Alignment for Progress: A National Strategy for Mental Health and Substance Use Disorders
It’s time for a meaningful national conversation about mental health and substance use care. We must remove the barriers to equitable and available coverage for these conditions so people can get the help they need.
Welcome To The National Strategy
Want to understand more about the importance of building a National Strategy for Mental Health & Substance Use Disorders?
How Content Is Organized and How Best to Search/Sort the Recommendations
The National Strategy recommendations are organized by category, with impacted populations and topical areas providing additional nuance and the ability to narrow a search. We have also included the option to search recommendations by the relevant House and Senate committees of jurisdiction.
Recommendation Selection Methodologies and Criteria
After conducting a thorough review of the federal policy landscape, The Kennedy Forum team created this first-of-its-kind compilation of policy recommendations needed to transform our mental health and substance use systems. The recommendations have been sourced and vetted from numerous organizations, advocates, and experts across the country in order to capture a robust set of recommendations for lawmakers and federal agencies to act on.
All National Strategy Recommendations
These featured recommendations are highlighted based on their importance in beginning the national movement towards better care for everyone.
Require the use of opioid prescribing guidelines
The Centers for Medicare and Medicaid Services (CMS) should incorporate the Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain into the Conditions of Participation (CoPs) for the Medicare and Medicaid programs and require all prescribers associated with Medicare Part D plans to take training on pain prescribing that follows the guidelines.[1]
In 2016, the CDC developed a “Guideline for Prescribing Opioids for Chronic Pain.”[2][3] To align with new evidence, the CDC updated its 2016 recommendations in the 2022 “Clinical Practice Guideline for Prescribing Opioids for Pain”[3] to go beyond recommendations for chronic pain (>3 months) and included management of acute (<1 month) and subacute (1-3 months) pain, as well as recommendations for primary and non-primary care prescribers.[3] In an effort to improve the safe prescribing of these drugs, the Food and Drug Administration (FDA) also incorporated guidelines, including the CDC guidelines, into its Risk Evaluation and Mitigation Strategies (REMS) for providers who prescribe opioid analgesics.[4]
CMS should require the use of similar guidelines for prescribers.[1] Medicare prescription drug plan sponsors are required to develop drug management plans (DMPs) for individuals with a history of an opioid-related overdose.[3] However, there is no required training for individuals who prescribe opioids for pain in Medicare. In addition, CoPs for Medicare and Medicaid do not include recommendations for prescribing opioids for pain.[5] To align with the CDC’s updated recommendations for prescribing opioids for pain, CMS should require trainings for prescribers and incorporate the guidelines into CoPs.[1]
Topics
Eliminate Medicaid’s Institutions for Mental Disease exclusion
Congress should eliminate the Medicaid Institutions for Mental Disease (IMD) exclusion found at 42 U.S.C. § 1396d(a)(29)(b) and allow federal financial participation for inpatient mental health and substance use disorder (MH/SUD) treatment facilities without reducing expenditures for outpatient services within Medicaid.[1] A Medicaid state plan option should be established to cover care in specialized inpatient and residential settings, including IMDs, while also improving transitions and access to outpatient treatment.[2]
IMDs are facilities of 16 beds or more that are primarily engaged in diagnosing and treating MH/SUD.[3] These facilities can provide timely and comprehensive care to patients with MH/SUD needs. However, Medicaid beneficiaries experience significant barriers to their services due to CMS’s exclusion of those facilities from coverage for patients between the ages of 21-64.[3] Most Medicaid beneficiaries receive no federal reimbursement toward their care when treatment at an IMD is required.[3] No patient should be denied coverage due to the type of facility required for their care. Establishing Medicaid state plan options for residential care that include IMDs would be an incremental improvement. However, eliminating the IMD exclusion under Medicaid is vital for long-term improvements in access to care.[1][2]
Topics
Eliminate Medicare’s 190-day lifetime coverage limit
Congress should eliminate Medicare’s 190-day lifetime limit on coverage in free-standing psychiatric hospitals found at 42 U.S.C. § 1395d(b)(3).[1][2][3][4]
Inpatient treatment for mental health and substance use disorders (MH/SUD) are a critical part of the continuum of care. While about 87 percent of free-standing psychiatric hospitals accept Medicare and/or Medicaid, there is a 190-day lifetime limit on inpatient psychiatric treatment services under Medicare Part A.[3][5] This discriminatory lifetime cap affects many individuals with MH/SUDs, particularly those individuals with disabilities caused by their MH/SUD who may be enrolled in Medicare for decades and may have multiple inpatient stays over time.[6] Particularly given that this lifetime limitation does not apply to any other treatment covered by any government payer, Congress should eliminate this arbitrary restriction.[4]
Topics
Make illegal denials of coverage subject to compensatory damages
Congress should amend the Employee Retirement Income Security Act (ERISA) to make illegal denials of coverage subject to compensatory damages.
