Senate Finance Committee Issues Testimony From Commonwealth Fund Vice President
* * *
I. Formal Greeting
Good morning. Thank you, Members of the
II. Personal Story and Background
I am
For over 10 years, I have also volunteered my time in the mental health community - currently serving on the boards of the
I testify today not only as someone who has spent more than 20 years in health policy but also as a Black man who strives to manage his own mental health - and as someone who has personally witnessed the impacts of mental health and substance use on my family, friends, coworkers, and my greater community.
III. Magnitude of the Crisis
There is a behavioral health crisis in
The crisis is being felt nationwide, without regard for political affiliation, economic prosperity, or education level - but, like so many other areas of our health care system, it is particularly acute for economically disadvantaged and underserved communities. The crisis predates COVID-19 but was exacerbated by the social isolation, economic disruption, and upheaval of the
There have been incredible strides made toward closing the coverage gap and achieving mental health parity with the passage of the Affordable Care Act in 2010.
Access to behavioral care and treatment, however, remains a major issue in the
Data from
There is a mismatch between the demand among people seeking behavioral care and the supply of behavioral health providers. Some 142 million people in the
When compared to other high-income countries, the
* * *
1
2 SAMHSA, "Key Substance Use and Mental Health Indicators in
3 HRSA, "Shortage Areas,"
4 Reginald D. Williams II and
* * *
The current behavioral health crisis is particularly notable for its impact on our nation's youth. Late last year, the
In 2020, less than half of adolescents (42%) with depression in the past year reported receiving any treatment, with Black and Indigenous people and youth of color having even worse access to care (only 37% of Hispanic youth reported accessing care) than white young people, teenagers, or adolescents. Among young adults with mental illness, 47 percent reported unmet needs for mental health care./6
Hospitals are reporting more emergency department (ED) visits among adolescents due to mental health and substance use issues as well as waits in the ED of days, sometimes even weeks, before treatment options become available./7
The Medicaid program serves as the single largest provider of behavioral health services in the
* * *
5
6 Highlights for the 2020
7
8 NAMD, "Federal Policy Briefs: Behavioral Health Integration,"
* * *
[See link at end of text for Exhibit 1. Black and Hispanic Americans Were Most Likely to Report Cost-related Problems Accessing Health Care]
* * *
One-quarter of all Medicare beneficiaries have mental illness. Analysis from the
The prevalence of mental illness is greatest among beneficiaries under 65 who qualify for Medicare because of disability, as well as among low-income beneficiaries who are dually eligible for Medicare and Medicaid./10
Nearly one-third of individuals dually eligible for Medicare and Medicaid have been diagnosed with a serious mental illness such as schizophrenia, bipolar disorder, or major depressive disorder, a rate nearly three times higher than for non-dually eligible Medicare beneficiaries./11
Prior to the pandemic, 22 percent of
The COVID-19 pandemic only intensified the unmet need for services and gaps in access to care for behavioral health services, with a higher percentage of adults in the
* * *
9
10
11
12
13 Reginald D. Williams II et al.,
* * *
The problem is big and complex. However, there are tools that can be leveraged to make meaningful change in people's lives. Here's what we can do:
1. Increase access to behavioral health services by integrating mental health and substance use treatment and services with primary care. This includes supporting integration and care coordination with innovative payment approaches.
2. Expand and diversify the behavioral health workforce, by engaging a wide variety of providers to meet people's unique needs.
3. Leverage the potential of health technology to fill gaps and meet unfulfilled needs with telemedicine and digital health solutions.
IV.
Expanding the capacity of primary care providers to meet the behavioral health needs of their patients provides an opportunity to increase access to early intervention and treatment as well as to promote social connectedness and suicide prevention.
Compared to other countries, the
This compounds the comparative underinvestment in primary care teams in the
Studies repeatedly show that patients view primary care providers as trusted sources of information. For example, in recent history, primary care providers ranked as the preferred source of information around COVID-19 vaccination for all age groups, races, and geographical location - regardless of political party./16 This trusted environment also offers an opportunity to combat stigma associated with discussing mental health and substance use and seeking treatment.
* * *
14
15 Yalda Jabbarpour et al., Investing in Primary Care: A State-Level Analysis (Patient-Centered Primary Care Collaborative, July 2019).
16 "American COVID-19 Vaccine Poll" (African American Research Collaborative, 2021).
