lack of
collaboration amongst the various Federal authorities in charge of
overseeing these resource allocations impede the ability of communities
to use these resources effectively.
As example, the Community Mental Health Services Block Grant
(CMHSBG) requires communities seeking funding to ``ensure that
community mental health centers provide such services as screening,
outpatient treatment, emergency mental health services, and day
treatment programs.'' While community mental health centers play an
important role, such requirements on local system performance
unnecessarily tie the hands of officials struggling to manage growing
service needs--especially in areas where solutions would otherwise
exist except for Federal regulation.
Reviewing the Federal requirements under existing community
mental health Federal funding streams and considering easing
requirements that unnecessarily impede care.
Including program sustainability measures with new sources of
funding or other resources meant to support the operation and
modernization activities of local systems.
Modern Federal laws like 988 promote modern programming
strategies such as program sustainability best practices combined with
local autonomy measures to ensure that local officials have sufficient
freedom to establish successful and predictable local systems for
individuals in need. The ability of local systems to improve their own
systems operations through use of information sharing that leads to
evidence development and best-practice adoption can help pave the way
for continuous system improvement. Such a ``system of learning'' can
provide Federal policymakers and local officials greater ability to
collaborate and plan for program modernization today and in the future.
Developing information-sharing and best practice development
processes to provide local communities and Federal policymakers
insights into the need for and design of future reforms.
While the above areas are the three priorities I have chosen to
focus on for today--reimagine care delivery, reconsider the design and
capabilities of our workforce, and modernize Federal programming and
operations strategies--outlined below are several other notable issues
this committee should consider.
Other Issues and Recommendations to Consider
Mental health parity and health insurance coverage
The Finance Committee could take aggressive steps to ensure
parity enforcement in Medicaid managed care and expansion populations,
which is critical to both mental health equity and racial equity. There
could now be an opportunity to engage consumers in setting key
indicators of access and track progress with intensive oversight from
CMS/CCIIO.
The Finance Committee could ensure parity be applied to
Medicare and Medicare Advantage. This will require eliminating
discrimination against MH/SUD that is baked into title XVIII of the
Social Security Act, and ensuring the full continuum of services are
covered, including all intermediately levels of care.\34\
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\34\ https://www.realclearpolicy.com/articles/2020/12/30/
medicare_must_cover_mental_health
_654797.html.
The Finance Committee could require Medicaid and Medicare
Advantage plans to follow Generally Accepted Standards of Care and use
level of care criteria from non-profit clinical specialty associations
as outlined in the Federal case Wit v. United Behavioral Health.
988 and crisis response
The Finance Committee could make the CAHOOTS enhanced match
permanent and extend it to a comprehensive range of crisis services to
create a continuum beyond response.
The Finance Committee could make sure Medicare and commercial
insurance plans cover crisis services and look to Medicaid crisis
benefits as a model.
______
Questions Submitted for the Record to Benjamin F. Miller, Psy.D.
Question Submitted by Hon. Catherine Cortez Masto
Question. In your testimony you noted that it is ``inconceivable to
rely upon clinician recruitment strategies alone to meet our ever-
growing need.'' Stakeholders across the behavioral health spectrum--
including policymakers--are looking at overwhelming workforce
challenges.
You mentioned peer support services as one solution. Can you
elaborate on how peers help to address unmet need?
Answer. Bringing a workforce that has experience, both firsthand
and through additional training, into clinical and community settings
can be a powerful tool in enhancing the capacity of our systems and our
frontline licensed workforce. And the evidence is clear that peer
support services (PSS) work.1 In fact, in 2007 CMS lifted up PSS as an
evidence-based practice, and--while Medicare still does not pay for
these services--many State Medicaid programs have adopted the model.
There are three characteristics that stand out about PSS.
First, as the name implies, they are peers to those they are
serving meaning they have some form of personal or lived experience. In
the mental health and addiction field, having a person that knows the
challenges of what you are going through can be a powerful tool for
healing unto itself.
Second, these peers are equipped with skills that not only allow
them to be more than supportive, but also to intervene with evidence-
based skills that can be further beneficial to the person they are
trying to help. This allows peers to provide higher-touch care than the
current workforce would allow, while also ensuring that other
clinicians work at the top of their licensure.
Third, PSS can offset the load placed on clinicians and become an
extension of clinical services and clinical settings. When we look at
wait times for clinicians, it forces us to begin to look to more
creative ways to help people in a more expeditious timeframe. PSS do
just that--there is an endless supply of individuals with lived
experience who can be trained as peers.
For PSS to scale, however, it could benefit from several policy
changes. Medicare and most commercial health insurers do not cover PSS,
as well as other mental health crisis services, Assertive Community
Treatment, Coordinated Specialty Care (for early psychosis), and other
team-based interventions. Allowing PSS services to be eligible for
Medicare payment would go a long way in helping expand this service
line.
In the immediate term, the committee could ensure that mental
health and substance use peers could be offered as a supplemental
benefit by Medicare Advantage plans, and that they can offer PSS
services in the context of integrated mental health care already
billable under Medicare, as the recently introduced PEERS Act of 2020
in the House would support. Peers also have a clear role in promoting
value in Medicare Accountable Care Organizations (ACOs), and the
committee could direct CMS to provide technical assistance to ACOs to
better integrate PSS.
And while outside of the scope of PSS specifically, it is important
to note that Medicare only covers certain licensed mental health
clinicians (e.g., LCSW, psychologists) to bill for services, which
leaves a major challenge in building and diversifying the clinical
workforce. Medicare has not updated its mental health provider
licensure standards since 1989 and is still unaccountable to the Mental
Health Parity and Addiction Equity Act. This presents major gaps in
coverage for Medicare beneficiaries and can further interrupt
continuity of care--leaving families to pay out of pocket or forego
essential care entirely. It seems time to modernize Medicare policies
for mental health in general and address PSS as we do so.
______
Questions Submitted by Hon. John Barrasso
Question. The health-care professionals, along with all front-line
workers, deserve our gratitude and appreciation.
Their dedication to our communities during this pandemic is
something we must recognize and never forget.
A top concern of Wyoming mental health facilities is making sure
there are enough staff to care for their patients. It is especially
challenging to attract and keep health-care providers in rural
communities.
Can you discuss solutions related to workforce development you
believe will improve the ability of mental health facilities to attract
and maintain staff in rural areas?
Answer. Mental health workforce recruitment and retention is a
major need, especially in rural communities. And while I will address
this issue, I think it's critical that we think beyond simply finding
more clinicians and opening up the pipeline. As I have written about in
my testimony, only choosing to focus on these pipeline issues,
including attracting the right kinds of clinicians to the settings they
are most needed, does not provide immediate relief nor does it enhance
a mental health clinic or systems capacity to see more people. If our
focus can become on better creating new pathways to allow for
individuals to be identified and treated, it's inevitable that new
solutions emerge beyond just a clinical workforce.
I believe that Congress and this committee should pursue options
like Community Initiated Care (CIC), a concept based on a rich
evidence-based often called ``task-sharing'' or ``task-shifting.'' This
is a model of intervention that is not dependent on licensed clinicians
and has shown to be highly effective by allowing non-specialized,
trained workers, and even ``lay'' members of the community to learn
mental health skills.\1\
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\1\ https://www.commonwealthfund.org/publications/2021/feb/making-
it-easy-get-mental-health-care-examples-abroad.
Community initiated care is a broadly inclusive concept that
democratizes knowledge and empowers individuals to learn how to respond
to mental health and addiction issues. Effective components include
training and supporting community members to ensure that they acquire
the knowledge, skills, and competencies necessary to deliver high
quality evidence-informed programs for prevention and early
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intervention of mental health concerns.
Bringing more mental health skills into the community can help
solve several issues at once--it can make the workforce more readily
available because we are creating capacity for communities to intervene
on issue of mental health and addiction.
To this end, Congress and this committee could consider grants or
financing mechanism to States to help them sort out the regulatory and
multi-payer financing issues that often stymie creative and innovative
ideas for mental health like the community initiated care model
described above. Offering up payment mechanisms like Medicare to
support critical services like peer support specialists or a community
workforce could go a long way in strengthening this approach and making
it more viable. SAMHSA could push out pilot programs with community
health workers, community-based organizations, and other community-
based non-professionals to deliver psychological interventions based on
the learnings from global mental health. Currently, SAMHSA funds
gatekeeper type programs through non-specialists as well as peer-
specialists programs, but there has been less support for these
community based models. A final option is to consider pilot programs
with additional funds through block grants if States commit to
exploring the community initiated care approach.
Question. Can you specifically discuss changes to GME policy you
believe would improve the pipeline of mental health physicians?
Answer. The first step to growing our pipeline of mental health
clinicians is to increase funding for Medicare residency slots. Without
this, it will be nearly impossible to increase the number of clinicians
like psychiatrists.
Parity implementation and enforcement may also help here,
considering that some clinicians eligible to bill for services may be
under-reimbursed. A lack of reimbursement makes mental health a less
desirable residency slot.
So too would modifying primary care residency training programs.
Primary care remains one of the largest platforms for mental health
delivery in this country. However, not all residency programs train the
future workforce much in mental health--family medicine training
programs do train their residents in mental health and in most cases,
expose them to onsite mental health clinicians who they can work and
train beside. Internal medicine and pediatrics residents get much if
any such training.
To change this, we should create mental health training
requirements in all primary care residency programs modeled off of
family medicines current requirements. In addition, residency programs
should also require and support mental health integrated in primary
care so that all trainees are acculturated to working in such models
and can advocate for them later. If medical education had additional
resources and incentives to bolster mental health and substance use
training for more categories of clinicians, this would further extend
the workforce.
In addition, I shared some ideas in my testimony that I feel could
be additive to changes in GME policy. For example:
Make permanent 1135 waiver allowing Medicaid providers in
another State to provide Medicaid services (though, State licensing
laws still apply).
Promote telehealth and other digital service options to expand
the service reach of our existing medical professionals.
Incentivize providers to take additional Continuing Medical
Education (CME) classes on current mental health best practices.
Focus existing federally funded quality improvement
organizations on mental health integration across diverse primary care
practices and for serving diverse populations, and finance additional
learning collaboratives as necessary.
Question. As a doctor, I strongly support increasing access to
mental health services, especially in rural communities. Senator
Stabenow and I have previously introduced legislation for many years
that would allow mental health counselors and marriage and family
therapists to receive reimbursement from Medicare.
Can you discuss how the Department of Health and Human Services can
improve access for mental health services, especially for those on
Medicare?
Answer. One of the best ways to improve access to mental health
services is to first consider who is eligible to bill what, where, and
for whom.
CMS can ensure that Medicare payments for mental health integration
are properly valued and that primary care clinicians have the necessary
support and technical assistance they need to implement integrated
care. Implementing integrated care models requires time, effort, and
practice expenses that may not be fully captured in the current
valuation. Further, interested clinicians might not have access to
resources they need to set up integrated care in their practice. CMS
should work with clinicians to identify barriers for the adoption of
integrated care in Medicare, including misvaluing of codes, to ensure
that beneficiaries get access to effective care.
Recently, CMS launched the Community Health Access and Rural
Transformation (CHART) model, which could be a promising approach to
building the infrastructure for defragmentation and care transformation
in rural America. One strategy that HHS could consider is building on
the Community Transformation Track of the CHART model but with a
specific focus on ensuring comprehensive access to mental health and
substance use treatment, unlocking the full range of innovations from
virtual care, peer support services, and integrated care models.
The committee could also work with CMMI to ensure that alternative
payment models (APMs) currently in progress adequately incentivize
implementation of integrated care for Medicare beneficiaries. Model
evaluations indicate that past APMs have had little effect on mental
health outcomes. However, as mental health has been subject to chronic
underinvestment--especially in rural communities--it counts against the
benchmark for shared savings when providers implement effective early
intervention (such as integrated care models), unless it very rapidly
reduces hospitalizations. To address this issue and incentivize
investment in early intervention, CMMI could:
Adjust risk adjustment in ACOs, CPC+, and others to
accommodate expected costs from integrated care in mental health, and
pair with appropriate quality measure recommendations to ensure
accountability; or
Temporarily waive costs from integrated care models
from shared savings calculations.
Question. In particular, can you comment on the merits of allowing
licensed professional counselors and marriage and family therapists to
receive reimbursements from Medicare?
Answer. Allowing other mental health clinicians outside of
psychologists and licensed clinical social workers the chance to bill
Medicare could be a slight help in our never-ending numbers game for
the clinical workforce--how to get more. There are several benefits to
allowing LPC and LMFT to bill Medicare, but the top one is infusing
thousands of new clinicians into the workforce.
______
Questions Submitted by Hon. Tim Scott
Question. The toll that union-sponsored excuses for ``virtual
learning'' has taken on actual kids is extraordinarily sad, especially
for our Nation's most vulnerable children. In October 2020, a survey
conducted by the Jed Foundation showed that 31 percent of parents said
their child's mental or emotional health was worse than before the
pandemic. Private insurance data also shows that while all health-care
claims for adolescents ages 13-18 were down in 2020 compared to 2019,
mental health-related claims for this age group increased sharply.
Additionally, the Centers for Disease Control and Prevention (CDC)
reports 25 percent of parents whose children attended school virtually
were more likely to report an overall worsened mental or emotional
health compared to only 16 percent of parents of children attending
school in-person.
What programs within the Department of Health and Human Services'
(HHS) purview are best poised to support children and schools as they
return to complete in-person learning?
Answer. Each agency within HHS offers incredible programs to help
support our Nation's children. This includes Project AWARE at SAMHSA,
Healthy Schools at CDC, school-based billing under Medicaid, support
for school-based health centers at HRSA, and support for families'
social and economic needs via the Administration on Children, Youth,
and Families (ACYF).
The biggest problem with these programs is scale--these programs
benefit the grantees, but don't help most of the children who need
them.
To meet this moment, interagency collaboration is needed to
coordinate and leverage all available resources to support States and
local school systems to provide effective mental health supports for
their students. CMS also needs to work with States to help them
streamline appropriate billing for mental health services in schools
under Medicaid. Several advocacy organizations have also offered up the
idea of creating a White House Office on Children and Youth, and/or a
Federal Children's Cabinet to help specifically on many of these issues
above.
Question. How can we integrate more telehealth opportunities to
expand access to mental health services in schools?
Answer. Congress has already done incredible work promoting access
to virtual mental health consults for children in primary care by
funding HRSA's Pediatric Mental Health Care Access Program. Congress
can integrate more telehealth opportunities in schools by expanding
this program further initiating a similar program to support
integration with schools as well. As part of this work, CMS can provide
technical assistance to States for ensuring that their current approach
to Medicaid billing supports telehealth for children's mental health in
schools. With these investments in infrastructure and attention to
sustainability, millions more children can gain access to virtual
mental health services where they are--in schools.
We should also allow States to continue utilizing telehealth
flexibilities put in place during the pandemic which facilitate schools
both delivering mental health services and billing Medicaid for those
services. For example, during the pandemic audio only was an allowable
modality of telehealth services, both in terms of being able to deliver
services and bill for services delivered using audio only. Other
flexibilities include allowing school districts to access out of State
providers for telehealth which helps address some of the workforce
shortage issues and in general, just allowing school health provider
types to bill Medicaid for services delivered.
Congress should also support States in expanding their school
Medicaid programs. States that had expanded their school Medicaid
programs to allow for billing for non-IEP (individualized education
program) services were able to do significantly more Medicaid claiming
for telemental health services.
And finally, there should be guidance issued to schools on how best
to utilize telehealth to expand access to mental health services in
schools. More guidance is needed to help States and school districts
navigate Federal policies around telehealth, including reimbursement
procedures.
Currently, there is no designated guidance on telehealth for
schools, and it would be a perfect opportunity for cross-agency
collaboration to develop a piece that supports school districts in
expanding access to mental health services in schools via
telehealth.\2\
---------------------------------------------------------------------------
\2\ https://healthyschoolscampaign.org/dev/wp-content/uploads/2021/
03/Providing-Health-Services-During-School-Closures-March-2021.pdf.
Question. Telehealth has expanded rapidly as a result of the COVID-
19 pandemic. Numerous studies have demonstrated the effectiveness of
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telehealth for behavioral health services.
As telehealth becomes more common among health-care providers, what
can Congress do to ensure that patients do not suffer from unnecessary
bureaucratic delays?
Answer. It's going to take time for Congress to ensure that every
American has access to broadband--this is needed so that everyone has
access to telehealth and that existing disparities aren't made worse.
However, in the interim, to make sure the greatest number of American
can most immediately access telehealth services, Congress should make
permanent some of the policies they temporarily put in place during the
pandemic. Congress should make audio-only telehealth services
permanent, enact payment parity, and allow for telehealth to be
available for all forms of outpatient care.
Question. There is a well-researched connection between
unemployment and mental health. As recently as April 2021, despite
billions of dollars of COVID-19 stimulus, aggregate employment remained
7.9 million jobs below its pre-recession level.
What impact will this failure to get people back to work have on
mental health?
Answer. There is a well-researched connection between unemployment
and mental health, but it just makes sense: financial insecurity can
increase stress, and stress can exacerbate underlying mental health and
addiction issues.\3\
---------------------------------------------------------------------------
\3\ https://wellbeingtrust.org/wp-content/uploads/2020/05/
WBT_Deaths-of-Despair-COVID-19-FINAL.pdf.
Unfortunately, despite billions of dollars of COVID-19 stimulus
funds, as recently as April 2021 aggregate employment remained 7.9
million jobs below its pre-
recession level. And the longer it takes use to close that gap, the
great risk we run of seeing an increase in the number of lives lost to
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suicide and drug overdoses.
