Consensus Study Report

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This activity was supported by contracts between the National Academy of Sciences and the Center for Medicare and Medicaid Services and the Substance Abuse and Mental Health Services Administration through A-G Associates (AWD-001983). Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-71872-1
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2024. Expanding behavioral health care workforce participation in Medicare, Medicaid, and Marketplace plans. Washington, DC: The National Academies Press. https://doi.org/10.17226/27759.

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COMMITTEE ON THE STRATEGIES TO IMPROVE ACCESS TO BEHAVIORAL HEALTH CARE SERVIES THROUGH MEDICARE AND MEDICAID¹

DANIEL POLSKY (Chair), Professor of Health Economics and Policy, Department of Health Policy and Management, Carey Business School, Johns Hopkins University

LONDON BREEDLOVE, Director of Integrated Behavioral Health, Clinical Associate Professor, Family Medicine Department, University of Washington, Seattle, WA; Director of Education, Osher Center of Integrative Health

RICHARD G. FRANK, Margaret T. Morris Professor of Health, Economics Emeritus at Harvard Medical School, Senior Fellow, Economic Studies, Director of Health Policy, Brookings Institution

MARIE GANIM, Brown University and Northeastern University

CYNTHIA GILLESPIE, Secretary of Arkansas Department of Human Services (former)

CHRISTINA L. GOE, Christina L. Goe, Attorney, PLLC

JENNIFER F. KELLY, Director, Atlanta Center for Behavioral Medicine

PARINDA KHATRI, Chief Executive Officer, Cherokee Health Systems

BENJAMIN F. MILLER, Advisory Chair, Inseparable, Inc.; Board of Directors, Mental Health Colorado, Policy Center for Maternal Mental Health

DOUGLAS P. OLSON, Medical Director of HAVEN, Connecticut Physician Health Program; President of the Board of Directors, Association of Clinicians for the Underserved

SALLY RAPHEL, Associate Editor, Archives Journal of Psychiatric Nursing

E. CLARKE ROSS, Public Policy Director, American Association on Health and Disability

JOSHUA JACOB SEIDMAN, Chief Research and Knowledge Officer, Fountain House

MARYLOU SUDDERS, Secretary of Health and Human Services of Massachusetts (former)

RACHEL TALLEY, Assistant Professor of Clinical Psychiatry, Director of Fellowship in Community Psychiatry, Associate Program Director, Adult Psychiatry Residency Program, Department of Psychiatry, University of Pennsylvania

___________________

¹ See Appendix B: Disclosure of Unavoidable Conflict of Interest.

JOHN TOROUS, Director of the Digital Psychiatry Division, Department of Psychiatry, Beth Israel Deaconess Medical Center

JANE ZHU, Associate Professor of Medicine, Division of General Internal Medicine, Oregon Health & Science University

Study Staff

UDARA PERERA, Study Director/Senior Program Officer

MARC MEISNERE, Senior Program Officer

ABIGAIL GODWIN, Research Associate

ELIZABETH FERRÉ, Research Associate (from April 2024)

EMMA ROONEY, Research Assistant (until December 2023)

JOSEPH GOODMAN, Senior Program Assistant

ELIZA SOUSER, Senior Program Assistant (January and February 2024)

VICTORIA BROWN, Program Coordinator (from April 2024)

SHARYL J. NASS, Senior Director, Board on Health Care Services

Consultants

JOE ALPER, Writer

Reviewers

This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

We thank the following individuals for their review of this report:

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by JACK EBELER, Former Member of Health and Medicine Division Committee, and LINDA C. DEGUTIS, Yale University School of Public Health. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.

Acknowledgments

The committee extends its sincere thanks to the many individuals who shared their time and expertise to support its work and inform its deliberations. This study was sponsored by the Centers for Medicare & Medicaid Services (CMS) and the Substance Abuse and Mental Health Services Administration (SAMHSA) through A-G Associates.

The committee benefited greatly from discussions with the individuals who presented at the committee’s webinars: Keris Jän Myrick, Audrey Levine, Laura Van Tosh, Lisa Butler, Laura Marshal, Eboni S. Dabney, Warren Ng, Karin Jeffers, Margaret Adam, Rakhee Patel, Tyler Vermillion, Heather Jefferies, Cara Cheevers, Brook Hall, Paula Stone, Sean M. Robbins, Lindsey Browning, and Douglas Jacobs. Agendas for the public meetings are provided in Appendix D.

