[Senate Hearing 117-503]
[From the U.S. Government Publishing Office]
S. Hrg. 117-503
THE COVID-19 PANDEMIC AND BEYOND:
IMPROVING MENTAL HEALTH AND
ADDICTION SERVICES IN OUR COMMUNITIES
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH CARE
OF THE
COMMITTEE ON FINANCE
UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
FIRST SESSION
__________
MAY 12, 2021
__________
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Finance
__________
U.S. GOVERNMENT PUBLISHING OFFICE
49-785-PDF WASHINGTON : 2022
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\ COMMITTEE ON FINANCE
RON WYDEN, Oregon, Chairman
DEBBIE STABENOW, Michigan MIKE CRAPO, Idaho
MARIA CANTWELL, Washington CHUCK GRASSLEY, Iowa
ROBERT MENENDEZ, New Jersey JOHN CORNYN, Texas
THOMAS R. CARPER, Delaware JOHN THUNE, South Dakota
BENJAMIN L. CARDIN, Maryland RICHARD BURR, North Carolina
SHERROD BROWN, Ohio ROB PORTMAN, Ohio
MICHAEL F. BENNET, Colorado PATRICK J. TOOMEY, Pennsylvania
ROBERT P. CASEY, Jr., Pennsylvania TIM SCOTT, South Carolina
MARK R. WARNER, Virginia BILL CASSIDY, Louisiana
SHELDON WHITEHOUSE, Rhode Island JAMES LANKFORD, Oklahoma
MAGGIE HASSAN, New Hampshire STEVE DAINES, Montana
CATHERINE CORTEZ MASTO, Nevada TODD YOUNG, Indiana
ELIZABETH WARREN, Massachusetts BEN SASSE, Nebraska
JOHN BARRASSO, Wyoming
Joshua Sheinkman, Staff Director
Gregg Richard, Republican Staff Director
______
Subcommittee on Health Care
DEBBIE STABENOW, Michigan, Chair
ROBERT MENENDEZ, New Jersey STEVE DAINES, Montana
THOMAS R. CARPER, Delaware CHUCK GRASSLEY, Iowa
BENJAMIN L. CARDIN, Maryland JOHN THUNE, South Dakota
ROBERT P. CASEY, Jr., Pennsylvania RICHARD BURR, North Carolina
MARK R. WARNER, Virginia PATRICK J. TOOMEY, Pennsylvania
SHELDON WHITEHOUSE, Rhode Island TIM SCOTT, South Carolina
CATHERINE CORTEZ MASTO, Nevada BILL CASSIDY, Louisiana
MAGGIE HASSAN, New Hampshire JAMES LANKFORD, Oklahoma
ELIZABETH WARREN, Massachusetts TODD YOUNG, Indiana
JOHN BARRASSO, Wyoming
(ii)
C O N T E N T S
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OPENING STATEMENTS
Page
Stabenow, Hon. Debbie, a U.S. Senator from Michigan, chair,
Subcommittee on Health Care, Committee on Finance.............. 1
Daines, Hon. Steve, a U.S. Senator from Montana.................. 3
WITNESSES
Armstrong, Victor, MSW, Director, Division of Mental Health,
Developmental Disabilities, and Substance Abuse Services, North
Carolina Department of Health and Human Services, Raleigh, NC.. 6
Woodard, Stephanie, Psy.D., Senior Advisor, Division of Public
and Behavioral Health, Nevada Department of Health and Human
Services, Carson City, NV...................................... 8
Kosovich, Lenette, R.N., MHA, chief executive officer, Rimrock
Foundation, Billings, MT....................................... 10
Newman, Malkia, team supervisor, CNS Healthcare Anti-Stigma
Program, Waterford, MI......................................... 12
ALPHABETICAL LISTING AND APPENDIX MATERIAL
Armstrong, Victor, MSW:
Testimony.................................................... 6
Prepared statement........................................... 25
Daines, Hon. Steve:
Opening statement............................................ 3
Prepared statement........................................... 26
Kosovich, Lenette, R.N., MHA:
Testimony.................................................... 10
Prepared statement........................................... 27
Responses to questions from subcommittee members............. 28
Newman, Malkia:
Testimony.................................................... 12
Prepared statement........................................... 29
Responses to questions from subcommittee members............. 30
Stabenow, Hon. Debbie:
Opening statement............................................ 1
Prepared statement........................................... 31
Woodard, Stephanie, Psy.D.:
Testimony.................................................... 8
Prepared statement........................................... 32
Responses to questions from subcommittee members............. 34
Communications
American College of Physicians................................... 39
American Pharmacists Association................................. 46
American Psychological Association............................... 48
Center for Fiscal Equity......................................... 51
Eating Disorders Coalition for Research, Policy, and Action...... 52
Healthcare Leadership Council.................................... 55
Mental Health Liaison Group...................................... 56
National Association of Health Underwriters...................... 60
THE COVID-19 PANDEMIC AND BEYOND:
IMPROVING MENTAL HEALTH AND
ADDICTION SERVICES IN OUR COMMUNITIES
----------
WEDNESDAY, MAY 12, 2021
U.S. Senate,
Subcommittee on Health Care,
Committee on Finance,
Washington, DC.
The hearing was convened, pursuant to notice, at 3 p.m.,
via Webex, in Room SD-215, Dirksen Senate Office Building, Hon.
Debbie Stabenow (chair of the committee) presiding.
Present: Senators Cardin, Whitehouse, Hassan, Cortez Masto,
Thune, Burr, Toomey, Cassidy, and Daines.
Also present: Democratic staff: Alex Graf, Legislative
Advisor for Senator Stabenow. Republican staff: Rachel Green,
Health Care Policy Advisor for Senator Daines; and Stuart
Portman, Senior Health Policy Advisor.
OPENING STATEMENT OF HON. DEBBIE STABENOW, A U.S. SENATOR FROM
MICHIGAN, CHAIR, SUBCOMMITTEE ON HEALTH CARE, COMMITTEE ON
FINANCE
Senator Stabenow. Well, good afternoon. It is my pleasure
to call this hearing of the Finance Subcommittee on Health Care
to order. And I am so pleased to be here during Mental Health
Month talking about the urgent need to improve behavioral
health-care services in our communities. And I am really
pleased to be here as well with Ranking Member Daines. I am so
glad you are my partner on this subcommittee, and I think there
are a lot of great things that we can do on this subject, and
others as well.
Everyone affected by mental illness or substance abuse
disorders should be able to get the help they need so they can
live a healthy and fulfilling life, period. And the good news
is, we can make this a reality.
Before the pandemic, nearly one in five Americans had some
form of mental illness, although fewer than half received
treatment. This lack of support was even worse in the
communities of color.
The pandemic has made things worse and exposed the
weaknesses in the way we pay for behavioral health care in this
country. In January, 41 percent of American adults reported
that they were struggling with anxiety or depression. That is
up from 11 percent before the pandemic. And more than one in
four young people have reported having suicidal thoughts.
Meanwhile, overdose deaths have surged during the pandemic.
The CDC reported that more than 87,000 Americans died of drug
overdoses during the 12-month period that ended last September.
That was the most deaths in any year since the opioid epidemic
began in the 1990s.
And long after the pandemic ebbs, these behavioral health
needs are going to continue, and that is why we are here today
talking about these issues. We need to finally treat health
care above the neck the same way we treat health care below the
neck. And the good news is, we are making progress.
I have worked with my friend Senator Roy Blunt and so many
people on the committee to create the Certified Community
Behavioral Health Clinics program, now fully operational in 10
States, with over 300 startup grants bringing services to
people in 41 States now.
We have a structure that allows clinics to truly meet the
needs of their communities. This has been a tremendous success
in a short amount of time, and it is the model for the future,
I believe. These clinics are required to provide comprehensive
services, including 24/7, 365 mobile crisis team services,
immediate screening and risk assessment, and easy access to
care. They see everyone who walks in the door. They have
tailored care for active duty military and our veterans, care
coordination with primary care providers, and coordination with
law enforcement.
The results are stunning. According to HHS numbers included
in the budget request last year, people who received services
through what we call CCBHCs had 63 percent fewer emergency
department visits for behavioral health. A lot of times folks
are just sitting in the emergency room, maybe an officer with
them, with no behavioral health services available.
We have seen 60 percent less time spent in jails by people
who really needed health services, and law enforcement now has
other opportunities and places where they can work with people
to get people the care they need rather than sitting in jail.
And we saw a 40.7-percent decrease in homelessness--so
important.
And today the National Council for Mental Wellbeing, which
was previously the National Council for Behavioral Health,
released a new CCBHC impact report with similarly stunning
results. They found that more than half of these clinics offer
same-day services, and nearly all of them offer treatment
within a week.
Compare that to the average wait time of 48 days
nationally. And they are serving thousands of new people.
Ninety-five percent of CCBHCs have engaged in promising new
practices in collaboration with law enforcement and our
criminal justice agencies.
This month, Senator Blunt and I, hopefully joined by all of
you, will be introducing legislation giving every State in the
country the option of participating in this fully successful
program.
It will ensure that behavioral health care clinics are
reimbursed for services in the same way we fund Federally
Qualified Health Centers. We can get this done, and we can
bring community care to millions of Americans who need it.
So I am going to thank our wonderful witnesses who are with
us today virtually. We have colleagues who are here with us in
the Finance Committee room, and others who are with us
virtually as well. And so many of my colleagues have focused on
this issue and care so much about it--I am so grateful--whether
it is what I am talking about with CCBHCs, or the importance of
telehealth, crisis supports, coordination with law enforcement
and schools, and so many other ways to address mental health
and substance abuse. It is all very important, and I really
look forward to working with each of you.
Now I would like to turn to Senator Daines.
[The prepared statement of Senator Stabenow appears in the
appendix.]
OPENING STATEMENT OF HON. STEVE DAINES,
A U.S. SENATOR FROM MONTANA
Senator Daines. Madam Chair, thank you. I am really glad to
be here with you today for the first subcommittee hearing of
the year. It is also great to have a fellow Montanan joining us
today. We will get into a more formal introduction in a bit,
but a warm welcome to Lenette. I am glad you could be here with
us today.
May is Mental Health Awareness Month, an issue at the top
of my mind and many others following a year of isolation for
Montanans and Americans across the country. In fact last year,
due to COVID restrictions, Montanans and Americans were forced
to stay home. We saw family-owned and small businesses shutter;
workers struggling; family members isolated from loved ones;
and schools closing, directly impacting our Nation's youngest
and brightest.
Through no fault of their own, hardworking Montanans and
Americans across the country lost their jobs, leaving them
wondering how they are going to keep a roof over their
families' heads, and food on the table. Instead of socializing
and learning with their friends in classrooms, students were
stuck behind computer screens. Symptoms of anxiety and
depression are on the rise.
In fact, one survey states that more than half of the
adults reported that worry or stress related to the pandemic
was having a negative effect on their mental health. As we all
know, mental health issues were a problem before the pandemic.
In fact, it is estimated that nearly one in five American
adults had some form of mental illness, but fewer than half of
those adults received treatment in 2019.
Since the pandemic, lockdowns, economic hardships, and
social isolation have only helped to intensify what we already
knew, and that is, we need mental health services in our
communities, and we need to make this a priority.
The pandemic has also helped expose and magnify the flaws
in our mental health system. Sadly, in 2020 suicide was the
10th leading cause of death, and drug overdose deaths hit a
record high. In Montana we are, unfortunately, not immune to
these devastating statistics. We are fourth in the Nation for
suicides. We are first in the Nation per capita for children
being placed in foster care, most often due to a parent's drug
or alcohol use. And we are witnessing a disturbing increase in
meth-related violent crime.
It is clear that more needs to be done to support
individuals and families struggling with addiction or mental
illness. We are fortunate in Montana to be home to treatment
facilities like Rimrock, which I have had the opportunity and
the privilege of visiting several times over the years. In
fact, I even had the opportunity to bring Vice President Pence
and his wife Karen to show them firsthand the great work the
organization does for Montanans struggling with addiction and
mental health issues.
In fact, one visit I will never forget. I had the chance to
meet with a few moms who were receiving substance abuse
treatment. I had just become a grandfather. I was overwhelmed
with emotion to see the little ones there with these moms
struggling with these addiction issues. But there I saw hope,
and I saw struggle, and I saw commitment, and so much love that
the Montana moms had for their children. Because at Rimrock,
thanks to a bill that I had led in the Senate and was signed
into law by President Trump, moms who are working to get back
on their feet are able to stay with their children. Let me tell
you, that means the world to these moms. It gives them a
reason, a very important reason, to get better.
Treatment centers like Rimrock make a world of difference
in our communities, and they are more important now than ever
before as we come out of this pandemic. And after a year of
lockdowns and closures, we are finally starting to see light at
the end of the tunnel. And thanks to the leadership of our new
Governor Greg Gianforte, life in Montana is on its way to
getting back to normal.
We have vaccinated over 350,000 Montanans and have led the
Nation in vaccine administration. We are now open for business
in Montanan, and we are open for school. We are incentivizing
getting back to work versus staying at home, something I
believe is also important for mental health, because I believe
there is dignity in work.
But the reality is that there will likely be long-lasting
impacts of the pandemic, particularly on mental health. We must
aim to meet the challenges of today, and prepare for the
increased needs that this pandemic has created. So I am very
committed to working with my colleague Senator Stabenow towards
that goal.
And again, I appreciate our witnesses being here today
offering their advice and their expertise on such a very
important topic.
Thank you, Madam Chair.
Senator Stabenow. Thank you so much.
[The prepared statement of Senator Daines appears in the
appendix.]
Senator Stabenow. We will now introduce our witnesses, and
I would like to start by inviting Senator Burr to introduce a
great witness from North Carolina.
Senator Burr. Madam Chair, thank you very much for having
this hearing, but more importantly for the opportunity to
introduce Victor Armstrong from Charlotte, NC, a constituent of
mine.
I am proud to say Mr. Armstrong has both decades of
experience with behavioral health, and strong North Carolina
roots. Mr. Armstrong currently serves as the North Carolina
Department of Health and Human Services Director of Mental
Health, Developmental Disabilities, and Substance Abuse.
He began serving in this capacity in March 2020, taking the
directorship at a critical time for behavioral health care.
COVID-19 was beginning to upend society as we knew it, causing
economic and social turmoil that has had extraordinary impacts
on mental health and addiction.
Prior to assuming his current role, Mr. Armstrong was the
vice president of behavioral health with Atrium Health Care,
where he was responsible for operations at Atrium's largest
behavioral health hospital. He currently serves on the board of
directors of the American Foundation for Suicide Prevention,
North Carolina. And he previously served as board chair of the
North Carolina chapter of the National Alliance of Mental
Health.
Mr. Armstrong, thank you for your service, for your
willingness to be here today, and for the challenging times we
continue to go through, both in North Carolina and across the
country. I look forward to your testimony, and I thank the
chair.
Senator Stabenow. Thank you very much.
I would now like to turn to Senator Cortez Masto, who I
know has placed these issues at the very, very top of her
issues that she is working on and leading on in Nevada. And so
I will turn to you, Senator.
Senator Cortez Masto. Madam Chair and Vice Chairman Daines,
thank you for holding this important hearing. I am honored to
introduce Dr. Stephanie Woodard, the Senior Advisor on
Behavioral Health for Nevada's Department of Health and Human
Services.
In that capacity, she manages the planning, policy, and
funding for our State's substance use disorder and mental
health programming. In addition to her deep knowledge of our
behavioral health system, Dr. Woodard also brings clinical
expertise as a front-line practitioner. She is a licensed
psychologist whose body of work has focused on behavioral
health integration, co-occurring disorders, and mindfulness-
based treatments.
I am especially pleased to have Dr. Woodard here to speak
to her great leadership in standing at Nevada's nine Certified
Community Behavioral Health Clinics, or CCBHCs, that Senator
Stabenow has been so instrumental in building here at the
Federal level.
My State has been particularly hard hit by this pandemic.
The twin public health and economic crises have taken a toll on
the mental health of Nevada families. And, Dr. Woodard, I am
glad to have you here today to share your experience and
insight on how we can better serve families across the country
as we emerge from the pandemic.
I look forward to your testimony.
Senator Stabenow. Thank you so much. And I am going to turn
it back over now to Ranking Member Daines to introduce a great
person from Montana.
Senator Daines. Well, thank you, Chair Stabenow. She is a
great person from Montana. I am very pleased to introduce and
welcome Lenette Kosovich to the committee. Lenette serves as
the CEO of Rimrock Foundation in Billings, MT, which is the
largest behavioral health organization in the State, providing
substance abuse treatment and mental health services.
She has been in this role for over a decade and is well-
versed on the complexities of providing mental health and
addiction services. I was with her when she hosted Vice
President Pence in fact, when she had a chance to show him what
they were doing to help these moms there. She is a trusted
advocate in Montana and works every day to improve the lives of
Montanans in need of substance use and mental health
assistance.
I am glad my colleagues and others here today will get to
hear her experiences firsthand. So, thanks for joining us
today, Lenette. It is great to have you here.
Senator Stabenow. Well, thanks so much. And last, but
absolutely not least, I would like to introduce Malkia Newman,
who is a team supervisor for the CNS Healthcare Anti-Stigma
Program in Michigan. I have known Malkia for many years, and
she is a leading advocate, not just in Michigan but nationwide,
for individuals with mental health and substance abuse issues.
She is a peer educator, developing and leading programs in
our State, and sharing her expertise around the country. She is
also an ordained minister at New Birth International Church in
Pontiac, MI, and she is a board member of the Oakland Community
Health Network and has served several terms as board chair and
vice chair. You know, I could go on and on, but let me just say
in summary, she is a voice for so many people struggling with
mental illness and substance use disorders. And she is working
hard every day to make people's lives better.
So I am so grateful that you are with us, Ms. Newman. Thank
you so much for participating today.
So let me start first--and we will ask each of our
witnesses to speak for 5 minutes, and we certainly welcome any
other supplemental information you want to share in writing
with the committee as well.
But, Mr. Armstrong, we will start with you. Welcome.
STATEMENT OF VICTOR ARMSTRONG, MSW, DIRECTOR, DIVISION OF
MENTAL HEALTH, DEVELOPMENTAL DISABILITIES, AND SUBSTANCE ABUSE
SERVICES, NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN
SERVICES, RALEIGH, NC
Mr. Armstrong. Good afternoon. Thank you, Chair Stabenow,
Ranking Member Daines, and honorable members of the committee,
for the opportunity to testify about North Carolina's approach
to equity in community behavioral health services.
My name is Victor Armstrong. I am the Director of North
Carolina's Division of Mental Health, Developmental
Disabilities, and Substance Abuse Services. I am a social
worker, a husband, and a father to three black boys. I am a
mental health advocate, and I am the son of a preacher, born
and raised in rural North Carolina--Plymouth, to be specific--
but I now reside in Charlotte, NC.
I share all of this because I am the sum of all of these
things. This will no doubt create a perception for who I am
based not only on what I have just shared, but also based on
your lived experiences and mine.
Much as you today will interact as tradition and formality
dictate, in many ways our mental health and substance use
system has worked the same way until COVID-19 and social
injustice rocked our Nation.
Unfortunately, it is a system that has not been practiced
nor been funded through a lens of equity. The lens of equity is
about the intersectionality of race, culture, and ethnicity in
addition to living with mental health and substance abuse
challenges.
It is about being black and living with a serious mental
illness. It is about being Latino and living with intellectual
disabilities and with traumatic brain injuries. It is about
being an American Indian and living with a substance abuse
disorder. It is about being an Asian or trans person,
struggling with an anxiety disorder exacerbated by the
discrimination that often accompanies mental illness, the
bigotry that is perpetrated toward trans Americans, and the
increasing rates of violence against Asian Americans.
We cannot ignore how a person of color enters the
behavioral health system. People of color often do not have
access to outpatient services within their communities. This
makes it more likely that they are introduced to the behavioral
system when they are in a state of crisis, and more likely to
enter the system via the back of a police car or an acute care
emergency department, neither of which is conducive to good
clinical outcomes, and neither of which is likely to foster
positive relationships with the mental health system.
Systemic racism and bias, both explicit and implicit, are
multilayered and seep into every crevice of society. This
includes our mental health and substance use care, but we can
change that if you are willing to help to reform our system.
We know that inequity exists. It is our moral
responsibility to address that inequity by leaning into equity.
Every decision that we make as clinicians, policy-makers, or
simply as agents of change, either leans into creating a more
equitable system or perpetuates our existing problem of
inequity.
We can address the issue of access by supporting the
creation of more mental health resources in communities of
color and under-served ZIP codes. We can create more community-
based resources that provide access to upstream treatment.
One way that communities are doing this is through the
Certified Community Behavioral Health Clinic, or CCBHC, model.
CCBHCs are required to provide comprehensive, timely, and
culturally competent services to anyone in their communities.
One CCBHC here in North Carolina--Monarch--has embedded a peer
support specialist with the EMS team that responds to opioid
overdoses. The peer stays with that person through the trip to
the hospital and helps to connect them to community treatment
upon release, making sure that that person does not get lost on
the road to recovery in the community.
We support the CCBHC model and appreciate any funding to
increase CCBHCs. We can support efforts to build a workforce
that mirrors the population it serves. In North Carolina we
have roughly 4,000 trained certified peer specialists
representing black, white, Latino, Asian, and American Indians,
with only about 1,600 individuals gainfully employed.
We need to utilize the peer workforce and pay them a living
wage. We need to partner with Historically Black Colleges and
Universities to build a multicultural workforce. We need to
partner with clinicians of color and provide them access to
government grants and contracts. We need to partner with the
faith-based organizations, and we need to fund studies that
consider the nuances of race, culture, and ethnicity and the
impact on mental wellness.
Further, we need to better understand the impact of
systemic racism and complex trauma experienced by people of
color. In North Carolina, it has taken intentionality to
mitigate the effects of the COVID-19 pandemic, particularly the
disproportionate impact of the virus on black and brown
communities.
