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

The external review process is key to ensuring that individuals denied coverage can have an external reviewer (i.e., not someone employed or contracted by the health plan) evaluate if denied services were medically necessary. In individual and group health plans, the Affordable Care Act guarantees the right to external reviews of denials (otherwise known as “adverse benefit determinations”). Unfortunately, in practice, this right to external review is often undermined. There are three categories of external review systems for individual and group health plans. First, there is a state-administered system that is created by state law and where states must contract with so-called Independent Review Organizations (IROs). Second, there is a federal external review process, in which federal law sets requirements under which plans must operate, but plans administer the process by contracting with IROs of their choice. Third, there is a federally-administered external review process, which the federal government administers.[1] For fully-insured individual and group plans that are subject to state law, states can administer their own external review system and, if they do not, can use either the federal external review process or the federally-administered external review process. Self-funded group plans (which are not subject to state law) are subject to the federal external review process.

Unfortunately, insurers and claims administrators often also have contracts with the same IROs that conduct external reviews to conduct internal reviews. IROs often view insurers and administrators as their clients, and IROs have said that “client preference” is a leading determinant of the basis for review. Under the federal external review process, claims administrators assign external reviews to IROs and frequently instruct them to limit the scope of reviews, despite regulations requiring IROs to evaluate non-quantitative treatment limitations (i.e., medical management techniques). Additionally, many states and the federal external review process (though not the federally-administered external review process) effectively are subject to no oversight, with no transparency as to whether external review timeframes and notice requirements are complied with. This is critical, because under the federal external review process, IROs are permitted to terminate external reviews and automatically reverse adverse benefit determinations when insurers/administrators fail to provide timely and complete information. Finally, the identity of external reviewers is concealed from consumers, making it impossible to validate their training and experience, credentials or conflicts.

To ensure proper external reviews, Congress should, for self-funded group plans, require use of the federally-administered external review process, which is more transparent and lacks such conflicts. For state-regulated fully-insured individual and group health plans, Congress should require that states only contract with IROs that do not accept direct business from health insurers or administrators in any market segment and require external reviewers’ identities to be made available to consumers. (California utilizes an external review vendor that does not accept private contracts from insurers/claims administrators.)[2] If a state does not administer its own system, Congress should require the state to use the federally-administered external review process.

Insufficient reimbursement has led to in-network provider shortages for Medicaid beneficiaries seeking mental health and substance use disorder (MH/SUD) treatment.[3][4] Medicaid is the single largest payer of MH/SUD services. However, 35 percent of beneficiaries report not being able to access treatment.[5] Congress should mandate that evidence-based MH/SUD treatments are reimbursed at their true cost to incentivize providers to accept Medicaid.[1] To facilitate increased access to treatment, the Medicaid Bump Act would increase the Federal Medical Assistance Percentage (FMAP) to provide states with additional financial resources to improve access to MH/SUD providers.[6] It would also require the Department of Health and Human Services to report on how the increased FMAP impacts access to MH/SUD services.[6] Congress should pass this important legislation.[2]

Immigrants and refugees need support in navigating the healthcare system and finding appropriate and culturally responsive care. Immigrant communities also encounter many challenges such as discrimination, isolation, stigma, and a sense of separation. These challenges often compound the trauma that they faced before and after migrating. Some of the most significant health and well-being service gaps are often language barriers, stigma, and lack of diversity amongst service providers. Providing resources and information about available services and providing culturally competent outreach and care are vital to ensuring that they access the services they need.[2]

The CLAS standards aim to ensure cultural competency of social workers, healthcare, and mental health care workers, so that they can better serve diverse communities, including immigrants. HHS should require, rather than simply making available, adoption of their Culturally and Linguistically Appropriate Services (CLAS) standards in health and health care settings by organizations receiving federal funding.[2] Title VI of the Civil Rights Act of 1964 requires organizations receiving federal funds to take “reasonable steps to provide meaningful access to their programs for individuals with limited English proficiency.” The Departments of Justice and Labor should prioritize handling language access discrimination cases in healthcare and other service settings.[3]

Many critical programs that serve people with low incomes are federally funded but state and locally administered. States and localities vary greatly in the resources they devote to language access and in the number of languages they translate important materials such as health care and mental health care materials. Federal agencies, such as HHS and OMH, should provide more translated materials that can be adapted by state and local agencies (adding specific program names, websites, phone numbers) and should enforce legal requirements to provide qualified translation and interpretation services. The National Virtual Translation Center assists in identifying the language of and ensuring quality of pre-translated materials for federal agencies; it can assist in ensuring information on health care access is appropriately translated across all relevant federal agencies. The Limited English Proficiency Federal Interagency Website provides links to documents that provide guidance on language access service and hosts actual translated documents; the website should host specific guides on culturally competent language access services in health and health care settings and actual translated documents on the topic for health care agencies to use. [3]

