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
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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.
Pass the Servicemembers Mental Health Improvement Act
Congress should pass the Servicemembers Mental Health Improvement Act as stand alone legislation or part of the National Defense Authorization Act (NDAA), which would establish a mental health task force within the Department of Defense (DoD), including DoD and non-DoD mental health experts, to examine mental health matters across the department and provide recommendations to improve mental health services in the Armed Forces. [1][2]
Over 456,000 active military members from 2016 to 2020 were diagnosed with at least one mental health/substance use disorder (MH/SUD).[3] In 2020, over 5.2 million Veterans experienced a MH/SUD.[4] These numbers likely underestimate the number of military personnel with a MH/SUD, as it is estimated that 60 percent do not seek treatment[3][5], with stigma an important abarrier to mental health care for military personnel.[6] Individuals often fear they may be perceived as weak or could losie their job.[6] Other barriers include the lack of awareness of potential treatment options and an inability to take time off. [6] Congress and the Department of Defense (DoD) must take action to improve mental health services for military personnel. [1][2]
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Develop quality measures to assess care integration
Congress should require the Centers for Medicare and Medicaid Services (CMS) to develop Medicare quality measures that assess the degree to which clinician practices integrate mental health and substance use disorder (MH/SUD) and primary care.[1]
Despite effective MH/SUD treatments being widely available, many individuals with MH/SUD do not receive needed treatment, in part due to historically siloed MH/SUD and physical health systems.[2] Integrating MH/SUD and physical health services is essential to improving access to care, as well as 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 providers, which has proven beneficial to patients and has evolved into the Collaborative Care Model (CoCM). This model has been demonstrated effective by more than 90 randomized-controlled trials and can help to utilize limited MH/SUD provider capacity more effectively.[4]
Quality measures are used by CMS to measure and track a range of outcomes and processes in order to determine the ability to provide effective, timely, safe, efficient, patient-centered, and equitable care based on related quality goals.[5] There are currently no quality measures tied to quantifying or monitoring the degree to which clinical practices integrate MH/SUD.[6] Congress should pass language included in the Senate Finance Committee’s 2022 Mental Health Care Integration Discussion Draft, which would require CMS to develop Medicare quality measures that assess BHI efforts undertaken by clinical practices.[1][7]
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Fund the Veterans Health Administration
Congress should appropriate additional funding to the Veterans Health Administration (VHA) to increase the number of mental health and substance use disorder (MH/SUD) providers, decrease wait and travel times, and attract culturally competent providers that serve the unique needs of the nation’s Veterans.[1][2]
The Veterans Health Administration (VHA) effectively integrates mental health and substance use disorder (MH/SUD) and physical health care, has expertise in conditions that disproportionately affect our Veterans such as post-traumatic stress disorder and depression, and understands military culture. Accordingly, investing in the VHA is critical to serving Veterans’ unique needs. While the premise of the Veterans Choice Program, which allows Veterans to get mental health care from non-VA professionals, is commendable, only about 13 percent of private mental health providers are able to provide culturally competent and evidence-based care, according to the National Alliance on Mental Illness.[3] Therefore, it is critical that Congress take steps to ensure that Veterans Choice Program-participating professionals demonstrate military cultural competency and increase rates to attract culturally competent providers.[3]
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Provide technical assistance for care integration
The Centers for Medicare and Medicaid Services (CMS) should provide technical assistance to provider practices for integrating behavioral health and primary care services. Congress should fund the Primary Care Extension Program (PCEP) at $110 million over ten years, and establish grant funding for technical assistance for the implementation and ongoing delivery of integrated care.[1]
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.
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Ensure accuracy of MA provider directories
Congress should codify existing regulatory requirements that Medicare Advantage plans maintain accurate provider directories, including provider contact information and whether a provider accepts new patients.[1] Congress should require independent audits of all network directories for accuracy, should impose delisting requirements for not billing any plan for more than 12 months, and should impose out-of-network reconciliation requirements.[2][3]
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]
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Require parity in disability insurance policies
Congress should require parity in disability insurance policies by outlawing the discriminatory limitation of benefits when a disability is caused by a mental health or substance use disorder (MH/SUD).
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.