As the North Carolina Department of Health and Human
Services sought to intervene, we recognized that without
incorporating trusted voices who represent the individuals we
seek to assist, we would lack credibility, and full engagement
would be difficult if not impossible.
Historically marginalized communities, those marginalized
by race, ethnicity, or diagnosis, are simply looking for a
collaborative partner who will value their expertise and life
experience. We have the resources to build a more equitable
system. If we do not build equity into our mental health and
substance abuse programs and practices, we will ultimately fail
the most powerless and vulnerable.
I will leave you with one final thought. Mental health and
substance use transcends barriers, divides, and differences.
People from all walks of life are dying every day from suicide
or overdose. Mental health and substance abuse do not see race,
culture, or ethnicity. The same cannot be said of our treatment
systems. It is time that we fix our system to serve the diverse
communities in our Nation. Thank you for your time.
[The prepared statement of Mr. Armstrong appears in the
appendix.]
Senator Stabenow. Thank you so much for that very, very
important testimony.
We will now turn to Stephanie Woodard. We appreciate very
much, Dr. Woodard, your being with us.
STATEMENT OF STEPHANIE WOODARD, Psy.D., SENIOR ADVISOR,
DIVISION OF PUBLIC AND BEHAVIORAL HEALTH, NEVADA DEPARTMENT OF
HEALTH AND HUMAN SERVICES, CARSON CITY, NV
Dr. Woodard. Thank you, Senator Stabenow, Ranking Member
Daines, and members of the committee.
My name is Stephanie Woodard, and I am a licensed
psychologist and serve as the Department of Health and Human
Services' Senior Advisor on Behavioral Health. I also serve on
the board at the National Association of State Mental Health
Program Directors.
I am humbled and honored to have the opportunity to testify
before you today to discuss how the COVID-19 pandemic has
highlighted the critical role of crisis services and Certified
Community Behavioral Health Clinics, as well as underscored the
importance of Federal spending strategies to support the States
as they look to build sustainable standards of care.
National guidelines by the NASMHPD, the Substance Abuse
Mental Health Services Administration, and the National Council
have been and continue to be invaluable resources as Nevada
develops our crisis continuum of care. A coordinated crisis
continuum of care ensures that when individuals are in crisis,
they have someone to talk to, someone to respond, somewhere to
go, and that the system is rooted in effective practices.
Crisis services should be available to anyone, anywhere,
any time, regardless of insurance status. It is this cascade of
care that provides appropriate community-based response to a
behavioral health crisis, and is essential in saving lives.
With the implementation of 988 coming in July of 2022, the
time to act is now. During COVID, Nevada has seen an influx of
calls and texts through our Lifeline, but also the acuity and
urgency of those calls have increased. And while we have huge
Federal grant funds to enhance staffing to meet the increased
demand, we are still faced with the limitations of the current
system. 988 presents challenges to States to ensure call
centers are sufficiently staffed to respond timely to people
who are reaching out in crisis.
With 80 to 90 percent of callers having their immediate
needs addressed by the call, the call center will need to have
technology to deploy mobile crisis teams, ensure individuals
have access to needed stabilization services, and
interoperability with 911.
We remain hopeful that sustainability will be possible with
pending 988 State legislation and through Medicaid.
Overutilization of the 911 emergency response system with EMS
and law enforcement has resulted in inappropriate and costly
use of public safety and health-care resources.
Mobile crisis teams offer an alternative response to
individuals and families in crisis, allowing for stabilization
in the community. By providing alternative destinations for
individuals in crisis, Crisis Stabilization Centers divert
patients away from costly emergency room visits and unnecessary
inpatient hospitalizations. Together, these services result in
cost savings across criminal justice, law enforcement, and
health care.
We thank Chairman Wyden and Senator Cortez Masto for the
inclusion of Medicaid crisis care funding in the American
Rescue Plan. Within Nevada, a new Medicaid rate for Crisis
Stabilization Centers is expected to result in a cost savings
to Nevada over the long term. The recent infusion of Federal
funds is necessary for the development of this essential
infrastructure. However, it is insufficient for long-term
sustainability.
To bring the entire crisis continuum to scale, Nevada,
along with other States, will need guidance from the Centers
for Medicare and Medicaid services to ensure these services are
sustainable into the future. For States to be successful in
rising to the challenge 988 presents, coordination between
SAMHSA and CMS is recommended by the Medicaid and CHIP Payment
Access Commission, or MACPAC. It will be essential.
Nevada was fortunate to be selected to participate in the
CCBHC demonstration grant in 2018. And over the course of the
demonstration, CCBHCs had increased access to critical safety
net behavioral health services, while lowering cost of care and
improving outcomes.
The success of the CCBHCs can be measured by the
relationships the clinics have within their communities,
collaboration with law enforcement for community-based crisis
intervention services, expansion of services into schools,
comprehensive case management and peer recovery support to
better address social determinants of health, and increased
engagement in care. Additionally, the cost-based reimbursement
has enhanced their ability to recruit and retain qualified
behavioral health professionals.
Nevada's CCBHCs were able to pivot quickly during the
pandemic to expand telehealth services, resulting in high rates
in the continuity of care. We would also like to express our
gratitude to Senator Stabenow, Senator Blunt, the National
Council, and Nevada's Governor Sisolak, who have supported the
CCBHC model and expanded the demonstration to 2022.
Since 2018, we have made significant investment in the
CCBHCs through our mental health block grant, and continue to
support the CCBHC expansion grant.
Thank you for your time, and I am happy to answer any
questions that you may have.
[The prepared statement of Dr. Woodard appears in the
appendix.]
Senator Stabenow. Thank you so much. We are really
appreciative that you are with us.
Lenette Kosovich--we would appreciate Ms. Kosovich sharing
her testimony.
STATEMENT OF LENETTE KOSOVICH, R.N., MHA, CHIEF EXECUTIVE
OFFICER, RIMROCK FOUNDATION, BILLINGS, MT
Ms. Kosovich. Senator Stabenow, Senator Daines, and members
of the committee, thank you for inviting me to talk about one
of the most complex and far-reaching issues facing Montana and
our Nation.
My name is Lenette Kosovich. I am the CEO of Rimrock
Foundation, the largest behavioral health-care facility in
Montana, and we are one that provides the full continuum of
services, including peer support and detoxification, inpatient
residential, outpatient, and mental health treatment. And we
have extended treatment for 12 months or longer, as Senator
Daines said, for women with their children as they recover. We
also have a reentry program for those recently released from
incarceration.
We serve seven treatment courts, including a Family Drug
Court, a Veteran Court, and recently an Indian Child Welfare
Act Family Recovery Court. And all in all, we see nearly 2,000
clients a year.
There is no doubt that COVID has exacerbated an already
complex problem. Before COVID, substance use disorder and
mental illness were already the top health needs in our county
and our State.
We have had a methamphetamine-fueled increase in violent
crime, and we have also had a burgeoning child welfare system
where four out of every five cases involved parental drug use.
And over the last 5 or 6 years, our clients are considerably
more compromised than even a decade ago. Along with serious
illicit substance use disorder, patients most likely have
mental health disorders, and they are accompanied by one or two
comorbidities like hypertension or diabetes. And it has become
the norm for us to have a 25-year-old patient in our care who
has already received a heart valve replacement due to
endocarditis resulting from IV drug use.
So, enter COVID. Alcohol consumption, drug use, and mental
illnesses have increased. Our referrals have gone up 40 percent
in 11 months. The calls to our State suicide hotline have
doubled. And unfortunately, violent crime in our county has
increased nearly 70 percent. And one thing we know for certain
is that drugs have played a part in all of this.
COVID complicated and delayed service delivery. The
quarantine and social distancing that we needed to do really
reduced the space we had to provide services by about a third.
And many of our industry partners suspended their services, or
even closed. And so our wait list has increased.
With physical space at a premium, COVID accelerated the
adoption of telehealth tenfold. And with that came incredible
pressure. iPads were needed for all, except it was hard to get
iPads in some cases. Group therapy via telehealth, except
Johnny's Internet wasn't that reliable in some parts of
Montana. Family week via Zoom is great, except Suzy's mom
didn't have a computer.
So training and new admission policies, new safety
protocols; every part of our industry was stretched to the max.
But the worst challenge of COVID for me was workforce. Before
COVID, the workforce shortage was severe. Wait times for
positive COVID results made the problem much worse. And when I
don't sleep at night, it is often because I am worried about
the number of my employees pulling a double shift on the brink
of a mental breakdown themselves.
History teaches us--we have talked about this--that the
mental health impact of a catastrophic event such as a pandemic
will far outlast the physical impact. So I, as well as you, are
probably buckled in for a bumpy road. Fortunately, we do
believe there is hope on the horizon with the expansion of the
Certified Community Behavioral Health Clinics.
Rimrock in Billings, and two other organizations in
Montana, were recently granted CCBHC expansion pilots. In the
active CCBHC sites, this innovative model of care has
dramatically increased access to mental health and substance
use disorder treatment. And it has been proven to address the
pain points, just as I have shared, and I am looking forward to
some of the same outcomes that were highlighted already by
Senator Stabenow that were recently released in an impact study
by the National Council for Mental Wellbeing.
We must increase the number of clients that are served.
There is no doubt about that. And we see that a CCBHC model
does increase the number that are available to serve.
Wait times are another issue that is always at the top of
our mind, and we know that 84 percent of clients in this model
are seen within a week. Investing in the workforce--this is an
enhanced reinforcement model that allows States to have the
funds for us to hire more people to the clinic. And then,
making the crisis service supports available to all.
Delivery of services in the community, not just in
facilities, and the innovation and the collaboration with
criminal justice, community services, helping to divert people
from crisis--from emergency rooms and jails--and getting them
into the appropriate level of care is a must.
Senator Stabenow, Senator Daines, and the committee, there
is not one constituent whose life has not been impacted by
substance use disorder or mental illness. And there is not one
of our economies that also has not had negative impact. And we
can do better. And the CCBHC model does do better, and I am
very encouraged and continue to urge you to support these
models throughout the States.
Thank you for inviting me to speak on this issue, and I am
open to answering any questions also.
[The prepared statement of Ms. Kosovich appears in the
appendix.]
Senator Stabenow. Well, thank you so much.
And again, last but not least, Malkia Newman. Ms. Newman,
we welcome you. It is wonderful to have a chance to see you
again, even if it is only virtually.
STATEMENT OF MALKIA NEWMAN, TEAM SUPERVISOR, CNS HEALTHCARE
ANTI-STIGMA PROGRAM, WATERFORD, MI
Ms. Newman. [Sings a song.]
Good afternoon, members of the U.S. Senate, staff, and
guests. I am very honored to be asked to give testimony to this
distinguished body today. I want to especially thank Health
Care Chairwoman Debbie Stabenow and Ranking Member Steve Daines
for convening this vitally important discussion today.
My name is Malkia Newman, and I am living proof that the
services and support that are available through our community
mental health system work. I am not naive to the fact that many
areas need to be improved, but I know that my life would not be
the amazing life that I am living now had I not received
treatment for bipolar disorder almost 20 years ago.
I am a survivor of childhood sexual trauma, as well as a
survivor of intergenerational trauma, a sad legacy of slavery
and discrimination. I wrestled with suicidal thoughts, had
difficulties maintaining relationships or employment. My
daughter Tracie--I call her my miracle--she was my reason for
living when all hope was gone.
Mental health conditions are prevalent in my family. The
treatment and hospitalizations that my brother Ronnie endured,
who had schizophrenia, terrified me, which made it harder for
me to ask for help until there was no other option available.
Fast forward 20 years. I have 15 years of continuous
employment with CNS Healthcare's Anti-Stigma Program. I have
been a homeowner for 9 years. And on June 5th, my husband
Dubrae and I will celebrate our 15-year wedding anniversary. I
have reconciled with my family, and I serve proudly as an
ordained minister at my Church, New Birth International. My
list of community service awards and recognitions is long.
I am living proof, I am an advocate, and I am proud to
speak on behalf of those who have not yet found their voice. It
is vitally important that we not just continue to offer
behavioral health treatment, but that we prepare for the
increased need that the pandemic has created.
We need more qualified providers--doctors, nurses,
therapists, and other support personnel, especially Peer
Support Specialists--people with lived experience and expertise
in the mental health field who can encourage and educate people
receiving services in a richer way than the other professionals
can.
We need to compensate our professionals at every level to
make sure that we have qualified, culturally and linguistically
competent people meeting the needs of people no matter what
their background.
The Certified Community Behavioral Health Clinics, the
CCBHCs, have made it easier for people to access services
regardless of if they have insurance or not, which in the past
has created a huge barrier for people needing help.
Integration of physical and mental health has been a topic
of discussion for many years. Integration is needed to help
people with mental health disorders live longer, healthier
lives, but the focus has shifted from people getting whole
health treatment from head to toe, to an argument about who
will fund and administer the dollars associated with the
treatment.
I believe that the people served, and their loved ones,
should have a role in shaping what health care should be, as
people with intimate knowledge of what works and what does not.
Advisory groups can and should be involved at every level of
program development, implementation, and evaluation. The
finished product would be more efficient and cost-effective as
well.
It is my prayer and hope that we will not rush to get back
to ``normal'' at the expense of programs and systems that work.
Thank you for this time of testimony, and I am available to
answer any questions that you may have. Thank you.
[The prepared statement of Ms. Newman appears in the
appendix.]
Senator Stabenow. Well, thank you so much, Malkia. It is
wonderful to see you again, and I so appreciate your courage
and your work in Michigan.
We will now turn to questions. And let me start by first
saying that there are so many things that we need to do in this
area, but fundamentally for me, and the work that Senator Blunt
and I have done, is to basically say we should fund mental
health and substance use disorders as health care--health care.
And yet we fund Federally Qualified Health Centers in a
permanent way, fully reimbursing for the cost of services, and
in the area of mental health, of course, and substance use, as
you know, we do not. We basically have done it traditionally
through grants. And when the grant runs out, the service is
gone.
So that is the whole point of CCBHCs: to move to what we
know works in the community. So right now we have wonderful
support for fully expanding across the country the opportunity
to fully fund health care that is above the neck. In fact, we
have 22 members of the Finance Committee now who have at least
the start-up grants in their State. There are 10 States that
are fully funded as health care, and we want to expand that.
But I would like to ask each of you a question relating to
CCBHCs as we move forward with the next legislation we will be
offering soon.
Ms. Kosovich, you were awarded a CCBHC expansion grant
earlier this year, and I understand you are going live next
month. I wondered if you might just speak a little bit more
about the kind of services that you are going to be able to
provide in the community as a result of the new funding, and
what it would mean to take the next steps to be fully funded
like health centers are.
Ms. Kosovich. Certainly. Thank you for the question. We
have already implemented one of the components, and that is the
PACT team, which is the Program for Assertive Community
Treatment.
This is about taking care of people where they are in the
community. Again, they are not necessarily coming to a
facility. They are being served at their house, at a coffee
shop, sometimes we take them for a ride in their car, or in our
car. And we have found already some amazing results from that.
Our local health-care organizations are talking about how
that has reduced ER visits already. We are a huge proponent of
peer supports, and we have been using those also with our PACT,
and with our other treatment services.
And one of the things probably most important to our county
right now is crisis services. We have had a plethora of crime
over the last 6 weeks, devastating crime, like I said earlier
in my testimony, methamphetamine-fueled. And for us to be able
to get to a crisis before it comes to the level that there
might be loss of life, is so important for us.
So those are some of the things that we are most excited
about bringing forward.
Senator Stabenow. Thank you so much. I appreciate it.
And, Dr. Woodard, I know that you were the lead for the
State of Nevada in putting together the CCBHC planning grants,
and one of the 10 States that are receiving the full funding
now, reimbursement and prospective payment for staffing and so
on.
So I wonder if you could talk a little bit about what this
program has meant for communities in the State and what
services you are providing that you were not able to provide
before you had the stability of this funding?
Dr. Woodard. Thank you for the question, Senator Stabenow.
CCBHCs actually have accelerated a lot of momentum related to
implementing evidence-based practices, as well as ensuring that
communities have a full continuum of care that is available to
them.
So one of the basic premises around CCBHCs is being able to
provide services in the community, moving outside of the four
walls, and ensuring that individuals, whether it be children,
adolescents, or adults and families, have access to the care
that they need in the most timely way.
Crisis services have expanded the opportunity for
individuals who need immediate services to be able to receive
those services, whether it is within the clinic or out in the
community. Partnerships with law enforcement have also
encouraged more individuals to be interfaced with crisis
services versus going to the emergency room or to jails.
The access to services, especially during COVID, has been
incredibly important. We have been able to see continued care
that has been throughout COVID. We actually did not see a big
decrease in access to care through our CCBHCs. So the
comprehensive array of services that is available, was, and
continues to be available during COVID, was really critical in
ensuring that individuals had timely access to services.
Through some of the evidence-based practices--I heard PACT
be mentioned before--making sure that assertive community
treatment is available in our communities has also been very
important. It is really critical to ensure that people have the
opportunity to remain in their communities, and are supported
with wrap-around services in order to continue to remain
stable.
We also have focused a lot on transitions of care. So as
individuals are moving from inpatient psychiatry back into the
community, or as they are moving at the continuum of care, the
CCBHCs are able to support that individual wherever they move
throughout the system so that they have a home, a behavioral
health home, which will allow them to continue to repeat those
services over the long term.
It is really the continuity of care and the continuum of
care that CCBHCs have provided that have had, I think, some of
the greatest results in the communities where CCBHCs are. We
also know that our CCBHCs were not previously community mental
health clinics. The vast majority, actually eight of the nine,
had started out as substance abuse and disorder treatment
providers. These providers had a lot of work to do in order for
them to be able to meet the demands and the rigors of the CCBHC
model, and in partnering with the States they are able to
achieve what I think are some pretty phenomenal achievements in
being able to build the expansion of services necessary to meet
the CCBHC certification criteria.
We have one FQHC, and that dually certified FQHC is also
working through what it means to have the dual certification
for the FQHC and the CCBHC. But we have leaned in very hard
into the CCBHC model, investing mental health block grant
dollars to expand the CCBHC even outside of the expansion
grants, because we have seen that the value these Certified
Community Behavioral Health Clinics bring to our communities is
worth the investment.
Senator Stabenow. Well, thank you so much.
I am going to turn now to Senator Hassan, and thanks,
Senator Daines. For the audience, we are in the middle of
votes, so we are running back and forth to vote and coming
back. Senator Daines voted and is now back, but I know Senator
Hassan is going to go vote in a moment. So I am going to turn
it over to Senator Hassan, who is certainly a passionate
advocate and certainly understands all of these issues, and we
are so glad to have your voice in the U.S. Senate.
Senator Hassan. Thank you so much, Senator Stabenow. And
thank you to the ranking member for his courtesy in letting me
go first.
I have a question for Dr. Woodard. Even before the COVID-19
pandemic, our health-care system was grappling with an
unprecedented workforce shortage. Today, as more and more
Americans are struggling to access mental health and substance
use disorder treatment services, it is critical that Congress
ensures robust support for the behavioral health workforce.
That is why I reintroduced bipartisan legislation with
Senator Collins that creates 1,000 new medical residency
positions focused on addiction medicine at teaching hospitals
in New Hampshire, Maine, and all across the country.
Dr. Woodard, can you please speak to the existing mental
and behavioral health-care workforce shortage that we are
facing? And what steps should Congress take to provide support
for these providers in the coming years?
Dr. Woodard. Thank you for the question. Nevada actually
has a very significant workforce shortage in the majority of
our State, about 14 counties that experienced severe workforce
shortages.
One hundred percent of Nevadans actually live in a
workforce shortage area. So workforce shortages are something
that we have prioritized as a State for quite some time. And
what we have seen is, when we have been able to track the
pipeline for behavioral health providers, it includes reaching
down to the K-12 programs and beginning to build opportunities
for specialization and introduction into careers in the
behavioral health-care system, as well as in the broader
health-care system.
Being able to track individuals and how students really
engage in education around health care and behavioral health
care is one of the greatest strategies that we can use--so,
ensuring that we have some opportunity to build capacity within
our K-12 system and to begin to introduce careers and then,
once individuals are engaged in education, making sure that the
cost of education is not so great that it keeps people who are
very capable and motivated in being part of the workforce from
actually engaging in education.
So we want to encourage individuals to go into careers,
especially in the behavioral health field, without fear of
being saddled with overwhelming student debt when they get out.
Certainly loan repayment programs--and from a Federal level,
loan repayment programs are very helpful in encouraging
individuals to move into these critical health-care fields,
knowing that the risk for financial burden in the future can be
limited.
Also the opportunity is there to build residencies and
internships within States so that people who are moving through
the professional training path can remain in the communities
that they wish to live and serve in so that they do not have to
travel to other communities in other States to receive the
enriched experience, education, and training necessary to move
into the professional field.
And it is also looking to stratify the behavioral health
workforce. You know, one of the greatest workforce multipliers
that we have seen in Nevada is the introduction of the Peer
Recovery Support Services. Community health-care workers and
Peer Recovery Supports really help to build upon a foundation
of a strong behavioral health care delivery system and really
do serve as a workforce multiplier.
So an opportunity to continue to build those professions as
well, can certainly help to offset some of the workforce
shortages that we see in the behavioral health-care field.
Senator Hassan. Thank you very much.
I have one more question to Director Armstrong. The
dramatic expansion of telehealth during the pandemic has
increased access to mental health services for many Americans.
But rural residents, low-income individuals, and communities of
color have faced unique hurdles accessing the technology needed
to get mental health telehealth services.
Moving forward, Congress has to work to address the
remaining inequities that limit access to mental health
telehealth services for underserved communities.
Director, how can Congress work to expand access to mental
health services through telehealth for rural areas, low-income
individuals, and communities of color?
Mr. Armstrong. Thank you for that question. I think there
are a number of things that we can do.