* * *
And they are working within a health care system that does not yet fully support providing integrated care. As many as 80 percent of people with behavioral health needs present in emergency departments and primary care settings; between 60 percent and 70 percent of these individuals leave without treatment for their conditions./17 Primary care providers see 45 percent of people within 30 days of a suicide attempt, and data show the primary care providers have an opportunity to intervene with routine depression screening and treatment to prevent suicides./18
The Case for Primary Care and Behavioral Health Integration
The term "integration" describes the bringing together of various providers and services. Integration has been used to reference everything from consultation to colocation to a setting of shared health goals around treating the whole person without clear boundaries./19 It is helpful to view models of care delivery as spanning a continuum of ways to integrate physical and behavioral health care (both mental health and substance use)./20
* * *
17
18
19 A Standard Framework for Levels of
20 Integrating Behavioral Health Care into Primary Care: Advancing Primary Care Innovation in Medicaid Managed Care (
2 Source: Integrating Behavioral Health Care into Primary Care: Advancing Primary Care Innovation in Medicaid Managed Care , (
* * *
[See link at end of text for Exhibit 2. Continuum of Physical and Behavioral Health Care]
* * *
It has been projected that effective medical and behavioral health service integration that includes a focus on primary care could generate nearly
Support Innovative Payment Approaches
New approaches to payment policies, including models that hold providers accountable for improving quality and controlling overall costs, and programs led by Medicaid and Medicare, offer promising approaches to encouraging integration.
Approaches that can be used to pay for integrated care include: 1) new fee-for-services billing codes (e.g.,
Implementation can be further supported by financing evidence-based learning collaboratives for providers, in addition to financing integrated care directly.
* * *
21 "Potential economic impact of integrated medical-behavioral healthcare," Milliman Research Report,
22 Integrating Behavioral Health Care into Primary Care: Advancing Primary Care Innovation in Medicaid Managed Care (
* * *
[See link at end of text for Exhibit 3. Spectrum of Payment Models]
* * *
Collaboratives help build practices' capacity to adapt to new work streams, team-based care, and digital technologies and improve integration with community resources.
As policymakers are contemplating ways to support the
Illustrative models include:
* Providing incentives for providers to achieve quality performance milestones related to behavioral health care integration and participate in quality improvement collaboratives, as
* Integrating substance use disorder services within an existing primary care setting, as the
In a large study of SBIRT outcomes, at six-month follow-up, illicit drug use was 68 percent lower and heavy alcohol consumption was 39 percent lower among individuals who had screened positive for hazardous drug and alcohol use./24
* Addressing isolation through psychosocial rehabilitation, as
* * *
23 "Tackling America's Mental Health and Addiction Crisis Through Primary Care Integration,"
24 "Integration of
25
* * *
* Embedding mental health teams with primary care practices to build stronger local service provider relationships that are responsive to community needs, as
V. Expand and Diversify the Workforce by Engaging a Wide Variety of Providers
The evidence supports engaging a wider array of providers in the behavioral health care team, a broader set of providers than most people have access to today. Medicare covers only a set of traditional providers, such as psychiatrists, psychologists, and social workers, but not other types of licensed providers, such as marriage and family therapists or counselors. Through their flexibility, state Medicaid managed care plans often cover a range of providers that also increasingly include paraprofessionals. Paraprofessionals encompass a range of workers, from certified peer support specialists to community health workers, that play important roles across the care continuum.
Trained and accredited peer support specialists leverage their lived experience of mental health or substance use conditions to support others in recovery. There is evidence that peer support specialists can be effective in engaging people with treatment, reducing the use of emergency rooms and hospitals and reducing substance use among people with co-occurring substance use disorders./27 Peer support, which was developed in response to the lack of access to effective care in many communities, is now increasingly part of the continuum of care. Approximately 25 percent of mental health treatment facilities and 56 percent of facilities treating substance use disorders self-reported offering peer support services in 2018./28 As of 2018, 39 states allowed for Medicaid billing of peer support specialists./29
* * *
26
27 "Peers Supporting Recovery from Mental Health Conditions," SAMHSA, 2017.
28
29
* * *
Often, peer support specialists assist with the transition from hospital to community or participate in intensive programs, providing necessary additional support as part of a care team. Increasingly though, peer support specialists are being engaged earlier and can be a critical partner and extender for integrated care models, including in collaborative care, where they help with navigating treatment and other services while building key self-management skills./30 Clinicians appreciate peer support specialists for the additional support they lend and for keeping care grounded in the needs of the individual, ensuring that the services ultimately advance recovery./31
Community health workers, on the other hand, work closely with the community in more of a public health role. Research has demonstrated that for every dollar invested in a community health worker intervention, it returned
Furthermore, engaging community health workers who are representative of the populations they are seeking to reach can be an important way to reduce disparities in communities where people might not feel comfortable reaching out for help.