Question. Last November, an article published in the Journal of the
American Medical Association noted that multiple studies indicated that
older adults may be less negatively affected by certain mental health
outcomes than other age groups.
Are these study outcomes consistent with your own professional
experiences working with older adults?
Answer. That study found that older adults appeared to experience
less mental health impacts during the early days of the COVID-19
pandemic that other age groups. The article also notes the following:
The data from various studies contrast the numerous personal
stories about how difficult the pandemic has been for the older
population. This divergence likely represents the heterogeneity
that is a hallmark of aging. Also, resilience captured at the
population level may not translate to individuals in specific
circumstances. Thus far, there is not a clear understanding of
which risk factors and protective factors are the strongest
determinants of mental health outcomes, although these may vary
from person to person.
Many older adults do not have the resources required to deal
with the stress of COVID-19. This may include material (e.g.,
lack of access to smart technology), social (e.g., few family
members or friends), or cognitive or biological (e.g.,
inability to engage in physical exercise or participate in
activities or routines) resources. Clinicians and caregivers
must estimate resource availability and consider how the
absence of resources can be mitigated for a given individual
and family. Of particular importance is the role of technology,
which has emerged as an important factor for maintaining social
connection as well as accessing mental health services.\4\
---------------------------------------------------------------------------
\4\ https://jamanetwork.com/journals/jama/fullarticle/2773479.
In general, older adults are heavily impacted by mental health
problems, although in different ways than their younger counterparts.
For example, among men, suicide rates are the highest for those over 75
years of age.\5\ Other recent studies find relatively consistent
prevalence of depression across adulthood.\6\ Although risk factors
evolve with age, mental health remains a serious issue and older adults
often do not have access to appropriate care that meets their
particular needs. This is in part why any conversations on Medicare
reform must begin to address the deficiencies in the program for mental
health and substance use disorders.\7\
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\5\ https://pubmed.ncbi.nlm.nih.gov/32487287/.
\6\ https://www.cdc.gov/nchs/products/databriefs/db303.htm.
\7\ https://www.realclearpolicy.com/articles/2020/12/30/
medicare_must_cover_mental_health_
654797.html.
Question. Current network adequacy standards often allow networks
of specialists who aren't taking new patients or who have long waiting
lists. That means that many people needing treatment must go out of
network to get care, and only those who can afford the high cost get
it. One of the biggest challenges to access to behavioral health-care
services is that many behavioral health specialists don't participate
---------------------------------------------------------------------------
in health plan networks.
Why is that, and how can we change that?
Answer. The consequences of inadequate networks can be devastating
for American families. Inadequate networks are a major driver of
enormous disparities in out-of-network utilization for mental health
and substance use disorder (MH/SUD) treatment compared to physical
health care. Patients are far too often forced to find out-of-network
MH/SUD services because in-network services are not available, and are
therefore exposed to much higher out-of-pocket costs, balance billing,
and more aggressive insurer utilization controls. Data from Milliman
shows out-of-network MH/SUD utilization for both inpatient and
outpatient facilities is more than five times higher than out-of-
network physical health utilization.\8\
---------------------------------------------------------------------------
\8\ Steve Melek, et al., Addiction and mental health vs. physical
health: Widening disparities in network use and provider reimbursement,
Milliman, November 19, 2019, https://assets.
milliman.com/ektron/
Addiction_and_mental_health_vs_physical_health_Widening_disparities_
in_network_use_and_provider_reimbursement.pdf.
Strong network adequacy standards are essential to ensuring access
to MH/SUD care. Unfortunately, for many types of health plans, network
adequacy standards are weak, if existent all, and often qualitative in
nature. Weak standards effectively contribute to inadequate networks
that result in Americans not receiving the MH/SUD services they need,
at enormous cost to individuals, families, and our society. For
example, while Federal law requires Medicaid managed care and
Affordable Care Act qualified health plans (QHP) to maintain adequate
networks, Federal law simply defers to a hodgepodge of State regulatory
standards, which often fail to establish concrete access standards that
are plainly transparent to consumers, providers, and health plans
alike. According to a recent report by the Legal Action Center, only
seven States have created standards for State-regulated plans relating
to the three most meaningful network adequacy measures: appointment
wait times, provider/enrollee ratio, and distance standards.\9\
---------------------------------------------------------------------------
\9\ Ellen Weber, Spotlight on Network Adequacy Standards for
Substance Use Disorder and Mental Health Services, Legal Action Center,
May 2020, https://www.lac.org/resource/spotlight-on-network-adequacy-
standards-for-substance-use-disorder-and-mental-health-services.
Importantly, self-funded health plans subject to the Employee
Retirement Income Security Act of 1974 (ERISA), which are exclusively
regulated by the U.S. Department of Labor, are not subject to any
legally imposed network adequacy standards at all. Given that the
majority of Americans in ERISA plans are covered by self-funded plans,
this significant gap in law leaves tens of millions of Americans
---------------------------------------------------------------------------
without a right to adequate networks.
Strong, quantitative network adequacy requirements should be
expanded to all types of health plans. These requirements should
include provider/enrollee ratios that only measure providers who are
active plan providers (measured by billings within the last 6 months to
prevent ``ghost'' networks), as well as appointment wait times (i.e.,
timely access standards) and distance standards. Timely access and
geographic standards directly measure patient access to care and should
be required together. After all, care that is theoretically available
now but at a great distance or theoretically available nearby but not
when needed is tantamount to no care at all. All health plans that
cannot ensure suitable, timely and geographically accessible in-network
care should be required to cover the cost of out-of-network treatment,
without any additional cost-sharing for patients.
Standards should be set, measured and enforced separately for MH
and SUD providers, with requirements that plans meet timely access,
distance, and patient/
enrollee ratios for the full range of provider types and settings that
are necessary to treat MH/SUD. While telehealth should be allowed to
help plans meet network adequacy requirements in areas with few
providers (e.g., rural areas), the availability of telehealth providers
should not be allowed to replace patients' ability to access in-person
care.
Placing the obligation of maintaining adequate networks on health
plans--particularly by requiring health plans to pay for out-of-network
care without additional cost-sharing by patients--is the only way to
ensure that patients are not continuously victimized by insurers'
phantom networks and inaccurate provider directories. Only when
insurers must bear the financial risk of out-of-network coverage will
they have sufficient incentive to maintain accurate provider
directories and recruit sufficient providers into their networks.
Question. Outside of the public health emergency, telehealth
services are restricted to certain geographic and clinical settings.
Beneficiaries must live in a rural area and have an initial face-to-
face visit with the distant-site provider. Once a relationship has been
established, periodic in-person visits are also required. With few
exceptions, patients must be located in a clinical setting and may not
receive care from their homes. In addition, the distant- site provider
cannot be located in a rural health clinic or FQHC.
Telehealth has been used broadly during the pandemic to expand
health-care access to individuals throughout the country. During the
pandemic, Medicare significantly expanded the coverage of telehealth
services. A recent Bipartisan Policy Center poll suggests that people
receiving mental health and substance use services want a combination
of in-person, video, and telephone services even after the pandemic has
passed.
What telehealth expansions should remain after the pandemic?
Answer. Telehealth has been used broadly during the pandemic to
expand health-care access to individuals throughout the country, as
Medicare significantly expanded the coverage of telehealth services.
Outside of the public health emergency, telehealth services are
restricted to certain geographic and clinical settings. Beneficiaries
must live in a rural area and have an initial face-to-face visit with
the distant-site provider. Once a relationship has been established,
periodic in-person visits are also required. With few exceptions,
patients must be located in a clinical setting and may not receive care
from their homes. In addition, the distant-site provider cannot be
located in a rural health clinic or FQHC. These are all barriers that
will emerge again if the emergency order provisions for telehealth
expire--with consequences. For example, placing an in-person
requirement back on the patient works against patients as it restricts
access to telehealth for those individuals with transportation issues,
those in provider shortage areas, or other access barriers. It also
prevents the use of telehealth for new patients experiencing a crisis.
The uptick in telehealth utilization for mental health signals that
people enjoy when care comes to them--and Americans should continue to
have that choice post-pandemic. That's why Well Being Trust supported a
Bipartisan Policy Center report earlier this year that highlighted the
importance of removing site of service, geographic, and established
patient restrictions for telehealth services.\10\ In addition, it
called for the elimination of the two-way video requirement, which will
begin to help address the digital divide and access disparities for
those without broadband or video technology.
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\10\ https://bipartisanpolicy.org/report/behavioral-health-2021/.
Congress should make permanent audio-only telehealth services,
enact payment parity, and allow for telehealth to be available for all
forms of outpatient care. Congress therefore must also, as many have
pointed out, make sure broadband is accessible and affordable as to not
further disparities, and encourage that we ask clinicians using
telehealth services to measure outcomes to show that they work for
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mental health.
______
Questions Submitted by Hon. John Cornyn
Question. Your testimony provides a piece to the puzzle of mental
health policy that our Nation is currently lacking: strategy. I would
like to follow up on this point with a few questions.
Your testimony included thoughts on how the Senate Finance
Committee and U.S. Senate should pursue reforms for immediate problems
strategically so that these efforts can also allow communities to begin
modernizing local systems of mental and behavioral health.
Could you elaborate on those thoughts?
How should Congress pursue legislation to support these twin goals?
Answer. Good mental health is foundational to the health and well-
being of every American. Our society, however, treats mental health all
too often as a system of medical services for people experiencing a
mental health crisis. It spends very little time investing thinking
about how we can prevent some of these episodes from occurring in the
first place or how to help young people develop strong foundations and
self-care tools so that individuals might avoid a mental health crisis
in the first place.
Immediate steps need to be taken by Congress to address unmet
medical needs such as increasing the availability of the workforce to
manage the expected increase in call volume from 988. S.B. 1902 holds
great promise in helping address this issue by clearly laying out
standards for what should be in a crisis continuum, assuring
comprehensive coverage of these services, and finding sustainable
funding mechanisms.
However, any legislative vehicle required to pass these reforms
could also be used to lay the groundwork for a modern, more wholistic
approach to solving our Nation's mental health needs. We need to get
ahead of our problems if we are to solve many of them, and reforms at
the local level are needed to get us there. We can achieve this by
creating opportunities for Americans at all stages of life to
participate in mental health and well-being.
First and foremost, we need to enhance the capabilities of local
workforces and programs to increase service availability for local
communities. Some of that can be addressed through medical professional
workforce development but we cannot solve our need for services through
them alone. The development of non-medical community workforces and use
of digital therapeutics are two steps that Congress can undertake to
broaden the response beyond the need to increase the numbers of local
medical workforces. The benefits of the overall availability of
services within local communities should have the added benefit of
taking some of the burden off of health professionals thereby allowing
them greater capacity to address the most severe cases.
Second, I believe the Federal Government needs to reimagine its
approach to funding mental health and addiction services in local
communities. There are numerous autonomous Federal funding streams and
other resources that have been developed over the years but no
comprehensive strategy for how they all work together to best support
Federal interests. This lack of coordination and differing funding
authorities needlessly places undue administrative burden and cost on
communities which can lead to inefficient spending and diminished
results. outdated approaches to addressing mental health and addiction
issues are contributing to ineffective community approaches that don't
do enough. Communities in this country need to go through the same type
of process to reimagine local operations--a process to help them reform
and hold them accountable for improved operations and programming could
help improve the effectiveness of the Federal effort even further.
Third, establishing foundations for good mental health should begin
early. Our formative years, from birth through the age of 18, are
critical to an individual's overall mental health and well-being.
Creating early opportunities for education and the development of self-
help tools to help a person manage mental health throughout their lives
can go a long way to preventing some medical issues before they arise,
and help every American build the tools they will need to succeed.
There is an immediate need to reinforce this approach right now in our
schools, assuring that the staff, the students, and all those connected
have access to mental health services and supports.
Lastly, there are concrete steps that Congress can take to improve
local health system approaches to mental health care. Some of these
ideas are already being advanced by members of the Senate. Others I am
happy to provide.
Legislatively speaking, I believe that the Senate Finance Committee
has unique statutory authority to lead the charge on larger reform.
While a comprehensive solution will need to involve the Public Health
Service Act as well, the Family First Prevention Services Act presents
a unique model that if adapted could help initiate the type of system
and generational reforms that are needed today. In the interest of
helping support your efforts, I am in the process of developing a draft
legislative outline for your consideration and should be delivering
that to you in the next couple of weeks.
Taken together, these steps can begin to create opportunities for
Americans at all stages of life to pursue and embrace mental health and
well-being.
Question. Your testimony touched on a key concept--updating Federal
approaches to funding care for local communities.
How can we more efficiently spend Federal funds already allocated
today to local communities?
Also, in what ways can modern technologies improve community and
Federal Government return-on-investments?
Answer. The Federal Government spends very inefficiently on mental
health and addiction care. There are dozens of Federal programs and
authorities created over the years by Congress with no overarching
Federal strategy for how they are to work together. This fact
contributes to duplicative and other wasteful spending practices.
In addition, some of the Federal rules governing these
authorities--such as spending requirements that prevent long-term
planning of awarded funds--encourages wasteful and inefficient spending
by communities fearful of missing out on Federal dollars. The lack of
an overarching strategy for how the Federal Government funds
communities, combined with the time and cost of running separate
regulatory channels, needlessly adds administrative burden on both
communities and Federal officials as well.
As for communities, being more efficient with Federal funds need
not only rely upon spending efficiencies alone. For instance, there are
numerous programmatic improvements already vetted and proven to save
money (under the Family First Prevention Services Act and other
sources) that many local communities have failed to adopt. In addition,
self-sustainability provisions and other mechanisms to ensure efficient
programming and spending can be added to reform efforts to ensure they
maintain fiscal integrity.
Digital technologies offer other options for improving access while
improving spending efficiencies. Digital therapeutics (like cognitive
behavioral therapy) offer communities alternative sources of medical
service without the commiserate cost of training and employing medical
professionals. Best practice and evidence development aided by modern
digital technologies such as AI can help systems identify where future
improvements can be made.
Digital therapeutics along with non-medical workforces also have
the added benefit of freeing up medical professionals so that they can
focus on the highest-acuity patients. Where local systems are able to
recognize and use such alternative service providers, access to care
can increase beyond what a traditional workforce can provide--at a
lower cost.
Question. You write in your testimony that, ``we need to bring
mental health care to where people are.'' This includes schools,
workplaces, and primary care. As primary care is the largest delivery
of health care this inclusion makes sense, but as you note, there are
some barriers.
Can you expand on this thinking?
Answer. Bringing mental health care to where people are is a way of
speaking to the need to engage individuals in all phases of their lives
in ways most conducive to securing engagement. Fragmentation of mental
health and addiction care has made it an ongoing challenge for people
to get easy and timely access to services. By bringing care to where
people are, we begin to offer more timely opportunities for engagement
and lessen the likelihood that a person does not get much-needed care.
Delaying care does not lead to improvement--we must be more responsive
to our communities needs by assuring care is integrated into the
settings they present. We need to pursue novel models that integrate
care and support those models with the appropriate payment mechanisms.
Erasing the stigma and improving societies embrace of mental health
can best be achieved by engaging people at all stages of life. The
stigma of mental health and addiction in our society may be one of the
biggest barriers our Nation faces. As a society, we are taught by
example to avoid talking about or seeking help for mental illness and
give little thought to building familiarity with the pursuit of well-
being. Parents typically do not realize the extent to which their own
behavior is held up as a model for children. Society does not typically
teach children the basics of mental health or the importance of
building self-care tools early on as a means of preparing for the years
to come. As we grow older, there are many different things that can
reinforce these avoidance lessons. The net result is a community
approach that encourages people to ignore mental and behavioral issues
until they manifest as health-care issues. By then, our lack of
familiarity with these areas makes treatment very difficult on people
who may have a long course of treatment and recovery ahead of them.
If we are to achieve more positive outcomes in areas of mental
health and addiction, we need to break this stigma for current and
future generations. For those alive today, that means finding ways to
engage people who might otherwise avoid these issues altogether. Each
generation alive today can benefit from opportunities to engage in
mental and behavioral well-being. If we are to succeed in breaking the
stigma for them, we need to create opportunities that relate to where
they are in their lives. For children, basic education on the ABCs of
mental health can help establish familiarity and strong foundations
upon which to deal with issues of mental and behavioral health later in
life. For families of young children or those expecting, educational
and medical services for mental health can be better integrated in the
physical care model in a physician offices or other site of service.
For adults and seniors, access to wellness, treatment, and referral
services through community workforces or community access points like
employers can help begin to break down barriers and make it easier for
people interested in taking the next step to more easily find answers.
All policies should be scrutinized for how they limit a person
getting access to mental health care--in some cases further fragmenting
care--and how they may inadvertently reinforce stigma.
______
Prepared Statement of Hon. Ron Wyden,
a U.S. Senator From Oregon
The Finance Committee meets this morning to discuss mental health
care in America. This issue ought to bring Democrats and Republicans
together, starting with a single, clear lodestar: every American must
have mental health care when they need it.
The shameful reality is, the United States does not come close to
meeting that bar today. Multiple Federal laws say that mental health
care is supposed to be on a level playing field with physical health
care. In practice, however, the system still reflects the dangerous,
old stigma against recognizing and treating mental illness, and that's
why millions of people are falling through the cracks.
For someone with a mental illness, it can be nearly impossible to
find a provider who can meet your needs, or one who accepts insurance--
particularly in rural areas or in communities of color. Insurance
claims too often get denied or cut off too quickly. Particularly for
those experiencing homelessness, the outcome of a mental health crisis
is too often incarceration instead of treatment.