First of all, we do need to expand broadband access in our
rural communities. We here in North Carolina have a number of
people in our most rural communities who do not have adequate
broadband access. So that is one of the things that we have to
address.
But one of the other things that I think we have to look at
is, while access to telehealth has been a huge advantage during
the COVID-19 pandemic because it has allowed us to continue to
provide services to people who otherwise would not have been
able to have access, the other thing that I think we have the
ability to do and that we could use support and funding for is
that we have done, over the years, a decent job of integrating
behavioral health into primary care, and primary care into
behavioral health. With the expansion of telehealth, it also
gives us an ability to expand into communities where people
live, work, and play. In addressing the social determinants of
health, that is our primary goal.
And by that, I give an example of looking at, particularly
in some of these rural communities where people may not have
access at home, why can we not incorporate telehealth and
behavioral health into the faith-based community, into the
YMCAs, into the community centers?
So one of the things I think Congress can look at is, how
do we provide more resources to expand and partner differently
than we have in the past? This also helps us to address some of
the issues around access to care for communities of color. In
many of the communities that have socioeconomic challenges,
access to those services is not available in their communities.
And if we want to address those access issues, we can do that
by expanding telehealth, by relaxing some of the restrictions
around utilizing telehealth, and by allowing funding that
allows organizations and State systems to partner more easily
with communities.
Part of our challenge oftentimes is that the funding that
we receive--while we greatly appreciate the Federal funding--is
often restricted in how we can use it. Oftentimes we can only
use the funding for individuals who are severely mentally ill,
or children who have severe emotional disturbances. And what
would allow us to utilize those services more easily would be
if we were able to use it for more prevention, and be able to
use that telehealth service to reach people before they reach
that point of crisis.
Senator Hassan. Thank you. Thank you very much. And thank
you, Madam Chair and Ranking Member, for your indulgence. And
now I am going to vote.
Senator Stabenow. Yes, please do. And thank you.
Now, Ranking Member Daines.
Senator Daines. Right. Thank you, Chair Stabenow.
In Montana, meth--and it's Mexican meth--is taking a
devastating toll on our communities. It has contributed to an
increase in violent crimes across our State. In fact, a few
weeks ago when I was on our southern border, I heard directly
from Border Patrol agents of the need to secure the southern
border to stop the flow of illegal drugs into our country, and
in this case into Montana, as well as directly into our State.
In fact, I spoke with the Cascade County sheriff recently
who told me they have Mexican cartel members who have been
incarcerated in the county jail there in Great Falls.
Ms. Kosovich, could you speak a bit about how Rimrock is
working to support those in need of behavioral health services?
And importantly, what might Congress or the Biden
administration do to help combat meth use and crime?
Ms. Kosovich. It is--thank you for the question, Senator
Daines. It is one of the most concerning things that we see
here. And like I said earlier, the amount of crime that we're
seeing resultant of meth use is seriously out of control.
I had the honor to work with Kurt Alme, who was our former
U.S. Attorney General for Montana for the last 3 years, and we
talked very deeply about where this meth is coming from. And he
said unequivocally we know there are five different Mexican
cartels that are using I-90 all the way up to Montana. They
have foregone the use of the middle man. They are selling
directly.
So there are a couple of things that I think would really
help. One, it is a supply and demand issue. Let's take away the
demand through treatment. Let's make sure that we get to those
folks who have been suffering with meth addiction and get them
on the road to recovery.
One of the challenges we know with meth is, it really does
change some brain chemistry. And it takes a while for a person
to have the clarity to even engage deeply in treatment when
they have been on meth.
One of the things that I would like to see is funding for
longer-term treatment for meth itself, meth addiction itself,
so we have that opportunity of time to get the brain to start
healing and reduce some of the cravings and those things that
make them want to continue to go out and seek and feed their
addiction.
So I think that that is one thing. If we have the funding
for longer-term meth use, let's also just cut off the supply
and get people treated so we do not have these cartels on this
highway-to-high coming up I-90.
Senator Daines. Thanks, Ms. Kosovich. In Montana and across
the country, we do not have a job shortage; we have a labor
shortage. Businesses across Montana, as I drive around the
State, I see their struggles to find workers. In fact, when you
drive across our State, you see a lot of ``Now Hiring'' or
``Help Wanted'' signs. Some Montana businesses in fact are
being forced to close because they cannot find enough workers.
Ms. Kosovich, in your experience, is there a correlation
between employment, working, and mental health?
Ms. Kosovich. There absolutely is. I mean, we look at it as
one of the social determinants of health. Your overall well-
being--there is data that shows it will be better if you are
employed.
A couple of weeks ago we actually partnered--the Billings
Chamber of Commerce partnered with the U.S. Chamber of Commerce
and gave a seminar to employers across Montana talking about
drug use in the work environment. How do you recognize it? What
do you do about it? Because, like you said, we need everybody
who wants to work and is available to work to work so we can
start addressing this shortage.
I felt it was very helpful. There were some great
questions. I think that there are some strategies that are
going to be coming out of both the Montana Chamber of Commerce
and the U.S. Chamber of Commerce to directly address this
issue, to make sure that we have everybody out there who wants
to work working.
It absolutely is a direct correlate of the social
determinant of care.
Senator Daines. So experts said, as you did in your
testimony, that we have not even reached the peak need for
behavioral health services as a result of the COVID-19
pandemic. In fact, local leaders in Montana say we will not see
the peak negative health effect until probably 18 to 24 months
after this public health emergency.
As discussed earlier, we are already facing workforce
shortages across Montana, including in the mental health and
behavioral health space.
Ms. Kosovich, how do we ensure that we are better equipped
to serve those in need when we have not even seen the full
effects of the pandemic on mental health? I will also ask Ms.
Newman to respond to that question.
Ms. Kosovich. It is a horrifying question to answer. We are
competing, with mental health worker wages, with every industry
there is. We have been historically paid poorly, or low, and it
is mainly because of the reimbursement levels. I believe the
CCBHC model really will give us a leg up to be able to be
competitive to attract that talent and the skill set that we
need to sustain a hardy behavioral health service.
I think there is hope on the horizon because of the CCBHC
and the enhanced reimbursement.
Senator Daines. Thank you.
Ms. Newman, do you have a thought on that question? Then
I've got to yield back my time; I'm over.
Ms. Newman. Yes, I do have a thought on that question. My
work on the Anti-Stigma team is to address the negative
connotation that is associated with mental health in general.
And sometimes when we speak to audiences, they do not always
understand what it is like living with a mental health
condition, and that you do not have to be fearful.
We speak to nursing students. We speak to psychiatric
students. We go into colleges. And we have a chance for them to
meet us on this side of graduation. And many times when they
have had a chance to interact with us and see that we are not
cutters and slashers, and that we will not con them, people are
more inclined to want to go into mental health as a profession
because the stigma has been taken away, that negative
connotation has been taken away. I think that is one of the
areas that we definitely need to do more work in: the way we
speak about mental health, the way we speak about people who
receive mental health treatment. We are not junkies. We are not
frequent fliers. We are not bipolar. We are people who have
conditions that are treated successfully and live very
successful lives, and we need to highlight that more so that
people know that this is an honorable profession and it is one
that you may want to pursue.
Senator Daines. Thank you, Ms. Newman.
Ms. Newman. Thank you for the question.
Senator Stabenow. Thank you very much, Senator Daines.
I believe Senator Cortez Masto is back with us.
Senator Cortez Masto. I am; thank you to the chairwoman. I
apologize. I have two committee hearings going at the same
time.
But let me start with Dr. Woodard. One of the most
concerning patterns that we have seen emerge from the pandemic
is the relative spike in behavioral health cases that present
in our emergency rooms. That worries me, and I think it worries
many of us, because it could suggest that we are seeing more
severe cases. But I am also concerned that the ER may not be
the best place for many of these cases.
So, Dr. Woodard, can you talk about the importance of
providing the right care in the right setting?
Dr. Woodard. Thank you for the question. We have seen that,
on any given day, pre-COVID, we had 90 individuals waiting in
our emergency rooms for inpatient hospitalization.
In an effort to try to resolve this, we have looked to see
what in our community is missing. Is there an opportunity for
us to do a better job of aiding individuals where they are at,
with the issues that they are bringing forward? And what we
have realized is that we have some pretty critically
significant gaps in our communities to be able to address some
of those most immediate needs.
As I had mentioned in some of my testimony before, we
really believe that building out the 988 system is critical to
helping individuals on the other end of the phone--who can
answer that call 24 hours a day, 7 days a week--to be able to
address whatever their needs are.
And what we see from some of the data is, approximately 80
to 90 percent of individuals who call the crisis line are able
to have their issues resolved, at least resolved to a point
where they can get maybe a same-day or a next-day appointment.
Without that critical service, an individual may, in a time of
desperation, go to the emergency room to present for treatment.
We also recognize that mobile crisis teams are an essential
component to getting services to an individual in the community
where they are at when they need the service. Our Children's
Mobile Crisis Team works with families 24 hours a day, 7 days a
week, to be able to go into the home, meet with the family,
help to deescalate the crisis. And more often than not, that is
a diversion from the emergency room. Parents and families who
are struggling with no other options most likely will seek care
in an emergency room.
What we also see is that crisis stabilization--so that
alternative destination, that alternative front door--is very
important so, instead of having people go to the emergency
rooms, which are providing critical emergency medical services,
we have a place for people to be able to go that is welcoming
that can serve them in a way that they need to be served by
providing screening and assessment in behavioral health
services. A large peer workforce incorporated into those Crisis
Stabilization Centers helps individuals really strategize and
problem-solve. And when we have seen this model work, we see
that actually relatively few individuals who were touched by
these systems end up needing that higher level of care for
inpatient psychiatry.
So overall, we believe that it is all solutions. It is 988,
it is Mobile Crisis, and it is Crisis Stabilization Services in
our community that will make the greatest difference in helping
to keep individuals from needing care in the emergency room.
Senator Cortez Masto. Oh, I could not agree more. And that
is why I so appreciate Chairwoman Stabenow for having this
hearing today, and all the good work that she has done on this
issue in addressing mental health in our communities--and
Senator Blunt as well.
I am working with Senator Cornyn on a bill that seeks to
better integrate behavioral health crisis services, including
those provided by the CCBHCs, and health planning, and to
really put crisis services on par with physical health care.
So, thank you for your comments, and for the panel members.
Thank you so much.
Ms. Newman, thank you for sharing your story. I believe
strongly that community leaders like you who have experienced
some of life's toughest challenges will be key to helping us
meet the country's mental and behavioral health needs moving
forward.
Can you talk a little bit about the benefits of peer
support when they are provided as part of a patient's care
plan?
Ms. Newman. One of the greatest benefits of peer support is
when you are in crisis and you are talking to a peer, you do
not have to explain. Some things you cannot even put into
words. We connect on a level that is really deep.
I will give you an example. A young lady called me a couple
of weeks ago and started to share with me why she was suicidal.
And she had three children. Two of her sons had been murdered.
One of them died in her arms, screaming, ``Mama, help me!''
She was going through a divorce, and she saw both of her
parents take their last breath. I started crying with her on
the phone, but I also told her any one of those things would be
enough to put somebody on the brink, but you must be a very
special person; you are surviving all of that.
I was able to help her see her situation in a different
light. Even though all those things were horrible things that
happened, and sad, she still came away from the conversation
with hope, because she did not want to die, and I recognized
that. She did not want to die. She just wanted the pain to stop
and for somebody to be able to say, ``I hear. You are hurt. I
hear that you need help.'' And she was in treatment within 4
days of that phone call. I reached out to our CCBHC and got her
an intake within days.
So when you talk to a peer, it is like a warm fuzzy
blanket. You do not have to explain. You do not have to be
ashamed. You do not have to feel like you are less than because
you are struggling. Peers do amazing work, amazing work. I love
my job. If I did not get paid to do what I do, I would still do
it.
Thank you for the question.
Senator Cortez Masto. Oh, thank you. I agree with you. I
have learned the benefits of peer support and peer counseling.
It just really makes the difference that I have seen. So thank
you. Thank you to all the panelists.
Senator Stabenow. Thank you so much, Senator Cortez Masto.
I just want to say ``amen'' to Malkia. Thank you so much. We
are so proud of you in Michigan and for all that you do to help
people reach out to get the help they need, and the recovery
they need. So we are so grateful that you are part of what is
happening in Michigan to help people.
At this point, I am going to have to leave to go vote on
the floor. There are actually a couple of votes. And so, we are
at a point where I am going to turn the gavel--we have a
bipartisan hearing going on. I am turning the gavel over and
trusting Senator Daines to wrap up the meeting.
He has one other question he wants to ask. I have 50 I
could ask, and certainly I will continue to work with all of
you because there is so much to do, and we are so grateful, and
we are excited about moving forward to the next step to be able
to make CCBHCs available to every State, the full funding,
treating health care above the neck, funding it the same as
health care below the neck. And so we are excited about moving
forward with all of you to get that done.
But at this point, I will turn to Senator Daines. And he
will wrap up the hearing, and we will follow up with questions
for everyone. But we appreciate you. Mental Health Month is
this month, and let's all reach out to tell our own stories and
then move forward together to make things better.
Thank you.
Senator Daines?
Senator Daines [presiding]. Senator Stabenow, thanks for
your help and your leadership. And I think the American people
would like to see more of this. We are literally sharing a
gavel. So thank you. I will be down to join the vote here in
just a minute. So thank you.
I do have one more question, Ms. Kosovich, that relates to
stigma associated with seeking mental health treatment. If your
neighbor can recognize your truck or a vehicle outside a
treatment facility, you might not be comfortable seeking help.
With Montana in the top five States with the highest
suicide rate, sadly, this seriously concerns me. That is why I
think it is important that we look for ways to increase access
to mental health treatment and really think outside the box
when it comes to increasing access, including using mental
health telehealth services.
Ms. Kosovich, do you think it is important for individuals
to have access to mental health services outside of the
traditional brick and mortar doctor's office?
Ms. Kosovich. I absolutely do believe so, and thanks for
that question. You know, we have been doing telehealth before
COVID. COVID forced us to do it better and look at different
access points for everything. And I would go as far as saying
there are other applications for telehealth too, when we are
talking about the crisis continuum and how we are going to
serve that.
We have some very promising pilots going on with tablets,
with our law enforcement, that they are out in the road and
they can actually connect somebody in mental health crisis with
the appropriate level of care, either a peer or a counselor,
whatever it may be.
So the applications are just so profound. And it should not
be contained just to a mere facility. We do have some people
who have done a lot better on telehealth during COVID,
especially people who have anxiety disorders. We also have a
contingency, if they really want to have that face-to-face, but
I think finally we have the opportunity to have both.
And one comment on stigma. I remember when I was a little
girl and my mom would have a coffee klatch, and I could hear
them whispering about the neighbor who had ``cancer.'' They
whispered the word ``cancer.'' And I thought it was something
so bad, and we know how far we have come over the years in
treatment of cancer.
And if we just would stop whispering about ``mental
health'' and ``addiction'' and people who--I am so proud of
this panel talking about their own stories. Maybe stopping that
whisper will be the impetus for us to stop the stigma. And that
would be my encouragement for everybody who has a story and can
tell it; we might get there some day.
Senator Daines. Well, thank you, Ms. Kosovich. And thanks
to the panel today. I share your gratitude, Ms. Kosovich. This
has been a great panel, and I appreciate the expertise, the
passion, and the compassion that we saw today from our
witnesses.
This concludes the subcommittee hearing. We have up to 7
days if changes need to be made to the record. But without any
further Senators here seeking to question, this subcommittee is
now adjourned.
[Whereupon, at 4:15 p.m., the hearing was concluded.]
A P P E N D I X
Additional Material Submitted for the Record
----------
Prepared Statement of Victor Armstrong, MSW, Director, Division of
Mental Health, Developmental Disabilities, and Substance Abuse
Services, North Carolina Department of Health and Human Services
Good afternoon. Thank you, Chair Stabenow, Ranking Member Daines,
and the honorable members of the committee, for the opportunity to
testify on North Carolina's approach to ensuring equity in community
behavioral health services.
My name is Victor Armstrong. I am the Director of the North
Carolina Division of Mental Health, Developmental Disabilities, and
Substance Abuse Services. I am a social worker, a husband, and a father
to three black boys. I am a mental health advocate, and I am the son of
a preacher, born and raised in rural North Carolina--Plymouth to be
specific--though I now reside in Charlotte, NC. I share all of this
because I am the sum of all these things. This will no doubt create a
perception of who I am, based not only on what I have just shared, but
also based on both your lived experience and mine. Much as you today
will interact as tradition and formality dictate, in many ways our
mental health and substance use system has worked the same way.
Unfortunately, it is a system that has not been practiced nor been
funded through a lens of equity.
The lens of equity is about the intersectionality of race, culture,
and ethnicity, in addition to living with mental health and substance
use challenges. It is about being black and living with a serious
mental illness. It is about being Latino and living with intellectual
disabilities or traumatic brain injury. It is about being American
Indian and living with a substance use disorder. It is about being an
Asian or trans person struggling with an anxiety disorder exacerbated
by the discrimination that often accompanies mental illness, the
bigotry that is perpetrated toward trans Americans, and the increasing
rates of violence against Asian Americans.
We cannot ignore how a person of color enters the behavioral health
system. People of color often do not have access to outpatient services
within their communities. This makes it more likely that they are
introduced to the behavioral health system when they are in a state of
``crisis'' and more likely to enter the system via the back of a police
car or an acute care emergency department, neither of which is
conducive to good clinical outcomes, and neither of which is likely to
foster a positive relationship with the mental health system.
Systemic racism and bias, both explicit and implicit, are
multilayered and seep into every crevice of society. This includes our
mental health and substance use care, but we can change that if you are
willing to help to reform our system. When we know that inequities
exist, it is our moral responsibility to address those inequities by
leaning into equity. Every decision that we make as clinicians, policy-
makers, or simply as agents of change, either leans into creating a
more equitable system or perpetuates our existing problem of inequity.
We can address the issue of access by supporting the creation of
more mental health resources in communities of color and underserved
ZIP codes. We can create more community-based resources that provide
access to upstream treatment.
One way that communities are doing this is through the Certified
Community Behavioral Health Clinic, or CCBHC, model. CCBHCs are
required to provide comprehensive, timely, and culturally competent
services to everyone in their communities. One CCBHC here in North
Carolina--Monarch--has embedded a Peer Support Specialist with the EMS
team that responds to opioid overdoses. The peer stays with that person
through the trip to the hospital and helps to connect them to community
treatment upon release, making sure that the person does not get lost
on the road to recovery in the community. We support the CCBHC model
and appreciate any funding to increase CCBHCs.
We can support efforts to build a workforce that mirrors the
populations served. In North Carolina, we have roughly 4,000 trained
Certified Peer Specialists, representing blacks, whites, Latinos,
Asians, and American Indians, with only about 1,600 individuals
gainfully employed. We need to utilize the peer workforce and pay them
a living wage. We need to partner with Historically Black Colleges and
Universities (HBCUs) to build a multicultural workforce. We need to
partner with clinicians of color and provide them access to government
grants and contracts. We need to partner with faith-based
organizations, and we need to fund studies that consider the nuances of
race, culture, and ethnicity and the impact on mental wellness.
Further, we need to better understand the impact of systemic racism and
complex trauma experienced by people of color.
In North Carolina, it has taken intentionality to mitigate the
effects of the COVID-19 pandemic, particularly the disproportionate
impact of the virus on black and brown communities. As the North
Carolina Department of Health and Human Services sought to intervene,
we recognized that without incorporating trusted voices who represent
the individuals that we seek to assist, we will lack credibility, and
full engagement will be difficult, if not impossible. Historically
marginalized communities--whether marginalized due to race, ethnicity,
or diagnosis--are simply looking for a collaborative partner who will
value their expertise and life experience. We have the resources to
build a more equitable system. If we do not build equity into our
mental health and substance use programs and practices, we will
ultimately fail the most powerless and vulnerable.
I will leave you with one final thought: mental health and
substance use transcends barriers, divides, and differences. People
from all walks of life are dying every day from suicide or overdose.
Mental health and substance use do not see race, culture, or ethnicity.
The same cannot be said of our treatment system. It is time that we fix
our system to serve the diverse communities in our Nation. Thank you
for your time.
______
Prepared Statement of Hon. Steve Daines,
a U.S. Senator From Montana
Thank you, Madam Chairwoman. I'm glad to be with you hosting our
first subcommittee hearing of the year. It's also great to have a
fellow Montanan join us today. We'll get into a more formal
introduction in a bit, but welcome, Lenette. I'm glad you could be
here.
May is Mental Health Awareness Month--an issue at the top of my
mind and many others following a year of isolation for Montanans and
Americans across the country. Last year due to COVID restrictions,
Montanans and Americans were forced to stay home--we saw family-owned
and small businesses shutter; workers struggle; family members isolated
from their loved ones; and schools close, directly impacting our
Nation's youngest and brightest.
Through no fault of their own, hardworking Montanans and Americans
across the country lost their jobs--leaving them wondering how they
were going to keep a roof over their families' heads and food on the
table. Instead of socializing and learning with their friends in
classrooms, students were stuck behind computer screens. Symptoms of
anxiety and depression are on the rise.
In fact, in one survey, more than half of adults reported that
worry or stress related to the pandemic was having a negative effect on
their mental health. As we all know, mental health issues were a
problem before the pandemic. In fact, it's estimated that nearly one in
five American adults had some form of mental illness, but fewer than
half of those adults received treatment in 2019.
Since the pandemic, lockdowns, economic hardships, and social
isolation have only helped intensify what we already knew: we need
mental health services in our communities, and we need to make them a
priority. The pandemic has also helped expose and magnify the flaws in
our mental health system.
