This analysis is part of the USC-Brookings Schaeffer Initiative for Health Policy, which is a partnership between Economic Studies at Brookings and the University of Southern California Schaeffer Center for Health Policy & Economics. The Initiative aims to inform the national health care debate with rigorous, evidence-based analysis leading to practical recommendations using the collaborative strengths of USC and Brookings.
This paper is a response to a request for policy ideas from Senators Wyden and Crapo, the Chair and Ranking Member of the Senate Finance Committee. We address several issues raised by the request including the application of digital and communication technology to expand access to treatment, implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA) and its extensions, the behavioral health care work force, as well as provider and health plan accountability.
Telehealth and Digital Behavioral Health: Expanded use of telemedicine offers opportunities to improve access to behavioral health services. This is especially the case for geographic supply shortages. During the pandemic, states and the federal government made it easier for providers to offer services across state lines. Policymakers could encourage the continued use of cross-state compacts and federal policy changes that would enable providers in areas with more supply to serve shortage areas through telehealth. The proliferation of apps and “affective computing” raise issues of the scientific basis for these apps, quality monitoring, and privacy concerns. One important concern is that the scientific foundations of these interventions are often very weak and embed cultural norms. Regulatory authorities for these digital technologies span a variety of agencies and statutes, including the Food and Drug Administration (FDA) and the Office of Civil Rights at the Department of Health and Human Services (HHS). Congress should build institutional authority and capacity to address both the initial approval and use of such apps.
MHPAEA Implementation: The unfinished business of MHPAEA focuses on Non-Quantitative Treatment Limitations (NQTLs) or the regulation of care management. Addressing NQTLs involves the regulation of interventions that touch on clinical matters. That means there are many nuanced features that guide care management decisions that cannot be fully accounted for in regulatory guidance. There are several approaches that could be taken to addressing parity that allow insurers some flexibility to structure their plans efficiently while requiring them to meet outcomes that reflect fair access to treatment. These include: monitoring and establishing standards for price outcomes; monitoring and establishing standards for access to treatment; and focusing on persistent incentives to “over-manage” care.
Work Force: The pandemic has brought a spike in the demand for behavioral health care and a reacceleration of the opioid epidemic along with a growing stimulant crisis. Together, these developments are stretching behavioral health resources. The ability to access behavioral health services has been especially acute for the participants in public insurance programs like Medicare and Medicaid due to limited availability of professionals. Actions aimed at greater network participation in public and private insurance; scope of practice regulations that allow for better use of trained mental health practitioners that are not doctorly trained and application of technology (discussed earlier) can ease access problems created by workforce shortages.
Accountability: For over 20 years since the Surgeon General issued his report on mental health it has been recognized that there are broad arrays of evidence-based practices that can effectively treat many of the major mental illnesses that affect Americans. It remains the case today that people who could benefit from these specific treatments are unlikely to receive them – even if they have access to services. The percentage of treatments making use of evidence-based interventions has been stagnant for nearly two decades. Patients also commonly receive treatments that are contraindicated such as the use of antidepressants alone for bipolar disorder or inpatient detox without follow-up medications for opioid use disorder. The absence of strong accountability contributes to these failures. One approach to promoting improved performance would build on the alternative payment mechanisms that exist in major public health insurance programs. This approach would introduce greater accountability through establishing performance metrics that reflect the use of modern clinical science, reward integration of behavioral health and other medical care, and bolster accreditation systems used by the government to ensure the adequacy of providers to meet the needs of their populations.
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Sherry Glied is on the board of Geisinger. The authors did not receive financial support from any firm or person for this article or from any firm or person with a financial or political interest in this article. Other than the aforementioned, they are currently not an officer, director, or board member of any organization with an interest in this article.
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