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

More than 95 percent of medical/surgical hospitals utilize EHRs, but only half of psychiatric hospitals do.[3] An important contributor to this gap was that MH/SUD providers were not eligible for $35 billion in federal assistance to adopt EHRs under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 Act.[4]

Lower EHR utilization by MH/SUD providers causes large systemic issues that negatively affect individuals with MH/SUDs in profound, yet underappreciated, ways. For instance, EHRs enhance efficiency and information sharing and have become integral to health care delivery in America. MH/SUD providers who lack EHRs are inhibited in care integration because their paper-based systems cannot interact with physical health providers who have modern EHRs.[1] Additionally, paper-based records are easily lost or damaged. EHRs have also become critical to measuring patient outcomes, advancing value-based care, and conducting clinical research.[5] Thus, it is essential to expand EHR adoption among MH/SUD providers to improve the quality of care and create a modern MH/SUD delivery system.

Congress must act to address its failure to include many MH/SUD providers in previous efforts to advance EHR adoption by passing legislation like the Behavioral Health Information Technology Coordination Act, which would dedicate $20 million a year over five years to assist MH/SUD providers in adopting EHRs.[1][2]

In response to the growing overdose crisis and the need for a wider variety of tools to help prevent and treat SUDs, the 2017 President’s Commission on Combating Drug Addiction and the Opioid Crisis recommended that CMS, FDA, and USPSTF implement a fast-track review process for new evidence-based Technology-Assisted Monitoring and Treatment (TAMT).[1]

TAMT may improve health outcomes for high-risk and SUD patients.[1][2] New technologies such as wearable devices, home monitoring systems, digital therapies, or software-based applications are being leveraged to improve access to care for SUDs and track outcomes.[1] These advances have allowed access to SUD monitoring, treatment, and services through phones, laptops, and tablets.[2] Congress should invest additional resources into further developing this technology and accelerate its safe use.

While this is still an emerging area of technology and care delivery, once a product is deemed safe and effective for the treatment of SUDs, it is critical to provide timely access and reimbursement. Ensuring access to new technology requires joint efforts among entities that play different regulatory roles. The FDA may be tasked with reviewing the safety and effectiveness of a new product or application. CMS will be responsible for evaluating insurance coverage for Medicare beneficiaries. The USPSTF may also have a role to play, given its authority to determine which preventive services must be covered by health insurance plans as required by the Affordable Care Act. Regardless of these agencies' regulatory roles, they should have expedited review processes in place to ensure new and emerging TAMT reaches patients as quickly as possible.[1]

Active duty military, reserve service members, and veteran populations have unique physical and mental health challenges related to their service that can contribute to and exacerbate pain conditions. Combat-related injuries are commonly accompanied by post-traumatic stress disorder and traumatic brain injury. Nearly half of combat-wounded veterans report misusing prescription opioids, and drug overdose mortality rates among veterans increased by 53 percent from 2010-2019.[1]

Yet, the Department of Veterans Affairs (VA) National Formulary (VANF) currently does not include several Food and Drug Administration (FDA)-approved non-opioid analgesic products while covering a wide range of opioid-based analgesic products to manage acute pain symptoms. The exclusion of these safe and effective products results in VA patients having little choice in how they manage their pain. Clinically appropriate non-opioid therapies include products that are (1) Approved by the FDA and therefore deemed to be safe and effective; (2) Indicated for use in providing analgesic support for acute, postsurgical pain; and (3) Proven to reduce quantities of opioids prescribed.[2]

In 2022, Congress passed the Non-Opioids Prevent Addiction in the Nation Act (“NOPAIN Act”) to ensure non-opioid therapies are widely available to Medicare recipients who receive outpatient surgical procedures. The Centers for Medicare and Medicaid Services (CMS) must move quickly to fully implement this law to ensure Medicare access to non-opioid therapies is available. Additionally, the VA should ensure that all FDA-approved  non-opioid therapies are included in the VANF.[3]