In 2020, suicide was the tenth leading cause of death, and drug
overdose deaths hit a record high. In Montana, we are unfortunately not
immune to these devastating statistics. We are fourth in the Nation for
suicides and first in the Nation per capita for children placed in
foster care--most often due to a parent's drug or alcohol use. And we
are witnessing a disturbing increase in meth-related violent crime.
It is clear that more needs to be done to support individuals and
families struggling with addiction or mental illness. We are fortunate
in Montana to be home to treatment facilities like Rimrock, which I've
had the privilege of visiting several times over the years. I even had
the opportunity to bring Vice President Pence to show him firsthand the
great work the organization does for Montanans struggling with
addiction and mental health issues.
One visit I will never forget, I had the chance to meet with a few
moms who were receiving substance use treatment. I had just become a
grandfather. I was overwhelmed with emotion. There I saw devotion,
struggle, commitment, and so much love that the Montana moms had for
their children.
Because at Rimrock, thanks to a bill I led in the Senate, which was
signed into law by President Trump, moms who are working to get back on
their feet are able to stay with their children. Let me tell you, this
means the world to these moms. Treatment centers like Rimrock make a
world of difference in our communities, and they are more important now
than ever as we come out of this pandemic.
After a year of lockdowns and closures, we are finally seeing a
light at the end of the tunnel. Thanks to the leadership of our new
Governor, Greg Gianforte, life in Montana is on its way to being back
to normal. We've vaccinated over 350,000 Montanans and have led the
Nation in vaccine administration.
Montana is now open for business. We are open for school. We are
incentivizing getting back to work versus staying home--something I
believe is also important for mental health, because I believe there is
dignity in working. But the reality is that there will likely be long-
lasting impacts of the pandemic, particularly on mental health. We must
aim to meet the challenges of today and prepare for the increased need
that this pandemic has created.
I am committed to working with my colleague Senator Stabenow toward
that goal.
Again, I appreciate our witnesses being here today and offering
their advice and expertise on such an important topic.
Thank you, Madam Chairwoman.
______
Prepared Statement of Lenette Kosovich, R.N., MHA,
Chief Executive Officer, Rimrock Foundation
Senator Stabenow, Senator Daines, and members of the committee,
thank you for inviting me to talk about one of the most complex and
far-reaching issues facing Montana and our Nation. My name is Lenette
Kosovich. I'm the CEO of Rimrock Foundation, the largest behavioral
health care facility in Montana. We provide a full continuum of
services, including peer support, medical detoxification, inpatient,
residential, and outpatient treatment. We have extended treatment--12
months or longer, for mothers with their children, and those recently
released from incarceration. We serve seven treatment courts, including
Family Drug Court, Veteran Court, and Indian Child Welfare Act Family
Recovery Court. All in all, we see nearly 2,000 clients a year.
There is no doubt that COVID has exacerbated an already complex
problem. Before COVID:
Substance use disorders and mental illness were already the
top health needs in our county.
We had a methamphetamine-fueled increase in violent crime, and
a burgeoning child welfare system where four out of every five cases
involved drugs or alcohol.
Over the last 5 or 6 years, our clients are considerably more
compromised than a decade ago. Along with serious illicit substance use
disorders, patients most likely have mental health issues accompanied
by 1 or 2 comorbidities, like hypertension or diabetes.
It has become the norm to have 25-year-old
patients in our care who have already received a heart valve
replacement due to endocarditis resulting from IV drug use.
Enter COVID.
(1) Alcohol consumption, drug use, and mental illness are up.
Our referrals are up forty percent.
Calls to our State suicide hotline have doubled.
Violent crime in our county has increased nearly 70 percent in
the past 12 months. One thing is certain: drugs played a role.
(2) While increasing the need, COVID complicated and delayed
service delivery.
Quarantine and social distance needs reduced the space we have
to provide treatment by about one third. Many of our industry partners
suspended services, so waitlists increased.
With physical space at a premium, COVID accelerated adoption
of telehealth tenfold. With that acceleration came incredible pressure.
iPad needed for all--except you couldn't get iPad. Group therapy via
telehealth, except Johnny's Internet doesn't work. Family week via
Zoom--great, except Suzy's mom doesn't have a computer. Training, new
admit policies, new safety protocols. . . . Every part of our industry
was stretched to the max.
But the worst challenge of COVID for me was workforce. Before
COVID, the workforce shortage was severe. Wait times for COVID results
and positives made the problem much worse. When I don't sleep at night,
it is often because I am worried about the number of my employees
pulling double shifts, on the brink of mental breakdown themselves.
History teaches us that the mental health impact of a catastrophic
event, such as the pandemic, will far outlast the physical impact. So I
am buckled in for a bumpy road.
Fortunately, there is hope on the horizon with the expansion of the
Certified Community Behavioral Health Clinic model or CCBHC. Rimrock in
Billings, and two other organizations in Montana, were recently granted
a CCBHC expansion pilot.
In active CCBHC sites, this innovative model of care has
dramatically increased access to mental health and substance use
disorder treatment and been proven to address the pain points I just
shared. I look forward to achieving outcomes like those highlighted in
the recent impact study by The National Council for Mental Wellbeing.
We must:
Increase the number of clients served--according to The
National Council, CCBHCs increased clients served by 17 percent.
Decrease wait times for care--remarkably 84 percent of clients
in a CCBHC are seen within 1 week.
Invest in the workforce--there is an enhanced reimbursement
with CCBHC which allows clinics to increase hiring.
Make crisis services and supports available to all--CCBHCs
deliver crisis support services in the community, not just in
facilities. Innovative collaboration with criminal justice and
community services help to divert people in crisis from emergency rooms
and jails and get them to the appropriate level of care.
Address health disparities--CCBHCs increase screening for
unmet social needs that affect health, like housing or transportation.
We improve care coordination and partnerships to address those needs.
Thanks to Federal and State investment, today 340 CCBHCs are
operating in 40 States, Washington, DC, and Guam.
Senator Stabenow, Senator Daines, and the committee, there is not
one of your constituents whose life has not been impacted by substance
use disorder or mental illness. There is not one of your economies that
has not suffered. We can do better, and the CCBHC model does do better.
I unequivocally urge your continued support of the CCBHC model of care.
______
Questions Submitted for the Record to Lenette Kosovich, R.N., MHA
Question Submitted by Hon. Debbie Stabenow
Question. What strategies have you used, or seen succeed around the
country, to provide high-quality comprehensive services in rural
communities? What is the role of mobile units?
Answer. Immediate access is necessary. Bringing the care to people
with a mobile unit eliminates traditional access barriers. It helps
increase compliance and carries with it a strong message that there are
people who can help.
______
Questions Submitted by Hon. Sheldon Whitehouse
Question. In your testimony, you describe how workforce shortages
challenge your ability to care for your patients. My legislation with
Senator Portman, CARA 3.0, would provide funding for training and
employment for substance abuse professionals, including peer recovery
specialists, and for dedicated retention efforts through SAMHSA and
HRSA.
How would additional funding for workforce training and employment
address the challenges you've identified?
Are there other workforce challenges beyond funding that we should
address?
Answer. This is a complicated question to answer. Montana, as well
as other States, is facing other challenges that are outside training
and employment. We have a shortage of affordable housing and many
people are willing to be employed but can't afford a place to live.
Also, they may simply lack reliable transportation to get to their work
or not have childcare.
Question. Your CCBHC offers same-day services, as does Newport
Mental Health in Rhode Island.
How does your ability to offer same-day services help you better
serve patients experiencing mental and behavioral health crises?
Answer. Access is everything. And immediate access is crucial in a
behavioral health crisis. A true behavioral crisis may gradually
subside with the passing of time (or conversely, end tragically). But
the root cause of the crisis may not diminish and the likelihood of a
reoccurrence of the crisis or one of a more elevated nature is great.
The urgency of access in a timely manner is key to getting people on
their way to wellness.
______
Prepared Statement of Malkia Newman, Team Supervisor,
CNS Healthcare Anti-Stigma Program
``I was born by the river, in a little tent. Then I go to my
brother, I say, brother, help me please. It's been too hard living, but
I'm afraid to die. It's been a long, a long time coming, but I know, a
change is gonna come, oh yes it will.''
Good afternoon, members of the U.S. Senate, staff, and guests. I am
very honored to be asked to give testimony to this distinguished body
today. I want to especially thank Health Chairwoman Debbie Stabenow and
Ranking Member Steve Daines for convening this vitally important
discussion.
My name is Malkia Newman, and I am living proof that the services
and supports that are available through our community mental health
system work. I am not naive to the fact that there are many areas that
need to be improved. But I know that that my life would not be the
amazing life that I'm living now had I not received treatment for
bipolar disorder almost 20 years ago.
I am a survivor of childhood sexual trauma, as well as a survivor
of intergenerational trauma, a sad legacy of slavery and
discrimination. I wrestled with suicidal thoughts, had difficulties
maintaining relationships or employment. My daughter Tracie, who I call
my miracle, was my reason for living when all hope was gone.
Mental health conditions are very prevalent in my family. The
treatments and hospitalizations that my brother Ronnie endured, who had
schizophrenia, terrified me, which made it harder for me to ask for
help until there was no other option available.
Fast forward 20 years. I have 15 years of continuous employment
with CNS Healthcare's Anti-Stigma Program, I've been a homeowner for 9
years, and on June 5th my husband Dubrae and I will celebrate our 15th
wedding anniversary. I have reconciled with my family, and I serve as
an ordained minister at my church, New Birth International of Pontiac,
MI. My list of community service awards and recognitions is long. I
have provided a copy of my resume to the subcommittee.
I am living proof, I am an advocate, and I am proud to speak on
behalf of those who have not yet found their voice. It is vitally
important that we not just continue to offer behavioral treatment, but
that we prepare for the increased need that the pandemic has created.
We need more qualified providers, doctors, nurses, therapists, and
other support personnel, especially Peer Support Specialists, persons
with lived experience and expertise in the mental health field who can
encourage and educate people receiving services in a richer way than
other professionals can. We need to compensate our professionals at
every level, to make sure that we have qualified, culturally, and
linguistically competent people meeting the needs of people, no matter
what their background.
The Certified Community Behavioral Health Clinics, CCBHCs, have
made it easier for people to access services regardless of if they have
insurance or not, which in the past created a huge barrier to people
needing help.
Integration of physical and mental health has been a topic of
discussion for many years. Integration is needed to help people with
mental health disorders live longer, healthier lives, but the focus has
shifted from people getting whole health treatment from head to toe to
an argument about who will administer the dollars associated with the
treatment. I believe that people served, and their loved ones, should
have a role in shaping what health care should be, as people with
intimate knowledge of what works and what doesn't. Advisory groups can
and should be involved at every level of program development,
implementation, and evaluation. The finished product would be more
efficient and cost-effective as well.
It is my prayer and hope that we will not rush to get back to
``normal'' at the expense of programs and systems that work.
______
Questions Submitted for the Record to Malkia Newman
Questions Submitted by Hon. Debbie Stabenow
Question. CNS Healthcare, where you serve as team supervisor of the
Anti-Stigma Program, has received a CCBHC expansion grant. What has
that meant for your work?
Answer. It has made it much easier to refer the people that I meet
in the community that are looking for help to CNS no matter where they
live or their ability to pay. They don't always have the insurance
necessary or sometimes they don't have any insurance at all. The safety
net that CCBHC provides takes the guesswork out of the equation. It has
made so many more families happier and healthier in every way.
Question. I think the work you and your team do as Peer Support
Specialists is incredibly important and effective. We talk a lot about
strategies to address stigma and break down the barriers to seeking
treatment, but I think what sometimes is underappreciated is the fact
that people like you are out in communities doing that right now.
What strategies do you use to help people get the treatment they
need? What types of services and connections do you provide to help
people recover?
Answer. I have a great working relationship with our intake staff,
they are good at following up on all the people I refer to the agency.
They did such a great job with me when I came in as a person in
desperate need of help, that I have peace of mind when I send someone
else in to get the lifesaving treatment that I was able to get way back
in 2004!
When people see us in the community, whether it's in a virtual
format or in person, they can see what a difference treatment has made
in our lives. We're open and honest about our experiences, that it
doesn't matter how far they have gone, there are places where people
can go and get the treatment and support necessary to help turn their
lives around.
We also make our presentations as entertaining as possible so that
people can hear our message. We want people to see that we're not weird
or unnatural, we have the same challenges, we've found a healthy way to
move past the stigma that has held us captive in the past. Truth really
does free you from misconceptions and stereotypes that limit the kind
of life you can have, no matter your age, race, culture, religion. We
love to bust stigmas with truth.
My role is more that of providing education, and hope. There aren't
many situations that we can't identify with, and in doing so let people
know, you still have an opportunity to live a life worth living by
taking advantage of the services and supports that our CCBHC provides.
The ability to access services without going through the uncertainty of
who's going to pick up the tab so to speak, and letting the system do
what it was designed to do. Help those with insurance and the ability
to pay and having to extra funds available to help those who aren't as
fortunate. I am living proof that there is a life worth living after
receiving a mental health diagnosis!
______
Questions Submitted by Hon. Sheldon Whitehouse
Question. In your testimony, you describe how workforce shortages
challenge your ability to care for your patients. My legislation with
Senator Portman, CARA 3.0, would provide funding for training and
employment for substance abuse professionals, including peer recovery
specialists, and for dedicated retention efforts through SAMHSA and
HRSA.
How would additional funding for workforce training and employment
address the challenges you've identified?
Answer. Ability to fully implement team-based care approach
(holistic approach to care with teams comprised of Case Managers,
Therapists, Peer Recovery Coaches, Peer Support Specialists, and Nurse
Practitioners).
Ability to offer competitive salaries for limited licensed and
fully licensed staff.
Ability to offer a good salary/wage for peers reflective of the
importance and value of hiring persons with lived experiences and the
significant positive contributions they make for those served and the
team overall. Would also allow for ability to hire more peers to
enhance offerings.
Ability for more staff to be trained, receive support/monitoring/
supervision towards substance use disorder credentialing (i.e.,
development plans) and more supervision time overall to increase the
number of staff obtaining substance use disorder credentialing.
Question. Are there other workforce challenges beyond funding that
we should address?
Answer. We need credentialing across health plans to be consistent.
Current limitations limit mental health professionals from providing
services they are trained to provide (i.e., significant limitations for
Licensed Professional Counselor and Limited License Psychologist).
Need for CCBHCs to have consistent policies/practices regardless of
what county individuals are seeking care from. Additionally,
established clinical care pathways with recommended guidelines are
needed similar to FQHCs to ensure continuity of care and remove
barriers.
Question. Your CCBHC offers same-day services, as does Newport
Mental Health in Rhode Island.
How does your ability to offer same-day services help you better
serve patients experiencing mental and behavioral health crises?
Answer. It increases our ability to engage individuals immediately
with no delays and to provide an expedited response when persons are
seeking help. Same-day services also reduce occurrences of emergency
department visits for mental health/behavioral health circumstances and
provides services through less restrictive,
community-based means.
______
Prepared Statement of Hon. Debbie Stabenow,
a U.S. Senator From Michigan
I call this hearing of the Finance Subcommittee on Health Care to
order.
I'm so pleased to be here, during Mental Health Month, talking
about the urgent need to improve behavioral health-care services in our
communities.
Ranking Member Daines, it is great to have you as my new partner on
this subcommittee, and I know we can do a lot of great work on this
issue, and many others.
Mental Health Month is when we raise awareness, take on stigma,
celebrate triumphs, and make sure no one feels alone. Everyone affected
by mental illness or substance use disorders should be able to get the
help they need so they can live a healthy and fulfilling life--period.
We can make this a reality!
This issue is personal to so many of us. It affected my own father.
Before the pandemic, nearly one in five Americans had some form of
mental illness, yet fewer than half received treatment. This lack of
support is even worse in our communities of color.
Our overworked and underfunded health-care system was already
leaving millions of Americans without the treatment they need. The
pandemic has made things worse and exposed the weaknesses in the way we
pay for behavioral health care in this country.
In January, 41 percent of American adults reported that they were
struggling with anxiety and depression. That's up from 11 percent
before the pandemic. And more than one in four young people have
reported having suicidal thoughts. Meanwhile, overdose deaths have
surged during the pandemic.
The CDC reported that more than 87,000 Americans died of drug
overdoses during the 12-month period that ended in September--the most
deaths in any year since the opioid epidemic began in the 1990s. And
long after the pandemic ebbs, these behavioral health issues will
linger. We need to finally treat health care above the neck the way we
treat health care below the neck. The need has never been more urgent.
The good news is that we are making progress. I've worked with my
friend Senator Roy Blunt and many of you to create and expand the
Certified Community Behavioral Health Clinics program.
Now fully operational in 10 States with startup grants bringing the
program to 41 States, we have a structure that allows clinics to truly
meet the needs of their communities. This has been a tremendous
success, and is the model for the future.
These clinics are required to provide comprehensive services
including 24/7/365 Mobile Crisis Team services; immediate screening and
risk assessment; easy access to care--they see everyone who walks in
the door; tailored care for active-duty military and veterans; care
coordination with primary care providers; and coordination with law
enforcement.
The results are stunning. According to HHS numbers included in the
budget request last year, people who received services at CCBHCs had
63.2 percent fewer emergency department visits for behavioral health
issues, spent 60.3 percent less time in jails, and saw a 40.7-percent
decrease in homelessness
And today, the National Council for Mental Wellbeing (previously
the National Council for Behavioral Health) released a new CCBHC impact
report with similarly stunning results:
More than half of CCBHCs offer same-day services, and nearly all
of them offer treatment within a week. Compare that to the average wait
time of 48 days nationwide--and they are serving thousands of new
clients.
CCBHC funding created an average of 41 new jobs per clinic.
Ninety-five percent of CCBHCs have engaged in promising new
practices in collaboration with law enforcement or criminal justice
agencies.
This month, Senator Blunt and I--hopefully joined by all of you on
this subcommittee--will be introducing legislation giving every State
in the country the option of participating in the full program. It will
ensure that behavioral health care clinics are paid in the same way we
pay Federally Qualified Health Centers (FQHCs).
We can get this done and bring quality community-based care to
millions of Americans who need it.
Thank you to our fantastic witnesses for being here today. I look
forward to hearing from you and know we will have a great bipartisan
discussion.
So many of my colleagues are focused on this issue, and whether it
is CCBHCs, telehealth, crisis supports, coordination with law
enforcement, schools, and many other issues, I look forward to working
with you.
______
Prepared Statement of Stephanie Woodard, Psy.D., Senior Advisor,
Division of Public and Behavioral Health, Nevada Department of Health
and Human Services
Senator Stabenow, Ranking Member Daines, and members of the
committee, my name is Stephanie Woodard. I am a licensed psychologist
and serve as the Nevada Department of Health and Human Services' Senior
Advisor on Behavioral Health. I also serve on the board for the
National Association of State Mental Health Program Directors and the
Nevada Board of Psychological Examiners.
I am humbled and honored to have the opportunity to testify before
you today to discuss how the COVID-19 pandemic has highlighted the
critical role of crisis services and Certified Community Behavioral
Health Clinics and our opportunities to build strong, resilient
communities throughout the recovery.
Inadequate access to critical behavioral health infrastructure has
long contributed to Nevada's struggles to address the behavioral health
needs of the population. Nevada's vast geography combined with
workforce shortages, insufficient access to critical health and
behavioral health resources, and high rates of uninsured and
underinsured have been amplified during the pandemic and contributed to
the disproportionate impacts of COVID-19 across communities in our
state.
When compared to previous years, in 2020 Nevadans experienced
higher rates of depression and anxiety. Emergency room admissions for
overdose, suicide attempt, and suicide ideation all increased over the
course of last year resulting in the highest number of admissions in
the past decade. While overall deaths by suicide decreased, the suicide
rate rose 25 percent in youth and young adults age 8 to 24.
Additionally, opioid-related overdose deaths increased 44 percent with
synthetic opioid overdose deaths accounting for more than 50 percent of
the overdose fatalities in Nevada. These data underscore the urgent
need to address substance use, mental illness, and suicide, they help
us to understand the magnitude of suffering occurring in our neighbors,
co-workers, children, friends, and family members, and they provide an
imperative to act.
Informed by the body of knowledge on disaster behavioral health,
Nevada's COVID-19 Disaster Behavioral Health Response and Recovery
Plan, established in May of 2020, used a population health model
focused on promotion, prevention, early intervention, continuity of
behavioral health care, and access to recovery supports. Our Certified
Community Behavioral Health Clinics, suicide prevention crisis hotline,
mobile crisis teams, and crisis stabilization centers provided the
necessary foundation for Nevada's plan.
nevada's comprehensive crisis continuum of care
National guidelines developed by the NASMHPD, SAMHSA, and the
National Council were valuable tools as we developed a coordinated
crisis continuum of care. Essentially, a coordinated system of crisis
care ensures that when individuals are in crisis, they have someone to
talk to, someone to respond, somewhere to go and the services and
supports are based on best practices. These guidelines have been the
road map for the crisis system in Nevada statewide, and regionally,
over the past 3 years.
Nevada completed assets and gaps mapping in July 2020 and found
significant gaps in the capabilities across continuum of care, however,
knowing the gaps in the system has led to strategic use of Federal
funding through CMS and SAMHSA to respond to community needs for crisis
services.
crisis call hubs/care traffic control
Crisis Support Services of Nevada is part of the National Suicide
Prevention Hotline, meaning no call goes unanswered. Through grant
funds we have been able to increase staffing on the crisis line to
increase in-state answer volume, decrease wait times for callers, and
begin to ready the system for 988 in July of 2022. Nevada has pending
legislation to establish a fee and a fund to support the implementation
of 988 by July 2022.
mobile crisis services
Ultimately, overutilization of emergency services within EMS and
law enforcement has resulted in costly use of critical public safety
resources with lengthy wait-times and a mismatch of intervention to
support the individual. COVID-19 grant funding has been used to divert
children and families away from emergency rooms through the expansion
of children's mobile crisis teams. We plan to further this work with
the new supplemental funding through the American Rescue Plan
Supplemental Block Grant funding and the enhanced FMAP through Medicaid
to sustain more mobile crisis teams across the State.
crisis stabilization centers
Prior to COVID-19, on any given day an average of 90 people would
be waiting in an emergency room for an inpatient psychiatric bed, the
vast majority of whom were underinsured or uninsured. We expanded
funding for uncompensated care to 24/7 crisis stabilization centers
through Federal grant funding in order to provide an alternative
destination for individuals in crisis and diverted from emergency
rooms.
