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

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.

Health Professional Shortage Areas is a designation for an area, population, or facility experiencing a shortage in health care services.[2] HPSAs are currently divided into three groups, which include primary care, dental health, and mental health.[3] More than 163 million people live across 6,546 mental health HPSAs.[4] However,substance use disorder (SUD) is not fully captured by the mental health HPSA designation.[1][4] Treatment for SUD can include counseling, medication, and other support services, which can be provided by SUD professionals and treatment facilities.[5] Unfortunately, HRSA projects workforce shortages of 25,940 full-time equivalent addiction counselors by 2035, resulting in only 81 percent of treatment demands being met.[6] Similar shortages are expected for psychiatrists, psychologists, counselors, and social workers.[6] To address shortages in SUD health professionals, the Health Resources and Services Administration (HRSA) should develop addiction HPSAs.[1]

Continuous care and treatment improves involvement and outcomes for people with substance use disorders (SUDs).[2] However, the cost for SUD treatment can be expensive, even with health insurance.[3] The use of case rates for SUD care that set a predetermined rate for each level of care once prior authorization has been approved would eliminate the need for further utilization review for each level of care, including detoxification, rehabilitation, partial hospitalization, and intensive outpatient services.[1][4] This would ensure individuals receive continuous care based on their treatment plan and not what is dictated by cost or insurance.[4]

Incarcerated individuals have higher rates of MH/SUD than the general public, and during the first two weeks after release, they are at 129 times higher risk of dying from a drug overdose.[1] Due to the Medicaid Inmate Exclusion Policy, coverage is not continued during incarceration, leaving a gap in coverage and access to care.[3] This exclusion also means that incarcerated individuals who are not adjudicated or convicted of a crime lose access to their coverage.[2][4] Members of Congress have sponsored legislation to ensure that incarcerated individuals under the age of 18 have access to Medicaid coverage.[7] Maintaining Medicaid eligibility for individuals who are not adjudicated or convicted of a crime and allowing coverage 30 days pre-release are essential steps towards decriminalizing MH/SUD.[5] The Medicaid Reentry Act extends Medicaid eligibility to 30 days prior to release. and the Due Process Continuity of Care Act continues Medicaid coverage for individuals not adjudicated or convicted of a crime, the passage of both would improve continuity of care, assist with successful reentry, and save lives.[8][9][10][11]