Why Medicare Advantage Plans May Struggle Finding Enough Behavioral Health Providers

The shortage of behavioral health professionals — especially psychiatrists — has spilled into realms adjacent to the industry as Medicare Advantage plans struggle to meet the provider standards set by the federal government.

The issue is prevalent enough to catch the attention of the Centers for Medicare and Medicaid Services (CMS) which announced in a proposed rule in January that it was soliciting feedback from the health care industry to better understand potential hurdle Medicare Advantage (MA) plans when trying to add behavioral health providers to their networks.

MA plans are a privately administered version of Medicare, the federal health plan for seniors.

While CMS didn’t explain precisely what will come out of the request for information — it doesn’t comment on matters under consideration for future rulemaking — it has said that plans are not meeting the network adequacy standards CMS set up in June 2020 “despite requiring a minimum number of behavioral health providers and encouraging use of telehealth providers.”

Allison Rizer, principal and business lead for Medicare-Medicaid integration at Washington, DC-based health care policy advisory firm ATI Advisory, said that requests for information give CMS the opportunity to better define issues and potentially influence its policies. However, it’s hard to know how severe the issue is or what CMS will do about it: There are no standard outcomes for CMS information requests, Rizer said.

In a previous role, Rizer was part of a team that contracted with CMS to develop the new network adequacy standards that were instituted in June 2020 and referenced in the January proposed rule. CMS established network standards as known today in 2011 to give the organization clear and defensible guidelines for looking at MA provider networks.

CMS regularly examines MA plan networks. If an MA plan can’t meet those standards, they are allowed to request an exception and defend why they can’t meet the standards.

“That’s important because I suspect that is also a strong underpinning of this [request for information] because if a health plan can’t meet network adequacy standards for psychiatry, for example, they’re going to send in an exemption request into CMS to say … we cannot meet the standards, and here’s why,” Rizer said.

If there is a systemic issue, CMS is likely receiving thousands of exception requests, Rizer added. In 2011, CMS received over 40,000 paper exception requests to review.

Rizer also highlighted that there are several issues that interrelate and play off each other that further complicate the ability of MA plans to get behavioral health providers into their networks, not the least of which are the providers themselves.

Psychiatrists have the highest rate among physician specialties in opting out of Medicare at 7.2%, according to the Kaiser Family Foundation. The overall opt-out rate across all specialties is about 1%. And among those that opt-out, psychiatrists make up about 42% of that group.

Peter Manoogian, a partner and health plan and provider practice lead for ZS Associates, said that the coronavirus pandemic and other powerful trends play off of each other and make it difficult for MA plans to find enough psychiatrists.

The population of people that qualify for MA plans, ages 65 and older, is rapidly growing. By 2030, about 73 million Americans, 21% of the population, will be 65 or older. By 2060, an estimated 95 million people, about 23% of the population, will be 65 or older. Both figures come from the U.S. Census Bureau.

And on top of that, MA plans are also increasing in popularity. In 2012, 26% of the Medicare population had an MA plan. In 2021, that number is up to 42%, according to the Kaiser Family Foundation. The giant consulting firm McKinsey finds that the number of people with a behavioral health need is expected to increase by 50% compared to pre-pandemic levels.

The U.S. faced a shortage of behavioral health professionals before the pandemic. The pandemic made this worse in two ways. The stigma around caring for mental health decreased while the added stress of the pandemic worsened the mental health of many.

“The demand is increasing and increasing at a pretty good clip. The supply of providers, which is really at the core of the CMS ask, is not increasing,” Manoogian said. “And in many respects, there’s good reason to believe that it will decrease.”

The generational shift is also at play among adult psychiatrists. In 2019, 61% of the psychiatrists in the U.S. are 55 years old or older, according to a report by the Association of American Medical Colleges (AAMC). As these providers age out of the workforce, the gap between supply and demand will widen, Manoogian said.

Even if there was a dramatic shift in where medical students choose to specialize in psychiatry, it would take nearly a decade for a cohort of providers to get into the workforce.

Around the same time that CMS announced that it was digging into MA plans’ apparent difficulties in having enough behavioral health providers, Mount Laurel, New Jersey-based telepsychiatry company Array Behavioral Care announced that it reached a deal to provide in-home counseling and psychiatric services to all of the MA members in individual and group plans offered by Humana Inc. (NYSE: HUM), about 5 million people.

Array Behavioral Care CEO Geoffrey Boyce said in an interview that CMS and plans may actually be contributing to the problem as many providers don’t accept the rates because it’s too low.

And CMS states that only clinical social workers may be reimbursed for therapy and counseling, narrowing the field of behavioral health providers. He also said that the bureaucratic aspect of enrolling in Medicare can be intimidating for psychiatrists whose scarcity allows them to command prices beyond what many health plans, including commercial plans, can provide.

“There are literally hundreds of thousands of scarce licensed mental health professionals that either are, or at least, feel excluded from participating in Medicare because it only reimburses for LCSW,” Boyce said.

Boyce also highlighted that it was only recently that CMS made permanent changes to how and what it will reimburse when it comes to telehealth. Historically, telehealth was reserved for patients that live in rural areas or lived in places with recognized health care provider shortages. And even then, a patient still had to go to a provider’s office to conduct a telehealth visit.

CMS announced at the beginning of November that it would allow Medicare beneficiaries to originate telehealth visits for mental health services in their homes — with the home being loosely and inclusively defined — regardless of where they live. Also, Medicare will allow providers to use audio-only visits when a patient declines to conduct a video chat.

“Everybody’s figuring it out and just getting comfortable with it,” Boyce said of telehealth and Medicare. “But when I think about the complexity and confusion lingering out there, particularly when clinicians are literally being hit with multiple job offers from every angle, it’s no surprise to me that an individual clinician doesn’t sign up for or really anything to do with Medicare.”