Statewide expansion of mobile crisis teams and crisis stabilization
centers is planned with new supplemental funding through the American
Rescue Plan Supplemental Block Grant and enhanced FMAP for
sustainability for mobile crisis. A new Medicaid rate for crisis
stabilization centers is expected to result in cost saving to Nevada
over the long term. The recent infusion of Federal funding is necessary
in the development of essential infrastructure; however, it is
insufficient for long-term sustainability. To bring the entire crisis
continuum to scale, Nevada, along with other States, will need guidance
from CMS to ensure these services are sustainable into the future. For
States to be successful in rising to the challenges 988 presents,
collaboration between SAMHSA and CMS, as recommended by the Medicaid
and CHIP Payment Access Commission (MACPAC), will be essential.
Nevada established Certified Community Behavioral Health Clinics
through the SAMHSA CCBHC planning grant in 2016 and the demonstration
grant in 2018. Nevada's investment in CCBHCs through the demonstration
grant, mental health block grant funding, and the CCBHC expansion grant
has resulted in nine CCBHCs under the Medicaid State plan.
Over the course of the demonstration, CCBHCs have increased access
to critical safety net behavioral health services including 24/7 crisis
services, while lowering costs of care and improving outcomes. CCBHCs'
success can also be measured by the relationships the clinics have with
the communities they serve. Collaboration with law enforcement for
community-based crisis intervention has reduced unnecessary
incarceration and emergency room visits. Expansion of services into
schools has increased access to care for students with behavioral
health needs. Comprehensive case management and peer recovery supports
better address social determinants of health and increase engagement in
care. Cost-based reimbursement has enhanced their ability to recruit
and retain qualified behavioral health professionals in competitive job
markets despite workforce shortages across all regions of our State.
In addition, while many behavioral health providers experienced
significant challenges in maintaining operations over the past year,
Nevada's CCBHCs were able to pivot quickly to expand telehealth
services and offer hybrid services to individuals for in-person care.
We anticipate continued CCBHC continued success and look forward to
onboarding an additional four CCBHCs under the most recent SAMHSA
expansion grant.
Nevada expresses our gratitude to Senator Stabenow, Senator Blunt,
the National Council, and countless others who have supported the CCBHC
model and expanded the demonstration until 2022.
opportunities and solutions
Collaboration between SAMHSA and CMS, as recommended by the
Medicaid and CHIP Payment Access Commission (MACPAC), will be essential
for States to fully leverage Medicaid to sustain the crisis continuum
of care.
Looking ahead, we would encourage SAMHSA to work closely with State
mental health program directors as they administer the expansion
grants. CCBHC certification requires State time and resources and is
essential in ensuring all clinics qualifying as CCBHCs meet the
rigorous certification criteria.
______
Questions Submitted for the Record to Stephanie Woodard, Psy.D.
Question Submitted by Hon. Debbie Stabenow
Question. We've seen a huge expansion of telehealth services during
the pandemic, particularly in behavioral health care. We hope that
COVID cases continue to go down, and in-person care becomes safer, but
I think we all agree telehealth is an important option.
As providers in your State scaled up their telehealth services,
what have you seen work well? What needs to happen to improve these
services going forward?
Answer. Nevada experienced a profound and rapid transition to
telehealth services following the declaration of the COVID-19 public
health emergency in March of 2020. Several factors facilitated this
rapid transition, including allowing our subgrant recipients to amend
subawards to allow for the purchase of telehealth equipment, Centers
for Medicare and Medicaid allowing for telephonic-only services, and
clear communication with providers on policy changes to allow for
telehealth services and information on how to properly bill for
services. We have heard from providers that the vast majority, if not
all, behavioral health services were offered both in-person and through
telehealth during 2020 and early 2021. As restrictions are lifted and
more providers are moving to greater availability of in-person
services, most providers anticipate a significant percentage of
services to still be provided via telehealth. Following the first 6
months of the pandemic, we conducted a study of Medicaid recipients
initiating and receiving behavioral health services in-person and
through telehealth the 12 months prior to March 2020 compared to March-
August of 2020. This study found that the year prior to COVID, only 29
percent of new behavioral health patients initiated care via
telehealth, whereas from March through August 2020, 41 percent of new
behavioral health patient initiated care by telehealth. The study also
found that for patients who were engaged in behavioral health care
prior to the pandemic, the majority of those patient continued with
care despite the public health crisis as much of their care continued
either in-person or via telehealth. In Nevada ongoing discussions
around the merits of telehealth expansion have promoted debate over
issues such as payment parity for telehealth or telephonic services
versus in-person care. Many patient advocates have expressed concern
that, gone unchecked, telehealth services that do not have enough
evidence to substantiate their efficacy or effectiveness is
commensurate with in-person care may be offered to vulnerable
populations or that patients may not have freedom of choice to receive
care by the modality of their choosing. Dialogue with national thought
leaders on these and other issues has underscored the need for
continued evaluation of telehealth practices and policies to ensure
equity in access, patient rights, medical necessity, and ethical
decision making are a taken into careful consideration at Federal and
State levels.
______
Questions Submitted by Hon. Sheldon Whitehouse
Question. Reforming how individuals experiencing mental and
behavioral health crises are treated requires working with a broad
coalition of stakeholders at the State and local levels, such as health
departments, behavioral health providers, and law enforcement.
Are there any jurisdictions in your State successfully coordinating
various State and local stakeholders? What best practices have they
developed?
Answer. Yes, Nevada has several regional and local coalitions of
stakeholders who convene around behavioral health issues, including
crisis services. Nevada established Regional Behavioral Health Policy
Boards (RBHPB) during the 2017 legislative session and further expanded
upon that work in 2019 (NRS433.429). The Regional Behavioral Health
Policy Boards are supported by the Department of Health and Human
Services (DHHS) to convene stakeholders monthly in each region to
address issues around behavioral health, including crisis. The RBHPB
have diverse memberships, including legislative representation and
members who represent law enforcement, community-based organizations,
the criminal justice system, providers of residential substance use
disorder treatment, social services, public health, psychology or
psychiatry, payers of health care, and individuals with lived
experience. The duties of the RBHPB include but are not limited to
advising the Department on the behavioral health needs of children and
adults in the region, planning to address the needs and improve access
to services, addressing gaps within the region, priorities for
allocating funding for behavioral health services, promoting
improvements in care, and collecting and reporting behavioral health
data. The RBHPBs and coordinators of the boards have been instrumental
in assessing the assets and gaps within each region's crisis continuum.
Beginning in 2018, the RBHPBs have been engaged in ongoing mapping,
planning, and prioritizing of crisis services with their region. In
2020, in collaboration with Regional Behavioral Health Coordinators,
stakeholders within each region supported the completion of assets and
gaps mapping, and prioritized activities to develop the crisis
continuum. A summary of this work can be found here: https://
socialent.com/2020/06/nevada-crisis-response-system-virtual-summit/.
Additionally, Nevada also convenes Regional Children's Mental
Health Consortia (RCMHC), which were established by statute in 2001
(NRS433b.333). The RCMHC are supported by DHHS to engage regional
stakeholders in developing long-term strategic plans for children's
mental health services and supports. The RCMHC have diverse membership,
including representation from State children's mental health services,
child welfare, State Medicaid, school districts, juvenile justice,
providers of behavioral health care and foster care, parents of
children with severe emotional disturbance, and providers of substance
use prevention services. The long-term strategic plans for mental
health service and support for children includes active engagement of
families whose children have severe emotional disturbance, ensures the
mental health system is flexible and offers timely access to affordable
care, emphasizes screening and early identification, offers services in
the least restrictive environment, and must be responsive to the
cultural and gender-based differences and special needs of children.
Nevada's RCMHC are strong advocates for crisis services to be designed
for children, youth, and families to access with the goal of offering
assessment and stabilization supports in-home with wrap-around
services, respite, and parenting support. Current planning for 988,
mobile crisis, and crisis stabilization services includes the design
and implementation for a children's system of care with the RCMHC as
critical partners in this work.
Question. How can the Federal Government promote better
coordination of funding, training, and resources among stakeholders
responding to behavioral and mental health crises?
Answer. Nevada strives to support better coordination of funding,
training, and resources among stakeholders. However, this work requires
an intentional approach to ensuring timely, clear communication,
transparent processes to determine allocation of funding, and
dissemination of best practices through training and technical
assistance, and resources. We have recognized the need to not only
continue to engage traditional stakeholders in the development of the
crisis continuum, but we have also recognized the need to reach
stakeholders across different sectors and individuals within
disproportionality impacted communities. We have begun to use an
approach called Community Based Participatory Research to engage
community members in meaningful dialogue to gather information needed
to design the crisis system with the community in mind. We would
encourage the Federal Government to consider the necessary time for
convening stakeholders in meaningful inquiry around the needs and
assets in their communities when developing plans when infusing dollars
into States to address behavioral health crisis. Nevada is grateful for
the additional funding through the block grants for crisis services,
however, the timeline for the plans for the funding is very aggressive
and does not necessarily allow for the time needed for the meaningful
engagement of the community in designing the plan for the allocation of
funding. We would encourage the consideration of sufficient time for
States to plan for the use of this funding to ensure the projects that
are funded are developed to have the greatest impact and have the
opportunities for sustainability once the funding ends.
Question. One of the primary challenges I hear from Rhode Island
providers is that the current funding streams for crisis intervention
and mental and behavioral health services are not consistent. This can
lead to funding cliffs that force States to scramble to come up with
money or programs to end.
How have cities and States created sustainable funding for these
programs?
Answer. Sustainability of programming is a primary consideration in
planning for the use of the funding offered to States for crisis
services. All States want the ability to give careful consideration of
the use of the funding to limit the risks of funding cliffs to occur.
When programs are built in communities without sustainability plans,
there is incredible risk that harm can come to those communities when
the grants funding ends and programming must be dismantled and
discontinued. Nevada is fortunate for the passage of Senate Bill 390
(SB390; https://www.leg.
state.nv.us/App/NELIS/REL/81st2021/Bill/8095/Text) during the 2021
legislative session which was enabled by the National Suicide
Prevention Designation Act of 2020 being signed into Federal law in
October 2020. Several States have initiated similar legislation under
the Federal frame which allows States to establish a fee on
telecommunications and a fund for that fee to support the necessary
expansion of the crisis system for 988 implementation. States have had
varying levels of success in passing such laws. In SB390, we were able
to establish a cap for the fee at .35 per line/month. The law also
established funding Nevada will receive as a result of opioid
settlement litigations as a possible additional funding sources for the
988 and crisis system. While these investments will assist the State in
long-term financing options for the crisis system we are working to
establish with the new allocation of block grant funding, Nevada also
realizes we must constantly evaluate the system as it is implemented to
identify any possible funding cliff that could arise without sufficient
funds to continue the services. The Medicaid payment enhancements
through the American Rescue Plan and existing Medicaid authority are
sources of possible sustainability that Nevada plans to evaluate. We
are encouraged by the promise of increased collaboration across Federal
Health and Human Services agencies to support States in exploring the
options to use Medicaid to support sustainability of crisis services.
Nevada anticipates the need for technical assistance to understand and
plan for the use of Medicaid options in our sustainability planning.
Question. What can the Federal Government do to help other
jurisdictions do the same?
Answer. Technical assistance from HHS agencies to States to plan
for sustainability through Medicaid would assist States in exploring
the possible long-term options for maintaining crisis services. In
addition, States would benefit from the expressed allowance of the use
of block grant dollars to be used more flexibly within their State to
invest in additional technical assistance and support to develop
changes to the Medicaid State plans, applications for Medicaid waivers,
building out the data and technology infrastructure needed to implement
programs through Medicaid State agencies. This type of flexibility
would support States in successfully leveraging Medicaid as a viable
source of sustainability for crisis services. Without such flexibility
in funding, it may be challenging for some States to move from concept
to implementation within Medicaid.
______
Questions Submitted by Hon. Patrick J. Toomey
Question. The COVID-19 pandemic has had a dramatic effect on our
Nation's public health. Recent data from the Centers for Disease
Control and Prevention (CDC) demonstrates that overdose deaths reached
an all-time high between October 2019 and September 2020.\1\ Moreover,
improper opioid prescribing and substance misuse has had substantial
effect on Medicaid enrollees living in Appalachian counties. The OIG
recently found that Medicaid enrollees across the Appalachian region
are even more at risk of opioid misuse and overdoes than prior to the
pandemic.\2\
---------------------------------------------------------------------------
\1\ ``12 Month-Ending Provisional Number of Drug Overdose Deaths,''
Centers for Disease Control and Prevention, https://www.cdc.gov/nchs/
nvss/vsrr/drug-overdose-data.htm#selection_
specific_states_jurisdictions.
\2\ U.S. Department of Health and Human Services Office of
Inspector General, ``Opioids in Medicaid: Concerns About Opioid Use
Among Beneficiaries in Six Appalachian States,'' December 2020, https:/
/oig.hhs.gov/oei/reports/OEI-05-19-00410.pdf.
While the pandemic exacerbated the Nation's opioid crisis, issues
with how State Medicaid programs identify overdose victims and connect
them to treatment pre-date the pandemic. One study found that less than
one in three Medicaid-enrolled adolescents who experienced an opioid-
related overdose received any treatment whatsoever.\3\ The trends are
similar for adult Medicaid beneficiaries--approximately 60 percent of
those who suffered a nonfatal overdose between 2007 and 2013 among a
sample of enrollees received another legal opioid prescription within
six months of the event.\4\
---------------------------------------------------------------------------
\3\ Rachel Alinsky, Bonnie Zima, Jonathan Rodean, et al., ``Receipt
of Addiction Treatment After Opioid Overdose Among Medicaid-Enrolled
Adolescents and Young Adults,'' JAMA Pediatrics, January 6, 2020,
https://jamanetwork.com/journals/jamapediatrics/article-abstract/
2758103.
\4\ Winfred Frazier, Gerald Cochran, Wei-Hsuan Lo-Ciganic, et al.,
``Medication-Assisted Treatment and Opioid Use Before and After
Overdose in Pennsylvania Medicaid,'' JAMA, August 22, 2019, https://
jamanetwork.com/journals/jama/fullarticle/2649173.
For these reasons, Senator Manchin and I recently introduced the
Improving Medicaid Programs' Response to Overdose Victims and Enhancing
(IMPROVE) Addiction Care Act (S. 1575) to address this information gap.
Among its provisions, the IMPROVE Addiction Care Act would require
State Medicaid programs to make efforts to connect Medicaid enrollees
to treatment after a nonfatal overdose and ensure that prescribers are
alerted of a patient's previous, nonfatal opioid overdose, as well as
---------------------------------------------------------------------------
fatal overdose.
Can you describe the barriers or fragmentation that occurs in the
Medicaid program that may be allowing prescribers to subsequently
prescribe an opioid to an overdose victim?
Answer. Nevada established statutory requirements for prescribing
controlled substances in 2017 through the Controlled Substance Abuse
Prevention Act through Assembly Bill 474. Among the many provisions
within the State statute is the requirement for providers register with
the Prescription Drug Monitoring Program (PDMP) if they have a license
to prescribe controlled substances, check the PDMP, assess for patient
risk for misuse, addiction and overdose, and obtain informed consent
from the patient. Since this legislation's implementation we have seen
a 40-percent decrease in the rate of opioid prescriptions per 100
people, with the most significant decrease occurring in initial
prescriptions. In that same time period, Nevada had a 68-percent
reduction in the co-prescribing of opioids and benzodiazepines.
Overdose deaths related to prescription drugs have also decreased since
2017, while overdose rates from synthetic opioids have increased to now
account for over 50 percent of opioid overdoses. Fragmentation occurs
when data on overdoses is not available to prescribers prior to
initiating or continuing a prescription for an opioid medication.
Nevada has long contemplated a adding a flag in the PDMP to alert
prescribers of an overdose for their consideration and evaluation of
risk for prescribing and subsequent overdose however, we have not yet
instituted such a warning system. Within the Medicaid program, it would
be possible to match data between a patient who has survived a non-
fatal overdose to provide such information to a prescribed for
consideration, but such a data matching process does not currently
exist.
Question. What factors or indicators are you aware of that have
been associated with increased risk for overdose deaths?
Answer. The number of opioid-related overdose deaths in Nevada
decreased from 437 in 2010 to 374 in 2019, in large part due to the
deaths associated with prescription opioids decreasing. The rate per
100,000 Nevada residents for opioid-related overdose deaths decreased
by 4 percent from 16.2 to 15.4 from 2010 to 2020. Roughly 85 percent of
all benzodiazepine-related overdose deaths in Nevada also involve
opioids while roughly 30 percent of all opioid-related overdose deaths
also involve benzodiazepines. The co-prescribing of benzodiazepines is
widely recognized as a risk factor for overdose death. Other risk
factors include risk of misuse and addiction, dosage, patient risk
factors including age and co-morbid medical conditions, and previous
overdoses. The Nevada Controlled Substance Abuse Prevention Act of 2017
addresses many of these risk factors through prescribing protocols
while maintaining the prescriber-patient relationship and supporting
prescribers' clinical
decision-making.
Question. Do States have the capability to implement a mechanism to
identify a Medicaid enrollee who has suffered a nonfatal overdose? Can
you discuss the challenges that a predominately fee-for-service State
versus managed care State may encounter?
Answer. Nevada is able to collect and report data on non-fatal
overdoses through both billing and claims records or through mandated
reporting from hospitals to the Department of Health and Human
Services. Through rigorous evaluation, Nevada has determined that
billing and claims data can be used to identify beneficiaries who have
survived a non-fatal overdose; however, claim lags create some issues
around timely notification to prescribers. Data matching from the
mandated reporting may be more timely, however data matching to the
Medicaid databases for medical and pharmacy to trace back to the
prescribing provider(s) of record may cause a delay.
Either approach is feasible in Nevada, though consideration would
need to be given to accuracy and timeliness of the information to
determine which process would be most efficient. While we cannot speak
to other States experiences with fee-for-service or managed care,
Nevada does operate Medicaid programs in both systems.
We anticipate Managed Medicaid may experience less challenges in
data matching and timely notification to prescribers because of the
closed system they operate within. Fee-for-service Medicaid may pose
more challenging because of the multiple data sets that would need to
be used for matching and likely cause a delay in prescriber
notification.
______
Communications
----------
American College of Physicians
25 Massachusetts Avenue, NW, Suite 700
Washington, DC 20001-7401
202-261-4500
800-338-2746
https://www.acponline.org/
The American College of Physicians (ACP) is pleased to submit this
statement and offer our views on how to improve mental health and
addiction services during and after the COVID-19 pandemic. We greatly
appreciate that Senators Stabenow and Daines have convened this
hearing, ``The COVID-19 Pandemic and Beyond: Improving Mental Health
and Addiction Services in Our Communities.'' Thank you for your
commitment to ensuring that clinicians have the opportunity to share
their views about the response to the public health emergency (PHE)
caused by COVID-19 including how we can use the lessons learned during
the PHE caused by COVID-19 to improve mental health and increase access
to addiction services. Through the experiences of its physicians on the
frontlines of furnishing primary care during the COVID-19 pandemic, ACP
would like to share its input and recommendations surrounding COVID-19
and mental health and addiction services, including integrating primary
care and behavioral health, expanding the available tools to treat
mental health, substance use disorders (SUDs), and increasing the
physician workforce.
The American College of Physicians is the largest medical specialty
organization and the second-largest physician membership society in the
United States. ACP members include 163,000 internal medicine physicians
(internists), related subspecialists, and medical students. Internal
medicine physicians are specialists who apply scientific knowledge and
clinical expertise to the diagnosis, treatment, and compassionate care
of adults across the spectrum from health to complex illness. Internal
medicine specialists treat many of the patients at greatest risk from
COVID-19, including the elderly and patients with pre-existing
conditions like diabetes, heart disease and asthma.
The Pandemic Increased Demand for Mental Health and Addiction Services
Recently, the U.S. Government Accountability Office (GAO) released a
report, Behavioral Health: Patient Access, Provider Claims Payment, and
the Effects of the COVID-19 Pandemic. The purpose of the report was to
determine if the need for and access to mental health and addiction
services varied as the availability to care diminished during the PHE
caused by COVID-19. The report showed several concerning trends. The
Centers for Disease Control and Prevention (CDC) found that 38 percent
of individuals surveyed reported symptoms of anxiety or depression from
April 2020 to February 2021. This was a 27 percent increase from 2019
for the same time period. CDC data found that emergency department
visits for overdoses was 26 percent higher and suicide attempts were 36
percent higher for the time period of mid-March through mid-October
2020 when compared to that period during 2019. The Substance Abuse and
Mental Health Services Administration (SAMHSA) found that in September
2020 opioid deaths in certain sections of the United States increased
anywhere from 25 to 50 percent when compared to the same time during
2019. SAMHSA data also showed that contacts by individuals to the
Disaster Distress Helpline increased during the PHE in 2020 over
comparable timeframes in 2019. For example, between March and August
2020, calls hit a high in April 2020 at almost 10,000 calls, which is
an 890 percent increase over April 2019. In August 2020, a survey
conducted by the National Council for Behavioral Health (NCBH), found
that over half of their member organizations had an increase in demand
for their services in the three-month period before the survey. A
February 2021 follow-up survey by NCBH discovered that the demand for
services had increased by 67 percent.\1\ Clearly, the U.S. population
has experienced a sharp increase in mental health issues and SUDs
during the COVID-19 pandemic.