Integrated behavioral health models that include paraprofessionals illustrate the potential for improving access to care and treatment. These include:
* Primary care providers who assess patients based on intensity of symptoms and then refer them to different types of providers based on level of need. Such providers could include a therapist for moderate to high needs or, for those with milder needs, lower-intensity therapies from providers of evidence-based mindfulness, self-help strategies, and well-being workshops. This model is akin to a stepped-care approach like the
* * *
30
31
32 Shreya Kangovi et al., "Evidence-Based Community Health Worker Program Addresses Unmet Social Needs and
33
34 "Adult Improving Access to Psychological Therapies Programme,"
* * *
* The engagement of peer specialists as a part of clinical teams, as both the
* The introduction of a new type of provider to fill workforce gaps, like general practice mental health workers, who are health professionals with a background in social support, basic psychology training, or nursing and work under supervision of a primary care provider. In
Despite the evidence on improved outcomes and cost savings, most Americans do not currently have access to the providers described here. To remedy that, policymakers could:
* Ensure that incentives, financing, and support for integrated care are inclusive of the paraprofessional workforce.
* Provide specific incentives for systems to recruit, integrate, and retain paraprofessionals, and other workforce extenders.
* Implement learning collaboratives and quality improvement initiatives around integrating a broader workforce into the continuum of care, including issues around effective supervision and delineation of roles to maximize impact.
* Consider how to improve coverage of a broader workforce, including reimbursement for peer support specialists in Medicare.
VI. Leverage Telemedicine and
Now is the time to be optimistic about the potential of technology to address behavioral health needs. The pandemic caused a sudden shift: at a time when the need for support was greater than ever, people sought mental health care over the telephone and via online platforms. In addition, technology-enabled solutions have resulted in unprecedented investment in digital health tools that can help solve the provider shortage through on-demand therapy, guided mediation, chat-bots and more.
* * *
35
36
* * *
Telemedicine can be an effective way to improve mental health, especially through cognitive behavioral therapy. Evidence shows that telemedicine is at least as effective as face-to-face interventions in tackling depression and anxiety, symptoms of obsessive-compulsive disorder, insomnia, and excessive alcohol consumption./37 Telemedicine has also been shown to alleviate maternal depression symptoms./38 The COVID-19 pandemic, and the expanded flexibilities that were authorized around the provision of telehealth services, brought about sharp increases in the number of facilities providing telehealth treatment for both mental health and substance use services. The proportion of substance use treatment facilities offering telehealth services jumped from 28 percent in 2019 to 59 percent in 2020. For mental health facilities, the share grew from 38 percent to 69 percent over the same period./39
Among Medicare beneficiaries, visits to behavioral health specialists accounted for the largest increase in telehealth in 2020. Telehealth comprised a third of total visits to behavioral health specialists. Yet despite the increase in available services, Black and rural Medicare beneficiaries had lower telehealth use compared with white and urban beneficiaries, respectively. Telehealth use varied by state, with higher use in the Northeast and the West and lower use in the Midwest and the South. Urban beneficiaries had about 50 percent higher telehealth use than rural beneficiaries -- 1,659 visits per 1,000 urban beneficiaries versus 1,112 visits per 1,000 among rural beneficiaries. Compared with pre-pandemic levels, this represents a 140- and 20-fold increase in telehealth use for urban and rural beneficiaries, respectively./40
* * *
37
38
39
40
41
* * *
It is also noteworthy that the temporary continuous coverage requirement that kept Medicaid coverage intact during the health emergency helped to ensure access to medical and behavioral health services./42 Multiple studies have found that living in a Medicaid expansion state was associated with relative reductions in poor mental health by improving access, including access to services delivered through telehealth./43 It is critical that expansion of telehealth and other digital innovations in medicine be undertaken with universal and equitable access to care in mind.
CMS has already begun to pilot some innovative models, such as Community Health Access and Rural Transformation (CHART), that specifically provide technical assistance to rural providers to help them fully benefit from technological innovations with both financial and regulatory flexibilities. The Committee could consider opportunities to provide additional support for these types of models, with a specific focus on building capacity for providers to offer telehealth for behavioral health as well as meeting the various access needs of beneficiaries so they can benefit from these innovations. This could include helping to identify spaces available to primary care providers that can be set aside for telehealth visits when patients do not have access at home or the knowledge to use the technology.