Prior to the pandemic, one in five Americans was living with a
mental illness. All the evidence suggests the pandemic is adding to the
crisis. The proportion of Americans reporting symptoms of anxiety or
depression has nearly quadrupled. On Friday, the Centers for Disease
Control and Prevention released a new report finding that over the last
year, suicide attempts among teenage girls were up by more than 50
percent. Meanwhile, a study the Government Accountability Office
conducted at my request found that many provider offices closed or cut
staff during the pandemic, resulting in too many patients turned away.
There's a lot for this committee to work on. There are a few key
challenges. First, the country needs a larger mental health workforce.
There simply are not enough providers, whether it's psychiatrists or
therapists or staff in inpatient facilities. For example, due to a
major staffing shortage, the psychiatric hospital in Salem is currently
being staffed in part by members of the Oregon National Guard. That's
in a State capital, where there are people and resources focused on
this issue. Other areas have it worse. More than one in three Americans
lives in an area with a severe shortage of mental health professionals.
Second, insurance companies must not cut corners when it comes to
mental health coverage. This issue comes up all the time during town
hall meetings I hold in Oregon--people describing having their claims
denied. In other cases, insurance only covers a portion of the
treatment people need. Furthermore, it doesn't make any sense to leave
somebody experiencing a true mental health crisis waiting for a green
light from an insurance company before they can get treatment.
Third, this committee must address the racial inequities in mental
health care. Black and Latino Americans are roughly half as likely as
white Americans to receive treatment for a mental illness. Suicide
rates are much higher among black children. There aren't enough black,
Latino, and Native American mental health providers. This is a basic
matter of health-care equity, and there's a long way to go.
Finally, the Finance Committee ought to build on areas of recent
progress. For example, early in the pandemic this committee led the
fight to get Medicare to cover mental health services via telehealth.
In December, the Congress made that permanent. This is going to be a
game changer, particularly for seniors who live in rural areas. It
would work outside of traditional Medicare too.
Senator Stabenow has long been a champion of mental health care.
Today the committee will hear about the success of Certified Community
Behavioral Health Clinics, a program she fought for and created. These
clinics are up and running in 40 States, including Oregon. It's an
approach that works, and it's meeting big needs. I believe the Congress
ought to look at ways to build on its success.
In March, the Congress also passed a big down payment for a
pioneering new approach on mental health services and law enforcement
called the CAHOOTS program. It originally comes from Eugene, OR, and it
has expanded in bigger cities and rural areas around the State. Under
this approach, when there's a 911 call dealing with someone
experiencing a mental health crisis, CAHOOTS sends trained health
professionals as first responders instead of just police. Health-care
providers like it; law enforcement likes it. The American Rescue Plan
included a billion-dollar down payment to help States build their own
programs like CAHOOTS. Now the Congress needs to consider what comes
next to build these programs successfully and make sure people are
getting the help they need, even after the immediate crises end.
It's clear there's a lot of work to be done. Members on both sides
have important ideas addressing these issues and more. I want to
continue working with members in the weeks ahead, because I believe
there's a big need and a big opportunity for legislation on mental
health.
Communications
----------
American Academy of Family Physicians
1133 Connecticut Ave,. NW, Suite 1100
Washington, DC 20036-4305
(800) 794-7481
(202) 232-9033
June 25, 2021
The Honorable Ron Wyden The Honorable Mike Crapo
Chairman Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
Washington, DC 20510 Washington, DC 20510
Dear Chairman Wyden and Ranking Member Crapo:
On behalf of the American Academy of Family Physicians (AAFP) and the
133,500 family physicians and medical students we represent, I applaud
the committee for its consideration of the mental health challenges in
the U.S. I write in response to the hearing: ``Mental Health Care in
America: Addressing Root Causes and Identifying Policy Solutions'' to
share the family physician perspective and the AAFP's policy
recommendations for ensuring all patients who need mental health care
are able to access it.
Mental illness is highly prevalent in the United States and is
associated with an increased risk of morbidity and mortality. There are
significant gaps in the provision of mental health care services in the
U.S., especially related to vulnerable populations. While psychiatric
and other mental health professionals can play an important role in the
provision of high-quality mental health care services, primary care
physicians are the main providers for the majority of patients. Most
people with poor mental health will be diagnosed and treated in the
primary care setting. Mental illness also complicates other medical
conditions, making them more challenging and more expensive to manage.
Together, this makes mental health an important issue for primary care
physicians.
Screening for mental illness is not new to family medicine but has more
recently been linked to quality metrics and payment. Screening for
mental illness can be an important strategy for decreasing morbidity,
as well as preventing adverse maternal and child health outcomes
associated with perinatal depressive symptoms, postpartum depression,
or maternal suicide.\1\, \2\, \3\ While
important, screening in a busy practice can seem overwhelming, but
practices can leverage technology, empower staff, and utilize wellness
visits to complete this screening.\4\
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\1\ LeFevre ML, U.S. Preventive Services Task Force. Screening for
Suicide Risk in Adolescents, Adults, and Older Adults in Primary Care:
U.S. Preventive Services Task Force Recommendation Statement. Ann
Intern Med. 2014;160(10):719.
\2\ Kendig S, Keats JP, Hoffman MC, et al. Consensus bundle on
maternal mental health: Perinatal depression and anxiety. Obstet
Gynecol. 2017;129(3):422-430.
\3\ Yonkers KA, Wisner KL, Stewart DE, et al. The management of
depression during pregnancy: A report from the American Psychiatric
Association and the American College of Obstetricians and
Gynecologists. Obstet Gynecol. 2009;114(3):703-713.
\4\ Savoy M, O'Gurek DT. Screening your adult patients for
depression. Fam Pract Manag. 2016;23(2):16-20.
Integrating mental health into primary care settings, as well as the
blending of primary and preventive medicine into traditional mental
health settings, represents a more holistic approach to treatment than
the traditional consultative and referral models. Integrating primary
care and mental health services increases access for patients by making
mental health services available in their regular primary care clinics.
When integrated into primary care, mental health clinicians can impact
the care of more patients than in the specialty mental health referral
sector.\5\ In the primary care setting, mental health clinicians take
on a more consultative and team-based role and focus on helping primary
care physicians treat mental health disorders. In this context, mental
health clinicians typically reach more patients, and have shorter and
more problem-focused encounters than in the context of traditional
specialty mental health.
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\5\ Collins C, Hewson DL, Munger R, Wade T. Evolving models of
behavioral health integration in primary care. Milbank Memorial Fund.
2010. Accessed January 22, 2018.
The Collaborative Care Model, supported by various organizations
including the AAFP and the American Psychiatric Association, is a model
for the successful integration of primary care and behavioral and
mental health.\6\ At its core, the idea of collaborative care is
anchored in team-based care, often in the context of a medical home,
and steered by primary care physicians. It involves behavioral health
specialists and consulting mental health professionals delivering
evidence-based care that is patient-centered.
---------------------------------------------------------------------------
\6\ American Psychiatric Association Academy of Psychosomatic
Medicine. Dissemination of integrated care within adult primary care
settings. Accessed January 22, 2018.
The collaborative care model at its core is: (1) team driven, (2)
population focused, (3) measurement guided, and (4) evidence based.
These four elements, when combined, can allow for a fifth guiding
principal to emerge--accountability and quality improvement.
Collaborative care is team-driven, led by a primary care clinician with
support from a ``care manager'' and consultation from a psychiatrist
who provides treatment recommendations for patients who are not
achieving clinical goals. Other mental health professionals can
contribute to the Collaborative Care Model. Collaborative care is
population focused, using a registry to monitor treatment engagement
and response to care. Collaborative care is measurement guided with a
consistent dedication to patient-reported outcomes and it utilizes
evidence-based approaches to achieve those outcomes. Care remains
patient centered with proactive outreach to engage, activate, promote
self-management and treatment adherence, and coordinate services.\7\
---------------------------------------------------------------------------
\7\ Ibid.
The AAFP urges Congress to support the adoption of the Collaborative
Care Model by funding grant programs for primary care practices and
encouraging Center for Medicare and Medicaid Innovation models for
---------------------------------------------------------------------------
behavioral health integration.
Telemedicine for mental health is a growing interest in primary care
and telehealth initiatives for mental health care are expanding
rapidly. While the research is limited on this topic, there are a
growing number of studies assessing the benefits, comparative
effectiveness with face-to-face visits, and cost comparisons. From
January to March 2020, at the beginning of the COVID-19 pandemic,
telehealth visits increased by 135% compared to that time period in
2019, and 93% of those visits were for non-COVID concerns.\8\ In
addition, mental health concerns increased rapidly during the pandemic.
Four in ten adults reported symptoms of anxiety, an increase from one
in ten the year prior, and more than half of all young adults ages 18-
24 reported symptoms of anxiety and depression and were more likely
than other age groups to report substance use and suicidal thoughts.\9\
Other trends should a disproportionate effect on mental health for
communities of color, mothers, and essential workers.\10\ The AAFP is
supportive of efforts to expand access to mental health services via
telehealth and encourage Congress to address the legislative barriers
outlined in our previous testimony and Joint Principles for Telehealth
Policy. In particular, the AAFP strongly believes that the permanent
expansion of telehealth services should be done in a way that advances
care continuity and the
patient-physician relationship. Telehealth for mental health can help
address the shortage of over 6,000 mental health professionals in the
U.S., particularly for rural and underserved areas that face a
disproportionate impact of the shortage.\11\
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\8\ Koonin LM. Trends in the Use of Telehealth During the Emergence
of the COVID-19 Pandemic--United States, January-March 2020. MMWR Morb
Mortal Wkly Rep. 2020;69. doi:10.15585/mmwr.mm6943a3.
\9\ Panchal N, Kamal R, 2021. The Implications of COVID-19 for
Mental Health and Substance Use. KFF. Published February 10, 2021.
Accessed June 17, 2021. https://www.kff.org/coronavirus-covid-19/issue-
brief/the-implications-of-covid-19-for-mental-health-and-substance-
use/.
\10\ Ibid.
\11\ Mental Health Care Health Professional Shortage Areas (HPSAs).
KFF. Published November 5, 2020. Accessed June 17, 2021. https://
www.kff.org/other/state-indicator/mental-health-care-health-
professional-shortage-areas-hpsas/.
Trauma-informed care, an approach to engaging individuals with a
history of trauma that recognizes their traumatic experiences, and how
it affects their lives, is a promising practice that may facilitate
healing and help prevent the consequences of exposure to trauma.\12\,
\13\ An estimated 60% of adults in the U.S. have experienced a
traumatic event at least once in their lives.\14\ Exposure to trauma,
such as intimate partner violence, sexual abuse, rape, neglect,
terrorism, war, natural disasters, and street violence predisposes
those affected to poor physical and mental health outcomes.\15\ The
principles of trauma-informed care include: realizing that there is a
high prevalence of trauma and it has serious effects; recognizing the
signs and symptoms of trauma; responding to the high prevalence by
integrating knowledge about trauma into practices, procedures, and
policies; and avoiding retraumatizing individuals by using best-
practices in screening and history taking.\16\
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\12\ Oral R, Ramirez M, Coohey C, et al. Adverse childhood
experiences and trauma informed care: The future of health care.
Pediatr Res. 2016;79(1-2):227-233.
\13\ Decker MR, Flessa S, Pillai R V., et al. Implementing trauma-
informed partner violence assessment in family planning clinics. J
Women's Heal. April 2017:jwh.2016.6093
\14\ National Council for Behavioral Health. Trauma-informed
approaches learning communities. Accessed January 22, 2018.
\15\ Agency for Healthcare Research and Quality. Trauma-informed
care (https://www.
ahrq.gov/ncepcr/tools/healthier-pregnancy/fact-sheets/trauma.html).
Accessed January 22, 2018.
\16\ Ibid.
Disparities are pervasive in all aspects of health, including mental
health conditions. While mental health conditions can affect everyone,
regardless of culture, race, ethnicity, gender or sexual orientation,
---------------------------------------------------------------------------
some populations experience those conditions at a higher rate.
American Indian and Alaska Natives (28.3%) experience higher
rates of mental illness than white (19.3%), black (18.6%), Hispanic
(16.3%), or Asian (13.9%) adults.\17\
---------------------------------------------------------------------------
\17\ National Alliance on Mental Illness. Mental health by the
numbers (https://www.nami.org/mhstats). Accessed January 22, 2018.
---------------------------------------------------------------------------
Individuals from the lesbian, gay, bisexual, transgender, and
questioning (LGBTQ) community are two or more times as likely as
heterosexual individuals to have a mental health condition, and LGBTQ
youth are two to three times more likely to attempt suicide than
heterosexual youth.\18\
---------------------------------------------------------------------------
\18\ Ibid.
---------------------------------------------------------------------------
Nearly one-fifth (18.5%) of the veterans who returned from
serving in either Iraq or Afghanistan suffer from either major
depression or post-traumatic stress disorder.\19\
---------------------------------------------------------------------------
\19\ Tanielian T, Jaycox LH, Schell T, et al. Invisible wounds.
Mental health and cognitive care needs of America's returning veterans.
RAND Corporation. 2008. Accessed January 22, 2018.
---------------------------------------------------------------------------
The prevalence of mental illness is similar for individuals
living in either rural or metropolitan areas, but the mental health
care needs are more often unmet in rural communities due to inadequate
services.\20\
---------------------------------------------------------------------------
\20\ Substance Abuse and Mental Health Services Administration.
Results from the 2015 National Survey on Drug Use and Health: Detailed
Tables (https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-
2015/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015.pdf). Prevalence estimates,
standard errors, P values, and sample sizes. 2016. Accessed January 22,
2018.
Disparities in mental health illness and mental health care are related
to coverage and availability of care, quality of care, rates of health
insurance, stigma, cultural insensitivity, racism, bias, homophobia,
discrimination in treatment settings, and language barriers.\21\
---------------------------------------------------------------------------
\21\ National Alliance on Mental Illness. Mental health by the
numbers (https://www.nami.org/mhstats). Accessed January 22, 2018.
College students face unique mental health concerns, such as non-
suicidal self-
injury and serious suicidal ideation.\22\ There are approximately 20
million students enrolled in U.S. colleges and universities, and the
rates of serious mental health concerns is rising in this
population.\23\,\24\ According to the Center for Collegiate
Mental Health's 2017 Annual Report, 52.7% of students attended
counseling for mental health concerns; 34.2% took a medication for
mental health concerns; 9.8% were hospitalized for a mental health
concern; 27% purposely injured themselves without suicidal intent; and
34.2% seriously considered attempting suicide, with 10% making a
suicide attempt.\25\ In fact, some data suggest that suicide may be the
most common cause of death in college students.\26\
---------------------------------------------------------------------------
\22\ Center for Collegiate Mental Health. 2017 Annual Report
(https://sites.psu.edu/ccmh/files/2018/01/2017_CCMH_Report-
1r3iri4.pdf). Accessed January 22, 2018.
\23\ Ibid.
\24\ National Center for Education Statistics. Fast facts. Back to
school statistics (https://nces.ed.gov/fastfacts/display.asp?id=372).
Accessed January 22, 2018.
\25\ Center for Collegiate Mental Health. 2017 Annual Report
(https://sites.psu.edu/ccmh/files/2018/01/2017_CCMH_Report-
1r3iri4.pdf). Accessed January 22, 2018.
\26\ Turner JC, Keller A. Leading causes of mortality among
American college students at 4-year institutions. Conference Paper:
American Public Health Association 139th Annual Meeting and Exposition.
Washington, DC 2011. Accessed January 22, 2018.
Attention-deficit/hyperactivity disorder (ADHD) is another prevalent
disorder in college students that family physicians may encounter.
ADHD's prevalence is estimated to be between 2-8% among college
students, and this condition is frequently associated with other
psychiatric comorbidities and increases individuals' risk of
psychosocial and substance-use problems.\27\
---------------------------------------------------------------------------
\27\ Unwin BK, Goodie J, Reamy BV, Quinlan J. Care of the college
student. Am Fam Physician. 2013;88(9):596-604.
Tobacco use is prominent among individuals living with mental illness.
Thirty-six percent of adults with any mental illness use tobacco
products, compared with 25.3% for adults without a mental illness.\28\
In addition, people who have any mental illness are only half as likely
to quit smoking compared to individuals without a mental illness.\29\
One study found that nearly half of all deaths were tobacco-
related for persons who received substance abuse services, or who
received both substance abuse and mental health services.\30\
Therefore, addressing tobacco addiction among individuals living with
mental illness is an important strategy for decreasing preventable
mortality and morbidity among individuals living with a mental illness.
---------------------------------------------------------------------------
\28\ Centers for Disease Control and Prevention. Tobacco use among
adults with mental illness and substance use disorders (https://
www.cdc.gov/tobacco/disparities/mental-illness-substance-use/
index.htm). Accessed January 22, 2018.
\29\ Centers for Disease Control and Prevention. Vital signs:
Current cigarette smoking among adults aged 18 years with mental
illness--United States, 2009-2011. MMWR. 2013;62(05):81-87.
\30\ Bandiera FC, Anteneh B, Le T, Delucchi K, Guydish J. Tobacco-
related mortality among persons with mental health and substance abuse
problems. PLoS One. 2015;10(3):e0120581.
The AAFP has position papers that detail substance use disorders and
---------------------------------------------------------------------------
addiction and tobacco prevention and cessation.
Payment for primary care physicians has historically been inadequate
for office visits for mental health diagnoses. This limitation in
reimbursement interfered with the family physician's ability to offer
comprehensive care and management of mental health conditions, as well
as the ability to integrate, from a business perspective, with
behavioral health services. However, new coverage policies adopted by
the Centers for Medicare and Medicaid Services (CMS) are more promising
and may incentivize primary care physicians to provide treatment for
mental and behavioral health conditions.\31\ These policies, effective
January 1, 2017, emphasize collaborative care, where primary care
physicians are expected to work in partnership with a behavioral health
care manager, and consult with mental health specialists. While
targeting populations with Medicare, these policies may also encourage
private insurers to offer similar options and may incentivize more
family physicians to offer behavioral and mental health care to other
populations.