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\1\ U.S. Government Accountability Office. (2021) Behavioral
Health: Patient Access, Provider Claims Payment, and the Effect of the
COVID-19 Pandemic. GAO-21-437R. https://www.gao.gov/assets/gao-21-
437r.pdf.
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Mental Health and Addiction Services Workforce Shortage Made Worse by
the COVID-19 Pandemic
Meanwhile, persistent mental health and addiction services workforce
shortages from before the pandemic only worsened during the PHE caused
by COVID-19. Before the pandemic, the Health Resources and Services
Administration (HRSA) found that by 2025, shortages of seven different
types of mental health clinicians were anticipated, with shortages of
10,000 and above in some clinician fields of practice. In September
2020, HRSA designated over 5,700 mental health provider shortage areas
with 119 million people living in one of these areas. HRSA estimated
that available mental health clinicians in these areas were only
adequate enough to meet 27 percent of the need for services.\2\ SAMHSA
reported that due to a combination of reasons, including laying off
staff and the closure of clinicians offices that could not sustain
themselves financially, led to a decrease in access. In February 2021,
NCBH reported that member organizations had decreased staff and
services because of the pandemic caused by COVID-19, including 27
percent laying off staff and 23 percent furloughing staff, resulting in
68 percent of member organizations canceling, rescheduling, or turning
away patients.\3\ Not unexpectedly, the demand for mental health and
addiction services rapidly increased during the PHE caused by COVID-19
while at the same time access to these services diminished.
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\2\ U.S. Government Accountability Office. (2021) Behavioral
Health: Patient Access, Provider Claims Payment, and the Effect of the
COVID-19 Pandemic. GAO-21-437R, https://www.gao.gov/assets/gao-21-
437r.pdf.
\3\ U.S. Government Accountability Office. (2021) Behavioral
Health: Patient Access, Provider Claims Payment, and the Effect of the
COVID-19 Pandemic. GAO-21-437R. https://www.gao.gov/assets/gao-21-
437r.pdf.
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Integrate Primary Care and Behavioral Health
ACP strongly supports the integration of behavioral health care into
primary care and encourages its members to address behavioral health
issues within the limits of their competencies and resources.
Accordingly, ACP supports using the primary care setting as the
springboard for addressing both physical and behavioral health care.
The basis for using the primary care setting to integrate behavioral
health is consistent with the concept of ``whole-person'' care, which
is a foundational element of primary care delivery. It recognizes that
physical and behavioral health conditions are intermingled: many
physical health conditions have behavioral health consequences, and
many behavioral health conditions are linked to increased risk for
physical illnesses. In addition, the primary care practice is currently
the entry point and the most common source of care for most persons
with behavioral health issues--it is already the de facto center for
this care. The degree of medical practice integration can vary, from
basic coordination between a primary care physician and behavioral
health clinicians, to collocation with a behavioral health clinician
practicing in close proximity to the primary care physician, to a truly
integrated care approach in which all aspects of care delivered in the
primary care setting recognize both the physical and behavioral
perspective. For example, the patient-centered medical home (PCMH) has
been proposed as an appropriate model to address the integration of
primary and behavioral care, highlighting its emphasis on primary care,
care coordination, and delivery of care by a team of professionals. The
Affordable Care Act incentivized the development of Medicaid health
homes, which promote addressing behavioral health issues in the primary
care setting. Evidence also shows opportunities in the primary care
setting not only to address current behavioral health conditions but
also to serve as a platform to promote prevention in at-risk patients
or populations and address behavioral health conditions before symptoms
can occur in patients.\4\
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\4\ Crowley R, Kirschner N; Health and Public Policy Committee of
the American College of Physicians. The Integration of Care for Mental
Health, Substance Abuse, and Other Behavioral Health Conditions into
Primary Care: An American College of Physicians Position Paper.
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M15-0510.
ACP recommends that public and private health insurance payers,
policymakers, and primary care and behavioral health-care professionals
work to remove payment barriers that impede behavioral health and
primary care integration. Stakeholders should also ensure the
availability of adequate financial resources to support the practice
infrastructure required to effectively provide such care. The barriers
to seamless integration of behavioral and primary care are both
administrative and financial. Behavioral and physical health-care
clinicians have a long history of operating in different care silos.
The artificial separation of behavioral and physical health care is
reflected in many ways. For example, primary care physicians generally
lack extensive clinical training in behavioral health, and traditional
medical and mental health training models and practice environments are
substantially different, which may lead to cultural clashes if they are
not thoughtfully integrated.\5\
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\5\ Crowley R, Kirschner N; Health and Public Policy Committee of
the American College of Physicians. The Integration of Care for Mental
Health, Substance Abuse, and Other Behavioral Health Conditions into
Primary Care: An American College of Physicians Position Paper.
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M15-0510.
Even though there are challenges, the evidence shows that integrating
behavioral health and primary care leads to improved mental health
outcomes, improved physical health, improved quality of life, and lower
costs. The available research evidence, while limited, does support the
efficacy of this approach.\6\ The Behavioral Health Integration (BHI)
Collaborative, in which ACP participates, has found that benefits of
integration can include promoting long-term value, improved patient
satisfaction, and reducing the stigma of mental health issues and
SUD.\7\ Primary care physicians also support integrated care and report
that the integrated care model encourages better communication and
coordination among behavioral health and primary care physicians and
reduces mental health stigma.\8\
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\6\ Crowley R, Kirschner N; Health and Public Policy Committee of
the American College of Physicians. The Integration of Care for Mental
Health, Substance Abuse, and Other Behavioral Health Conditions into
Primary Care: An American College of Physicians Position Paper.
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M15-0510.
\7\ Behavioral Health Integration Collaborative. Behavioral Health
Integration Compendium. American Medical Association, 2020. https://
www.ama-assn.org/system/files/2020-12/bhi-compendium.pdf.
\8\ Crowley R, Kirschner N; Health and Public Policy Committee of
the American College of Physicians. The Integration of Care for Mental
Health, Substance Abuse, and Other Behavioral Health Conditions into
Primary Care: An American College of Physicians Position Paper.
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M15-0510.
Accordingly, Congress can and should take action to encourage primary
care and behavioral health integration. Congress could establish grant
programs with adequate funding to incentivize primary care uptake of
the various integrated care models. These grants could help defray
costs of establishing and delivering integrated primary and behavioral
health services. These costs can include but are not limited to, hiring
additional staff such as behavioral health managers, contracts with
other needed health-care clinicians such as psychiatrist consultants
and behavioral health managers, and purchasing or upgrading software
and other resources to provide new services such as more coordinated
care. Congress could also encourage additional payment models that
potentially facilitate integrated care including bundling payments,
partial and full capitation, and even fee-for-service. For example,
additional fee-for-service payment codes could be aligned to
incentivize integration by establishing payment for behavioral health--
primary care consultations, multidiscipline care plan development, and
related activities.\9\
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\9\ Crowley R, Kirschner N; Health and Public Policy Committee of
the American College of Physicians. The Integration of Care for Mental
Health, Substance Abuse, and Other Behavioral Health Conditions into
Primary Care: An American College of Physicians Position Paper.
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M15-0510.
ACP also strongly supports increased research to define the most
effective and efficient approaches to integrate behavioral health care
in the primary care setting and Congress should prioritize research in
this area. Although a review of the current literature supports the
efficacy of the integration of behavioral health care in the primary
care setting, it is limited and filled with many gaps. Substantial
research is needed to focus on the efficacy of various models of
integration, as well as the diagnostic and treatment interventions most
appropriate for use in these models. The following additional factors
should be considered within research efforts: specific conditions
addressed, populations involved (such as child vs. adult), funding
structures, personnel employed, and resources available to the
participating practices.\10\ Federal research agencies, such as the
Agency for Healthcare Research and Quality (AHRQ) are well suited to
study the best ways of integrating behavioral health care in the
primary care setting and Congress should provide the resources to
enable this type of care.
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\10\ Crowley R, Kirschner N; Health and Public Policy Committee of
the American College of Physicians. The Integration of Care for Mental
Health, Substance Abuse, and Other Behavioral Health Conditions into
Primary Care: An American College of Physicians Position Paper.
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M15-0510.
Improve Mental Health Parity with Increased Federal Oversight and
Enforcement
One of the barriers to true integrated primary and behavioral health
care are the likely instances of noncompliance by insurance plans with
mental and SUD coverage parity required by federal law. While the Paul
Wellstone and Pete Domenici Mental Health Parity and Addiction Equity
Act of 2008 (MHPAEA) requires parity for mental health and SUD
coverage, state and federal oversight and compliance efforts have been
uneven. Unfortunately, according to the GAO, the true nature of the
problem of noncompliance with MHPAEA is not well known.\11\ While
noncompliance violations have been reported, these complaints were
relatively small in number and not considered a true snapshot of the
magnitude of noncompliance. While the GAO found that insurance-plan
compliance with federal parity law was key to coverage parity, federal
agencies are only aware of a small number of patient complaints and
discovered violations of coverage parity law. In addition, the GAO
found that when federal agencies did engage in compliance reviews for
coverage parity that there was a high rate of insurance plan
violations. This frequency, the GAO determined, could indicate that
insurance-plan noncompliance with mental health and SUD coverage parity
law could be a common occurrence.\12\ In response, the GAO recommended
that the federal government should determine whether current targeted
oversight of compliance efforts are sufficient and effective and then
develop better ways in which to enforce MHPAEA as well as attain
greater oversight authority if needed.\13\ ACP strongly recommends that
federal and state governments, insurance regulators, payers, and other
stakeholders address behavioral health insurance coverage gaps that
remain barriers to integrated care. This includes strengthening and
enforcing relevant nondiscrimination laws, including oversight and
compliance efforts by federal and state agencies.\14\
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\11\ U.S. Government Accountability Office. (2019) Mental Health
and Substance Use, State and Federal Oversight of Compliance with
Parity Requirements Varies. GAO-20-150. https://www.gao.gov/assets/gao-
20-150.pdf
\12\ U.S. Government Accountability Office. (2019) Mental Health
and Substance Use, State and Federal Oversight of Compliance with
Parity Requirements Varies. GAO-20-150. https://www.gao.gov/assets/gao-
20-150.pdf.
\13\ U.S. Government Accountability Office. (2019) Mental Health
and Substance Use, State and Federal Oversight of Compliance with
Parity Requirements Varies. GAO-20-150. https://www.gao.gov/assets/gao-
20-150.pdf.
\14\ Crowley R, Kirschner N; Health and Public Policy Committee of
the American College of Physicians. The Integration of Care for Mental
Health, Substance Abuse, and Other Behavioral Health Conditions into
Primary Care: An American College of Physicians Position Paper.
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M15-0510.
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Make Naloxone More Available to Prevent Overdoses
ACP supports funding to distribute naloxone to individuals with opioid
use disorder to prevent overdose deaths and train law enforcement and
emergency medical personnel in its use. A 2019 CDC report found that
not all individuals in need of naloxone are receiving it due to
prescribing and dispensing variations across the country. The CDC
recommended actions to improve naloxone access such as reducing patient
insurance copays, enhancing clinician training and education, and
focusing allocation, especially to rural areas.\15\ Legal protections
(that is, Good Samaritan laws) should continue to be established or
refined to encourage use of naloxone and the reporting of opioid
overdoses in instances where an individual's life is in danger. A GAO
review found that overall state Good Samaritan laws helped in reducing
deaths by overdose and that states that enacted such laws have lower
rates of opioid overdose deaths when compared to before the law's
enactment or to states without these laws at all.\16\ Physician
standing orders to permit pharmacies to provide naloxone to eligible
individuals without a prescription should be explored. Insurance and
cost related barriers that limit access to naloxone should also be
addressed. As the need for naloxone has grown, so has its price. In
response, government representatives and private sector entities have
partnered to make bulk purchases of naloxone at substantial discounts
for state and local jurisdictions fighting the opioid epidemic. These
and other efforts must be accelerated to ensure that naloxone continues
to reach those in need.\17\
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\15\ Life-Saving Naloxone from Pharmacies, More dispensing needed
despite progress. CDC Vital Signs. Centers for Disease Control and
Prevention, August 2019. https://www.cdc.gov/vitalsigns/naloxone/
index.html.
\16\ U.S. Government Accountability Office. (2020) Drug Misuse,
Most States Have Good Samaritan Laws and Research Indicates They May
Have Positive Effects. https://www.gao.gov/assets/gao-21-248.pdf.
\17\ Crowley R, Kirschner N, Dunn A, Bornstein S; Health and Public
Policy Committee of the American College of Physicians. Health and
Public Policy to Facilitate Effective Prevention and Treatment of
Substance Use Disorders Involving Illicit and Prescription Drugs: An
American College of Physicians Position Paper. Washington, DC: American
College of Physicians, 2017. https://www.acpjournals.org/doi/pdf/
10.7326/M16-2953.
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Expand Medication-Assisted Treatment (MAT) for Physicians
In order to expand access to medication-assisted treatment (MAT) of
opioid use disorders, improved training in the treatment of substance
use disorders is necessary, including for buprenorphine-based
treatment. Pre- and post-buprenorphine training support and education
tools and resources should be made available and widely disseminated to
assist physicians in their treatment efforts. Physician support
initiatives, such as mentor programs, shadowing experienced providers,
and telemedicine, can help improve education and support efforts around
substance use treatment.\18\ In addition, continued efforts are needed
to remove barriers or administrative burdens for physicians to fully
take advantage of using MAT to treat their patients, such as
eliminating burdensome prior authorization requirements. These
roadblocks can delay or deny needed treatment that utilize already
approved medications in the course of MAT to treat SUDs. Several states
have already taken action to eliminate or reduce prior authorization
requirements for MAT and Congress should explore legislative options on
the federal level.\19\
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\18\ Crowley R, Kirschner N, Dunn A, Bornstein S; Health and Public
Policy Committee of the American College of Physicians. Health and
Public Policy to Facilitate Effective Prevention and Treatment of
Substance Use Disorders Involving Illicit and Prescription Drugs: An
American College of Physicians Position Paper. Washington, DC: American
College of Physicians, 2017. https://www.acpjournals.org/doi/pdf/
10.7326/M16-2953.
\19\ American Medical Association. Opioid Task Force 2019 Progress
Report. https://www.end-opioid-epidemic.org/wp-content/uploads/2019/06/
AMA-Opioid-Task-Force-2019-Progress-Report-web-1.pdf.
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Establish a National Prescription Drug Monitoring Program (PDMP)
ACP reiterates its support for the establishment of a national
Prescription Drug Monitoring Program (PDMP). Until such a program is
implemented, ACP supports efforts to standardize state PDMPs through
the federal National All Schedules Prescription Electronic Reporting
program. The College strongly urges prescribers and dispensers to check
PDMPs in their own and neighboring states (as permitted) before writing
and filling prescriptions for medications containing controlled
substances. All PDMPs should maintain strong protections to ensure
confidentiality and privacy. In addition to a national PDMP, ACP
strongly encourages Congress to be helpful in this area by requiring
efforts to facilitate the use of PDMPs, such as by linking information
with electronic medical records and permitting other members of the
health-care team to consult PDMPs.\20\
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\20\ Crowley R, Kirschner N, Dunn A, Bornstein S; Health and Public
Policy Committee of the American College of Physicians. Health and
Public Policy to Facilitate Effective Prevention and Treatment of
Substance Use Disorders Involving Illicit and Prescription Drugs: An
American College of Physicians Position Paper. Washington, DC: American
College of Physicians, 2017. https://www.acpjournals.org/doi/pdf/
10.7326/M16-2953.
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Conduct Research to Implement Effective Public Health Interventions
ACP believes more federal research is needed. The effectiveness of
public health interventions to combat substance use disorders and
associated health problems should be studied further. Public health-
based substance use disorder interventions, such as syringe exchange
programs (SEPs) and safe injection sites that connect the user with
effective treatment programs should be explored and tested. Risky
injection drug use habits, such as needle sharing, contribute to the
spread of HIV, hepatitis C virus, and other blood-borne pathogens.
Several SEPs have shown the potential to reduce the spread of these
diseases. Indeed, the federal government has already established and
funded Syringe Services Programs (SSPs) through the CDC.\21\ These
community-based prevention programs have a track record of furnishing
much-needed services, such as disposal of sterile syringes,
vaccination, testing, infectious disease care, and most critically, SUD
treatment.\22\ These programs may also connect individuals with other
health and social services, as well as referrals to SUD treatment, as
mentioned above, prevention supplies, and health screenings. As the
opioid epidemic continues to increase the number of people who inject
drugs, federal and state funding should be directed to communities to
prevent the spread of blood-borne diseases, such as HIV infection and
hepatitis C, as well as connect people to social and health-care
services that can provide necessary assistance. Because safe injection
facilities have not been extensively tested in the United States, state
and local health officials need the resources to conduct pilot tests
prior to any possible full implementation.\23\
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\21\ Centers for Disease Control and Prevention. Syringe Services
Programs (SSPs) Funding. Accessed at https://www.cdc.gov/ssp/ssp-
funding.html.
\22\ Centers for Disease Control and Prevention. Syringe Services
Programs (SSPs) Safety and Effectiveness Summary. Accessed at https://
www.cdc.gov/ssp/syringe-services-programs-summary.html.
\23\ Crowley R, Kirschner N, Dunn A, Bornstein S; Health and Public
Policy Committee of the American College of Physicians. Health and
Public Policy to Facilitate Effective Prevention and Treatment of
Substance Use Disorders Involving Illicit and Prescription Drugs: An
American College of Physicians Position Paper. Washington, DC: American
College of Physicians, 2017. https://www.acpjournals.org/doi/pdf/
10.7326/M16-2953.
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Ensure Adequate Physician Workforce to Integrate Behavioral Health and
Primary Care
ACP encourages efforts by federal and state governments, relevant
training programs, and continuing education providers to ensure an
adequate workforce to provide for integrated behavioral health care in
the primary care setting. Cross-
discipline training is needed to prepare behavioral health and primary
care physicians to effectively integrate their respective specialties.
Primary care physicians need to be trained to screen, manage, and treat
common behavioral health conditions, and behavioral health providers
need to be trained to understand care for common medical needs. Both
sectors need to overcome the operational and cultural barriers that
prevent seamless integration. A report from the SAMHSA-HRSA Center for
Integrated Health Solutions cited inadequate skills for integrated
practices and reluctance to change practice patterns.\24\
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\24\ Crowley R, Kirschner N; Health and Public Policy Committee of
the American College of Physicians. The Integration of Care for Mental
Health, Substance Abuse, and Other Behavioral Health Conditions into
Primary Care: An American College of Physicians Position Paper.
Washington, DC: American College of Physicians, 2015. https://
www.acpjournals.org/doi/pdf/10.7326/M15-0510.
The workforce of professionals qualified to treat behavioral health and
substance use disorders should be expanded. ACP supports policies to
increase the professional workforce engaged in treatment of behavior
health and substance use disorders. Loan forgiveness programs,
mentoring initiatives, and increased payment may encourage more
individuals to train and practice as behavioral health
professionals.\25\
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\25\ Crowley R, Kirschner N, Dunn A, Bornstein S; Health and Public
Policy Committee of the American College of Physicians. Health and
Public Policy to Facilitate Effective Prevention and Treatment of
Substance Use Disorders Involving Illicit and Prescription Drugs: An
American College of Physicians Position Paper. Washington, DC: American
College of Physicians, 2017. https://www.acpjournals.org/doi/pdf/
10.7326/M16-2953.
Primary care physicians, including internal medicine specialists,
continue to serve on the frontlines of patient care during this
pandemic with increasing demands placed on them. Funding should be
continued and increased for programs and initiatives that work to
increase the number of physicians and other health-care professionals
providing care for all communities, including for racial and ethnic
communities historically underserved and disenfranchised.\26\ According
to the Association of American Medical Colleges (AAMC), before the
Coronavirus crisis, estimates were that there would be a shortage of
21,400 to 55,200 primary care physicians by 2033. In addition, the
federal government determined that an additional 14,900 primary care
physicians and 6,894 psychiatrists were needed in 2018 to provide
services that would have eliminated a HPSA designation for areas with
primary care and mental health shortages.\27\ Now, with the closure of
many physician practices and near-
retirement physicians not returning to the workforce due to COVID-19,
it is even more imperative to assist those clinicians serving on the
frontlines and increasing the number of future physicians in the
pipeline.
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\26\ Serchen J, Doherty R, Hewett-Abbott G, Atiq O, Hilden D;
Health and Public Policy Committee of the American College of
Physicians. Understanding and Addressing Disparities and Discrimination
Affecting the Health and Health Care of Persons and Populations at
Highest Risk: A Position Paper of the American College of Physicians.
Philadelphia: American College of Physicians; 2021. https://
www.acponline.org/acp_policy/policies/understanding_discrimi
nation_affecting_health_and_health_care_persons_populations_highest_risk
_2021.pdf.
\27\ Prepared for the AAMC by IHS Markit Ltd. The Complexities of
Physician Supply and Demand: Projections From 2018 to 2033. Association
of American Medical Colleges, June 2020. https://www.aamc.org/media/
45976/download.
For example, many residents and medical students are playing a critical
role in responding to the COVID-19 crisis all while they carry an
average debt of over $200,000. In addition, international medical
graduates (IMGs) are currently serving on the frontlines of the U.S.
health-care system, both under J-1 training and H-1B work visas and in
other forms. These physicians serve an integral role in the delivery of
health care in the United States. IMGs help to meet a critical
workforce need by providing health care for underserved populations in
the United States. They are often more willing than their U.S. medical
graduate counterparts to practice in remote, rural areas and in poor
underserved urban areas. More must be done to support their vital role
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in health-care delivery in the United States.
ACP supports several pieces of legislation from the 116th Congress that
should be reintroduced as well as legislation recently introduced that
should be passed in the current 117th Congress to assist medical
graduates and the overall physician workforce as well as address the
mental and behavioral health needs of physicians themselves.
