Nov 01, 2022

Strengthening Behavioral Health Care for People with Medicare

Meena Seshamani, MD, PhD, and Douglas Jacobs, MD, MPH

Note: This blog is an updated version from the July 7, 2022 blog. This updated blog reflects the new behavioral health policies in CMS’ finalized CY 2023 Physician Fee Schedule and Outpatient Prospective Payment System rules.

COVID-19 has exacerbated the nation’s struggle with mental health and substance use disorders (collectively called “behavioral health conditions”), fueling a full-blown crisis. For some Americans during the pandemic, this has meant feeling depressed and hopeless, making it challenging for them to perform everyday tasks. For older Americans and people with disabilities who may have already felt socially isolated, the pandemic has made it even harder to connect with family and friends. And for many people with substance use disorders, it has led to higher substance use, dangerous overdoses and even death, including suicides.

As doctors, we’ve seen firsthand how quality, affordable, and timely behavioral health care can be life changing. From urgently taking a woman to the operating room because a needle broke off into her neck while injecting drugs, to providing care to a man whose alcohol consumption caused him to develop liver disease and vomit blood, we have seen the central role of behavioral health care in keeping people healthy and saving lives.

To ensure that every American gets the behavioral health care they deserve, President Biden announced a strategy to address our national mental health crisis as part of the Administration’s Unity Agenda. Earlier this year, CMS issued our own Behavioral Health Strategy, seeking to adopt a data-informed approach that removes barriers to care and services and promotes person-centered behavioral health care, including emotional and mental wellbeing. With almost $1 trillion in claims and covering more than 63 million Americans, Medicare plays a critical role in implementing this strategy as evidenced by a series of new behavioral health policies in CMS’ recently finalized CY 2023 Physician Fee Schedule  and Outpatient Prospective Payment System rules.

Mobilizing the Behavioral Health Workforce

To start, we know that to help combat the behavioral health crisis in our country, we must mobilize the behavioral health workforce. So, we are finalizing changes to the Medicare program to ensure that behavioral health practitioners across the country can practice to the full extent of their license. We are creating an exception to supervision requirements, allowing marriage and family therapists, licensed professional counselors, addiction counselors, certified peer recovery specialists, and others to provide behavioral health services while being under general supervision rather than “direct” supervision. Practically speaking, this means that these behavioral health practitioners will be able to provide services without a doctor or nurse practitioner physically on site, expanding access to behavioral health services like counseling and cognitive behavioral therapy in additional communities, particularly rural or underserved communities where care can be hard to find.

We will also pay psychologists and social workers to help manage behavioral health needs as part of the primary care team, in addition to on their own, because it can be easier for a person to get behavioral health care like psychotherapy when the care is coordinated through their primary care provider. And we are making permanent one of our policies during the public health emergency to allow clinical staff of hospital outpatient departments to provide remote behavioral health services to patients in their homes, expanding access to behavioral health services for rural and other underserved communities.

Additionally, we want to mobilize the behavioral health workforce by giving them the ability to connect with people in different ways. For example, we know that sometimes people need significant care for their behavioral health condition, but rather than resorting to hospitalization, many people can benefit from intensive management in community settings. We received robust feedback from the public on a request for information regarding how Medicare should think about covering these services, and will take the feedback into consideration for future policies.

Making Care More Effective

Alongside mobilizing the behavioral health workforce, we need to make sure that these professionals are working in the most effective way. This means working in teams and making sure that behavioral health is integrated with other aspects of health care. Paying psychologists and social workers to help manage behavioral health needs as part of the primary care team is just one example of how we can encourage integrated care. We also want to ensure that people get access to comprehensive care for their chronic pain, which is something that affects more than 20% of Americans and can be debilitating. Medicare has not historically recognized the team-based approach to pain management and treatment — including aspects such as person-centered care planning, medication management, and coordination between providers — that is often needed to manage chronic pain in ways that result in better outcomes. So, for the first time, Medicare will provide payments for team-based, comprehensive management and treatment of chronic pain.

We are also finalizing several policies to strengthen and grow a program that has succeeded at providing high quality behavioral health care — the Medicare Shared Savings Program. Shared Savings Program Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers who join together voluntarily to give coordinated, high-quality care to people with Medicare. The program’s goal is to ensure that people receive the right care at the right time, keeping them healthy while preventing medical errors and avoiding unnecessary and duplicative tests and treatments. We have seen that this type of coordinated, whole-person care can have a greater impact on someone’s health. For example, if someone has diabetes and depression, that individual may not have the energy to get out of bed, exercise, keep track of their medications, or make healthy meals. Treating the diabetes alone, isolated from the other factors affecting that person’s health, may not be as effective as addressing both the diabetes and depression together. We are strengthening the whole-person capabilities of ACOs by making advanced shared savings payments to new, smaller ACOs, which could use the funds upfront to hire behavioral health practitioners and address the social needs of people with Medicare, such as food and housing.

Addressing the Nation’s Substance Use Disorder Crisis

To help combat the increase in overdoses that has marked this pandemic, we are clarifying that, in line with requirements of the Drug Enforcement Administration (DEA), Opioid Treatment Programs may bill Medicare for services performed by mobile units, such as vans, without obtaining a separate registration. This can improve treatment access for hard-to-reach populations, such as individuals who are homeless or who live in rural areas. We are also increasing our payment rates to Opioid Treatment Programs in order to better reflect the costs of individual therapy services, while also finalizing policies to pay for the initiation of buprenorphine (which treats opioid use disorder) using telecommunications, rather than just in person, to further improve access. Additionally, in response to the public comments received on the proposed rule, we are also extending allowing payment to Opioid Treatment Programs for periodic assessments furnished over audio-only telephone calls through the end of 2023.

These policies in Medicare will allow for important strides forward for behavioral health care in this country. However, the behavioral health crisis that continues to shake the nation cannot be solved by CMS alone. We look forward to continued partnership, working together to ensure that every American gets the behavioral health care that they need and deserve.