Non-Quantitative Treatment Limitations (NQTLs) are non-numerical limitations or restrictions to an insurance benefit’s scope or duration (e.g., prior authorization, step therapy, medical necessity exclusions).[1][2] The Mental Health Parity and Addiction Equity Act (MHPAEA) requires that an NQTL applied to mental health/substance use disorder benefits be comparable and not more restrictive than the same NQTL applied to medical/surgical benefits.[1][2][3] The Consolidated Appropriations Act of 2021 (CAA) amended MHPAEA to require most individual and group health plans to perform analyses demonstrating their compliance with MHPAEA.[2][4][5] These analyses must be submitted to the Secretaries of Health and Human Services (HHS), Labor (DOL), or Treasury, as well as any applicable state regulator, upon request.[2][4][5]

While this is important progress toward ensuring the parity compliance envisioned by the implementation of the MHPAEA, the CAA currently applies to individual and group health plans but not Medicaid, leaving tens of millions of Americans without important protections relating to MHPAEA compliance.[6][7][8] Applying the CAA requirements to Medicaid, CHIP, and alternative benefit plans is particularly important given that these plans serve disproportionately low-income populations and people of color.[7]

Peer support specialists are formally trained providers who offer peer support, using their lived experience with a mental health or substance use disorder (MH/SUD) to promote recovery in other individuals. Peer support specialists are cost-effective and provide critical support that helps individuals build stronger support systems, engage with treatment, and manage both MH//SUD and physical health conditions. Increasing utilization of peer support specialists (including through telehealth) is a critical way to alleviate shortages of MH/SUD professionals, particularly in rural and other underserved areas. More than half of U.S. counties lack any MH/SUD professionals. By helping individuals get the support and care they need, peer support specialists help prevent costly negative outcomes, including disability, hospitalization, incarceration, and even homelessness.[1] Indeed, research has shown that peer support services were associated with 2.9 fewer hospital admissions each year, and Medicaid programs saved an average of over $2,000 per month.[2]

While the Veterans Administration and a majority of state Medicaid programs have recognized the value of peer support specialists and cover these services, Medicare lags behind.[3] This is particularly problematic given that older adults are the least likely to receive needed mental health services; only 80 percent of older adults needing care receive it.[1] Congress took initial steps in 2022 when it passed legislation allowing Medicare billing of peer support services as part of mobile crisis interventions and integrated care.[4] However, many settings are still not allowed to bill peer support services, including important settings such as Community Mental Health Centers, Rural Health Centers, Federally Qualified Health Centers, and Community-Based Organizations. Congress should pass legislation ensuring full coverage of peer support services in Medicare.

MA provides healthcare coverage through private managed care plans for hospital and physician services as an alternative to traditional Medicare FFS. Enrollment in MA has continued to grow over the years and now accounts for more than 50 percent of Medicare enrollees. As enrollment continues to increase in the MA program, it’s critical for policymakers and regulators to fully understand any key differences in the ability to access care between MA and traditional Medicare FFS, including the ability to access care for MH/SUDs and the quality of the care that is delivered to MH/SUD patients.

CMS’ Star ratings are measures to help Medicare beneficiaries assess the performance of Medicare Advantage plans. The highest-performing plans can receive five stars. The rankings are based on a set of weighted measures, including services covered, administrative efficacy and service, and quality of care provided.[2] Not included in these measures is access to MH/SUD services, the quality of care received, or the degree to which MH/SUD care is integrated with physical health care.[1] Roughly a quarter of MA beneficiaries are enrolled in plans with access barriers, such as referral requirements, indicating a need for better plan reporting on MH/SUD treatment access and quality.[3] With about 20 percent of adults over 65 reporting symptoms of anxiety or depression, tools are needed to help beneficiaries pick a MA plan that best fits their care needs.[3] CMS should update its Star Ratings system to include measures that evaluate and track plans’ MH/SUD service accessibility and integration with physical healthcare.[1]