The Resident Education Deferred Interest Act (H.R. 1554, 116th
Congress) would make it possible for residents to defer interest on
their loans.
The Conrad State 30 and Physician Access Reauthorization Act (S.
948, 116th Congress) and the Healthcare Workforce Resilience Act (S.
3599, 116th Congress), would help with medical student loan forgiveness
and support IMGs and their families by temporarily easing immigration-
related restrictions so IMGs and other critical health-care workers can
enter the U.S. to train in internal medicine residency programs, assist
in the fight against COVID-19, and provide a pathway to permanent
residency status.
The Student Loan Forgiveness for Frontline Health Workers Act
(H.R. 2418, 117th Congress) would assist frontline clinicians as they
provide care during the pandemic.
The Dr. Lorna Breen Health Care Provider Protection Act (H.R.
1667/S. 610, 117th Congress) is an important proposal because it aims
to prevent and reduce incidences of suicide, mental health conditions,
substance use disorders, and long-term stress, sometimes referred to as
``burnout'' among physicians themselves. Through grants, education, and
awareness campaigns, the legislation will help reduce stigma and
identify resources for health-care clinicians seeking assistance. The
legislation also supports research on health-care professional mental
and behavioral health, including the effect of the COVID-19 pandemic.
View ACP's letter of support to the House and Senate for H.R. 1667 and
S. 610.
In addition, ACP was encouraged that bipartisan congressional leaders
worked together last year to provide 1,000 new Medicare-supported
Graduate Medical Education (GME) positions in the Consolidated
Appropriations Act, 2021 (H.R. 133)--the first increase of its kind in
nearly 25 years--and that some of those new slots will be prioritized
for hospitals that serve Health Professional Shortage Areas (HPSAs).
ACP now calls on Congress to pass the Resident Physician
Reduction Shortage Act of 2021 (H.R. 2256/S. 834, 117th Congress) which
would provide 14,000 new GME positions over seven years, or 2,000 per
year to build on the 1,000 new GME slots mentioned above.
Congress should also pass the Opioid Workforce Act of 2021 (S.
1483, 117th Congress). This bill would provide Medicare funding for
1,000 more GME positions over five years in hospitals that already have
established, or are in the process of establishing, accredited
residency programs in addiction medicine, addiction psychiatry, or pain
medicine.
ACP also supports other physician and clinician workforce programs and
we strongly supported providing $800 million for the National Health
Service Corps (NHSC) and $330 million to expand the number of Teaching
Health Centers (THC) Graduate Medical Education (GME) sites nationwide
and increase the per resident allocation that were enacted in the
American Rescue Plan (ARP) Act, H.R. 1319. Indeed, a recent study
appearing in the Annals of Internal Medicine showed that in counties
with fewer primary care physicians (PCP) per population, increases in
PCP density would be expected to substantially improve life
expectancy.\28\ Accordingly, Congress should enact policies that will
not only increase the overall number of PCPs, but also ensure that
these additional PCPs are located in the communities where they are
most needed in order to furnish primary care, behavioral health, and
SUD services. Enhanced investments in programs such as the NHSC and
THCGME that increase the physician workforce should be sustained after
the pandemic caused by COVID-19 has come to an end.
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\28\ Sanjay Basu, M.D., Ph.D.; Russell S. Phillips, M.D.; Seth A.
Berkowitz, M.D., MPH. Estimated Effect on Life Expectancy of
Alleviating Primary Care Shortages in the United States. Ann Intern
Med. 2021. https://www.acpjournals.org/doi/pdf/10.7326/M20-7381.
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Conclusion
We commend you and your colleagues for working in a bipartisan fashion
to examine any lessons learned about treating mental health and
addiction services during the COVID-19 pandemic to improve health
outcomes and to develop legislative proposals to combat not only the
ongoing Coronavirus crisis--but to address any issues caused by the
current pandemic as well as future pandemics. We wish to assist in the
Finance Committee's efforts in this area by offering our input and
suggestions about ways that Congress and federal health departments and
agencies can intervene through evidence-based policies both now and
beyond the PHE. Thank you for consideration of our recommendations that
are offered in the spirit of providing the necessary support to
physicians and their patients going forward. Please contact Brian
Buckley, Senior Associate, Legislative Affairs, by phone at (202) 261-
4543 or via email at [email protected] with any further questions
or if you need additional information.
______
American Pharmacists Association
Chairwoman Stabenow, Ranking Member Daines, and Members of the
Committee, the American Pharmacists Association (APhA) is pleased to
submit the following Statement for the Record for the U.S. Senate
Finance Subcommittee on Health Care Hearing, ``The COVID-19 Pandemic
and Beyond: Improving Mental Health and Addiction Services in Our
Communities.''
APhA is the largest association of pharmacists in the United States
advancing the entire pharmacy profession. APhA represents pharmacists
in all practice settings, including community pharmacies, hospitals,
long-term care facilities, specialty pharmacies, community health
centers, physician offices, ambulatory clinics, managed care
organizations, hospice settings, and government facilities. Our members
strive to improve medication use, advance patient care, and enhance
public health.
APhA thanks the Committee for holding this important hearing on
improving mental health and substance use disorder (SUD) and opioid use
disorder (OUD) services. Unfortunately, the COVID-19 pandemic has
exacerbated the drug overdose crisis. According to the Centers for
Disease Control and Prevention (CDC), during the period October 2019
through September 2020, there were more than 87,000 overdose deaths--a
record high.\1\ Clearly, additional steps need to be taken to address
this crisis.
---------------------------------------------------------------------------
\1\ CDC National Center for Health Statistics. 12 Month-ending
Provisional Number of Drug Overdose Deaths, based on data available for
analysis on 4/4/2021, available at: https://www.cdc.gov/nchs/nvss/vsrr/
drug-overdose-data.htm.
Pharmacists are important providers on the patient's health care team
and play a critical role in caring for patients with acute and chronic
pain and/or OUD including prescribing medications, as authorized;
medication management; administering; dispensing; and educating
patients about opioid and non-opioid pain medications, as well as
talking to patients about nonpharmacologic therapies. Pharmacists also
provide services focused on screening for mental health conditions and
work with other members of the patient's team to manage medications
---------------------------------------------------------------------------
used in the treatment of mental health conditions.
Pharmacists have more medication-related education and training than
any other health care professional. As medication experts, pharmacists
are uniquely qualified to provide opioid stewardship and medication
management services including comprehensive medication management, dose
optimization, appropriate tapering of opioids and other pain
medications, and education on safe storage and disposal methods. In
addition, pharmacists aid opioid overdose reversal efforts by
furnishing naloxone and training patients and community members on its
use.
In order to increase access to pharmacist-provided patient care
services for patients with mental health conditions, SUD, and OUD, APhA
urges Congress to pass the following legislation:
S. 1362/H.R. 2759, the Pharmacy and Medically Underserved Areas
Enhancement Act
Despite the fact that many states and Medicaid programs are turning to
pharmacists to increase access to health care, Medicare Part B does not
cover many of the impactful and valuable patient care services
pharmacists can provide. While over 90% of Americans live within 5
miles of a community pharmacy,\2\ and pharmacists are also present in
clinics and physician office practices, many of our nation's seniors
are medically underserved. As proven during the COVID-19 pandemic,
pharmacists are an underutilized and accessible health care resource
who can positively affect beneficiaries' care and the entire Medicare
program.
---------------------------------------------------------------------------
\2\ NCPDP Pharmacy File, ArcGIS Census Tract File. NACDS Economics
Department.
Accordingly, APhA strongly urges the Committee to include S. 1362, the
Pharmacy and Medically Underserved Areas Enhancement Act, recently
introduced by Committee members Charles Grassley (R-IA), Robert Casey
(D-PA), and Sherrod Brown (D-OH), in the Committee's legislative
package to allow pharmacists to deliver vital patient care services in
medically underserved areas to help break down the barriers to
achieving health care equity in this country, improve patient care,
health outcomes, the impact of medications,\3\ and consequently, lower
health care costs and extend the viability of the Medicare program.
---------------------------------------------------------------------------
\3\ See, Avalere Health. Exploring Pharmacists' Role in a Changing
Healthcare Environment. May 2014, available at: http://avalere.com/
expertise/life-sciences/insights/exploring-pharmacists-role-in-a-
changing-healthcare-environment. Also, see, Avalere Health. Developing
Trends in Delivery and Reimbursement of Pharmacist Services. October
2015, available at: http://avalere.com/expertise/managed-care/insights/
new-analysis-identifies-factors-that-can-facilitate-broader-
reimbursement-o.
By recognizing pharmacists as providers under Medicare Part B, S. 1362
would enable Medicare patients in medically underserved communities to
better access health care--including mental health, SUD, and OUD care--
through state-licensed pharmacists practicing according to their own
state's scope of practice. In medically underserved communities,
pharmacists are often the closest health care professional and the most
accessible outside normal business hours. The ongoing COVID-19 pandemic
has further illustrated how difficult it is for patients living in
medically underserved communities to access care and achieve optimal
medication therapy outcomes. S. 1362 recognizes that pharmacists can
play an integral role in addressing these longstanding disparities to
help meet health equity goals \4\ and ensure that our most vulnerable
patients have access to the care they need. Helping patients receive
the care they need, when they need it, is a common sense and bipartisan
solution that will improve outcomes and reduce overall costs.
---------------------------------------------------------------------------
\4\ The White House. Executive Order on Advancing Racial Equity and
Support for Underserved Communities Through the Federal Government.
January 20, 2021, available at: https://www.whitehouse.gov/briefing-
room/presidential-actions/2021/01/20/executive-order-advancing-racial-
equity-and-support-for-underserved-communities-through-the-federal-
government/.
---------------------------------------------------------------------------
S. 445/H.R. 1384, the Mainstreaming Addiction Treatment (MAT) Act
Only 1 in 5 Americans with opioid use disorder receive
buprenorphine.\5\ The Department of Health and Human Services' (HHS)
recent issuance of Practice Guidelines for the Administration of
Buprenorphine for Treating Opioid Use Disorder \6\ is a step in the
right direction to increase patient access to buprenorphine, which has
been proven to cut the risk of overdose death in half.\7\ However, the
Practice Guidelines exclude pharmacists--the most accessible healthcare
providers--because pharmacists are statutorily ineligible to apply to
the Substance Abuse and Mental Health Services Administration (SAMHSA)
for a DATA 2000/X waiver \8\ necessary to prescribe buprenorphine as
medication-assisted treatment (MAT) for OUD.
---------------------------------------------------------------------------
\5\ Rebecca Haffajee, Ph.D., J.D., M.P.H. et al., Policy Pathways
to Address Provider Workforce Barriers to Buprenorphine Treatment, 54
Am. J. Prev. Med. S230-42 (2019).
\6\ HHS. Practice Guidelines for the Administration of
Buprenorphine for Treating Opioid Use Disorder. 86 FR 22439. April 28,
2021, available at: https://www.federalregister.gov/documents/2021/04/
28/2021-08961/practice-guidelines-for-the-administration-of-
buprenorphine-for-treating-opioid-use-disorder.
\7\ National Academy of Sciences, Engineering, and Medicine.
Consensus Study Report: Medications for Opioid Use Disorder Save Lives,
Nat'l Acad. Press (2019), available at: https://www.nap.edu/catalog/
25310/medications-for-opioid-use-disorder-save-lives.
\8\ 21 U.S.C. Sec. 823(g)(2).
Under certain states' scope of practice laws, pharmacists are eligible
to prescribe Schedule III controlled substances but are unable to
prescribe certain Schedule III medications, such as buprenorphine,
because they are not eligible for a DATA waiver. When pharmacists
partner with physicians and other healthcare providers to provide MAT,
they streamline and improve care. Pharmacists' MAT-related services may
include treatment plan development, patient communication, care
coordination, and adherence monitoring and improvement activities,
among others. Allowing pharmacists to prescribe buprenorphine according
to their states' scope of practice laws will increase patients' access
---------------------------------------------------------------------------
to MAT and help address treatment gaps.
Accordingly, APhA strongly urges the Committee to include S. 445, the
Mainstreaming Addiction Treatment (MAT) Act, introduced by Committee
member Maggie Hassan (D-NH) and Senator Lisa Murkowski (R-AK), in the
Committee's legislative package to further expand the number of
practitioners--including pharmacists--who are ready, willing, and able
to prescribe buprenorphine to patients in their jurisdictions.
Conclusion
APhA would like to thank the Committee for holding this important
hearing and for continuing to work with us by including S. 1362 and S.
445 in your legislative package to increase access to pharmacist-
provided patient care services for patients with mental health
conditions, substance use disorder, and opioid use disorder. Please
contact Alicia Kerry J. Mica, Senior Lobbyist, at [email protected] or
by phone at (202) 429-7507 as a resource as you consider this
legislation. Thank you again for the opportunity to provide comments on
this important issue.
______
American Psychological Association
750 First Street, NE
Washington, DC 20002-4242
202-336-5800
202-336-6123 TDD
https://www.apa.org/
Statement of Katherine B. McGuire, Chief Advocacy Officer
The American Psychological Association (APA) thanks the Subcommittee
for the opportunity to offer evidence-based solutions to address the
mental and behavioral health impact of the COVID-19 pandemic, which the
nation will continue to confront long after the pandemic ends. 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.
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 ``one size fits all'' approach to
addressing this crisis. This Subcommittee and its members have at their
disposal an array of solutions, which we respectfully outline in this
document.
Support Permanent Expansions in Medicare Coverage of Certain
Audio-Only Telehealth Services. Congress' and CMS' 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
members of the Subcommittee will help avoid this ``access cliff'' and
permanently authorize Medicare to cover audio-only telehealth for
mental, behavioral, and substance use disorder services. Additionally,
while APA supports Congress's decision to eliminate certain site-of-
service requirements on Medicare tele-mental health coverage in the
year-end budget and COVID package, we are concerned that the new six-
month in-person service requirement will inequitably limit access to
services. Finally, we hope this Subcommittee will support a bipartisan
bill co-sponsored by Chairwoman 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.
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 Subcommittee to advance similarly innovative
approaches to this crisis, such as those outlined in: (1) the
bipartisan Medicaid Reentry Act (S. 285), co-sponsored by Sen.
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) H.R. 2051, legislation introduced by Rep. Scott Peters to designate
methamphetamine as an emerging drug threat; and (4) H.R. 2366, the
``Support, Treatment, and Overdose Prevention of Fentanyl Act of
2021'', introduced by Rep. Ann Kuster. We would like to especially
highlight H.R. 2366's provisions that: (a) 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); (b) fund grants to states, localities, and
community-based programs for harm reduction programs; (c) remove the
one-year waiting period for admission to maintenance treatment for
opioid use disorders; and (d) request a study on the effectiveness of
overdose prevention centers on reducing overdose deaths and improving
access to effective treatment and recovery.
Support Increased Funding for Programs to Strengthen School-
Based Mental Health Programs. 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 particular 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.
One of the major disruptions in the lives of children and youth
involve disruption in their daily school schedules, which often led to
higher levels of social isolation. 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). We hope members of the Subcommittee will consider a
significant increase in funding for services under the Individuals with
Disabilities in Education Act, Project AWARE, Title IV-A Student
Support and Academic Enrichment Grants, and the Safe Schools National
Activities Program, along with support for school-based health centers
that provide an array of mental health services to Medicaid-eligible
students and their families.
Expand Research in Social and Behavioral Science to Invest in
Health Equity. 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, APA hopes members of the Subcommittee will support H.R.
1475, the Pursuing Equity in Mental Health Act, which is among the
bills listed on the House suspension calendar this week. 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.
To develop more innovative approaches to health equity, we hope
members of this Subcommittee will also support National Institutes of
Health (NIH) and National Science Foundation (NSF) research in social
and behavioral science, as well as increased funding for the health
equity offices across HHS to enhance equity-focused emergency
preparedness planning and response to future public health emergencies.
Specifically, we hope that members of this Subcommittee will support a
significant increase in funding for the NIH Office of Behavioral and
Social Sciences Research, which has a critical role in coordinating
trans-NIH initiatives examining the social and economic impact of the
COVID-19 crisis including its effect on mental health. Understanding
the disruption in work and schooling, the economic uncertainty, grief,
stress, unhealthy coping mechanisms, and the mechanisms that convey
risk and resilience will help policymakers improve their long-term
response to the current pandemic.
Increase Funding for the Psychology Workforce Programs. Among
the most effective ways to expand access to services for those
experiencing mental health challenges from the pandemic is to develop
the psychology workforce to reach underserved and marginalized
communities. Programs such as the Graduate Psychology Education (GPE)
program and the Behavioral Health Workforce Education and Training
(BHWET) Grant Program serve a critical role in expanding access to
mental health services in traditionally underserved areas, while the
Minority Fellowship Program (MFP) serves a dual function to both expand
access to patients while increasing the racial and ethnic diversity of
the workforce itself. We hope members of this Subcommittee will support
increased funding for all these programs to help meet an expected
increase in need for mental health services due to the public health
and economic impact of the pandemic.
APA stands ready to assist the Subcommittee in finding impactful
bipartisan solutions to address the mental health and substance use
disorder impact of this pandemic. Please contact Andrew Strickland,
J.D. at [email protected] if our association can serve as a resource.
REFERENCES
Ahmad FB, Rossen LM, 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.
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.
______
Center for Fiscal Equity
14448 Parkvale Road, Suite 6
Rockville, MD 20853
[email protected]
Statement of Michael G. Bindner
Chairman Stabenow and Ranking Member Daines, thank you for the
opportunity to submit these comments for the record to the
Subcommittee.
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.
Detox and rehabilitative services for alcohol and drug abuse are still
active, although sometimes bringing in outside speakers is not possible
if there are glitches in electronic media or in the event a facility is
moving to a new location. This is the exception, not the rule.
In Montgomery County, housing of Drug Court clients has been moved from
our Pre-Release Center to contracted half-way houses. The system has
kept up with COVID.
Regular Twelve Step meetings are occurring remotely as well. Some new
members have never been to an in-person meeting, although clubhouses
and church basement meetings are now opening up and outdoor meetings
(both masked and unmasked) have been occurring throughout the pandemic.
Coronavirus and SARS2 infections occurred in the recovery community
even when meetings were not held in person. People have mostly gotten
sick in other places. Last year, older members got sick. This year, it
is our younger members who suffer from the second wave. Older members
have not been ill, having already recovered.
For many, including me, the virus spreads by being sneezed on in
private during the first phase of the illness, which occurs before the
asymptotic phase and the more serious symptoms.
The first phase is largely attributed to seasonal allergies or bad
colds. People die in the more serious phase because they expect it to
go away as the first did. The CDC has either not detected this pattern
or has not informed the nation of it, for whatever reason. This is more
of a factor in causing death than masking ever was.
While I might have been infected at a public event last February, it is
as or more likely that infection occurred as I was typing Comments for
the Record at the local library or by having coffee or a meal or seeing
a movie during that period. I infected others during the first period.
During the later part of the asymptotic period, no one I breathed on
took ill.
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.
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
Phone: 202-543-9570
http://eatingdisorderscoalition.org/
Chairwoman Stabenow, Ranking Member Daines and members of the U.S.
Senate Committee on Finance, Subcommittee on Health Care, thank you for
holding this important hearing entitled, ``The COVID-19 Pandemic and
Beyond: Improving Mental Health and Addiction Services in Our
Communities'' 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.
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\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\
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\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/reporteconomic-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\
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\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 and 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 Ballwin, MO
Recovery 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 Pekin, IL
Disorders Professionals
International Federation of Eating Dallas, TX
Disorders 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 Chicago, IL
Nervosa 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 Street, NW, Suite 500
Washington, DC 20001
May 11, 2021
The Honorable Debbie Stabenow The Honorable Steve Daines
Chair Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
Subcommittee on Health Care Subcommittee on Health Care
Washington, DC 20510 Washington, DC 20510
Dear Chair Stabenow and Ranking Member Daines:
On behalf of the Healthcare Leadership Council (HLC), we thank you for
holding a hearing on, ``The COVID-19 Pandemic and Beyond: Improving
Mental Health and Addiction Services in Our Communities.''
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 health-care system that makes
affordable high-quality care accessible to all Americans. Members of
HLC--hospitals, academic health centers, health plans, pharmaceutical
companies, medical device manufacturers, laboratories, biotech firms,
health product distributors, post-acute care providers, homecare
providers, and information technology companies--advocate for measures
to increase the quality and efficiency of healthcare through a patient-
centered approach.
The COVID-19 health pandemic has further 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.\1\ Preliminary data expects
2020 to be the worst year on record for drug overdoses.\2\ 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 needed medications through the duration of the public health
emergency (PHE) while maintaining robust safety and monitoring
programs.
---------------------------------------------------------------------------
\1\ 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/.
\2\ 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/.
While HLC supports the regulatory flexibilities implemented during the
PHE, Congress should further examine ways to combat the SUD crisis. We
support efforts to permanently remove the ``X-Waiver'' provision under
the Drug Treatment Act of 2000 that requires providers to receive a
special waiver from the DEA to prescribe buprenorphine. We also
encourage Congress to allow patients to receive prescriptions for
controlled substances via telemedicine permanently once the waivers
---------------------------------------------------------------------------
under the PHE expire.
As stakeholders continue to respond to the growing SUD challenges, we
encourage Congress to work with federal agencies and additional
partners to continue to develop educational resources on appropriate
use of controlled substances as well as resources for patients
struggling with SUDs. These tools will allow stakeholders to take
sustainable steps in responding to the substance use disorder crisis by
identifying best practices in prevention and treatment and ensure that
patients have essential SUD healthcare options.
The COVID-19 health pandemic has also created 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.\3\ If left untreated, many of these mental health
challenges can further exacerbate SUD. We applaud Congress for
providing over $4 billion in the Consolidated Appropriations Act for
mental health services. HLC hopes that Congress will continue to
examine ways to improve access to mental health services, particularly
through telehealth.
