Alignment for Progress: 
A National Strategy for Mental Health and Substance Use Disorders

Despite effective mental health treatments being available for a wide range of conditions, many Americans remain untreated or undertreated due to historically siloed mental health and substance use disorder (MH/SUD) and physical health systems.[2] Integrating MH/SUDs and physical health services can bridge the gap to accessing sufficient MH/SUDs treatment, improving patient outcomes.[2]

In 2017, the Centers for Medicare and Medicaid Services (CMS) began paying physicians and non-physician practitioners for supplying patients with Behavioral Health Integrated Services (BHI).[3] These services involve a closer partnership between treating physicians and mental or MH/SUD health professionals, which has proven beneficial to patients and has evolved into the Collaborative Care Model (CoCM).[4] This model has been demonstrated effective by more than 90 randomized-controlled trials and can help to more effectively utilize limited MH/SUD provider capacity.[5]

However, critical infrastructure is required to effectively implement BHI services.[4] Technical support is also vital to successful implementation, especially for smaller practices who may not have the resources to undertake it alone, but whose patient population would most benefit. Technical support grants can provide staff training, billing, financing, and EHR implementation.[1] Insufficient technical support resource allocation has effectively contributed to continued operational silos between MH/SUD  health and primary care.[1] Through the Affordable Care Act (ACA), Congress directed the Agency for Healthcare Research and Quality to establish the Primary Care Extension Program (PCEP) to improve and integrate community-based health programs, and authorized $120 million over two years for the program.[1] However, funding was never appropriated.[1][6][7] Congress should appropriate $110 million over ten years for the PCEP to empower primary care practices to implement the technical and administrative changes needed for effective integration of MH/SUD services.

Medicare Advantage Plans (MA or Part C) are plans offered by private insurance companies and will pay enrollees Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) on their behalf.[4] Existing federal regulations governing the MA program mandates that all Medicare Advantage organizations must maintain a publicly accessible standard-based interface which, among other things must include a “complete and accurate” provider directory.[5] This directory must include provider name, address, and phone number; and must be updated within 30 days of MA networks being made aware of changes to provider contact information, and must update in/out of network statuses within two days.[1][5] However, the Senate Finance Committee has investigated and found significant lapses in accurate provider information, making the process of finding an appointment more challenging.[6] No person experiencing a mental health of substance use disorder crisis should be expected to navigate an inaccurate provider list, or the resulting delay to care.

Congress should codify these administrative requirements, while also providing regulators with resources to ensure enforcement capacity. The Better Mental Health Care for Americans Act, for instance, would provide $10,000,000 of otherwise unallocated funding to be directed at implementing independent audits.[7] The Department of Health and Human Services (HHS) should also be empowered to automatically remove providers who have not billed Medicare or Medicaid for more than 12 months and to impose out-of-network reconciliation when a provider has been found to be incorrectly listed as in-network.[3]

Currently, most disability policies’ benefits are limited to 24 months for disabilities caused by a mental health or substance use disorder (MH/SUD) when no such limitations exist for physical health conditions. The State of Vermont outlawed disability insurance discrimination against MH/SUDs in 2008, just weeks after the signing of the federal Mental Health Parity and Addiction Equity Act.[1] In requiring parity in disability insurance, the state issued a bulletin citing its responsibility “to protect consumers against unfair and unconscionable practices.”[2] After parity requirements were implemented in Vermont, the disability insurance market remained stable. Other states have also started to take steps towards reforming their disability insurance markets. Illinois’ legislature created a task force that issued a report on parity in disability insurance, and legislation has been introduced in Massachusetts to outlaw discrimination.[3][4] While state-based reforms represent progress, Congress should pass legislation outlawing disability insurance discrimination against individuals with disabilities caused by MH/SUDs.

Current regulations require the Centers for Medicare and Medicaid Services (CMS) to develop a Medicaid Managed Care Quality Rating System in consultation with states and other stakeholders.[2][3] Under these regulations, CMS is responsible for identifying key performance indicators, including a subset of mandatory performance indicators, and providing guidance to states regarding these or their own proprietary quality measurement programs.[1] States may opt to implement additional criteria but must at least include the subset of mandatory measures.[1] CMS has developed a set of behavioral health measures which primarily cover screening for mental health concerns and adherence to medication protocols.[4] While measurement is a vital step to ensure MCO care quality is upheld, measurement alone is insufficient without minimum performance thresholds.[1] CMS should include more robust measures regarding behavioral health integration and provide guidance to states to set a minimum rating for MCOs on performance measures.[1]

OSHA has established workplace standards that employers must follow to protect employees from physical hazards that could result in illness or injury.[2] In addition to physical workplace standards, the agency should take steps to improve the psychological health of employees.[1] According to OSHA, workplace stress can negatively impact job performance and productivity, with 80 percent of U.S. workers reporting job-related stress.[3] Stress is a risk factor for cardiovascular disease, which directly affects employee physical health.[3] It can also increase an employee’s risk of developing mental health conditions, including depression, anxiety, and substance use disorders.[3] A national psychological health workplace standard is essential to improve the health of employees nationwide.[1]

Unfortunately, the U.S. healthcare system has long reimbursed procedures and other high-cost interventions at the expense of primary and MH/SUD care. As a result, primary care physicians and psychiatrists have average annual incomes less than half of top-earning specialties – and fall in the bottom half of specialties – contributing to chronic physician shortages in these areas.[1] Primary care spending accounts for less than five percent of all healthcare spending (a percentage that has been declining).[2] Similarly, MH/SUD spending as a proportion of private insurance reimbursement is also about five percent, with significantly lower reimbursement for MH/SUD providers than physical health providers for the same billing codes.[3] By comparison, other high-income countries spend a significantly higher percentage of their health care spending on primary care – an average of 14 percent versus five percent in the U.S.[4]

An important driver of this deeply flawed system is the Medicare Physician Fee Schedule (PFS), which undervalues primary and MH/SUD care and sets a benchmark for the entire healthcare system. In the long-established process, the American Medical Association’s RVS [Relative Value Scale] Update Committee (RUC) advises CMS on the supposed relative value of physicians’ work for purposes of setting Medicare reimbursement rates. CMS broadly defers to the RUC’s recommendations. Unfortunately, the RUC has long undervalued primary and MH/SUD care[5] and has numerous methodological problems, including small sample sizes, lack of transparency, conflicts of interest, and overestimates of physician time for some specialties.[6] The resulting Medicare PFS contributes to just over half of psychiatrists accepting Medicare, far less than the more than 85 percent of physicians in other specialties.[7]

Even without the inherent flaws in the RUC process, Congress and CMS should be setting Medicare reimbursement based on the value of services, prioritizing primary and MH/SUD care, which drive enormous value by improving health and well-being. Our failure to invest in MH/SUD has enormous costs, with patients with one or more MH/SUD accounting for an estimated 57 percent of total healthcare costs. Yet half of these individuals received less than $68 in annual MH/SUD treatment.[8]

Congress should also reject the current zero-sum game that demands that any increase in investments through the Medicare PFS for primary and MH/SUD care must come at the expense of other services. Such a zero-sum game creates a system in which significant investments in primary and MH/SUD care are extraordinarily difficult, preventing our country from moving upstream to promote health and prevent more costly illnesses. To get the U.S. healthcare system out of the vicious cycle where it underprovides primary and MH/SUD care and then must pay for overvalued procedures when individuals are sicker than they would be had they received appropriate primary and MH/SUD care, CMS and Congress must make the foundational changes necessary to change our current “sick care” system into a real healthcare system.