---------------------------------------------------------------------------
\31\ Press MJ, Howe R, Schoenbaum M, et al. Medicare payment for
behavioral health integration. N Engl J Med. 2017;376(5):405-407.
Health care for all people with mental illness should be ``affordable,
nondiscriminatory, and includes coverage for the most effective and
appropriate treatment.''\32\ Coverage for mental illness should be
equal in scope to coverage for other illnesses and all clinically-
effective treatments appropriate to the needs of individuals with
mental illness should be covered.
---------------------------------------------------------------------------
\32\ National Alliance on Mental Illness. Public policy platform of
the National Alliance on Mental Illness (https://www.nami.org/
getattachment/learn.more/mental-health-public-policy/public-policy-
platform-december.2016(1).pdf). Twelfth Edition. 2016. Accessed January
22, 2018.
Thank you for the opportunity to provide testimony on this important
issue. For further questions, please contact Erica Cischke, Senior
---------------------------------------------------------------------------
Manager, Legislative and Regulatory Affairs at [email protected].
Sincerely,
Gary L. LeRoy, M.D., FAAFP
Board Chair
End notes
https://www.aafp.org/dam/AAFP/documents/advocacy/health_it/telehealth/
TS-SenateFinanceCmte-DavisTelehealth-051921.pdf.
https://www.aafp.org/dam/AAFP/documents/advocacy/health_it/telehealth/
LT-Congress-TelehealthHELP-070120.pdf.
https://www.aafp.org/about/policies/all/substance-use-disorders.html.
https://www.aafp.org/about/policies/all/tobacco-
preventingtreating.html#::text=
The%20AAFP%20opposes%20all%20forms,of%20tobacco%20products%20to%20chil
dren.
______
American Hospital Association
800 10th Street, NW
Two CityCenter, Suite 400
Washington, DC 20001-4956
(202) 638-1100
On behalf of our nearly 5,000 member hospitals, health systems and
other health care organizations, our clinician partners--including more
than 270,000 affiliated physicians, 2 million nurses and other
caregivers--and the 43,000 health care leaders who belong to our
professional membership groups, the American Hospital Association (AHA)
appreciates the opportunity to submit this statement for the record.
America's hospitals and health systems play a central role in
delivering behavioral health care and are uniquely positioned to help
patients navigate the behavioral health resources that are available in
communities. Psychiatric and community hospitals are a vital source of
care for behavioral health patients, providing treatment for a full
range of psychiatric and substance use disorders (SUD) by stabilizing
patients, establishing and providing quality treatment regimens, and
transitioning patients to outpatient and community-based services. The
AHA strongly supports efforts to increase access to, and improve the
quality of, behavioral health care.
Even before the COVID-19 pandemic, one in five American adults was
estimated to have a behavioral health condition, and nearly 60% of
adults with behavioral health disorders reported not receiving services
for their conditions. But the nation's level of unmet behavioral health
needs has been exacerbated by the COVID-19 pandemic. As of June 14, the
Centers for Disease Control and Prevention (CDC) reports that more than
33 million Americans have been infected with COVID-19, and, of those,
more than 597,000 have died.
The effects of high unemployment, anxiety over the risk of contracting
COVID-19, grief over the death of loved ones, isolation from neighbors
and friends, and an increase in domestic violence and child abuse are
all increasing the incidence and prevalence of mental health conditions
and substance use disorder. For example, one in three adults reported
symptoms of an anxiety disorder in 2020, compared with one in 12 in
2019.
In addition, the inability to access in-person group therapy and
medication-assisted treatment (MAT), in part because of social
distancing requirements, has led many with substance use disorders to
relapse. According to the CDC, overdose deaths spiked after the start
of the pandemic, driven by synthetic opioids such as fentanyl.
Further, the behavioral health effects of COVID-19 are manifesting at a
time when the nation's behavioral health care system is ill-prepared to
meet the nation's needs. According to the Substance Abuse and Mental
Health Services Administration (SAMHSA), only 43% of U.S. adults with
mental illness received treatment in 2018, and a JAMA study found that
50.6% of U.S. youth aged 6-17 with a mental health disorder received
treatment in 2016.
Unfortunately, due to financial pressures, hospitals' capacity to care
for behavioral health patients has been significantly diminished,
exacerbating a trend that began decades ago. The number of state-funded
psychiatric beds per capita decreased by 97% between 1955 and 2016,
with the per capita psychiatric inpatient bed count approximately 70%
lower than the average among developed nations, as noted by a March
2019 National Association for Behavioral Healthcare report. Lack of
access to psychiatric inpatient services and resources will exacerbate
existing sever shortages in psychiatric beds nationally. This trend,
combined with new closures, will result in more preventable deaths from
psychiatric and substance use disorders and more cases of emergency
room boarding. As the number of psychiatric beds has declined, the
demand for inpatient services has continued to increase, and
correspondingly, wait times for those beds has increased dramatically
as well.
To address the urgent need for greater access to behavioral health
services, the AHA offers the following recommendations to the Committee
on Finance.
ADDRESS PHYSICIAN SHORTAGES
At the core of our health care system is a well-trained, diverse
workforce. But critical physician shortages deprive many communities of
access to needed care. The Association of American Medical Colleges
estimates that the United States faces a shortage of between 54,100 and
139,000 physicians by 2033.
In the 1997 Balanced Budget Act, Congress froze the number of Medicare-
funded residency slots at 1996 levels, based on projections that the
nation would soon have a surplus of physicians. Over the past 24 years,
millions more Americans have attained health insurance, the nation's
population has grown and aged, and more physicians are retiring--
leading to a crisis in physician access. The shortage is even more
acute for substance use disorder providers. A recent report from the
National Academies of Sciences, Engineering and Medicine highlighted
the dearth of clinicians with specialized training in MAT, and SAMHSA
has estimated that only 10% of the 22 million Americans with an SUD
receive treatment.
Last December, Congress lifted the cap on Medicare-funded residency
positions, allowing growth for the first time since 1997. That
provision, in the Consolidated Appropriations Act, 2021, created 1,000
new slots that will begin to be distributed in fiscal year (FY) 2023.
Increasing the number of Medicare-funded slots would help ease current
shortages, and bolster the foundation of our health care system.
The AHA supports the Opioid Workforce Act of 2021, introduced by
Senators Margaret Wood Hassan and Susan Collins, which would help abate
the national shortage of opioid treatment providers by increasing the
number of resident physician slots in hospitals with programs focused
on SUD treatment. Existing shortages of SUD treatment providers have
led to lengthy waiting periods for treatment and increased mortality
from opioid misuse and addiction. The Opioid Workforce Act would help
address existing shortages by adding 1,000 Medicare-funded training
positions in approved residency programs in addiction medicine,
addiction psychiatry or pain medicine. These new slots would constitute
a major step toward increasing access to SUD treatment for communities
in need. We look forward to working with you to ensure passage of this
important legislation.
REPEAL THE IMD EXCLUSION
Since 1965, the Institutions for Mental Diseases (IMD) exclusion has
prohibited federal payments to states for services for adult Medicaid
beneficiaries between the ages of 21 and 64 who are treated in
facilities that have more than 16 beds, and that provide inpatient or
residential behavioral health treatment. The discriminatory IMD policy
was established at a time when behavioral health conditions were not
considered medical conditions on the same level as physical health
conditions, state-operated psychiatric facilities were a primary
setting for behavioral health care, and patients were admitted for
longer-term stays.
We know that successful treatment requires access to the full continuum
of care--namely, inpatient care, partial hospitalization, residential
treatment and outpatient services. Different types of patients require
different clinical services from across the care continuum. Investing
only in outpatient care and failing to provide states with relief from
the IMD exclusion would continue to deny many of these patients access
to the most clinically appropriate care. Additionally, advances in
behavioral health care have allowed for shorter inpatient stays and
more outpatient treatment options, while funding challenges have led to
a decline in the number of inpatient psychiatric beds. Repealing the
IMD exclusion would help reverse this decline.
ELIMINATE MEDICARE'S 190-DAY LIMIT ON INPATIENT PSYCHIATRIC TREATMENT
Medicare covers only 190 days of inpatient care in a psychiatric
hospital in a beneficiary's lifetime. This discriminatory limit erects
a barrier to accessing care for individuals who have gone beyond their
190-day limit, particularly those with a chronic mental condition.
As the nation looks to recover from COVID-19 pandemic, an even greater
mental health crisis awaits. Medicare beneficiaries who did not seek
inpatient care during the pandemic because they hesitated to leave
their homes or because they have conditions that were exacerbated by
the pandemic will need inpatient services. Further, as the nation's
elderly population continues to grow and life expectancy continues to
rise, the 190-day limit will severely affect access to needed care. To
effectively address the needs of America's seniors, Congress should
repeal Medicare's 190-day limit on inpatient psychiatric care.
MAKE TELEHEALTH FLEXIBILITIES PERMANENT
Telehealth services, including for mental health and SUD treatment,
have improved access to care. The increased use of telehealth since the
start of the public health emergency (PHE) is producing high-quality
outcomes for patients, enhancing patient experience, and protecting
access for individuals susceptible to infection. With the appropriate
statutory and regulatory framework, this beneficial shift in care
delivery could continue to improve patient experiences and outcomes and
deliver health system efficiencies beyond the pandemic. The AHA urges
the Committee to consider making these flexibilities permanent.
Additionally, telehealth policies should work together to maintain
access for patients by connecting them to vital health care services
and their personal providers through videoconferencing, remote
monitoring, electronic consults and wireless communications. We support
the following: elimination of the 1834(m) geographic and originating
site restriction; coverage and reimbursement for audio-only services;
an expanded list of providers and facilities eligible to deliver and
bill for telehealth services, including rural health clinics and
federally qualified health centers; a national approach to licensure so
that providers can safely provide virtual care across state lines; and,
adequate reimbursement for the substantial costs of establishing and
maintaining a telehealth infrastructure, among others.
PROMOTE INTEGRATION OF PHYSICAL AND BEHAVIORAL HEALTH
The use of electronic health records (EHR) can promote the integration
of physical and behavioral health care. Yet, significant barriers
remain for the adoption of EHRs by behavioral health providers. The
2009 HITECH Act incentivized EHR adoption with payments for providers
who participate in the Medicare and Medicaid Promoting Interoperability
Programs; however, psychiatric hospitals are ineligible for these
programs. In addition to this financial pressure, the nature of
behavioral health records--that is, that they are often narrative or
follow a different structure than physical health records--as well as
conflicting regulatory requirements regarding information sharing has
led to far lower adoption of EHRs in psychiatric hospitals compared to
general acute care hospitals. We urge the Committee to create
opportunities for behavioral health providers to acquire interoperable
electronic health records that enable improved information sharing
among providers and with public health and other government agencies.
CONCLUSION
The AHA is encouraged that the Committee is examining ways to improve
Americans' access to mental health and substance use disorder
treatment. We stand ready to work with the Committee as you consider
legislation to expand vital behavioral health services to patients and
families.
______
American Psychological Association
750 First Street, NE
Washington, DC 20002-4242
202-336-5800
202-336-6123 TDD
https://www.apa.org/
Statement Submitted by Katherine B. McGuire, Chief Advocacy Officer
The American Psychological Association (APA) thanks the Committee for
the opportunity to offer solutions to strengthen the nation's mental
health system, which even prior to the COVID-19 pandemic could not meet
the needs of people in need of care. APA is the nation's largest
scientific and professional nonprofit organization representing the
discipline and profession of psychology. APA has more than 122,000
members and affiliates who are clinicians, researchers, educators,
consultants, and students in psychological science.
As the U.S. Government Accountability Office (GAO) recently found,
``longstanding unmet needs for behavioral health services'' continue to
persist and were in fact ``worsened by new challenges associated with
the COVID-19 pandemic'' (GAO, March 31, 2021). Over the past year, the
pandemic created ``a cascade of societal challenges, including illness
and death, prolonged social isolation, job loss, and reliance on remote
work and online education'' while also ``cast[ing] a bright light on
the destructive effects of health, educational, employment, legal, and
criminal justice disparities and inequities'' (American Psychological
Association, August 2020). The results of APA's ``Stress in America''
survey series during this time tell a compelling story about the mental
health impact of the pandemic on everyday Americans, particularly on
communities of color and other underserved communities (American
Psychological Association, 2021). This impact manifests in a highly
individualized manner, which includes but is not limited to higher
rates of emotions associated with prolonged stress, such as anxiety,
stress and anger; unexpected fluctuations in weight; disruptions in
sleep; and increased consumption of alcohol and dangerous substances.
Innovative solutions are urgently required if we are ever to meet the
challenge of addressing the long-term mental health impact of this
pandemic while remedying preexisting barriers to accessing these
services. However, there is no single solution to addressing this
crisis, and the Committee and its members will need to improve policies
in multiple areas, including the following:
Preserve Recent Expansions in Medicare Coverage of Mental and
Behavioral Health Services Furnished by Telehealth. Congress's and
CMS's decision to expand Medicare coverage of mental and behavioral
services via telehealth--including those furnished via audio-only
communication--prompted a long-overdue expansion of mental health
services to many communities that traditionally lacked access to such
services. Audio-only services in particular are a critical (and often
the only) link to mental and behavioral health services for many
individuals and communities that are less likely to have reliable
access to technological training or broadband technology, such as older
adults, individuals with disabilities, people in rural and frontier
areas, lower-income families, and communities of color.
We remain concerned, however, that this access expansion will
abruptly end once the current public health emergency ends, and we hope
this Committee will help avoid this ``access cliff'' and permanently
authorize Medicare to cover audio-only telehealth for mental,
behavioral, and substance use disorder services. Specifically, we urge
the Committee to approve legislation such as the bipartisan bill H.R.
3447, introduced by Reps. Jason Smith and Josh Gottheimer. This bill
would permanently establish Medicare coverage of mental, behavioral,
and substance use disorder services furnished via audio-only
telehealth, provided that the patient has at least one in-person or
audio-video telehealth visit within the past 3 years.
Additionally, while APA supported Congress's decision to eliminate
certain site-of-service requirements on Medicare tele-mental health
coverage in the year-end budget and COVID package (Pub. L. 116-260), we
are concerned that the new six-month in-person service requirement will
inequitably limit access to services. Accordingly, APA asks the
Committee to take up and pass the bipartisan Telemental Health Care
Access Act (S. 2061) sponsored by Senators Cassidy, Smith, Thune, and
Cardin, which removes this arbitrary and unnecessary barrier to
coverage of tele-mental health services. AP A also hopes that members
of this Committee will consider introducing a Senate counterpart to
Representative Matsui's Telemental Health Care Access Act (H.R. 4058),
which in addition to removing this in-person service requirement, will
also eliminate the aforementioned site-of-service requirements for
behavioral health services.
Finally, we hope this Committee will support a bipartisan bill co-
sponsored by Senator Stabenow, the Tele-Mental Health Improvement Act
(S. 660), which will--both during and shortly after the pandemic--place
coverage and reimbursement for mental health and substance use disorder
services on the same footing as services provided in-person. We hope
members of this Committee will also consider long-term measures to
address the inequities in reimbursement between care furnished in
person and care furnished via telehealth.
Support Innovative Approaches to Combating the Resurgent Opioid
and Substance Use Disorder Crisis. Despite Congress' commendable
efforts to combat the opioid epidemic, the COVID-19 pandemic worsened
rates of opioid and substance use. According to CDC data, over 88,000
individuals died due to a drug overdose between August 2019 and August
2020, an astounding 26.8% increase over the previous year (Ahmad, et
al. 2021). CDC data also shows that while opioids, and especially
fentanyl, continue to account for the bulk of overdose deaths, the use
of psychostimulants such as methamphetamine increased by 46% over the
previous year (Volkow, 2021). The drug overdose crisis demands a strong
public health response which meets individuals with substance use
disorders where they are. The CAHOOTS Act (S. 764) introduced by
Chairman Wyden embodies this approach, and we urge both its enactment
and the adoption of mobile crisis intervention services by Medicaid
programs nationwide.
We urge the Committee to advance similarly innovative approaches
to this crisis, such as those outlined in: (1) the bipartisan Medicaid
Reentry Act (S. 285), co-sponsored by Senator Whitehouse, which allows
inmates within 30 days of release to enroll in Medicaid to reduce the
risk of relapse upon release; (2) Sen. Hassan's Mainstreaming Addiction
Treatment Act (S. 445), which eliminates the unnecessary and
counterproductive requirement that prescribing providers obtain a
waiver from the Drug Enforcement Agency (DEA) before prescribing
buprenorphine for the treatment of substance use disorders; (3) S. 854,
legislation introduced by Sen. Grassley to designate methamphetamine as
an emerging drug threat; and (4) S. 1457, the STOP Fentanyl Act of
2021--introduced by Senators Warren, Whitehouse, Baldwin, and Booker--
that, among other provisions, would remove barriers to the
establishment of contingency management programs, an evidence-based
form of behavioral treatment developed by psychologists for treatment
of methamphetamine, cocaine, and other substance use disorders (De
Crescenzo, et al., 2018).
Allow Clinical Psychologists to Practice Independently in All
Medicare Treatment Settings. Current law requires physician supervision
of psychologists' treatment of Medicare patients in certain settings,
such as partial hospitalization programs, surgical centers, and
community mental health centers. Medicare is the last health insurer
that requires physician supervision of psychologists. Unlike Medicare,
all other health insurers and state licensure laws allow psychologists
to practice independently in all treatment settings.
