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

Over nine million people use TRICARE to provide for their healthcare needs, which includes coverage for MH/SUD services.[2] Copays under TRICARE have been increasing[3] and are higher than those under the Federal Employee Health Benefits (FEHB) program and some commercial plans.[3] The current lack of parity between copayments for outpatient MH/SUD visits and primary care outpatient visits must be addressed. Discriminatory cost barriers should not be a reason why someone does not receive the MH/SUD care they need.[2] To address reduce these costs on active military families, Congress should pass the Stop Copy Overpay Act.[1][2]

According to the Substance Abuse and Mental Health Services Administration, “SOGI change efforts, commonly referred to as ‘conversion therapy’ or ‘reparative therapy,’ are practices that aim to suppress or alter an individual’s sexual orientation or gender to align with heterosexual orientation, cisgender identity, and/or stereotypical gender expression.”[1] SOGI change efforts have been linked to increased risk for psychological distress, suicidality, and depression.[1] About 698,000 LGBTQ+ adults have been subject to SOGI change efforts, with about half subject to the efforts in adolescence.[2] SOGI change efforts have been performed by licensed mental health providers as well as unlicensed providers and faith leaders.[3]

The Biden Administration has called on the Department of Health and Human Services (HHS) to ensure that federally funded health services are not used for SOGI change efforts.[4] The Therapeutic Fraud Prevention Act, as introduced in the 118th Congress, would ban SOGI change efforts and identify it as a fraudulent practice.[5][6] While several states have banned SOGI change efforts, federal legislation should be passed to ban the harmful practice, restrict federal funding, and define the efforts as consumer fraud.[1][3]

Over the past two decades, there has been increasing interest and movement towards value-based healthcare models, including the implementation of new payment reforms and demonstration programs. One of the main goals of value-based care is to move away from a fragmented fee-for-service model of delivering and paying for care to a more holistic system focused on health outcomes, including quality and cost.

New value-based care models can be used to drive further integration of primary care and MH/SUD services. Specifically, Congress should authorize CMS to create and offer the Integrated Health Model as a voluntary option for primary care providers currently in traditional fee-for-service Medicare.[1] Under such a program, risk-adjustment payments would be made to healthcare providers for primary care and integrated MH/SUD services, including preventive physical care, prevention, and management of mild to moderate MH/SUDs, and stress-related physical symptoms.[1]

While new value-based payment models are needed to help speed integration, building on existing models should also be considered. Medicare’s Merit-based Incentive Payment System (MIPS) is designed to improve care and health outcomes by tying payments to a provider's performance.[2] Healthcare providers can have their reimbursements adjusted upwards or downwards based on their performance in four categories: quality, cost, promoting interoperability, and improvement activities.[1] MIPS already includes some MH/SUD measures under the category of improvement activities, including activities related to integration (e.g., completion of a collaborative care management training program). To accelerate further integration, CMS should include additional MH/SUD integration measures in the MIPS mental/behavioral health measure and improvement activity set.[1]

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 ability to access care between MA and traditional Medicare FFS, including the ability to access care for MH/SUDs.

Unlike Medicare FFS, MA plans employ utilization management tools, such as cost-sharing and prior authorization requirements, that may impact how beneficiaries are able to access treatments and services. MA plans  may also provide additional services and benefits that are not covered by traditional Medicare FFS (e.g., dental and vision benefits).

Presently, the Mental Health Parity and Addiction Equity Act of 2008 does not apply to any part of Medicare. Thus, it is critical  to understand whether and how MA plans may be restricting access to MH/SUD care. While some information is known about the differences between the two programs [2], a clearer and more comprehensive assessment is needed. Congress should require the GAO to conduct a study that seeks to understand the differences in enrollee cost-sharing and utilization management with the goal of ensuring that MA plans are not restricting access to MH/SUD, particularly as compared to Medicare FFS.[1]

Healthcare practitioners are required to have a medical license for each state where they provide care. MH/SUD providers who prescribe medications for opioid use disorder (MOUD) are also required to have a DEA registration for every state they have a medical license.[2][3] This current policy has resulted in challenges for prescribers who face administrative burdens that may impact their willingness to seek DEA registrations, such as multiple fees and duplicative documentation requirements.[1][4] To alleviate administrative burdens and address workforce shortages related to MH/SUD providers, the DEA should have one registration that covers every state in which a prescriber has a medical license.[1]

Thirty-seven percent of Americans live in an area with a shortage of MH/SUD professionals, and two-thirds of those shortage areas are rural.[2] One quarter of rural residents receive health insurance through Medicaid and are more likely to report having poor mental health, making access to timely MH/SUD care vital for this population. However, many residents of rural communities often struggle to find care.[3] Pathways to workforce development and training grants currently exist, but more needs to be done to address provider shortages areas.[4] Congress should direct the Department of Health and Human Services (HHS) to issue guidance regarding workforce capacity in rural and other provider shortage areas, a step that was called for by a bipartisan group of Senate Finance Committee members.[1]