Our appreciation goes to the reviewers for their invaluable feedback on an earlier draft of the report and to the monitor and coordinator who oversaw the report review. The committee acknowledges the many staff within the Health and Medicine Division who provided support in various ways to this project, including Udara Perera (study director), Abigail Godwin (research associate), Marc Meisnere (senior program officer), Elizabeth Ferré (research associate), Torrie Brown (program coordinator), Eliza Souser (senior program assistant), Emma Rooney (research assistant), and Greysi Patton (finance business partner). The committee extends great thanks and appreciation to Sharyl J. Nass, senior director, Board on Health Care Services, who oversaw

the project. The committee also appreciates Anne Marie Houppert and Christopher Lao-Scott (senior librarians) for their research assistance and fact checking. The report review, production, and communications staff all provided valuable guidance to ensure the success of the final product. Robert Pool is credited for the superb editorial assistance in preparing the final report.

Contents

PREFACE

SUMMARY

Behavioral Health Workforce and Structural Barriers

Challenging Insurance Practices

The Urgent Call for Innovation

Focusing on the Individual’s Needs

Committee Goals and Recommendations

1 INTRODUCTION

Background

Medicare, Medicaid, and Marketplace Beneficiaries

Project Origin and Statement of Task

Scope of the Report and Guiding Principles

Committee’s Approach

Organization of the Report

References

2 BEHAVIORAL HEALTH NEEDS IN THE UNITED STATES

Behavioral Health Across the Lifespan

Unmet Behavioral Health Needs

References

3 THE U.S. BEHAVIORAL HEALTH CARE SYSTEM

The Behavioral Health Workforce

Medicare, Medicaid, and Marketplace Insurance Programs

Medicare and Medicare Advantage

Medicaid and CHIP

Dually Eligible Beneficiaries

Marketplace Plans

Payment Models for Behavioral Health Services

Settings for Delivering Behavioral Health Care

References

4 FACTORS CONTRIBUTING TO THE EXPANSION AND RECRUITMENT OF BEHAVIORAL HEALTH PROVIDERS SERVING MEDICARE, MEDICAID, AND MARKETPLACE BENEFICIARIES

Workforce Education Programs

Diverse Representation in the Behavioral Health Workforce

Graduate Medical Education Funding

Billing Capability for Behavioral Health Care Providers-in-Training in Medicare, Medicaid, and ACA Marketplace Insurances

Billing Coverage of Non-Licensed Behavioral Health Providers and Services

Telehealth and Expanded Licensure to Address Behavioral Health Provider Maldistribution

Billing Coverage of Additional Clinical Behavioral Health Providers and Services

Conclusions

References

5 ENHANCING WORKFORCE RETENTION IN MEDICARE, MEDICAID, AND MARKETPLACES: KEY FACTORS AT PLAY

Reimbursement as a Driver of Behavioral Health Care Provider Participation

Rising Costs may Restrict Needed Investment in Workforce: The Role of Cost Containment

Administrative Barriers

Other Burdens and Stress Factors that Lead to Attrition, Burnout, or Dissatisfaction

Integrating Care to Improve Behavioral Health Care Provider Satisfaction

Conclusions

References

6 INNOVATIVE INFRASTRUCTURE: BALANCING SUPPORT AND CHALLENGES FOR THE BEHAVIORAL HEALTH WORKFORCE IN MEDICARE, MEDICAID, AND MARKETPLACE

Payment System Incentives That Affect Workforce Participation

Regulating Health Care Provider Networks in Medicare, Medicaid, and Marketplace

Telehealth: An Infrastructure for Advancing or Limiting Health Care Provider Participation

Payment Models: Barriers and Facilitators for Health Care Provider Participation

Bi-Directional Integration of Behavioral Health, Primary Care, and General Health

Addressing Complex Needs

Conclusions

References

7 RECOMMENDATIONS

Recommendations

Reference

APPENDIXES

A Committee and Staff Biographies

B Disclosure of Unavoidable Conflict of Interest

C Chapter 3 Tables

D Public Meeting Agendas

E Exploring Strategies to Improve Access to Behavioral Health Care Services through Medicare and Medicaid: Proceedings of a Workshop—in Brief

F Recommendations and Conclusions Matrix

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Boxes, Figures, and Tables

BOXES

1-1 Statement of Task

1-2 Committee Definitions of Select Terms

2-1 Mental Illnesses in Adults

2-2 Mental Illnesses in Children and Adolescents

2-3 Defining Need and Unmet Need for Behavioral Health Services

3-1 Workforce Standards and Definitions

3-2 A Note on Rural Health Centers, Indian Health Services, and Tribal Health Clinics

3-3 An Example of Promising State Practices in Behavioral Health

4-1 Child and Adolescent Psychiatrists

5-1 What Influences Behavioral Health Care Provider Decision Making?