Most older Americans with mental disorders do not receive mental
health treatment from a mental health specialist, and older Americans
are much more likely to be prescribed psychoactive drugs--even without
an established diagnosis for a mental disorder-than to receive
psychotherapy or other behavioral health services, despite the ongoing
opioid epidemic and concerns about overmedication in nursing homes and
other facilities. Allowing clinical psychologists to practice
independently in all treatment settings, as they can do through other
health insurance programs, would contribute to reversing this trend.
Medicare patients would benefit from improved access to psychologists'
services, including psychological and neuropsychological assessments,
psychotherapy, and health and behavior assessments and interventions.
Incentivize Adoption of a Broad Array of Integrated Care Models.
APA appreciates the Committee's discussions around the integration of
primary care and mental health services. Integrated care is an
innovative way of improving patient outcomes and satisfaction with
care, as well as reducing overall treatment costs, but it requires
significant changes to primary care practices' physical offices,
information technology systems, management procedures, clinical
staffing and policies, health records and data tracking practices, and
provider education and training. With these challenges and given
differences in patient populations and the goals of the integration
effort, there is no ``one size fits all'' approach to effective
integrated primary care. As stated in a recent review, ``[t]here are
several models and differing levels of integration described in the
literature, suggesting that approaches to integration should be
responsive to the needs and context of the community'' (Vogel et al.,
2017, p. 81).
We urge the Committee to provide support for the implementation of
integrated care programs by primary care providers that gives them the
flexibility to blend services, models, and interventions in a way that
best meets the needs of their patient populations and reflects the
healthcare workforce in their community. Support should be made
available for all evidence-based integrated care programs meeting the
following four criteria:
A multi-professional approach to patient care;
A structured management plan;
Scheduled patient follow-ups; and
Enhanced inter-professional communication.
Support Programs that Strengthen Access to School-Based Mental
Health Services. The pandemic continues to have an outsized impact on
children and youth, with nearly a third of parents reporting that their
child experienced some degree of harm to their emotional or mental
health during the pandemic (Gallup, 2020). This population is of
concern not only due to their higher overall vulnerability to stress,
but also because of the increased risk they will experience adverse
childhood experiences (ACEs) such as various forms of abuse, neglect,
and household dysfunction. As schools are a key provider of mental and
behavioral health services to children, the pandemic often cut off
access to mental health services for many children (Nuamah, et al.,
2020).
To aid the nation's school-age children in recovering from the
mental, social, and educational impact of the COVID-19, we ask that
members of the Committee support the following pieces of legislation:
The Increasing Access to Mental Health in Schools Act (S.
1811), introduced by Sen. Tester (D-MT), which would expand mental
health services in low-income schools by supporting partnerships
between institutions of higher education and local education agencies
to increase the number of school-based mental health professionals;
The Mental Health Services for Students Act (S. 1841),
introduced by Sen. Tina Smith (D-MN), which would build partnerships
between local educational agencies, tribal schools, and community-based
organizations to provide school-based mental health care for students
and provide resources for the entire school community on warning signs
of mental health crises; and
A Senate counterpart to the Comprehensive Mental Health in
Schools Pilot Program Act (H.R. 3549), which would create a new 4-year
grant program to help schools that predominantly serve low-income
students with building their capacity to address students' mental and
behavioral well-being.
Address Inequities in Access to Mental and Behavioral Health
Services. The COVID-19 pandemic both highlighted and exacerbated
longstanding disparities in access to mental health services,
particularly amongst individuals from communities of color.
Psychological science continues to inform innovative solutions to
combat challenges related to health equity including, for example,
guidance on facilitating transparent and thoughtful conversations
between community leaders and individuals to enable informed decisions
about vaccine behaviors. As a critical first step in remedying these
disparities, AP A hopes this Committee will take up and pass H.R. 1475,
the Pursuing Equity in Mental Health Act adopted by the House last
month. Among other provisions, this bill would authorize funding to
support health equity research, build outreach programs to reduce the
stigma of seeking mental health treatment, and develop a training
program for providers.
APA stands ready to assist the Committee in finding impactful
bipartisan solutions to expand the nation's mental and behavioral
health system to serve all in need of these services. Please contact
Andrew Strickland, J.D. at [email protected] if our association can
serve as a resource.
REFERENCES
Ahmad F.B., Rossen L.M., Sutton P. Provisional drug overdose death
counts. National Center for Health Statistics. 2021. Accessed at
https://cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.
American Psychological Association (August 2020). Psychology's
Understanding of the Challenges Related to the COVID-19 Global Pandemic
in the United States. https://www.apa.org/about/policy/covid-
statement.pdf.
American Psychological Association (2021). Stress in America Press
Room. https://www.apa.org/news/press/releases/stress?tab=2.
De Crescenzo et al., PLoS Medicine 2018; 15(12): e1002715.
Gallup (June 16, 2020). U.S. Parents Say COVID-19 Harming Child's
Mental Health. https://news.gallup.com/poll/312605/parents-say-covid-
harming-child-mental-health.aspx.
Gold, J.A., Rossen, L.M., Ahmad F.B., et al. Race, Ethnicity, and Age
Trends in Persons Who Died From COVID-19--United States, May-August
2020. MMWR Morb Mortal Wkly Rep 2020; 69:1517-1521. DOI: https://
www.ncbi.nlm.nih.gov/pmc/articles/PMC7583501/.
Nuamah, S., Good, R., Bierbaum, A., and Simon, E. (2020). School
closures always hurt. They hurt even more now. Education Week.
Retrieved from https://www.edweek.org/ew/articles/2020/06/09/
schoolclosures-always-hurt-they-hurt-even.html.
U.S. Government Accountability Office, March 31, 2021. Behavioral
Health: Patient Access, Provider Claims Payment, and the Effect of the
COVID-19 Pandemic. https://www.gao.gov/assets/gao-21-437r.pdf.
Vogel, M.E., Kanzler, K.E., Aikens, J.E., and Goodie, J.L. (2017).
Integration of behavioral health and primary care: Current knowledge
and future directions. Journal of Behavioral Medicine, 40(1), 69-84.
Volkow, N. National Institute on Drug Abuse, 2021. ``U.S. Overdose
Deaths Involving Psychostimulants (Mostly Amphetamine), by Race''
[Powerpoint presentation]. Accessed at https://www.apa.org/members/
content/methamphetamine-addiction.
______
Association for Behavioral Health and Wellness
1325 G Street, NW, Suite 500
Washington, DC 20005
https://abhw.org/
June 15, 2021
Dear Chairman Wyden and Ranking Member Crapo:
The Association for Behavioral Health and Wellness (ABHW) appreciates
the opportunity to provide comments for the record on the hearing:
``Mental Health Care in America: Addressing Root Causes and Identifying
Policy Solutions'' that took place Tuesday, June 15, 2021. We
appreciate the Committee's leadership on and dedication to addressing
behavioral health issues.
ABHW serves as the national voice for payers that manage behavioral
health insurance benefits. ABHW member companies provide coverage to
approximately 200 million people in both the public and private sectors
to treat mental health (MH) and substance use disorders (SUDs), and
other behaviors that impact health and wellness.
Overarchingly, our organization's goals aim to increase access, drive
integration, support prevention, raise awareness, reduce stigma, and
advance evidence-based treatment and quality outcomes. Furthermore,
through our policy work, we strive to promote equal access to quality
treatment and address the stark inequities created by systemic racism.
We are deeply concerned about health disparities in this country in the
areas of MH and SUD services and are committed to addressing systemic
racism in the healthcare system. We applaud the Committee's commitment
to health equity and look forward to working with you to improve
behavioral health services in this country.
Behavioral health services have become increasingly important as a
result of social isolation, job loss, illness and death, and domestic
violence related to COVID-19 and we suspect the utilization of such
services will continue long after the public health emergency (PHE) is
lifted. Addressing the following issues can play a critical role in
expanding access to MH and SUD services and provide long lasting
improvements to our nation's behavioral health system.
Expand the use of telehealth for MH and SUD services.
Increase access to medication-assisted treatment (MAT).
Support suicide prevention efforts and increase focus on crisis
services.
Eliminate the Institution for Mental Diseases (IMD) Medicaid
exclusion.
Develop a clear, universal compliance standard related to mental
health and addiction parity.
Ensure health coverage for individuals released from jails and
prisons.
Align 42 CFR Part 2 with the Health Insurance Portability and
Accountability Act (HIPAA).
As you further examine behavioral health issues, we urge you to
consider and include the following:
Expand the use of telehealth for MH and SUD services. We appreciate the
current guidance and flexibilities in response to the PHE and request
that the flexibilities continue for at least one year after the PHE is
lifted. These long overdue changes to telehealth policies have allowed
payers and providers to ensure people can access necessary MH and SUD
services in midst of physical distancing. ABHW members support
extending flexibilities past the PHE and simultaneously collecting and
analyzing data before making permanent changes. As the need for
behavioral health services continues to grow, we urge Congress to
support the following policy changes:
Eliminate the new in-person visit requirement for mental health
services: We applaud the recent changes made to remove geographic and
originating site restrictions on originating sites for mental health
services, allowing beneficiaries across the country to receive virtual
care from a location of their choosing. However, these changes were
accompanied by a new requirement, mandating that an individual must
have an in-person visit no less than six months before he or she is
eligible to receive mental health services via telehealth. Given that
many individuals with mental health issues may not physically be able
to leave the home, we urge you to support the Telemental Health Care
Access Act, S. 2061/H.R. 4058, which removes the in-person requirement
visit prior to receiving Medicare telehealth services for mental
health.
Expand cross state licensure: During the pandemic, all 50 states
have used emergency authority to waive certain aspects of state
licensure laws, thus providing widespread access to care. We encourage
efforts for states to foster cross state licensure reciprocity to
support increased access to services. We also propose convening a task
force of federal and state leaders to examine this issue and outline
recommendations on changes that would increase access to behavioral
health services.
Examine audio-only telehealth services. ABHW supports patient
access to audio-only behavioral health services for the duration of the
PHE. However, before audio-only services are made permanent, ABHW
strongly suggests that the appropriate regulatory agencies conduct
research as to whether or not behavioral health services provided via
audio-only are an effective long-term strategy to provide quality,
evidence-based, and clinically appropriate care. One way to do this
would be to create an audio-only modifier so that it can be used in
effectiveness research to differentiate between audio-visual and audio-
only services.
Currently, it is unclear whether audio-only is appropriate for all
behavioral health treatments. Specifically, ABHW advocates for audio-
only services to be evaluated in partial hospitalization programs,
applied behavioral analyses, psych testing, and group therapy before
they are reimbursed permanently. Ultimately, audio-only behavioral
health treatments should have safeguards built around them and should
not be a primary or default avenue for care. Post PHE, audio-only
should only be used after it has proven to be effective and is deemed
to be in the individual's best interest (for example, the patient has
limited broadband access and difficulty accessing video technology).
Increase access to medication assisted treatment (MAT). Research has
shown that MAT is the most effective intervention to treat opioid use
disorders (OUDs) as it significantly reduces illicit opioid use
compared to nondrug approaches and increased access to MAT can reduce
overdose fatalities.\1\ As such, ABHW supports the following policy
changes to increase MAT access.
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\1\ Medication-Assisted Treatment Improves Outcomes for Patients
with Opioid Use Disorder, Pew Fact Sheet, November 22, 2016.
Eliminate the X-waiver. During the COVID-19 pandemic, overdoses
and related deaths continue to rise, making access to MAT crucial. HHS
recently published a Notice which allows providers to treat up to 30
patients using MAT without first obtaining the X-waiver. While this is
a step in the right direction to treat OUDs, more must be done. As
such, we ask that Congress pass the Mainstreaming Addiction Treatment
(MAT) Act, S. 445/H.R. 1384. This bipartisan legislation would remove
the federal rules established by the DATA 2000 Act that require health
care practitioners to obtain a waiver (X-waiver) from the Drug
Enforcement Administration (DEA) before prescribing buprenorphine to
treat OUDs. The legislation would remove a major hurdle to prescribing
MAT, impact existing nationwide shortage of treatment providers, and
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expand access to OUD treatment.
Eliminate the in-person evaluation requirement. Given that not
all individuals with SUDs are able to have an initial in-person visit
with a provider due to behavioral health provider shortages or physical
difficulty traveling, ABHW advocates for actions which would eliminate
the in-person evaluation requirement before a provider can prescribe
MAT via telehealth. The Ryan Haight Act, originally passed to combat
the rise of rogue online pharmacies, requires an in-
person evaluation before a provider can prescribe MAT via telehealth.
This safeguard likely suppresses the use of MAT because under current
law, the evaluation requirement cannot be fulfilled via a telehealth
visit.\2\ While the Ryan Haight Act allows for providers to use
telemedicine when engaged in the ``practice of medicine,'' it is nearly
impossible for providers to do so. The definition of ``practice of
telemedicine'' includes seven categories in which a provider could meet
the in-person requirement through a virtual care platform, including
under a special registration granted by the DEA. However, the DEA never
created that registration process. With the Special Registration for
Telemedicine Act of 2018, which was part of the Substance Use-Disorder
Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) Act,
the DEA had until October 24, 2019, to outline rules for providers with
a special registration to prescribe controlled substances. That
deadline passed without action, severely impeding those with OUDs from
receiving the care they need.
---------------------------------------------------------------------------
\2\ Kayla R. Bryant, Health Law Daily Wrap up, Strategic
Perspectives: States Fail to Fully Use Telemedicine to Fight the Public
Health Crisis, Wolters Kluwer (September 28, 2018), p. 2.
As such, we recommend that Congress urge the DEA to move forward
with promulgating the telemedicine special registration process rule,
as mandated by federal law, to enable providers to prescribe MAT to
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patients with SUDs by employing telemedicine.
Support suicide prevention efforts and increase focus on crisis
services. Last year Congress passed the National Suicide Hotline
Designation Act of 2019, making the National Suicide Prevention
Lifeline an easy to remember three-digit number, 9-8-8. The need for
Americans to have readily available access to mental health crisis
services through a ubiquitous number like 9-8-8 is more urgent than
ever. We urge Congress to work with the Federal Communications
Commission (FCC) to ensure the timely implementation of 9-8-8 by July
2022. Incidences of mental health crises and suicide attempts have been
increasing annually, and are exacerbated by the COVID-19 pandemic.
In addition to swiftly creating the crisis line, it is equally
important that the crisis line have adequate resources so that it can
operate effectively and ensure that all Americans can access it. Since
demand will undoubtedly increase for services of the crisis line, there
will need to be significant investment after the initial implementation
to expand capacity and provide services consistently for mental health
crises. Therefore, we ask Congress to pass H.R. 2981, the Suicide
Prevention Lifeline Improvement Act of 2021. This legislation would
require increased coordination, data sharing, and provide more funding
to support community-based crisis service delivery. ABHW supports an
evidence-based continuum of crisis care for individuals experiencing a
behavioral health crisis, and look forward to working with Congress to
promote access to quality crisis services.
Eliminate the Institution for Mental Diseases (IMD) Medicaid exclusion.
We urge Congress to remove policy barriers that limit beneficiary
access to needed and appropriate MH and SUD care. This includes ending
the IMD exclusion, which prohibits Medicaid reimbursement for adults
under the age of 65 in residential behavioral health facilities with
more than 16 beds. Although the IMD exclusion cannot be fully
eliminated without Congressional action, the Administration could
increase access and improve appropriate care through expanded use of
waivers under section 1115, which would enable states to more broadly
cover IMD services. Further, as we have witnessed, national hospital
capacity has been pushed to its limits during the COVID-19 pandemic.
Waiving the IMD exclusion to Medicaid funding for inpatient behavioral
health treatment would free up beds in local hospitals, allowing them
to better manage the surge capacity in both inpatient and emergency
departments to care for COVID-19 patients. Additionally, new
legislation was introduced this year by Representative Napolitano, the
Increasing Behavioral Health Treatment Act, H.R. 2611. This legislation
would remove the IMD exclusion for states that have submitted a plan
to: increase access to outpatient and community-based behavioral health
care; increase availability of crisis stabilization services; and
improve data sharing and coordination between physical health, mental
health and addiction treatment providers and first-responders. We urge
Congress to pass this important legislation.
Develop a clear, universal compliance standard related to mental health
and addiction parity. ABHW member companies continue to invest
significant time and resources to understand and implement Mental
Health Parity and Addiction Equity Act (MHPAEA). Our member companies
have teams of dozens of people working diligently to implement and
provide MH/SUD parity benefits to their consumers. We have also had
numerous meetings with the regulators to help us better comprehend the
regulatory guidance and to discuss how plans can operationalize the
regulations.
While parity has progressed since its adoption in meaningful ways and
access to MH and SUD treatment providers has greatly expanded, systemic
issues continue to be a challenge due to other non-parity factors such
as the looming shortage of physicians (both psychiatrists as well as
other MH and SUD providers). Examples of key changes since the parity
law and regulations were enacted include: the fact that routine MH
outpatient treatment no longer habitually requires prior authorization
or has explicit quantitative treatment limits; evidence-based levels of
care for MH conditions are no longer subject to blanket exclusions
(e.g., residential treatment for eating disorders); and transparency,
documentation, attention to medical necessity criteria all have
improved.
However, despite these gains and the parity language in the 21st
Century Cures Act, aspects of the law and regulations remain overly
complex and technical. As a result, compliance has become a moving
target through a patchwork of conflicting and changing guidance. There
is new parity language in Section 203 of the recently passed
Consolidated Appropriations Act of 2021, and we hope that the
regulations related to these parity provisions will provide the clarity
payers need to appropriately implement MHPAEA. We strongly support the
flexibility built into the law, yet there has been a proliferation of
different compliance approaches, tools, and interpretations, which
continues to lead to confusion in implementation, is costly for
stakeholders, and ultimately hinders patient care. We believe this
Administration can re-invigorate efforts to clarify and improve the
application of the law for the benefit of all.