Digital mental health is expanding, with a host of startups offering solutions that promise to fill gaps in access to care. Digital health startups offering mental health services raised
* * *
42
43
44
* * *
Technology brings a clear promise for extending the existing behavioral health system. The potential benefits include on-demand access, tailored to individual needs, and well-tested interventions. Technology also increases the potential for reducing disparities for people facing the greatest barriers to obtaining access to traditional systems of care, such as rural Americans, people who lack access to transportation, or persons with disabilities. On the other hand, digital tools raise concerns: we need our behavioral health dollars spent wisely, and we don't want to champion the use of tools that are ineffective or inaccessible for beneficiaries.
There is an opportunity to build capacity at CMS to work with
Policymakers can also help CMS work with states to host a learning collaborative and to provide technical assistance on appropriate coverage of digital tools in Medicaid, as well as strategies for ensuring access for the beneficiaries most likely to benefit./45 Currently, states often make these decisions in isolation, left to identify, evaluate, and implement digital tools without the benefit of information on models or technologies that have demonstrated success in other health systems or states.
Among the many examples of the potential to harness technological innovations to improve behavioral health, illustrative ones include:
* Utilizing telepsychiatry and sharing electronic medical records to promote and encourage provider communication and co-management of patients, like
* Introducing a portfolio of digital patient engagement and self-management tools, as
* * *
45
46 Chapter 4: Integration of
47
* * *
VII. Conclusion: We Can Be Better
As I stated earlier, the problem is big and complex. However, we have tools to improve people's lives. It is certainly within our power to ensure that people's mental health and substance use needs are better met, especially youth, people with severe mental illness, residents of rural communities, and historically excluded Black, Latino, and Indigenous communities. There are myriad approaches to expanding access to services and prioritizing mental health, making care more convenient, and scaling treatment approaches to help more people.
This can all be done, and our communities will be the stronger for it. There is inspiration from abroad that we can draw upon.
* * *
[See link at end of text for Exhibit 4. Lessons Learned from Other Countries' Approaches to
* * *
For example, we can take inspiration from
We can be inspired by
In the coming months, we can work to implement policy approaches that reflect our own values and commit the investments necessary to guarantee a better future for individuals, families, and communities in America. You can lead the way by advancing bipartisan policies for meeting these goals.
I believe that, as a nation, we can do better. And by providing new opportunities to expand access to equitable, affordable care and treatment and address our behavioral health crisis, ultimately, we can be better.
* * *
48
49
Research Data from Far Eastern Memorial Hospital Update Understanding of Health Services Research (Evaluating the comparative efficiency of medical centers in Taiwan: a dynamic data envelopment analysis application): Health and Medicine – Health Services Research
New Findings in Healthcare Economics Described from American Dental Association (The Effect On Dental Care Utilization From Transitioning Pediatric Medicaid Beneficiaries To Managed Care): Economics – Healthcare Economics
Advisor News
- Health-related costs are the greatest threat to retirement security
- Social Security literacy is crucial for advisors
- The $25T market opportunity in mid-market and mass-affluent households
- Advisors must lead the policy risk conversation
- Gen X more anxious than baby boomers about retirement
More Advisor NewsAnnuity News
- CT commissioner: 70% of policyholders covered in PHL liquidation plan
- ‘I get confused:’ Regulators ponder increasing illustration complexities
- Three ways the Corebridge/Equitable merger could shake up the annuity market
- Corebridge, Equitable merge to create potential new annuity sales king
- LIMRA: Final retail annuity sales total $464.1 billion in 2025
More Annuity NewsHealth/Employee Benefits News
- Families worry their fragile peace could be at risk with Medicaid cuts
- Anthem again pays restitution, fine over Virginia claims delays
- Progressive think tank proposes plan to lower health care costs
- SENATE COMMITTEE PASSES BIOMARKER TESTING COVERAGE BILL ACS CAN URGES FULL SENATE TO FOLLOW SUIT
- Navigator cuts leave Americans with less help to find Obamacare plans
More Health/Employee Benefits NewsLife Insurance News
- Virginia orders rate cuts for 16 Aflac policies
- Virginia insurance regulators order rate cuts for several Aflac policies
- Life insurers post modest gains following record 2024, S&P Global finds
- Aflac overcharging Virginians, SCC finds
- Virginia orders rate cuts for Aflac policies
More Life Insurance News