---------------------------------------------------------------------------
\3\ 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/.
HLC, through its National Dialogue for Healthcare Innovation, continues
to be focused on ways to address the substance use disorder crisis and
make continued investments in mental health. Please feel free to
contact Tina Grande at 202-449-3433 or [email protected] with any
---------------------------------------------------------------------------
questions.
Sincerely,
Mary R. Grealy
President
______
Mental Health Liaison Group
1400 K Street, Suite 400
Washington, DC 20005
https://www.mhlg.org/
May 21, 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
The Honorable Debbie Stabenow The Honorable Steve Daines
Chair Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
Subcommittee on Health Care Subcommittee on Health Care
Washington, DC 20510 Washington, DC 20510
Re: Comments for the Record for the May 12, 2021 Hearing on ``The
COVID-19 Pandemic and Beyond: Improving Mental Health and Addiction
Services in Our Communities''
Dear Chairmen Wyden and Stabenow and Ranking Members Crapo and Daines:
On behalf of national organizations representing consumers, family
members, mental health and addiction professionals, advocates, payers
and other stakeholders, we thank you for your ongoing leadership to
address the rising demand for mental health and substance use disorder
treatment and to advance telehealth both during the COVID-19 Public
Health Emergency (PHE) and beyond.
As you are well aware, the flexibilities granted by the '1135 emergency
telehealth waivers have provided critical stability for healthcare
professionals, patients and families across the nation during this
challenging time. In particular, telehealth access for mental health
and substance use disorder treatment services have served as a lifeline
for many Americans struggling with isolation, grief, future
uncertainty, and other new stressors this past year. On August 14,
2020, the Centers for Disease Control and Prevention (CDC) reported
that rates of substance abuse, anxiety, severe depression, and suicidal
ideation increased across many demographics.\1\ Of grave concern, the
report indicated that over 1 in 4 young adults had recently
contemplated suicide. Additional research revealed that over 40 states
saw a rise in opioid-related overdose deaths since the start of the
pandemic.\2\ Overall, mental health conditions were the top telehealth
diagnoses in the nation in November 2020--signifying an almost 20%
increase year over year, with no indication that this trend is
reversing.
---------------------------------------------------------------------------
\1\ https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6932-
H.pdf?deliveryName=USCDC_
921-DM35222.
\2\ https://www.ama-assn.org/system/files/2020-11/issue-brief-
increases-in-opioid-related-overdose.pdf.
To that end, we applaud the Committee for holding this important
hearing to examine policy considerations for mental health and
substance use treatment and telehealth as the nation moves out of the
COVID-19 Public Health Emergency. With a surge in demand for behavioral
health services that are only expected to increase, our nation needs to
apply every tool at our disposal to ensure that Americans have access
to the mental health and substance use services they need. As such, our
respective organizations offer the following recommendations to the
---------------------------------------------------------------------------
Committee as Congress reviews next steps on telehealth.
I. Extend all telehealth flexibilities for mental health and substance
use disorders at least one year beyond the end of
the PHE to maintain access to care and better
inform policymakers how to make permanent
telehealth policies that increase equitable access
to quality, evidence-based care
Telehealth helps to reduce the stigma around seeking mental health or
substance use disorder treatment for those who want to seek care
confidentially, and it makes access to services more available to those
without childcare or transportation. Furthermore, audio-only
telehealth, which has been a digital equalizer for those who lack
access to broadband Internet or video-enabled devices and for those who
cannot utilize dual audio-video devices, is a critical flexibility. The
ability to communicate between patients and behavioral health providers
according to individuals' own needs is crucial to eliminating
artificial barriers to care.
Extending these flexibilities for at least one year beyond the
conclusion of the PHE will allow for additional time to evaluate
questions associated with cost, utilization, efficacy, and compliance.
Taking this step is fully consistent with recent recommendations to the
Congress from the Medicare Payment Advisory Committee, which asked for
an extension of current telehealth flexibilities--including audio-
only--for up to 2 more years to gather more evidence about the impact
of telehealth on access, quality, and cost, and for policymakers to use
this evidence to inform any permanent changes.\3\ This additional time
could provide more baseline data to address concerns, such as those
relative to Congressional Budget Office (CBO) scoring, by allowing real
world data rather than non-dynamic projections to guide policy decision
making. Historical advancements have been made in telehealth over the
last year and consumer support for continuing these advancements
remains strong, particularly for mental health and substance use
disorder treatments. We therefore implore this Committee to take
action--via seeking an extension of telehealth flexibilities at least
one year beyond the PHE--to ensure that these immense gains in virtual
care are not lost or discontinued abruptly.
---------------------------------------------------------------------------
\3\ Medicare Payment Advisory Commission, Report to Congress (March
15, 2021).
---------------------------------------------------------------------------
II. Allow telephonic (audio only) services for mental health and
substance use disorder services after the PHE
concludes
In 2019, the Federal Communications Commission (FCC) reported that
between 21.3 and 42 million Americans lacked access to broadband. 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 access to them. Likewise, many in racial/ethnic and low-
income communities lack access to broadband or video-enabled devices.
Additionally, there is strong evidence to support the efficacy of
telephonic behavioral health services. A review of 13 studies found
reduced symptoms of anxiety and depression when therapy was conducted
via telephone.\4\ Patients have also benefited from receiving various
interventions over the telephone, such as combined tele-pharmacotherapy
and tele-cognitive-behavioral therapy (tele-CBT),\5\ tele-CBT
alone,\6\, \7\, \8\ receiving short-term tele-CBT
in primary care settings,\9\ and tele-bibliotherapy for older adults
with anxiety.\10\ Veterans with comorbid psychological distress and
combat-related mild traumatic brain injury have also benefited
significantly from receiving telephone-problem solving therapy (Tele-
PST).\11\ After receiving tele-PST, veterans reported improved quality
of sleep and reduction of symptoms of depression and PTSD.
---------------------------------------------------------------------------
\4\ Coughtrey, A.E., and Pistrang, N. (2018). The effectiveness of
telephone-delivered psychological therapies for depression and anxiety:
A systematic review. Journal of Telemedicine and Telecare, 24(2), 65-
74. https://doi.org/10.1177/1357633X16686547.
\5\ Ludman, E.J., Simon, G.E., Tutty, S., and Von Korff, M. (2007).
A randomized trial of telephone psychotherapy and pharmacotherapy for
depression: Continuation and durability of effects. Journal of
Consulting and Clinical Psychology, 75(2), 257-266. https://doi.org/
10.1037/0022-006X.75.2.257.
\6\ Mohr, D.C., Hart, S.L., Julian, L., Catledge, C., Honos-Webb,
L., Vella, L., Tasch, E.T. (2005). Telephone-administered psychotherapy
for depression. Archives of General Psychiatry, 62, 1007-1014. https://
jamanetwork.com/journals/jamapsychiatry/article-abstract/1108409.
\7\ Stiles-Shields, C., Kwasny, M.J., Cai, X., and Mohr, D.C.
(2014). Therapeutic alliance in face-to-face and telephone-administered
cognitive behavioral therapy. Journal of Consulting and Clinical
Psychology, 82(2), 349-354. https://psycnet.apa.org/fulltext/2014-
02032-001.html.
\8\ Stiles-Shields, C., Corden, M.E., Kwasny, S., Schueller, M.,
and Mohr, D.C. (2015). Predictors of outcome for telephone and face-to-
face administered cognitive behavioral therapy for depression.
Psychological Medicine, 45(15), 3205-3215. https://doi.org/10.1017/
S0033291715001208.
\9\ Watzke, B., Haller, E., Steinmann, M., Heddaeus, D., Harter,
M., Konig, H.-H., Wegscheider, K., and Rosemann, T. (2017).
Effectiveness and cost-effectiveness of telephone-based cognitive-
behavioural therapy in primary care: study protocol of TIDe--telephone
intervention for depression. BMC Psychiatry, 17(263). https://doi.org/
10.1186/s12888-017-1429-5.
\10\ Brenes, G.A., McCall, W.V., Williamson, J.D., and Stanley,
M.A. (2010). Feasibility and acceptability of bibliotherapy and
telephone sessions for the treatment of late-life anxiety disorders.
Clinical Gerontologist, 33(1), 62-68. https://doi.org/10.1080/
07317110903344968.
\11\ Bell, K.R., Fann, J.R., Brockway, J.A., Cole, W.R., Bush,
N.E., Dikmen, S., Hart, T., Lang, A.J., Grant, G., Gahm, G., Reger,
M.A., De Lore, J.S., Machamer, J., Ernstrom, K., Raman, R., Jain, S.,
Stein, M.B., and Temkin, N. (2017). Telephone problem solving for
service members with mild traumatic brain injury: a randomized,
clinical trial. Journal of Neurotrauma, 34, 313-321. https://doi.org/
10.1089/neu.2016.4444.
Given the significant increase in demand for behavioral health services
and the significant role of audio-only as a digital equalizer, we
recommend continuing this flexibility for the provision of mental
health and substance use disorder services for at least 1 year beyond
the PHE. During this time, regulators may evaluate data to better
understand which modalities may be considered for audio-only on a
permanent basis.
III. Remove the in-person requirement for telemental health services
While we applaud inclusion of the telemental health services in the
end-of-year COVID relief package, we urge Congress to remove the in-
person requirement it established. Imposing service restrictions on
telehealth access through arbitrary in-person requirements undermines
the flexibility and access afforded by telehealth and other virtual
care modalities. Additionally, as many providers around the nation have
created virtual front doors for their services, they have also started
serving larger geographic areas. As such, this new requirement, which
would go into place after the PHE concludes, would place an unnecessary
burden on consumers and providers alike.
IV. Continue payment parity for telehealth services
As more providers transitioned to telehealth, payers are starting to
evaluate cutting rates, often making the case that delivering care for
telehealth is less expensive. This is simply not the case for
behavioral health providers that provide both in-
person and telehealth services. First, it assumes that behavioral
health rates were already actuarially sound. However, because the
Mental Health Parity and Addiction Equity Act has not been enforced
since its inception over ten years ago, in many cases rates are already
below the actuarial costs of delivering care and coverage of behavioral
health services is limited.\12\, \13\ Second, proposing
rate cuts for telehealth assumes that telehealth delivery for providers
operating a hybrid (in-
person and digital) service environment is less costly than the
delivery of in-person care. However, this is also inaccurate as many
providers continue to maintain much of their brick and mortar overhead
while also seeking to invest in telehealth platforms, hire more tech
support staff, and make overall and continuing IT investments. These
additional costs do not have a reimbursement mechanism and overlay
current operating costs. As such, we recommend that telehealth--for
mental health and substance use disorder services--continue to be
reimbursed on par with in-
person services.
---------------------------------------------------------------------------
\12\ https://www.naatp.org/sites/naatp.org/files/MillimanReport11-
20-19.pdf.
\13\ https://www.statnews.com/2019/03/18/landmark-ruling-mental-
health-addiction-treatment/.
In conclusion, even with today's telehealth emergency waivers,
providers around the nation are struggling to meet the growing need for
services at a time when many payers are already beginning to decrease
rates for telehealth encounters. These combined effects--limited
workforce, rate cuts, and an already underfunded system coupled with
predictions that demand for behavioral health services will only
increase--signals the clear need for urgent and immediate action.
Through passing legislation that extends the telebehavioral health
flexibilities, including audio-only services, beyond the PHE, removes
the in-person requirement for telemental health services, and secures
telebehavioral health parity--we can provide additional tools to
---------------------------------------------------------------------------
increase access, break down stigma, and advance health equity.
We thank the Committee for its ongoing attention to addressing the
mental health and substance use disorder crisis in our country, as well
as for its consideration of the critical role that telehealth access
can play for our nation both during and, importantly, beyond the PHE.
Should you have any questions, or we can be of further assistance,
please reach out to Laurel Stine ([email protected]), Lauren Conaboy
([email protected]), and Elizabeth Cullen
(elizabeth.cullen@jewish
federations.org).
Sincerely,
American Art Therapy Association
American Association for Geriatric Psychiatry
American Association for Marriage and Family Therapy
American Association for Psychoanalysis in Clinical Social Work
American Association of Child and Adolescent Psychiatry
American Association of Nurse Anesthetists
American Association of Suicidology
American Association on Health and Disability
American Foundation for Suicide Prevention
American Group Psychotherapy Association
American Psychiatric Association
American Psychological Association
Anxiety and Depression Association of America
Association for Ambulatory Behavioral Healthcare
Association for Behavioral and Cognitive Therapies
Centerstone
Center for Law and Social Policy
Children and Adults with Attention-Deficit/Hyperactivity Disorder
Clinical Social Work Association
College of Psychiatric and Neurologic Pharmacists (CPNP)
Confederation of Independent Psychoanalytic Societies
Depression and Bipolar Support Alliance
Eating Disorders Coalition for Research, Policy & Action
Education Development Center
Global Alliance for Behavioral Health and Social Justice
The Jed Foundation
The Jewish Federations of North America
International OCD Foundation
International Society for Psychiatric-Mental Health Nurses
Mental Health America
NAADAC, The Association for Addiction Professionals
National Alliance on Mental Illness
National Association for Children's Behavioral Health
National Association of County Behavioral Health & Developmental
Disability Directors
National Association of Pediatric Nurse Practitioners
National Association for Rural Mental Health
National Association of Social Workers
National Association of State Mental Health Program Directors
National Board for Certified Counselors
National Council for Behavioral Health
National Federation of Families for Children's Mental Health
National League for Nursing
National Register of Health Service Psychologists
Network of Jewish Human Service Agencies
Postpartum Support International
Psychotherapy Action Network (PsiAN)
REDC Consortium
RI International, Inc.
Schizophrenia and Psychosis Action Alliance
SMART Recovery
The American Counseling Association
The Kennedy Forum
The Michael J. Fox Foundation for Parkinson's Research
The National Alliance to Advance Adolescent Health
The Trevor Project
Well Being Trust
Wounded Warrior Project
______
National Association of Health Underwriters
1212 New York Avenue, NW, Suite 1100
Washington, DC 20005
202-552-5060
http://nahu.org/
I am writing on behalf of the National Association of Health
Underwriters (NAHU), a professional association representing over
100,000 licensed health insurance agents, brokers, general agents,
consultants and employee benefits specialists. The members of NAHU work
daily to help millions of individuals and employers of all sizes
purchase, administer and utilize health plans of all types. These plans
include coverage for mental and behavioral health benefits as is
required by law. We are pleased to have the opportunity to submit
recommendations to the subcommittee in regards to improving access to
behavioral and mental healthcare. These recommendations were put
together with the help of NAHU's Mental Health Task Force, a
legislative working group made up of NAHU members who are health
insurance and employee benefit professionals with an advanced
understanding of mental and behavioral health services and how they are
provided and used in health plans.
Access to mental health services is a crucial component of healthcare.
National discussion has addressed mental health care for years, but
often focuses more on physical health. The COVID-19 pandemic has
reminded us of the importance of adequate mental health care and
exposed a mental health crisis: About 4 in 10 adults in the U.S. have
reported symptoms of anxiety or depressive disorder, a share that has
been largely consistent, up from one in ten adults who reported these
symptoms from January to June 2019.\1\ For these reasons it is more
vital than ever that consumers are able to access and afford behavioral
health services.
---------------------------------------------------------------------------
\1\ March 15, 2021. Adults Reporting Symptoms of Anxiety or
Depressive Disorder During COVID-19 Pandemic. Kaiser Family Foundation.
https://www.kff.org/other/state-indicator/adults-reporting-symptoms-of-
anxiety-or-depressive-disorder-during-covid-19-pandemic/?current
Timeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22
%7D.
---------------------------------------------------------------------------
Continuity of Care
The Mental Health Parity and Addiction Equity Act of 2008 created
standards for the financial requirements and treatment limitations that
a group health plan or group health plan issuer may impose on mental
health and substance use disorder (MHSUD) benefits. MHPAEA established
that financial requirements (such as copayments, coinsurance) and
treatment limitations (such as limits on the number of outpatient
visits, or prior authorization requirements) cannot be more restrictive
than those that apply to medical and surgical benefits. With regard to
financial requirements or quantitative treatment limitations (such as
the number of inpatient days covered), a plan cannot impose a
requirement or limitation on MHSUD benefits that is more restrictive
than what is imposed on two-thirds of the medical and surgical benefits
in the same classification. While this legislation made great strides
in improving access and affordability, more must be done to improve
continuity of care and network adequacy in the behavioral health space.
One major example of an improper break in continuity of care occurs
during the appeals process when a claim for mental or behavioral health
service is denied. The family, or responsible party, of a patient must
sign a financial agreement that makes them liable for the full cost of
care during the grievance process if the individual is to remain in
treatment while appeals are completed, imposing undue financial and
emotional duress.
Currently the time allowed for appeal of a denial of payment for Mental
Health Services is 30 days, the same length of time for medical and
surgical appeals. For mental health patients, this gap in treatment can
lead to the loss or reversal of clinical gains. For some patients this
can include life-threatening consequences, readmissions and the
potential waste of initial investment in treatment. Ultimately, this
gap caused by a long appeal process has an immensely harmful impact on
the patient and their family or caregiver, emotionally and financially.
For these reasons, NAHU recommends requiring all appeals of denials and
grievances for MHSUD to automatically be escalated to urgent status.
Urgent status usually allows a review time of significantly less than
30 days and will ensure that these appeals are expedited leveraging an
existing method.
Network Adequacy
Another way in which Congress can improve Americans' access to mental
and behavioral health services is by addressing network adequacy.
Network adequacy has been an issue in the mental and behavioral health
service sphere for quite some time. While attempts have been made to
make improvements in this area, there is still a significant amount of
ground to cover. There are 119.3 million Americans that live in areas
designated as ``Mental Health Professional Shortage Areas.''\2\ Often
it is difficult for patient to locate a provider that accepts insurance
at all, much less participates in their insurer's network. If a
provider does participate, that participation may not be consistent
resulting in provider directory inadequacy. A survey of privately
insured patients found that 53 percent of those that used provider
directories found inaccuracies in their insurer's provider directory,
often leading them to receive care from out-of-network providers.\3\
---------------------------------------------------------------------------
\2\ September 30, 2020. Mental Health Care Health Professional
Shortage Areas (HPSAs). Kaiser Family Foundation. https://www.kff.org/
other/state-indicator/mental-health-care-health-
professional-shortage-areas-hpsas/
?currentTimeframe=0&sortModel=%7B%22colId%22:%22Loca
tion%22,%22sort%22:%22asc%22%7D.
\3\ Busch, S. and Kyanko, K. June 2020. Incorrect Provider
Directories Associated with Out-Of-Network Mental Health Care and
Outpatient Surprise Bills. Health Affairs. Retrieved February 1, 2020
at https://www.healthaffairs.org/doi/10.1377/hlthaff.2019.01501.
NAHU recommends that Congress consider incentives to encourage
providers to participate in network plans including plans that use
mental health carve-outs, as well as increase incentives for plans with
mental health carve-outs to contract with willing MHSUD providers,
possibly by increasing the percentage of the Medicare rate at which
they are reimbursed. We also recommend increasing incentives for
carriers with mental health carve-out plans to expedite the contracting
process, and prioritize updating provider lists. The contract
negotiation process between carriers and providers is a source of
inefficiency, as the process can take a significant amount of time and
can add yet another barrier to receiving care.
Collaborative Care Model
One glaring cause of inefficiency impeding Americans' access to mental
and behavioral health is the lack of communication between behavioral
health and primary care providers. Since mental and behavioral health
is often not integrated with primary care, this leaves patients with
undiagnosed or poorly managed mental and behavioral health conditions,
despite the fact that mental and behavioral health conditions often
initially appear in a primary care setting.
Currently, primary care clinicians provide mental health and substance
use care to the majority of people with mental and behavioral disorders
and prescribe the majority of psychotropic medications. NAHU believes
that a collaborative care model that incorporates behavioral health and
primary care could significantly decrease the weight of other illness,
lessen the demand for mental and behavioral health services, and
thereby lower medical costs and reduce disparities in identification
and the effectiveness of treatment for behavioral health issues.
Telehealth
Because of the pandemic, rules related to all aspects of telehealth,
including tele-behavioral health (TBH), have been loosened. This has
resulted in immense increase in the use of tele-behavioral health
services, enabling cross-state care which has been critical to
underserved areas and rural communities. TBH has the potential to
overcome patient stigma and improve access and efficiency of care for
mental and behavioral health services. 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 which could lead
in a decrease in cost for treatment of an individual over the course of
their care.
Unfortunately, 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 ethnic
and low-income communities lack access to broadband or video-enabled
devices, which only expands the health inequities in the U.S. Due to
this, NAHU recommends eliminating cross-state border restrictions on
tele-behavioral health, permanently, as well as adopting technology-
neutral requirements, permitting use of different types of technology
platforms that are designed for telehealth.
Mental Health Parity
Fully insured and self-funded ERISA plan sponsors are required to
comply with the quantitative treatment limits imposed by the Mental
Health Parity Act. However, fully insured and ERISA plan sponsors have
no control over the non-quantitative treatment limits associated with
Mental Health parity laws since they rely on their intermediaries such
as third party administrators to monitor and comply with network
adequacy requirements for access to mental and behavioral health care.
There have been several lawsuits related to the non-quantitative
treatment limits of mental health parity laws. NAHU recommends that the
federal government create a safe harbor status for fully insured and
self-insured ERISA plan sponsors which rely on independent
certification of compliance with Mental Health parity requirements as
included in the MHPAEA and most recently the Consolidated
Appropriations Act of 2021.
We appreciate the opportunity to provide these comments and would be
pleased to respond to any additional questions or concerns of the
committee. If you have any questions about our comments or if NAHU can
be of assistance as you move forward, please do not hesitate to contact
me at either (202) 595-0639 or [email protected].
Sincerely,
Janet Stokes Trautwein
CEO, National Association of Health Underwriters
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