Behavioral Health Providers, Leaders Treading Cautiously on Workforce Vaccination Mandate

On September 9, the Biden administration issued a mandate for all health care workers at federally funded facilities to receive COVID-19 vaccinations. The order also extends to behavioral health care workers, whom a leading industry group last year described as being an afterthought when it came to inoculating frontline staff.

A number of behavioral health workers are employed in various facilities reimbursed by the Centers for Medicare & Medicaid Services (CMS), such as hospital emergency departments and outpatient facilities for psychiatric care and substance use disorder (SUD) treatment.

While the new mandate is ostensibly a way to prioritize the needs of behavioral care staff along with frontline medical personnel, some in the industry worry it does not completely address concerns providers have when it comes to ordering employee vaccination.

Specifically, industry providers and groups are uncertain about the scope of the mandate, given the variety of roles within various behavioral health settings. And, they are concerned about how the mandate could exacerbate workforce pressures that are already severe.

“As many questions as answers”

National Association for Behavioral Healthcare (NABH) President and CEO Shawn Coughlin is all for vaccinations, but he is pushing for more clarity and guidance on applying the mandate.

“As an association, we strongly support and encourage vaccinations,” Coughlin told Behavioral Health Business. “But I’d be remiss if I didn’t tell you we are facing as many questions as we got answers coming out of this new mandate. Mandating vaccines — as a condition of participation in Medicare and Medicaid programs — is obviously something we want to fully understand before this is fully implemented.”

Coughlin said that because behavioral health employs a wide spectrum of workers, he questions if the mandate needs to be extended to all staff, even ones not dispensing frontline services. He mentioned that CMS’s website talks about the mandate being applied to certified facilities, but said there is no clear information regarding centers providing behavioral services in particular.

“It’s not just about doctors and nurses,” he said. “In our industry, we use a lot of paraprofessionals, we use a lot of techs. We have administrative staff, we have remote workers, and it’s not at all clear from the announcement how the full breadth and scope of our service providers are going to be impacted.”

What especially concerns those like Coughlin is the possibility of the mandate exacerbating the problematic issue of workforce shortages in the industry, at a time when anxiety, depression and SUD have been on the rise nationwide.

Behavioral health employers had already been struggling with the workforce gap pre-COVID, as a majority of Americans had been expressing a demand for assistance. The situation has intensified during the pandemic, as behavioral health care demand has increased, while a number of organizations had to either close programs or reschedule patient sessions due to decreasing organizational capacity.

Additionally, it has been estimated that nearly a third of Americans currently live in areas lacking sufficient mental health services, due to a shortage of workers.

“It really focuses around the workforce shortage issues that we have been facing prior to COVID,” Coughlin said. “Now we’ve got this issue where whether it’s political, philosophical, religious or disability-related, there is a strong anti-vax undercurrent. For providers like [our] members who operate in multiple states, that is already a difficult process in trying to sort through what’s being mandated.”

Providers balance workforce concerns with federal requirements

Many of NABH’s member organizations are trying to walk a fine line on the issue. One such provider is Plano, Texas-based Oceans Healthcare, which operates over 40 hospital and outpatient locations across Texas, Louisiana and Mississippi.

Like Coughlin, Oceans CEO Stuart Archer is in favor of Americans getting the COVID jab.

“For all hospitals, the first duty we have is to do no harm to our patients,” Archer told BHB. “A vaccine mandate helps us to fulfill that in order to ensure that our patients and their families are cared for in safe environments.”

Archer said he is fully aware of how the vaccination debate — which has caused sharp ideological divisions nationwide — has also worked its way into the behavioral health realm. He said that while Oceans is sensitive to concerns staff may have about vaccinations, the company is working to comply with the mandate.

“People who have deeply held religious beliefs or medical exemptions, I think those should be respected,” he said. “But outside of that, to be with a legitimate organization moving forward, they’re going to have to commit and take the vaccine.”

Cheryl Rapier has ties to the behavioral health industry and has been following the mandate closely. She is the managing partner of PsychPros, a Cincinnati-based behavioral health staffing firm that places a variety of workers — from C-suite executives to psychiatric technicians — at employers nationwide.

Rapier has heard from would-be behavioral health workers who have expressed hesitancy about the vaccine and noted that it has made them have second thoughts about going into the field. She said that has particularly been the case with some prospective workers going after frontline positions.

“We have lost a few candidates that have decided not to get the vaccine, and they’re not willing to do so,” she told BHB. “We have had to eliminate them from consideration for a few of the positions we have with companies.”

Nonetheless, Rapier says her firm’s focus is making sure companies have enough vaccinated candidates to pick from by October, which is when a final federal guideline for following the mandate is expected to be issued by CMS.

“We’ve been trying to get everything in order for that now, so we’re definitely feeling it,” she said. “Those candidates that we’re speaking with, or have placed, have already had the vaccination. So it hasn’t been a real issue for us.”

The vaccine mandate could have implications as well on providers that have increased their remote care.

More therapy and counseling services have moved to telehealth during COVID, with a significant number of those offerings potentially remaining in place post-pandemic, as more individuals warm up to virtual care delivery.

Additionally, entities like CMS and the American Medical Association have proposed new reimbursement codes to accommodate the rise of telebehavioral health services, which would seem to factor in a substantial demand for virtual care going forward.

Dr. Steve North is also paying close attention to the mandate from his position as vice president of medical operations for Eleanor Health, a Waltham, Massachusetts-based provider of SUD treatment and mental health care that has value-based payment arrangements with CMS. 

Eleanor Health operates 18 clinics along with a virtual care model across six states. The provider moved primarily to a virtual environment last year during the onset of the pandemic, but more of its employees have since returned to its clinics for work — even as a majority of patients continue to be seen virtually.

“After an initial period of our team members being entirely remote, we began to see the move back into clinics,” North said in an email to BHB. “Curbside collaboration is one of the benefits of working in a shared space that was lost when our teams were entirely virtual.”

North said that by early August, 85% of Eleanor Health employees were either vaccinated with at least one shot or were planning to receive the vaccine. The company has been able to navigate the issue effectively as it looks at its near term future, he said.

“We want to keep our patients and our team members as safe as possible and hope to see our practices return to hybrid care,” he said.

The behavioral health industry is a formidable one, estimated to be worth $77 billion. But Coughlin believes that because the mandate — in his opinion — fails to take into account the workforce considerations of the sector, it is yet another example of how behavioral health providers are often relegated behind other segments of the health care ecosystem.

“That has been the problem, that they come around thinking about us after the fact in too many instances, for too many years,” he said. “That’s not unique to this [current presidential] administration. It’s not always clear that they take into account the implications on our segment of the industry.”

Hopefully, Coughlin said, all is not lost for the industry down the line when it comes to their voices being heard at the federal level.

“We hope to be able to work with the [Biden] administration, once we have a more clear understanding of just exactly how this [mandate] is going to be implemented,” he said. “It would be very helpful for us to have a full understanding of if they are talking about all providers and staff. We really need much more information and guidance to understand really where they’re going with us.”