With the growing senior population and rising mental health and substance use issues among this demographic, the Centers for Medicare and Medicaid (CMS) are looking for new approaches to address behavioral health concerns.
Roughly 20% of people over the age of 55 have experienced a behavioral health issue, according to the CDC. In order to combat this issue, CMS has rolled out several initiatives to help expand the behavioral health workforce, offer more services and move toward value-based care.
“Mental health and substance use disorder in elderly and disabled populations is well understood and is also a growing need, while at the same time, we continue to have workforce shortages,” Dr. Katherine Hobbs, founder and CEO of Author Health, said during Behavioral Health Business’ VALUE event. “So opening up access to different types of providers and different types of services is critically important for us to be able to meet the future need.”
Author Health is a hybrid care mental health provider that serves seniors on Medicare Advantage plans. It raised $115 million in its debut funding round.
The Biden administration continues prioritizing behavioral health for seniors in its new 2025 budget proposal. The proposal includes $8.1 billion for the Substance Abuse and Mental Health Services Administration, including specific funding for older adult suicide prevention programs.
Despite these efforts, Medicare has a long way to go regarding behavioral health and moving the dial on value-based care.
Mental health and substance use disorder in elderly and disabled populations is well understood and is also a growing need, while at the same time, we continue to have workforce shortages.
Dr. Katherine Hobbs, founder and CEO of Author Health
The promise and limitations of CMS’ New efforts
CMS has made a number of changes over the past few years that could expand the types of mental health clinicians and services that Medicare beneficiaries can access.
In November, the agency finalized a rule allowing marriage and family therapists and mental health counselors to enroll in Medicare for the first time. It also increased payment for crisis care, SUD treatment and psychotherapy.
The impact of the changes could help Medicare beneficiaries access care more readily.
“Adding these providers, hopefully, will increase access, particularly for people who might live in rural communities where there isn’t a psychiatrist and there may not be a psychologist,” Michelle Guerra, clinical programs manager of health care services at Premera Blue Cross, said at VALUE. “We also know that there is a provider shortage in the United States and people with commercial insurance or even no insurance at all are having trouble finding care.”
Premera Blue Cross is a non-profit Blue Cross Blue Shield health plan serving members in Washington state and Alaska. It has 2.8 million members.
I’m going to wait and see how many providers take up the mantle and accept the Medicare payment rate.
Michelle Guerra, clinical programs manager of healthcare services, Premera Blue Cross
However, this new change is likely not a cure-all for expanding access to behavioral health clinicians for Medicare beneficiaries.
“About 20-30% of counselors don’t take any insurance whatsoever,” Guerra said. “So yes, Medicare beneficiaries have more access now to these providers, but they might also be struggling to get timely appointments just like everybody else. So I’m going to wait and see how many providers take up the mantle and accept the Medicare payment rate.”
The agency also opened up new services for coverage, including intensive outpatient programs (IOPs).
“Having IOP accessible to Medicare beneficiaries is extremely important,” Dr. Lori Ryland, chief clinical officer of Pinnacle Treatment Centers, said at VALUE. “It allows for a more intense level of care than a traditional outpatient would.”
Pinnacle is a private equity-backed substance use disorder provider with 140 locations across California, Georgia, Indiana, Kentucky, New Jersey, North Carolina, Ohio, Pennsylvania and Virginia.
Still, there are some limitations to where those services are offered. For example, these IOP services must be provided in a hospital setting, a federally qualified health center, a community mental health center, a rural health center, or an opioid treatment program, according to Ryland. This means that facilities treating other conditions, such as alcohol use disorder, would not be eligible to offer these services.
And there are still other gaps in Medicare coverage. For example, residential addiction treatment is not covered and there remains a cap on lifetime inpatient behavioral health stays.
A path forward
One of the major focus areas for CMS is prevention and upstream intervention. This is evident across health care. For example, Medicare now covers navigation services to help its beneficiaries reduce the barrier to care created by social needs.
Screenings are a significant part of these prevention efforts. Tobacco screenings are covered under Medicare, and if a beneficiary screens positive, then a free session is covered. Still, not all behavioral health services have this streamlined approach.
“What’s interesting is depression screening is also covered under the [Medicare] benefit but there are no free counseling sessions that go with that,” Guerra said. “The scaffolding is there. The opportunity is there. I would really like to see Medicare go the little extra step of bringing in some free sessions to support depression since about 18 to 20% of older adults on Medicare are dealing with depression.”
Upstream interventions could be a significant factor in moving Medicare to a more value-based care future. In many ways, Medicare providers are positioned to engage in value-based care contracting.
“There have been major advances in value-based reimbursement and value-based care delivery within Medicare, and it was really the main area of innovation over the last several decades,” Hobbs said. “So a lot of the infrastructure that’s required to deliver a value-based payment model already exists within Medicare and we can gain a lot from our learnings on the physical health side. There are measures that are validated for quality and behavioral health that can be applied here and that are currently used within Medicare.”
These outcomes and quality measures include clinical measures, including the PHQ-9 and GAD-7, as well as seniors-specific measures, including HEDIS, which are tailored to the Medicare population.
But the path to a truly value-based care future may be very forward-looking.
“I think there are a lot of opportunities there. I go back to the fact that there tended to be some gaps,” Ryland said. “So it’s difficult to see a significant push forward in value-based care with some of the gaps existing.”
Companies featured in this article:
Author Health, Pinnacle Treatment Centers, Premera Blue Cross