Given the chronic and complex nature of MH/SUDs, fee-for-service payments continue to present challenges to improving quality and outcomes in our systems. Individuals with MH/SUD often need a variety of services across a continuum that, in today’s system, are largely not economically linked and are being reimbursed in fragmented inefficient pathways. There is a tremendous need to integrate MH/SUD and physical health outcomes in model design to produce overall value for the health system.

Though numerous MH/SUD VBP models are ongoing across the country, CMS could play an important role in helping identify best practices, barriers to adoption, and solutions to overcome them. For example, a number of VBP models for SUD are being piloted in states across the country and are being tracked by the Alliance for Addiction Payment Reform.[1] By increasing the visibility of promising payment models and how to address common barriers, CMS can help providers and public and private payers with best practices and seed additional innovation.

Therefore, Congress should direct CMS to issue a VBP model report. Key information that CMS should be required to report include: Current market adoption of MH and SUD market adoption; best practices, barriers, and potential solutions for using VBP models to drive long-term value for MH and SUDs, including key outcomes measures; and state-by-state analysis of the differences in furnishing MH and SUD VBP models that examine utilization and retention rates, program costs and total costs of care, avoidable negative outcomes (e.g., inpatient admissions), quality of care, and patient, family, and provider satisfaction.

CMS should also be required to issue guidance to States regarding the adoption of VBP models for MH/SUD treatment and recovery services in Medicaid. The guidance should include State options for using VBP models in Medicaid 1115 waivers, state-directed payments, in lieu of services, contracts with managed care entities, and provide specific guidance for best practices to States that carve out MH/SUD services.

Primary care providers (PCPs) provide critical MH/SUD services. The majority of patients with mental health conditions are first seen in non-psychiatric medical settings, and such conditions frequently co-occur with physical health conditions.[1] PCPs often treat a wide range of MH/SUDs and prescribe a variety of medications.[2] For instance, PCPs prescribe 79 percent of antidepressant medications and see 60 percent of patients being treated for depression, often with little support from specialist services.[3] Consultation programs can help ensure PCPs are treating MH/SUDs in accordance with accepted clinical standards, including screening, preliminary diagnosis, and treatment plans. A national MH/SUD consultation line would provide real-time support by connecting primary care providers to MH/SUD professionals and enable them to provide clinically sound and efficient MH/SUD treatment. This could be particularly important for PCPs in rural and underserved communities. Such a consultation line could be modeled after the Health Resource and Services Administration’s National HIV/AIDS Clinical Consultation Center. [4]

In most fee-for-service payment models for mental health and substance use disorder (MH/SUD) care, providers and payers are unable to control or directly influence all facets of a person’s recovery journey, including the various manifestations of recovery disruptions. In recent years, both public and private payers have increasingly introduced payment demonstrations designed to promote improved integration of disparate parts of the delivery system to foster improved collaboration and efficiency. Transitioning to value-based payment (VBP) models from the traditional fee-for-service model requires significant restructuring of incentives to encourage collaboration, record sharing, and outcome tracking.[1]

However, the infrastructure required to do this for existing providers is lacking.[2] There is a need for a care transformation funding pool that can support providers to develop Independent Practice Associations (IPA)[3], or other network structures to act as local market organizers of disparate elements of the existing care continuum, provide care coordination to the targeted beneficiaries, and shore up technology gaps in the region to support patient retention and track outcomes across specific care sites. An IPA can provide a single point of engagement for Medicaid managed care organizations and commercial payers across a focused geographic area. These entities can provide shared administrative services, offer increased numbers of beneficiaries to payers, and provide critical quality measurement and data reporting functions foundational to support value-based care.

Such a funding pool could be administered by the Centers for Medicare and Medicaid Services (CMS) through grants or as part of a “meaningful use” type incentive payments to IPAs that create the infrastructure necessary for VBP model contracting. The “meaningful use” model was used by CMS previously to give incentive payments for improvements in provider infrastructure specifically to adopt electronic health records. This model could be targeted at MH/SUD providers to bring together disparate providers to work together in local markets to advance VBP opportunities.[4]