Strengthen and expand the behavioral health workforce. We appreciate
your support to expand access to care, and address ongoing workforce
shortages across the country in order to help ensure people who need MH
and/or SUD treatment get the care they need. As one first step, we ask
that the Administration and Congress work to increase funding to
behavioral health providers so that we have an adequate workforce to
meet the increasing need for MH and SUD services. We recommend
expanding eligible Medicare providers to include marriage and family
therapists (MFTs), mental health counselors (MHCs), and certified peer
support specialists.
Medicare coverage of mental health counselors and marriage and
family therapists. Recognition of MHCs and MFTs as Medicare providers
would increase the pool of eligible mental health professionals by over
200,000 licensed practitioners. Studies have shown that these providers
have the highest success and lowest recidivism rates with their
patients as well as being the most cost effective.\3\ We encourage you
to work with Congress to pass the Mental Health Access Improvement Act
(S. 828, H.R. 432), which recognizes MHCs and MFTs as covered Medicare
providers, helps address the critical gaps in care, and ensures access
to needed services.
---------------------------------------------------------------------------
\3\ D. Russell Crane and Scott H. Payne, ``Individual Versus Family
Psychotherapy in Managed Care: Comparing the Costs of Treatment by the
Mental Health Professions,'' Journal of Marital and Family Therapy 37,
no. 3 (2011): 273-289.
Medicare coverage of peer support services. Certified peer
support specialists can be vital in providing support to people living
with mental health conditions and SUDs. These paraprofessionals are
individuals with lived experience of recovery from a MH disorder or
SUDs. This evidence-based practice helps individuals navigate the
often-confusing health care system, get the most out of treatment,
identify community resources, and develop resiliency. Due to the COVID-
19 pandemic, engagement with treatment and care has been disrupted, but
finding and utilizing support in a timely manner can help mitigate
negative health outcomes of the disruption. Recently, the Promoting
Effective and Empowering Recovery Services in Medicare (PEERS) Act of
2021, H.R. 2767/S. 2144, was introduced. This legislation is an
important step in recognizing the unique role of peer support
specialists in helping individuals better engage in services, manage
physical and mental health conditions, build support systems, and,
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ultimately, live self-directed lives in their communities.
Ensure health coverage for individuals released from jails and prisons.
ABHW strongly supports H.R. 955/S. 285, the Medicaid Reentry Act of
2021, to grant Medicaid eligibility to incarcerated individuals 30 days
prior to their release to promote the health care needs of individuals
transitioning back into communities. According to the Bureau of Justice
Statistics, more than half of those in the criminal justice system
suffer from a mental illness. Of those with serious mental illness,
approximately 75 percent also have a co-occurring SUD. Allowing
incarcerated individuals to receive services covered by Medicaid 30
days prior to their release from jail or prison will expand access to
vital mental health and addiction services. Equipping individuals with
timely access to addiction, mental health, and other health-related
services before release, will facilitate the transition to community-
based care upon release that is necessary to help break the cycle of
recidivism. This is even more critical in the midst of the COVID-19
pandemic.
Issue regulation for 42 CFR Part 2. We look forward to the promulgation
of the next 42 CFR Part 2 (Part 2) rule pursuant to the Coronavirus
Aid, Relief, and Economic Security (CARES) Act of 2020. Part 2, which
governs the confidentiality of SUD records, sets requirements limiting
the use and disclosure of patients' SUD records from certain substance
use programs, including the cumbersome requirement of a signed consent
by the patient each time the SUD record is to be shared. The CARES Act
brings Part 2 into significant alignment with the Health Insurance
Portability and Accountability Act of 1996 (HIPAA). Changes in the
CARES Act permit a patient to provide one written consent to disclose
their Part 2 information for all future treatment, payment, and health
care operations (TPO), unless the patient revokes consent.
Additionally, under the CARES Act, breaches in a Part 2 program trigger
patient notification, Part 2 programs are now subject to HIPAA civil
and criminal penalties, and discrimination against Part 2 program
patients is prohibited. This legislation culminates years of work from
a broad range of organizations, and it represents a number of critical
compromises.
Attached you will find recommendations from the Partnership to Amend 42
CFR Part 2 (Partnership), which we have previously shared with the U.S.
Department of Health and Human Services (HHS), the Substance Abuse and
Mental Health Services Administration (SAMHSA) as well as the Office
for National Drug Control Policy (ONDCP). The Partnership, founded by
ABHW, brings together a broad spectrum of the healthcare industry to
advocate for aligning Part 2 with HIPAA. We urge HHS to ensure that the
requirements for Part 2 stated in the CARES Act are reflected in the
next Part 2 Rule.
Thank you for the opportunity to provide suggestions to address
important behavioral health policies. If you have any questions or
would like to discuss ABHW's policy priorities please contact Maeghan
Gilmore, Director of Government Affairs, at [email protected] or 202-
503-6999.
Sincerely,
Pamela Greenberg, MPP
President and CEO
______
Center for Fiscal Equity
14448 Parkvale Road, Suite 6
Rockville, MD 20853
[email protected]
Statement of Michael G. Bindner
Chairman Wyden and Ranking Member Crapo, thank you for the opportunity
to submit these comments for the record.
It seems like we covered this ground last month in the subcommittee,
but looking at the budget comments and appropriations history, I see
that there is much to pull together. This is a very ambitious title.
While I can trace my mental illness to an adrenal tumor and some have a
genetic predisposition to disease, while others arrive at dysfunction
through abuse, neglect or drug use, I suspect we won't cover everything
in the 90 or so minutes that this hearing will last.
Mental health care and addiction services have actually stood up rather
well during the pandemic. Zoom, and similar platforms, have stepped in
nicely to continue face to face care where needed. Phone appointments
and video calls have also worked in family practice settings where
medication management is the only task.
Managing my prescriptions and assisting my housemate in managing his
contacts with his are much easier than a trip to our respective mental
health providers.
There is one area of major concern that must be addressed, although I
am not sure how we can go about it. During this crisis, before there
was vaccine hesitancy, there was Zoom hesitancy. Some of our older
members simply could not figure out or declined to use video calls to
attend meetings.
I experienced this reticence myself, not wanting to download software
to my phone that was unknown to me. In the beginning, I was also too
ill to do much more than eat, be tired from eating, rest and then go
back to bed. It was only the usual miracles experienced by those who
are spiritually awake that had me download the software and attend a
midnight meeting.
My housemate is not technically savvy. Without my help, and the use of
my Chromebook, he would still be visiting his psychiatrist in person,
where he would be taken into a room for a teleconference with his
doctor.
He is a victim of the digital divide. It inhibits him (as well as the
lack of a computer of his own) to seek English as a Second Language
courses, which are free at Montgomery College (our local community
college). His disability, which is matched by his lack of education and
equipment hamper both his treatment and his ability to improve his
skills.
This is where improvement is necessary. As I have stated in previous
comments for the record, paying a stipend to undertake both computer
and basic literacy training is an essential incentive to seek it. Such
stipends should not count against his disability payments. If they did,
they would be a disincentive toward learning. It is a conservative meme
that poverty leads to self-improvement. Research has shown that the
opposite is the case. It certainly is for him.
And yes, better broadband in some areas of the country would be
helpful, although this would not solve the problem of digital
illiteracy, especially among vulnerable populations. Most people have
access to the Internet through their cable companies, although those
that do not should be given free access paid for by higher cable fees.
During the pandemic many mentally ill SSDI beneficiaries were not going
out much and did not have many places to go. Libraries and movie
theaters have been closed. Some were working in tense situations and
need a vacation. Those of us receiving SSDI benefits are spending more
on food of late. Let me illustrate.
Even before the pandemic, my SSDI was inadequate for food, medicine,
clothing and cable. If I owned a vehicle, there is no way I could
maintain it or even buy gas. I have an above average benefit, high
enough to be ineligible for SNAP or Medicaid. Many are not so lucky,
even on a good day.
In the last few months, days have not been so good. Were it not for
stimulus payments, I would be running out of food as I write this and
would not have just bought new clothes, from socks and underwear to a
jacket I can wear when the Committee finally asks me to testify in
person. As it is, I will need to use the last $600 from my December
payment (which should have come through Social Security) to attend my
upcoming high school reunion. While I have wifi, I cannot afford cable
and a car is still out of reach.
Let me underline a point. In most months, new underwear is not an
option, I rely on free bus rides due to the pandemic and subsidies from
Ride On and there is never enough money in that last week before the
check comes. When it does arrive, the cupboard is bare.
Double underline: food prices are skyrocketing. Part of the problem may
be too much money chasing too few goods, but retirees and the disabled
find (our)selves between a rock and a hard place. We need a COLA and we
need it now. Most of us cannot even afford cola. Because this is a
short term emergency due to the Pandemic, it should be funded out of
the general fund until the normal process kicks in for next year.
The important point is that, if wage growth is considered inflation,
the retired and disabled can be given not only a Cost of Living
Adjustment, but also have their income history rebased for inflation.
Even with Chained CPI, such an increase will take the financial
pressure off of many such households, including mine.
Home and Community-Based Health Care are addressed in the President's
Budget. Home and community-based care should be funded by goods and
services taxes as part of a newly created Medicare Part E. Senior
Medicaid should be entirely federalized, with other clients insured
through the President's proposal for a public option.
President Reagan's New Federalism proposal would have removed Medicaid
from state budgets in exchange for ending or block granting other
federal programs. This was a good idea then and a better idea now.
Medicaid Part E should be created to both relieve states and the
District of Columbia (or Washington, Douglass Commonwealth) from
providing Medicaid for seniors and the Disabled and seeing to the
enforcement of practice standards for nursing homes who receive these
funds.
For workforce development and general recovery, Psychiatric
Rehabilitation Programs, such as the Center for Behavioral Health in
Rockville and Cornerstone Montgomery in Gaithersburg are essential. To
make them more attractive, and to increase our ability to manage--
especially in the period before disability programs kick in,
participation should be paid at the minimum wage.
People will participate in this care more frequently if their
opportunity costs are met. Those with less than a full education should
receive it through public and private providers and also be paid to do
so.
Health care currently provided through Medicaid should be dual eligible
for everyone, regardless of income and before it kicks in entirely be a
public option. Instead of using a larger system, clients should have
the option of receiving coverage through the PRP provider's employee
plan.
Low wages are endemic among the mentally ill. We need a raise, along
with the rest of the working poor (and not so poor--who make more when
the minimum goes up). The Minority proposed a $10 wage as a counter-
offer to $15. A $12 wage for a 40 hour week puts us at parity to 1965,
when the wage peaked and the war over wages started with the Kennedy-
Johnson tax cuts. An $11 wage with a 32 hour week is also acceptable.
With increased productivity, the work week should be shorter. The
minimum wage should be indexed to inflation, including during any
transitional period--which should have the goal of $18 per hour ($15 is
a 20th Century goal).
Not raising minimum wages has been justified by the reactionary sector
that claims that in the end, the market will sort everything out. The
perception that doing the right thing makes a business non-competitive
is the reason we enact minimum wage laws and should require mandatory
leave. Because the labor product is almost always well above wages
paid, few jobs are lost when this occurs. Higher wages simply reduce
what is called the labor surplus, and not only by Marx. Any CFO who
cannot calculate the current productive surplus will soon be seeking a
job with adequate wages and sick leave.
The requirement that this be provided ends the calculation of whether
doing so makes a firm non-competitive because all competitors must
provide the same benefit. This applies to businesses of all sizes. If a
firm is so precarious that it cannot survive this change, it is
probably not viable without it.
Mentally ill people deserve to have families, just as others do.
Increasing the child tax credit is as essential to us as to anyone. The
child tax credit level passed in the American Recovery Act should be
made permanent and doubled, with distribution through private sector
payrolls, unemployment insurance benefits, emergency benefits for
families and paid participation in educational programs.
There are two avenues to distribute money to families. The first is to
add CTC benefits to unemployment, retirement, educational (TANF and
college) and disability benefits. The CTC should be high enough to
replace survivor's benefits for children.
The second is to distribute them with pay through employers. This can
be done with long term tax reform, but in the interim can be
accomplished by having employers start increasing wages immediately to
distribute the credit to workers and their families, allowing them to
subtract these payments from their quarterly corporate or income tax
bills.
In recent decades, the problem of veteran disability determinations has
remained troubling, with the Pandemic complicating processing. When a
job gets too big to manage with staff, two options remain--contract out
as much work as possible, including consolidating case files and making
easy determinations--and sharing responsibility for processing with the
Department of Defense. The handoff from DoD to DVA should be seamless.
The mental health and housing needs of veterans, both recent and
lingering, is endemic. This is another area where coordination with DoD
would prove helpful. This help must go beyond management and computer
systems and include the human element of soldiers, veterans using
services and those who need services can interact on a less formal, but
not unprogrammed basis.
The DVA and DoD must both actively facilitate this and join state and
local governments in reaching out to those who suffer, from active duty
soldiers to veterans both receiving and in need of services. For those
mentally ill or addicted veterans who do not trust the system, less
restrictive systems should be developed--including providing camping
supplies and a place to camp and a more permissive attitude to active
drinking and drug use until help is sought. Such systems do not
encourage use. No addict needs encouragement. They build the trust that
makes recovery possible.
The largest provider of mental health services (including to veterans)
is the correctional system. Job one is to shift from correctional
modalities to new methods featuring mental health, education (including
ESL programs) and addiction medicine. Warehousing young males of any
race, but particularly African-Americans multiplies societal
pathologies. While some forms of illness, such as sexual violence and
physical violence or murder may require higher security, others can be
treated as patients rather than criminals.
The Department of Justice can take the lead in both practice and in
developing best practices for state correctional systems. Part of this
would be specialized facilities based on the type of crime committed.
For example, sex offenders would be in facilities of their own. Those
who remain dangerous post-sentence would still be detained until they
are no longer dangerous. Such decisions must be based on science, not
the desire for further punitive measures.
This change would migrate to local law enforcement, i.e., policing.
A pilot program could be developed to respond to certain incidents
(especially those involving mental illness or alcohol) with immediate
dispatch of emergency medical teams. This would require more
ambulances, more mental health facilities and a pause in applying
restraints until medical personnel arrive.
Funding more hospitals and ambulances would be part of this, possibly
with some form of federal grant program. Private corrections facilities
can also be transformed into contracted medical facilities with
security contracting provided as a subcontract to mental health
systems, both secular and religious. Catholic Health Association
members come to mind. Both public and private educational systems would
be an integral part of such facilities and be treated as an essential
function, rather than the first item cut when states wish to minimize
their spending by essentially torturing (and dehumanizing) inmates.
New standards of individual and societal protection must be developed.
Improved standards of care and security will require much more funding
than state and local governments are willing to commit to. This simply
drives the problem to the correctional system, which is the largest
provider of mental healthcare in this nation. The term for this
practice is pennywise and pound-foolish.
It is too easy to get out of treatment and too hard to get it.
Hospitalization for medication management is sometimes needed but
rarely given. Often, people are released before a stable routine is
established, including management of side effects. It is hard to create
a good care plan in a five day hold. For both mental illness and
alcoholism, it must be harder to simply sign out without a real
prospect for long- term recovery. Again, the term is penny wise and
pound foolish.
A final reform, which will save money and resources, is to create a
plea in criminal cases of guilty by reason of insanity. Those who enter
this plea would be confined in the facilities detailed above for at
least the minimum sentence for their offences, with no release after
that if the subject remains a danger to society.
If relapse occurs or treatment protocols are evaded after release,
rehospitalization must be automatic and last until a treatment program
is more deeply ingrained. There should, of course, be protections on
both sides in the decision to release subjects--both for the protection
of the rights of subjects who made be held for punitive, rather than
hygienic reasons and, as importantly, the interests of the victims of
crime, including but not limited to the possibility of physical danger.
Sometimes, exile should be a part of release.
Thank you for the opportunity to address the committee. We are, of
course, available for direct testimony or to answer questions by
members and staff.
______
Eating Disorders Coalition for Research, Policy, and Action
PO Box 96503-98807
Washington, DC 20090
Statement of Allison Ivie, MPP, MA, Government Relations Representative
Chairman Wyden, Ranking Member Crapo, and members of the U.S. Senate
Committee on Finance, thank you for holding this important hearing
entitled, ``Mental Health Care in America: Addressing Root Causes and
Identifying Policy Solutions'' to ensure the nation has the services
and supports in place to care for individuals across the nation with
mental illness and addiction, including those with eating disorders.
The Eating Disorders Coalition for Research, Policy, and Action (EDC)
is a nonprofit organization comprised of patient and caregiver
advocates, treatment providers, advocacy organizations, and academics,
aimed to advance the recognition of eating disorders as a public health
priority throughout the U.S. By promoting federal support for improved
access to care, the EDC seeks to increase the resources available for
education, prevention, and improved training, as well as for scientific
research on the etiology, prevention, and treatment of eating
disorders.
As the number of new COVID-19 cases continues to decline, eating
disorders diagnoses continue to climb. Research indicates a 30 percent
increase in eating disorder diagnoses since March 2020 compared with
data in previous years.\1\ EDC members, the National Eating Disorders
Association has seen a 53 percent increase in their call volume to
their helpline since March 2020 and the Alliance for Eating Disorders
Awareness has already served 7,000 individuals representing all 50
states and 32 countries and provided approximately 50,000 referrals for
treatment since January 2021. This is just a sampling of the magnitude
of services our coalition members are doing to support individuals and
families in need. Despite this incredible work, we know there is still
work to be done to improve the care for individuals with eating
disorders.