ERISA governs private-sector employer-sponsored benefits for nearly 140 million Americans.[1] Under ERISA, individuals can only recover the value of the benefits due under their plan if a claim is wrongfully denied. They cannot receive compensation for any other harms suffered or for punitive damages, no matter how egregious the conduct. The failure of ERISA to hold health plans accountable for damages that illegal conduct has caused leaves individuals and their families without recourse for the harm they have experienced. When plans are only liable for the benefits that they have denied, there is a clear incentive to deny coverage, particularly when less than one percent of denials are ever appealed.[2] By allowing individuals to bring a civil action under ERISA to recover damages that are a result of bad-faith conduct or breaches of the health plan’s fiduciary duty, plans would be incentivized to proactively avoid violations of health coverage laws, including the Mental Health Parity and Addiction Equity Act.
Topics
Create an ACO screening demonstration
The Centers for Medicare and Medicaid Services (CMS) should create a Medicare demonstration project with one or more accountable care organizations in which they screen for all common mental health and substance use disorders (MH/SUDs), including depression, anxiety disorders, psychoses, bipolar disorder, schizophrenia, and various addictions, and track outcomes for all of these conditions by using a quantifiable and standardized symptom rating scale.[1]
Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other healthcare providers who work together to coordinate the delivery of health care treatment and services on behalf of a patient. ACOs have been shown to be effective at reducing waste without compromising the quality of care, particularly for those with chronic conditions.[2][3] However, services for MH/SUDs have generally been left out of the ACO model despite the known cost and quality benefits of integrating MH/SUD care into primary care practices.[4][5] Screening for MH/SUD within ACOs continues to be primarily limited to depression and alcohol use disorder based on CMS’ preventive services guidelines.[6]
Medicare demonstration programs allow providers to test innovative approaches to care delivery while being sponsored by CMS, thus reducing risk to healthcare organizations. Given the known benefits of ACOs and the known benefits of MH/SUD care integration in other settings, a demonstration program that leverages ACOs to screen for all common MH/SUDs, including depression, anxiety disorders, psychoses, bipolar disorder, schizophrenia, and various addictions has significant opportunity for improving outcomes. The demonstrations should be evaluated on a standardized and quantifiable symptom rating scale to be monitored for efficacy.[1]
Topics
Increase awareness of telehealth rights in Medicare
Congress should require original Medicare Fee-for-Service and Medicare Advantage plans to implement an awareness and education campaign regarding Medicare beneficiaries’ rights to receive telehealth services for mental health/substance use disorder (MH/SUD) treatment, as well as information on approximate cost-sharing obligations for telemental health services.[1]
While telehealth utilization has decreased slightly from COVID-19 pandemic peaks, demand has remained high for mental health and substance use disorder (MH/SUD) treatment.[2] Telehealth services for MH/SUD treatment can improve patient access, as providers can serve more geographically dispersed populations and help alleviate provider shortages in underserved areas. However, telehealth adoption for Medicare beneficiaries has consistently lagged behind adoption among those with private insurance.[3]
Although the Centers for Medicare and Medicaid Services (CMS) has made policy changes to facilitate access to telehealth services for Medicare beneficiaries during the Covid-19 Pandemic, beneficiaries may not have a clear understanding of what services are covered currently.[4][5] It is imperative this population have clear guidance on their rights to receive telehealth services for MH/SUD and related cost-sharing obligations so they are empowered to make informed decisions about their care.[1] The Department for Health and Human Services (HHS) has provided some guidance on how to inform patients about their options, but this is not sufficient as it relies heavily on individual providers and plans to act.[6] Congress should require CMS and any health plan serving Medicare beneficiaries to implement an awareness and education campaign about the telehealth services available to them, including MH/SUD treatment.