5-2 Prompt-Pay Rules

5-3 Review of State Innovations Aiming to Increase Behavioral Health Provider Participation in Medicaid

6-1 Two Separate Diagnostic Classification Systems

6-2 Audio-Only Coverage and Payment

6-3 Benefits of Bi-Directional Integration

6-4 Pregnancy and Post-Partum Care

7-1 Goals

FIGURES

3-1 Income range of Medicare enrollees by coverage type

3-2 Share of Medicare beneficiaries with mental health conditions by Medicaid coverage status, 2020

3-3 MCO coverage of behavioral health services as of July 2022

3-4 Number of U.S behavioral health facilities by facility type, 2020

3-5 Populations served by SBHCs

3-6 Supports provided to clients and their families to obtain services to address social determinants of health

4-1 Outpatient services as part of overall hospital revenue grew between 1994 and 2016

4-2 Number of Medicare-funded training positions per 100,000 population

4-3 Current flow of GME Funds

5-1 Medicare reimbursement rate for behavioral health providers over the last 5 years

5-2 Enrollment process for Medicare providers and suppliers

5-3 Typical credentialing process to participate in Medicaid managed care

5-4 Factors affecting clinician well-being and resilience

6-1 Medicaid telehealth flexibilities

TABLES

3-1 Professional Licensure and Credentialing Qualifications in Behavioral Health Care

3-2 Medicare Provider Payment Rates for Mental Health and SUD Services

4-1 RFI Selected Quotes: Trainee Issues

4-2 Comparison of Common Compact Licenses in the United States

5-1 Medicaid Reimbursement Eligibility for 90791: Psychiatric Diagnosis Evaluation without Medical Services, by State and Occupation

5-2 Medicaid Reimbursement Eligibility for 90846: Family or Couples Psychotherapy with Patient, by State and Occupation

5-3 Selected RFI Quotes about Provider Experiences and Perceptions with Enrollment and Credentialing for Medicare, Medicaid, and Marketplace Plans

5-4 Selected Quotes from the Committee’s RFI on Behavioral Health Workforce Experience by Setting

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Preface

About one in five people in the United States have a mental health condition, but only half of them get needed treatment. These statistics suggest that just about everyone reading this report has experience with, either personally or through a loved one, a mental health or substance use challenge. The statistics also suggest that we know someone who has benefitted from treatment and/or faced barriers accessing needed care in a timely way. Our committee came together over the past year to look beyond anecdote and experience to examine the evidence and propose strategies to increase participation of the behavioral health workforce in Medicare, Medicaid, and Marketplace programs.

The challenges are daunting, but the opportunities to improve access to behavioral health providers have the potential to be transformative through a coordinated approach across Medicare, Medicaid, and Marketplace. It is not just that these programs offer insurance coverage to half of Americans, but also that they provide a safety net to the most vulnerable. The context of behavioral health care, when centered on the patient experience, is one of fragmentation, confusion, and disruption. This is not a system organized around the whole-person needs of those served by this system. When the context is centered on behavioral health providers caring for those covered in Medicare, Medicaid, and Marketplace, the system is not organized around enabling provider participation.

In this complex interaction of settings and coverage, we submit nine recommendations for improving provider participation in Medicare, Medicaid, and Marketplace. These recommendations come at an inflection point for behavioral health as the landscape of mental health care delivery

is undergoing a profound evolution. COVID-19 brought behavioral health to the forefront, shifting the landscape of mental health care delivery, propelled by advancements in technology, shifting societal norms, and changing patient preferences. In addition, the inflection point extends to the Medicare, Medicaid, and Marketplace programs themselves because the vast majority of care now flows through managed care organization; provider payment, provider availability, and access arrangements for behavioral health must be considered in this context.

As we navigate these transformations, it becomes increasingly evident that our traditional clinical settings, training programs, and policy approaches are insufficient to meet the diverse needs of individuals seeking mental health support. And we must not lose sight of the broader vision for advancing mental health care access and delivery that this report was commissioned to begin to address through the lens of provider participation. From this lens, it also became clear to all of us on the committee that broader delivery transformation may also be necessary to move towards a care experience in behavioral health that prioritizes whole-person needs.

This work, conducted at the request of the Centers for Medicare & Medicaid Services and the Substance Abuse and Mental Health Services Administration, provided a statement of task that gave us a focus to recommend a number of actions that could be implemented in the short term under existing statutory authorities. These action steps for federal policy makers have the potential to improve provider participation in Medicare, Medicaid, and Marketplace. Longer-term actions have also been recommended under a vision of attaining behavioral health provider participation sufficient to meet the whole-person care needs of those seeking behavioral health care in Medicare, Medicaid, and Marketplace programs.

Daniel E. Polsky, Chair
Committee on Strategies to Improve Access to Behavioral Health Care Services through Medicare and Medicaid

Acronyms and Abbreviations

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