---------------------------------------------------------------------------
\1\ Tanner, Lindsay. (May 23, 2021). Pandemic has fueled eating
disorders surge in teens, adults. Associated Press. Retrieved from:
https://apnews.com/article/coronavirus-pandemic-virus-lifestyle-eating-
disorders-health-27c9d5680980b1452f7e512db4d9f825.
Eating disorders are serious mental illnesses that affect 28.8 million
Americans over the course of their lifetime.\2\ They have the second
highest mortality rate of any psychiatric illness, with one death
occurring every 52 minutes as a direct result of an eating disorder.\3\
Without access to comprehensive treatment, eating disorders create
great economic distress, costing the U.S. economy $64.7 billion
annually with the federal government shouldering $17.7 billion of that
cost.\4\ Ensuring comprehensive coverage for eating disorders treatment
has the potential to mitigate disease progression or relapse into
higher levels of treatment. Without access and/or coverage to
treatment, higher levels of eating disorders treatment cost the U.S.
$29.3 million in emergency room visits and $209.7 million in inpatient
hospitalizations annually.\5\
---------------------------------------------------------------------------
\2\ Deloitte Access Economics. The Social and Economic Cost of
Eating Disorders in the United States of America: A Report for the
Strategic Training Initiative for the Prevention of Eating Disorders
and the Academy for Eating Disorders. June 2020. Available at: https://
www.hsph.harvard.edu/striped/report-economic-costs-of-eating-
disorders/.
\3\ Ibid.
\4\ Ibid.
\5\ Ibid.
Eating disorder prevalence rates among the senior and disabled
populations are similar to the general population at approximately 3
percent to 6 percent.\6\, \7\ However, older Americans with
eating disorders are particularly serious as chronic disorders or
diseases may already compromise their health.\8\ Inadequate nutrition
as a result of their eating disorder can result in memory deficits;
cognitive decline; decubitus ulcers; impaired healing of sores, wounds,
or infections; and dizziness, disorientation, and falls, which can
initiate a cascade of pathophysiological events leading to a 30 percent
to 40 percent mortality rate.\9\ Tragically, 78 percent of deaths from
anorexia nervosa occur in the elderly.\10\
---------------------------------------------------------------------------
\6\ Peat, Christine; Peyerl, Naomi; and Muehlenkamp, Jennifer.
(2010). Body Image and Eating Disorders in Older Adults: A Review. The
Journal of General Psychology, 135:4, 343-358.
\7\ Mangweth-Matzek B, Hoek HW. Epidemiology and treatment of
eating disorders in men and women of middle and older age. Curr Opin
Psychiatry. 2017;30(6):446-451. doi: 10.1097/YCO.0000000000000356.
\8\ Peat, Christine; Peyerl, Naomi; and Muehlenkamp, Jennifer.
(2010). Body Image and Eating Disorders in Older Adults: A Review. The
Journal of General Psychology, 135:4, 343-358.
\9\ Dudrick, Stanley. (2013). Older Clients and Eating Disorders.
Today's Dietitian, 15:11, 44.
\10\ Dudrick, S. (2014). Older clients and eating disorders.
Today's Dietitian, 15(11), 44.
Prevention and early intervention are the best tools to prevent disease
progression for those with mental illness or substance use disorders.
Given the complexity of eating disorders, a multidisciplinary treatment
team that includes a medical provider, psychiatrist, psychologist, and
registered dietitian is considered to be the four key provider
components for comprehensive eating disorders treatment. The
exponential rise in eating disorders as a consequence of the pandemic
---------------------------------------------------------------------------
further underscores the importance of early intervention.
Unfortunately, Medicare does not provide outpatient coverage for
medical nutrition therapy (MNT) for individuals with eating disorders.
This coverage only applies to beneficiaries that are diagnosed with
diabetes or end stage renal disease. This lack of coverage leaves
individuals susceptible to disease progression and in need of a higher,
costlier level of treatment. According to the American Dietetic
Association, nutritional therapy conducted by a registered professional
is an ``essential component'' for the treatment of patients with
anorexia nervosa, bulimia nervosa, and other eating disorders.\11\
Research shows mental health interventions for eating disorders may not
be successful if the underlying nutritional issues haven't been
addressed first, since nutritional deficiency causes cognitive issues
(e.g., depression) that can impede recovery.\12\ Nutrition counseling
guides patients in identifying problematic behaviors and setting
realistic and achievable nutrition related goals to support clients in
making behavior changes. Nutrition education includes conversations
about discrepancies between knowledge, beliefs and behaviors,
ultimately empowering the patient to normalize eating and make
healthier decisions.\13\
---------------------------------------------------------------------------
\11\ Ozier, AD; and Henry, BW. ``Position of the American Dietetic
Association: Nutrition intervention in the treatment of eating
disorders.'' NCBI/NLM/NIH. https://www.ncbi.nlm.nih.gov/pubmed/
21802573.
\12\ Rosen, David. (2010). Clinical Report--Identification and
Management of Eating Disorders in Children and Adolescents. American
Academy of Pediatrics, 126:6.
\13\ Ruiz-Prieto, Inmaculada; Bolanos-Rios, Patricia; and Jauregui-
Lobera, Ignacio. (2013). Diet Choice in weight-restored patients with
eating disorders; progressive autonomy by nutritional education.
Nurtricion Hospitlaria, 28:5, 1725-1731.
Fortunately, Congress has legislation to address this gap in coverage
with a bipartisan bill entitled, the Nutrition Counseling Aiding
Recovery for Eating Disorders Act or the Nutrition CARE Act (H.R. 1551/
S. 584) led by Senators Maggie Hassan (D-NH) and Lisa Murkowski (R-AK)
and Representatives Judy Chu (D-CA-27), Jackie Walorski (R-IN-02) and
Lisa Blunt Rochester (D-DE-AL). The legislation would provide Medicare
Part B coverage for medical nutrition therapy for beneficiaries
diagnosed with an eating disorder at the same coverage levels
---------------------------------------------------------------------------
beneficiaries with diabetes and end stage renal disease receive.
This legislation is a small, critical step in ensuring the federal
government is meeting the mental health needs of Americans across the
lifespan. We urge the U.S. Senate Committee on Finance, Health
Subcommittee to move this bill forward for consideration to the full
committee as we work together to support the 2 to 2.5 million Medicare
beneficiaries with eating disorders that could benefit from the
Nutrition CARE Act.
Thank you for your consideration.
Sincerely,
Eating Disorders Coalition for Research, Policy, Pand Action Members in
Formation:
Academy for Eating Disorders Reston, VA
Academy of Nutrition and Dietetics Chicago, IL
Alliance for Eating Disorders Awareness West Palm Beach, FL
Alsana: Eating Disorders Treatment and Recovery Ballwin, MO
Centers
Bannister Consultancy Durham, NC
BE REAL USA Chicago, IL
Cambridge Eating Disorder Center Cambridge, MA
Center for Change Orem, UT
Center for Discovery Los Alamitos, CA
Eating Disorder Coalition of Iowa Clive, IA
Eating Disorder Hope Redmond, OR
Eating Recovery Center Denver, CO
Farrington Specialty Centers Fort Wayne, IN
Gail R. Schoenbach FREED Foundation Warren, NJ
International Association of Eating Disorders Pekin, IL
Professionals
International Federation of Eating Disorders Dallas, TX
Dietitians
Laureate Eating Disorders Program Tulsa, OK
Monte Nido and Affiliates Miami, FL
Montecatini Carlsbad, CA
Moonshadow's Spirit Webster, NY
Multi-Service Eating Disorders Association Newton, MA
National Eating Disorders Association New York, NY
Park Nicollet Melrose Center St. Louis Park, MN
Project HEAL Brooklyn, NY
REDC Consortium St. Paul, MN
Rogers Behavioral Health Oconomowoc, WI
Rosewood Centers for Eating Disorders Wickenburg, AZ
Stay Strong Virginia Chesterfield, VA
Strategic Training Initiative for the Boston, MA
Prevention of Eating Disorders
SunCloud Health Northbrook, IL
The Donahue Foundation Richmond, VA
The Emily Program St. Paul, MN
The National Association of Anorexia Nervosa Chicago, IL
and Associated Eating Disorders
The Renfrew Center Pittsburgh, PA
Veritas Collaborative Durham, NC
Walden Behavioral Care Waltham, MA
WithAll St. Louis Park, MN
Wrobel and Smith, PLLP St. Paul, MN
______
Healthcare Leadership Council
750 9th St., NW, Suite #500
Washington, DC 20510
June 21, 2021
The Honorable Ron Wyden The Honorable Mike Crapo
Chair Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
Washington, DC 20510 Washington, DC 20510
Dear Chair Wyden and Ranking Member Crapo:
On behalf of the Healthcare Leadership Council (HLC), we thank you for
holding a hearing on, ``Mental Health Care in America: Addressing Root
Causes and Identifying Policy Solutions.''
HLC is a coalition of chief executives from all disciplines within
American healthcare. It is the exclusive forum for the nation's
healthcare leaders to jointly develop policies, plans, and programs to
achieve their vision of a 21st century healthcare system that makes
affordable high-quality care accessible to all Americans. Members of
HLC--hospitals, academic health centers, health plans, pharmaceutical
companies, medical device manufacturers, laboratories, biotech firms,
health product distributors, post-acute care providers, home care
providers, and information technology companies--advocate for measures
to increase the quality and efficiency of healthcare through a patient-
centered approach.
The COVID-19 health pandemic has created significant barriers to
accessing mental health services. A January study found that over 40%
of adults have reported struggling with anxiety or depression since the
beginning of the pandemic.\1\ The impact of COVID on mental health is
expected to continue to be a challenge in the coming years. We applaud
Congress for providing over $4 billion in the Consolidated
Appropriations Act and $3.8 billion in the American Rescue Plan Act for
mental health services. These investments will provide much-needed
assistance to struggling communities.
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\1\ Nirmita Panchal et al., The Implications of COVID-19 for Mental
Health and Substance Abuse, Kaiser Family Foundation (February 10,
2021), https://www.kff.org/coronavirus-covid-19/issue-brief/the-
implications-of-covid-19-for-mental-health-and-substance-use/.
We encourage the Committee to examine ways to improve access to mental
health services, particularly via telehealth options. A recent survey
found that approximately 50% of patients using telehealth services were
seeking behavioral health treatment.\2\ Providing mental health
treatment via telehealth provides a unique opportunity to reach
underserved patients. Estimates have found that up to 60% of patients
do not arrive for their behavioral health appointments.\3\ By using
telehealth solutions to deliver such care, providers have been able to
deliver much needed assistance to patients in their homes. Patient
satisfaction in receiving behavioral health treatment via telehealth
\4\ has shown that providers can innovate in care delivery without
sacrificing quality.
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\2\ Shira Fischer et al., The Transition to Telehealth During the
First Months of the COVID-19 Pandemic, RAND Corporation (January 8,
2021), https://link.springer.com/content/pdf/10.1007/s11606-020-06358-
0.pdf.
\3\ Eric Berger, No-Cancel Culture: How Telehealth Is Making It
Easier to Keep that Therapy Session, Kaiser Health News (May 24, 2021),
https://khn.org/news/article/no-cancel-culture-how-telehealth-is-
making-it-easier-to-keep-that-therapy-session/.
\4\ Joe Gramigna, Patient satisfaction high for psychiatric
telehealth platforms in partial hospital program, Healio (March 25,
2021), https://www.healio.com/news/psychiatry/20210325/patient-
satisfaction-high-for-psychiatric-telehealth-platforms-in-partial-
hospital-program.
The COVID-19 health pandemic has also exacerbated the substance use
disorder (SUD) crisis in the United States. From May 2019-June 2020,
the number of deaths related to drug overdoses rose 20% and a record
number of Americans died from overdoses.\5\ Preliminary data expects
2020 to be the worst year on record for drug overdoses.\6\ In order to
respond to this crisis, Congress and federal agencies took swift action
to ensure patients struggling with SUDs received proper care. We
applaud the Drug Enforcement Agency's (DEA) decision to temporarily
waive in-person requirements to prescribe controlled substances. This
has allowed patients to continue to receive important medications,
particularly buprenorphine. HLC also thanks the Centers for Medicare
and Medicaid Services (CMS) for finalizing regulations mandated under
the SUPPORT Act that require providers to use electronic prescribing
for controlled substances (EPCS). Requiring EPCS puts a more advanced
monitoring system in place to ensure that controlled substances are
only prescribed when necessary and allows for relevant authorities to
monitor potential trends. We encourage Congress to work with federal
agencies to further implement flexibilities that would allow patients
to receive medications through the duration of the public health
emergency (PHE) while maintaining robust safety and monitoring
programs.
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\5\ Usha Lee McFarling, As the pandemic ushered in isolation and
financial hardships, overdose deaths reached new heights, STAT News
(February 16, 2021), https://www.statnews.com/2021/02/16/as-pandemic-
ushered-in-isolation-financial-hardship-overdose-deaths-reached-new-
heights/.
\6\ Chris Sweeney, A crisis on top of a crisis: COVID-19 and the
opioid epidemic, Harvard T.H. Chan School of Public Health (February
16, 2021), https://www.hsph.harvard.edu/news/features/a-crisis-on-top-
of-a-crisis-covid-19-and-the-opioid-epidemic/.
HLC appreciates your work on improving mental health outcomes for
patients and looks forward to working with you on future solutions.
Please feel free to contact Tina Grande at 202-449-3433 or
---------------------------------------------------------------------------
[email protected] with any questions.
Sincerely,
Mary R. Grealy
President
______
HR Policy Association, American Health Policy Institute, and
National Alliance of Healthcare Purchaser Coalitions
June 15, 2021
The HR Policy Association, the American Health Policy Institute, and
the National Alliance of Healthcare Purchaser Coalitions appreciate the
Committee holding this important hearing on behavioral and mental
health care issues.
The HR Policy Association is the leading organization representing
chief human resource officers of over 390 of the largest employers in
the United States. Collectively, their companies provide health care
coverage to over 20 million employees and dependents in the United
States. The American Health Policy Institute, a part of HR Policy
Association, examines the challenges employers face in providing health
care to their employees and recommends policy solutions to promote
affordable, high-quality, employer-based health care. The Institute
serves to provide thought leadership grounded in the practical
experience of America's largest employers.
The National Alliance of Healthcare Purchaser Coalitions (National
Alliance) is the only nonprofit, purchaser-led organization with a
national and regional structure dedicated to driving health and health
care value across the country. Its members represent private and public
sector, nonprofit, and Taft-Hartley organizations, and more than 45
million Americans, spending $300 billion annually on healthcare.
The National Alliance, HR Policy Association and the American Health
Policy Institute are also part of The Path Forward initiative to
execute a disciplined, private sector approach to systematically and
measurably improve five established best practices of mental health and
substance use care. Below are our policy recommendations to improve
access to behavioral and mental health care services.
Sincerely,
D. Mark Wilson Michael Thompson
President and CEO, American Health
Policy Institute President and CEO
Vice President, Health and
Employment Policy National Alliance of Healthcare
Purchaser Coalitions
HR Policy Association 1015 18th Street, NW, Suite 705
1001 19th St. North, Suite 1002
Arlington, VA 22209 Washington, DC 20036
Collaborative Care Model (CoCM)
While employer health plans and Medicare reimburse providers in
collaborative care practices, behavioral health is not broadly
integrated with primary care. Because behavioral health conditions
often initially present themselves in primary care settings, this lack
of integration leaves patients with undiagnosed or poorly managed
behavioral health conditions. Increasing the number of collaborative
care practices would improve access to behavioral health services,
increase the effectiveness of treatment, and reduce disparities in
identification of behavioral health issues. Over 70 randomized
controlled trials have demonstrated collaborative care models are more
effective and cost efficient than usual care.\1\
---------------------------------------------------------------------------
\1\ https://www.chcs.org/media/
HH_IRC_Collaborative_Care_Model__052113_2.pdf.
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Policy Recommendations
1. Allocate funds to support a change effort to provide technical
assistance, training and startup funds to allow for large scale
adoption for collaborative care across the country. Collaborative care
can be delivered virtually or by in person care managers meaning this
model can deliver to large medical groups or small and rural primary
care practices.
2. CMS should establish a national Technical Assistance (TA)
center and regional extension centers to assist primary care practices
in implementing the CoCM.
3. Incentivize behavioral health care providers to adopt
electronic health record technology that is interoperable with general
health care providers into their practices.
4. Expand research on promising integrated care models.
TeleBehavioral Healthcare (TBH)
Background--During the COVID-19 pandemic, Medicare rules related to
TBH have been liberalized resulting in an exponential growth in the use
of TBH, including enabling cross-state care which has been critical to
underserved areas and rural communities. However, the requirements for
employer health plans around how TBH is provided and reimbursed remain
far too restrictive and result in access and quality disparities. TBH
has the potential to overcome patient stigma and improve access and
efficiency of care for BH services. We know that since the COVID-19
public health emergency, there has been a significant increase in
patients keeping their appointments. In general, when patients keep
their first appointment, they are more likely to keep subsequent
appointments; and when patients are satisfied with treatment, they are
more likely to continue with their course of therapy. Research also
suggests that TBH results in better medication compliance, fewer visits
to the emergency department, fewer patient admissions to inpatient
units, and fewer subsequent readmissions. However, many older adults
and people with disabilities, lack access to video-enabled devices or
struggle to use the more complex video-enabled devices even if they
have them. Likewise, many in racial/ethnic and low-income communities
lack access to broadband or video-enabled devices, which only expands
the health inequities in the U.S.
Policy Recommendations
1. Eliminate cross-state border restrictions on TBH on a permanent
basis for Medicare, employer and commercial plans. Licensing
requirements should be based on the location of the provider not the
patient.
2. Enable patient access to TBH without having the first provider
appointment be in person.
