Medicare’s Proposed Workforce Changes Could Shake Up the Market, Boost Access to Care

Medicare’s recently proposed Physician Fee Schedule for 2023 could change how the health insurance industry deals with the behavioral health clinician shortage.

Introduced on July 7, the proposed rule seeks to allow more practitioners to address Medicare members’ behavioral health needs. In turn, Medicare’s influence may inspire other health plans to take similar action.

“Medicare sets the tone for every other payer,” Vatsala Kapur, head of government affairs at Bamboo Health, told Behavioral Health Business. “When Medicare takes that lead, it sends a lot of positive signals to the market, to other payers.”

Stakeholders tell BHB that Medicare has major, informal sway over health care on top of its formal reach.

Medicare is the federal health plan for Americans aged 65 and older. It accounted for 22% of all health care spending in the U.S. in the federal fiscal year 2021.

In the same year, it covered about 64 million beneficiaries, or about 19% of the total population. Across all U.S. Centers for Medicare & Medicaid Services (CMS) programs, it had about $1.24 trillion of federal outlays, according to government data. In other words: When Medicare moves, it matters.

The Medicare and the workforce

CMS’s 2023 Medicare Physician Fee Schedule proposes wide-ranging provisions touching on behavioral health and many other parts of Medicare.

The COVID-19 pandemic, according to CMS, is “fueling a full-blown crisis” in the behavioral health of Americans.  

The behavioral health reform loosens supervision requirements for several types of providers. Specifically, it shifts supervision from “direct” to “general.” CMS specifically named marriage and family therapists, licensed professional counselors, addiction counselors and certified peer recovery specialists in its announcement.

“It may not look like such a big thing to the rest of the world but it’s a big step for them,” Judy Waltz, health care attorney at Foley & Lardner LLP, told BHB. 

In practical terms, this new rule would no longer require supervising clinicians to be on-site for certain behavioral health services to be billable to Medicare. Thus, it would be easier for Medicare beneficiaries to see these providers.

“These services can safely be provided without a physician or nurse practitioner in the building,” Dr. Lori Ryland, chief clinical officer for addiction care provider Pinnacle Treatment Centers, told BHB in an email. “The provision of general supervision meeting credential-specific licensing requirements can adequately support the behavioral health services while improving availability and access.”

About 52.9 million adults in 2020 reported having a mental illness, according to a federal survey. The same survey found that 31% of adults, or 16.1 million people, reported having unmet care needs. About 130 million Americans live in areas deemed to have a mental health clinician shortage.

What the Medicare rule doesn’t do

The proposed rule doesn’t allow for these providers to bill Medicare on their own. These providers’ services still get billed under the name of their supervising provider, Waltz said. 

These providers also still need to follow regulations dictating how providers establish relationships with each other and patients. Supervising clinicians can’t delegate care privileges, according to Waltz.

General supervision doesn’t necessarily mean less oversight from clinicians. If anything, it requires stronger coordination and communication of patient needs.

“The doctor should be looking at the notes like every time that the LMFT is seeing the patient,” Waltz said, adding that the behavioral health provider also needs to be proactive in communicating issues.

Care coordination is a perennial challenge in several segments of health care. This is true for behavioral health, which lags other health care segments in electronic health record use. Only 6% of behavioral health facilities and 29% of substance use disorder treatment centers use electronic health records.

“The federal government and the Medicare program specifically can play a leadership role in funding technology to support and advance care coordination because, right now, it is inadequate,” Kapur said, suggesting legislation comparable to the HITECH Act for behavioral health.

MAT, OTPs and telehealth

The proposed Medicare rule, if enacted as is, would increase funding for and clarify rules for addiction treatment.

Opioid treatment programs (OTPs) may bill Medicare for services provided by mobile units without a separate registration. CMS gives the example of mobile OTPs being offered from vans. Treatment offered in mobile units includes medication-assisted treatment (MAT).

For opioid use disorder (OUD) for example, this includes pairing other treatments with a prescription for methadone or buprenorphine. MAT with these medications is considered a gold standard of care.

“[MAT] does require regular appointments with a physician for prescribed MAT (such as Suboxone) or frequent visits to a clinic to receive methadone dosing,” Ryland said. “There is often greater demand than availability and for those without reliable public or personal transportation, this can be an insurmountable treatment barrier.”

OTPs can also expect an increased payment rate for starting MAT with buprenorphine via telehealth “ in order to better reflect the costs of the counseling services,” CMS said in a blog post.

“Patients who experience the optimal outcomes in medication-assisted treatment receive long-term, comprehensive treatment that includes counseling, nursing and physician services, medications, and ancillary services,” Ryland said. “The access to an integrated treatment plan to address multiple areas of need provides the best opportunity for long-term recovery and healthier families and communities.”

The rule would also extend the temporary flexibilities for telehealth 151 days after the end of the public health emergency (PHE).

Since March 2020, the federal government has extended loosened regulations for telehealth as a COVID mitigation effort. Under the PHE framework, certain services not on the physician fee schedule were temporarily billable.

The PHE-era telehealth flexibilities also allow for mental health services for Medicare beneficiaries to originate from the home and without an in-person visit.

More integrated care

CMS is also “proposing to pay for clinical psychologists and licensed clinical social workers to provide integrated behavioral health services as part of a patient’s primary care team.”

In some circles, the co-location or close coordination of behavioral health services with primary care is called integrated care.

“There’s been an ongoing movement probably for at least the last two decades to push integrated care,” Kapur said. “Allowing behavioral health practitioners to get compensated to participate with the primary care provider team is going to help really move the ball on that.”

Presently, Medicare covers certain mental health and addiction treatment services apart from primary care.

In 2017, CMS started paying Medicare care providers for what it called behavioral health integration (BHI). The proposed rule would allow for clinical psychologists or licensed clinical social workers to act as the “focal point of care integration” and to personally provide or direct the behavioral aspects of BHI. The new rule would also allow a psychiatric diagnostic evaluation to serve as the initiating visit for the new general BHI service. The rule also allows for the previous process of having the treating provider initiate BHI services.