3. Make permanent the allowance of first-dollar coverage of
telehealth in high deductible health plans. Specifically, Congress
should pass the Telehealth Expansion Act of 2021 (S. 1704).
4. Allow employers to offer standalone ``excepted benefit''
telehealth benefits.
5. Adopt technology-neutral requirements, permitting use of
different types of technology platforms for telehealth services.
6. Establish a uniform set of rules for multi-state telehealth
benefit plans to eliminate state restrictions that block patients from
telehealth benefits.
The HR Policy Association, the American Health Policy Institute, and
the National Alliance welcome any opportunity to provide input and
speak in further detail about improving access to behavioral and mental
health care services. We look forward to working with you on this
important topic.
______
The Partnership to Amend 42 CFR Part 2
April 13, 2021
Robinsue Frohboese
Acting Director and Principal Deputy
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, DC 20201
Dr. Neeraj Gandotra
Chief Medical Officer
Substance Abuse and Mental Health Services Administration
5600 Fishers Lane
Rockville, MD 20852
Re: 42 CFR Part 2--Recommendations for Next Rule
Dear Ms. Frohboese and Dr. Gandotra,
The Partnership to Amend 42 CFR Part 2 (Partnership), writes to provide
recommendations for the U.S. Department of Health and Human Services'
(HHS) Office for Civil Rights (OCR) and the Substance Abuse and Mental
Health Services Administration (SAMHSA) to consider when drafting the
new rule for the 42 CFR Part 2 (Part 2) provisions in the Coronavirus
Aid, Relief, and Economic Security Act (CARES Act). We have appreciated
working with HHS and SAMHSA on Part 2 in the past and welcome the
opportunity to partner with both SAMHSA and OCR on this important issue
moving forward.
The Partnership is a coalition of nearly 50 organizations committed to
aligning Part 2 with the disclosure requirements of the Health
Insurance Portability and Accountability Act (HIPAA) for the purposes
of treatment, payment, and health care operations (TPO).
This is a time of unprecedented urgency. First, the Centers for Disease
Control and Prevention's preliminary estimate is that more than 81,000
Americans died of drug overdose in 2020. Second, federal health
officials believe the drug crisis is only being amplified by months of
social isolation, high unemployment, and diversion of public health
resources, all a result of the COVID-19 pandemic.\1\ Given this
alarming correlation, an important part of responding to the COVID-19
pandemic will be to simplify coordination of care for substance use
disorders (SUDs), which ultimately will prevent gaps and expand access
to care. Furthermore, we anticipate SUDs may continue to rise even
after the COVID-19 pandemic is over, reflecting the extreme toll it has
taken on Americans. As such, we believe quickly issuing the proposed
rulemaking, as required by section 3221 of the CARES Act, will both
help curb the SUD epidemic and also strongly supports the incoming
Biden-Harris Administration's Build Back Better strategy.
\1\ Dan Goldberg and Brianna Ehley, Biden's other health crisis: A
resurgent drug epidemic, Politico, November 28, 2020.
Previous requirements in the Part 2 regulation led to segmented data,
interrupted flow of that data, and ultimately hindered informed
diagnosis, treatment, and implementation of an individual's care plan
and access to care. The CARES Act takes great strides to remedy these
issues by promoting partial alignment between Part 2 and HIPAA, though
the two privacy frameworks remain distinct, particularly for consent
purposes. Nevertheless, the law clearly strives to bring Part 2 in line
with HIPAA, a fact being embraced by industry thought leaders. For
example, the Medicaid and CHIP Payment and Access Commission (MACPAC)
noted during its December 2020 meeting that the CARES Act
``[p]ermanently aligns 42 CFR Part 2 and HIPAA.''\2\
---------------------------------------------------------------------------
\2\ Aaron Pervin and Erin McMullen, Promoting Behavioral and
Physical Clinical Integration Through EHRs, 2020. https://
www.macpac.gov/wp-content/uploads/2020/12/Integrating-Clinical-Care-
through-Greater-Use-of-Electronic-Health-Records-by-Behavioral-Health-
Providers.pdf, last visited April 1, 2020.
Additionally, and most importantly, the Partnership staunchly supports
patient privacy. We are acutely aware that even if the sharing of
information is made easier, it has limited utility without continued
strong protections for patient privacy. Without trust, patients may not
seek the care they need to treat SUDs. We are also aware that
individuals may be concerned that SUD records will be used against them
---------------------------------------------------------------------------
by law enforcement.
These are significant concerns. However, the CARES Act protects patient
rights in two important ways. First, it allows an individual to revoke
his or her consent to sharing SUDs records, giving patients control
over their information.\3\ Second, SUD records are expressly prohibited
by law from being used in civil, criminal, administrative, or
legislative proceedings against a patient by any government authority
(unless authorized by court order or patient consent). Furthermore, SUD
records specifically cannot: (a) be entered into evidence in criminal
prosecutions or civil actions; (b) form part of the record for a
decision or otherwise be taken into account in government agency
proceedings; (c) be used by a governmental agency for law enforcement
purposes or investigations; or (d) be used in a warrant application.\4\
As such, we believe the changes made to Part 2 by the CARES Act will
allow for smoother care coordination while simultaneously strengthening
patient privacy.
---------------------------------------------------------------------------
\3\ Coronavirus Aid, Relief, and Economic Security Act (CARES Act),
Pub. L. No. 116-136, section 3221(b)(1)(C).
\4\ Id. at section 3221(e).
As you begin drafting the next Part 2 rule, we submit the following for
---------------------------------------------------------------------------
your consideration:
Original Consent Process. While the Confidentiality of Substance Use
Disorder Patient Records Final Rule (final rule) issued in July 2020
takes an important step forward to address the issue of patient
consent, we believe more needs to be done in this regard. The final
rule allows an entity, instead of an individual, to be specified as the
recipient of Part 2 records, which broadens the scope of the consent
and incrementally relieves the burden on patients and providers.
However, this is not enough because a new patient consent is needed
each time there is a new entity where the Part 2 record needs to be
disclosed.Fortunately, the CARES Act further simplifies the process by
requiring only one consent, after which the Part 2 record can be used
or disclosed by a covered entity or business associate for the purposes
of TPO in accordance with the HIPAA regulations.
Additionally, please note that although the initial consent requirement
was amended under section 3221 of the CARES Act to allow a general
designation (instead of a specific practice), there still remains a
roadblock in practice: the list of disclosures requirement in Part 2.
Specifically, section 2.31 of Part 2 mandates that ``upon request,
patients who have consented to disclose their patient identifying
information using a general designation must be provided a list of
entities to which their information has been disclosed pursuant to the
general designation'' [emphasis added]. Due to the list of disclosures
requirement, practitioners are often uncomfortable attempting to use
the general designation in the consent.
Recommendation: Ensure that the consent requirements in the next rule
are simple and straightforward so additional administrative processes
are not imposed on patients, providers, or payers (including health
plans and their subcontractors). The consent process should be easily
folded into existing HIPAA compliance processes, preferably with the
patient's acknowledgement of HIPAA practices and the patient's Part 2
consent incorporated into the same document at intake where feasible.
Furthermore, include language to address the conflict with Part 2's
list of disclosures requirement.
Transmission and Retransmission of Data. The CARES Act plainly states
that once written consent is obtained, a Part 2 record may be
transmitted and retransmitted for TPO in accordance with HIPAA
regulations. No further consent should be required for TPO unless the
patient revokes consent.
Recommendation: Include specific language directing covered entities
and business associates to disclose and redisclose data in accordance
with HIPAA regulations.
The final rule also requires physically separating records with Part 2
data. However, such physical separation is difficult once the data is
transmitted, as very few integrated systems or Health Information
Exchanges (HIEs) can manage the consent process for a completely
separate database for Part 2 records. The separation of data not only
creates an administrative burden, but also makes the data difficult to
obtain by subsequent treating providers, ultimately hindering patient
care. For example, we have heard anecdotes of physicians physically
carrying two separate laptops for the purposes of compliance with the
data segregation requirements.
Recommendation: Specify that once Part 2 data is transmitted or
retransmitted with patient consent, there is no requirement to
segregate a patient's Part 2 data from the rest of a HIPAA database,
with the regulatory requirement for data segmentation terminating upon
transmission or retransmission.
Revocation of Consent Provisions. The patient's ability to revoke
consent is an important privacy protection supported by the
Partnership. However, serious administrative issues arise when there is
an expectation that a revocation be retroactively effective.
Specifically, practices are now required, under the Promoting
Interoperability program, to incorporate information from outside
sources for medications, allergies, and other problems. If revocation
is mandated to be retroactive, there is technically no way to go back
and isolate this data from a patient's overall clinical record.
Furthermore, it is critical that the responsibility for managing the
revocation remain with a designated entity. We believe that the
management of the consent revocation should be the responsibility of
the Part 2 treatment entity that contributed that data and that program
would be responsible for seeing that the Part 2 data is not being
transmitted either to another covered entity or business associate.
Recommendation: Specifically state that the revocation of consent for
Part 2 data transmission is effective only from the point of revocation
going forward and that responsibility for the revocation should be
limited to those who are so notified by the patient and their
respective actions.
Scope of Part 2 Consent Process. SAMHSA's current guidance seems to
indicate that a Part 2 consent should not impede the transmission of
behavioral health data that does not originate with a Part 2 program.
However, this is very different in practice as there is much confusion
on how to handle behavioral health data. Providers hesitate to share
behavioral health data because they are concerned that they may be
violating Part 2 requirements related to consent.
Recommendation: OCR and SAMHSA should explore, in partnership with
stakeholders, how to exclude behavioral health data from the Part 2
data and incorporate the findings into the rule and any subsequent
frequently asked questions or guidance. Similarly, OCR and SAMHSA
should explore, in conjunction with the States and stakeholders, policy
mechanisms for promoting the use of behavioral health data for care
coordination purposes when state privacy laws may impose restrictions
beyond both Part 2 and HIPAA.
Research. The final rule permits disclosures for the purposes of
research under Part 2 by a HIPAA covered entity or business associate
to non-HIPAA covered individuals and organizations. However, the CARES
Act does not specifically address disclosures for the purpose of
research.
Recommendation: Include a provision in the next rule, consistent with
the last rule, to ensure that disclosures for the purposes of research
from a HIPAA covered entity to a non-HIPAA covered entity are
permissible.
Patient Rights. The final rule does not address patient rights.
However, in Section 422(j) of the CARES Act, it is stated that nothing
in that section can be construed to limit patient rights related to
privacy protections for protected health information as defined under
Section 164.522 of the HIPAA Privacy Rule.
Recommendation: Include specific language to ensure that patient
privacy rights are protected in accordance with the CARES Act and
HIPAA.
Claims Data Access. Currently, HHS provides patients' claims data
through various initiatives, including to organizations participating
in alternative payment models. Accountable care organizations, for
example, are provided claims data at least monthly, and sometimes
weekly. But these data lack SUD-related information because of limits
of Part 2.
Recommendation: We urge HHS to start providing SUD-related claims data
to providers practicing in alternative payment models to help support
their work in population health management.
Thank you for your time and consideration on this crucial issue. Please
feel free to contact Deepti Loharikar, Director of Regulatory Affairs,
Association for Behavioral Health and Wellness, at [email protected]
or (202) 505-1834 with any questions.
Sincerely,
Maeghan Gilmore, MPH
Chairperson, Partnership to Amend 42 CFR Part 2
Members of the Partnership
Academy of Managed Care Pharmacy Alliance of Community Health
Plans American Association on Health and Disability
American Health Information Management Association American
Hospital Association American Psychiatric Association
American Society of Addiction Medicine American Society of
Anesthesiologists America's Essential Hospitals America's
Health Insurance Plans AMGA Association for Ambulatory
Behavioral Healthcare Association for Behavioral Health and
Wellness Association for Community Affiliated Plans
Association of Clinicians for the Underserved Blue Cross Blue
Shield Association The Catholic Health Association of the
United States Centerstone College of Healthcare Information
Management Executives Confidentiality Coalition Employee
Assistance Professionals Association Global Alliance for
Behavioral Health and Social Justice Hazelden Betty Ford
Foundation Healthcare Leadership Council InfoMC The Joint
Commission The Kennedy Forum Medicaid Health Plans of
America Mental Health America National Alliance on Mental
Illness National Association for Behavioral Healthcare
National Association for Rural Mental Health National
Association of ACOs National Association of Addiction
Treatment Providers National Association of Counties
National Association of County Behavioral Health and
Development Disability Directors National Association of
State Mental Health Program Directors National Rural Health
Association Netsmart OCHIN Opioid Safety Alliance
Otsuka America Pharmaceutical, Inc. Primary Care
Collaborative Pharmaceutical Care Management Association
Premier Healthcare Alliance Population Health Alliance
Smiths Medical Strategic Health Information Exchange
Collaborative
______
Office of the United States Surgeon General
The Honorable Ron Wyden
Chairman
U.S. Senate
Committee on Finance
Washington, DC 20510
The Honorable Mike Crapo
Ranking Member
U.S. Senate
Committee on Finance
Washington, DC 20510
Dear Chairman Wyden and Ranking Member Crapo,
Thank you for your leadership and dedication to this critical issue. As
you mention in your letter, the COVID-19 pandemic has not simply
created a new mental health crisis, but rather exacerbated a
longstanding crisis that continues to affect people across this
country. I was deeply concerned about the mental health of our country
before the pandemic, and my concerns have grown over the past year.
Before COVID-19, mental health conditions were widespread in the United
States, and there was significant unmet need for mental health
diagnosis and treatment among young people and adults. Drivers of this
crisis before the pandemic included stigma, shortages in the mental
health workforce, health disparities, limited investments in
prevention, and treatment services that were too limited and
insufficiently integrated with primary care. And the cost of this
crisis is accumulated in both human suffering and financial losses, as
people with mental illness incur higher health care spending for non-
mental health associated conditions and billions of dollars in lost
earnings per year.
The pandemic has added urgency to these challenges. Millions of people
have experienced the trauma of family, friends, and neighbors dying or
being hospitalized with COVID-19. Working people have lost jobs or had
their hours cut. Parents, disproportionately mothers, have endured
significant stress in caring for their children and adapting to virtual
schooling. An estimated 40,000 children in America lost a parent to
COVID-19, and millions of children have been isolated from their
friends and supportive school environments. Patients dealing with
anxiety, depression, addiction, and other illnesses have had their
access to treatment disrupted. And health care workers have gone
through unimaginable pain watching, in some cases, dozens of their
patients die of this terrible disease. The statistics on substance
misuse, which so often occurs alongside mental illness, are also
heartbreaking:
More than 87,000 of our neighbors, friends, and family members died of
a drug overdose over the past year--the highest number of yearly drug
overdose deaths in recent memory.
Mental health has been an important issue for the Office of the Surgeon
General dating back to 1999, when my predecessor, Dr. David Satcher,
released the landmark Surgeon General's Report on Mental Health. As a
nation, we've come a long way since then in raising awareness about
mental health, helping reduce stigma and shame, and expanding access to
mental health treatment.
But the pandemic has reminded us just how much more remains to be done.
We must expand access to mental health services, by supporting mental
health telehealth programs, training more mental health professionals,
enforcing the 2008 Mental Health Parity and Addiction Equity Act, and
integrating mental health services with primary care. We must do more
to protect our children, who at times struggle for years with
undiagnosed mental illness, by increasing access to mental health
diagnostic and treatment services and by investing in evidence-based
social emotional learning programs. We must extend further help to
those at risk for suicide, including transitioning to full national
availability of 988 as the new national suicide prevention and mental
health crisis number. And we must target our efforts to communities
that have struggled with high rates of depression, anxiety, and
suicide--including health care workers whose alarmingly high rate of
mental illness and burnout poses a threat to our ability to provide
care to people throughout our nation. In all this work, we must
prioritize equity, as we know that rural communities and communities of
color face higher rates of mental health stigma and less access to
treatment.
Perhaps most challenging of all, we must change the way we think about
mental health. For too long, mental illness was a source of shame, and
that shame prevented people from seeking help and compounded their
suffering. Through our words, our actions, and our example, we can help
people recognize that you are not broken or deficient if you are
struggling with your mental health. Each of us can play a role in
providing support to those who are suffering and in affirming their
humanity. When we treat mental health with the same importance and
urgency as physical health, when we apply ourselves as much to
prevention programs as treatment efforts, when we set bold goals and
hold ourselves to account, then we will see the change our nation
needs.
We have many reasons to be hopeful. We have evidence-based programs,
such as the Certified Community Behavioral Health Clinics, that are
well-positioned to provide critical behavioral health services and
expand access to care across the nation. We have school-based programs
which have demonstrated their ability to reduce rates of mental illness
and substance use disorders in a cost- effective manner. And we have
millions of people across America whose lives have been touched by
mental illness and who now want to be part of the solution. We can use
this opportunity during the COVID-19 pandemic, when more people are
talking about mental health and increased funding is being directed to
address mental health issues, to act and take bold steps to improve the
mental health of our country.
Responding to the mental health needs across America should be a
central focus both during and after this pandemic, and I appreciate the
attention you and others in Congress have brought to this issue. I know
the road ahead is steep. We have much work to do. And we are still
making our way through a difficult pandemic. But the progress we have
made gives me faith in what is yet to come.
As the Committee moves forward under your leadership, HHS is committed
to working with the Senate Finance Committee--and all of Congress--to
address America's mental health crisis. Thank you for the opportunity
to weigh in on such an important issue. I look forward to learning from
you and partnering with you in the months ahead to tackle the nation's
mental health crisis.
Sincerely,
Vivek Murthy, M.D., M.B.A.
U.S. Surgeon General
Vice Admiral, U.S. Public Health Service
[all]