Last Friday, the U.S. Department of Health and Human Services (HHS or the Department) released a roadmap for addressing the mental health crisis facing this country. Many of you are acutely aware of the staggering statistics around mental health disorders, which are cited in HHS’ report: in 2020, 52.9 million adults, or 21 percent of the U.S. population, were affected by mental illness and 37.9 million, or 15 percent, of U.S. adults had a substance use disorder.
This isn’t the first time this administration (or prior ones) has tried to come up with a plan to tackle this issue. With respect to the current administration, President Biden announced a national strategy in his first State of the Union Address to prevent and treat mental health and substance use disorders. The strategy included three overarching pillars:
- Strengthen System Capacity: Expand the supply and diversity of the behavioral health workforce and ensure the full continuum of behavioral health care is available.
- Connect Americans to Care: Bridge the gap between services the system offers and people's ability to get the care they need.
- Support Americans by Creating Healthy Environments: Make "a whole-of-society effort," recognizing the importance of "culture and environment" in promotion, prevention, and recovery.
HHS has already tried to advance some of these objectives, releasing initiatives such as the HHS Overdose Prevention Strategy, the U.S. Surgeon General’s Advisory on Protecting Youth Mental Health, and the implementation of 9-8-8 as the new National Suicide Prevention Lifeline along with linking 9-8-8 to mobile crisis services.
The roadmap issued last week focuses on another important goal— the integration of behavioral health services with health care, social service, and early childhood systems. It also focuses on the need to achieve equity in access to “affordable, high quality, culturally appropriate” care for mental health and substance use disorders.
So how does HHS intend to achieve these goals?
- First, the roadmap states that we need to build a more diverse workforce prepared to practice in integrated settings in order to combat barriers to access, including staffing shortages, inadequate reimbursement, inadequate education and training opportunities, lack of diversity, and burnout. Further, in order to address gap between behavioral health care providers and physical health care providers in adoption of technologies, including telehealth, HHS has identified opportunities to increase behavioral health integration, coordination, and consultation in a range of settings. HHS lists specific examples in the roadmap of publicly announced programs and activities to that address these challenges to behavioral health integration.
- Second, behavioral health services must be made more affordable. Although HHS states that the Mental Health Parity and Addiction Equity Act and the Affordable Care Act “have driven substantial progress towards narrowing gaps in patient cost sharing and other treatment limitations between M/SUD services and other medical services across a range of health plans,” but that “further efforts are needed to close these gaps entirely and fully realize the goal of parity.” The Department identifies ways in the roadmap to ensure that high-risk populations who need behavioral health services the most actually receive them. In many cases, it is these individuals who have faced the greatest barriers to receiving care due to structural inequities and those at elevated risk for mortality and other serious adverse outcomes related to their behavioral health conditions.
- Finally, HHS highlights ways to align structural supports and financing to integrate promotion and prevention programs in community-based settings. In other words, investments in behavioral health need to be more focused on “culturally relevant, person-centered, and evidence-based promotion and prevention services.”
Many of the goals highlighted in the roadmap are areas that ACEP has supported in the past, particularly around ensuring coverage parity between mental health and physical health services; addressing workforce challenges; and making coverage more affordable.
However, while the goals articulated in the roadmap are admirable, they don’t directly tackle the challenges you as emergency physicians face every day dealing with mental health patients in the emergency department (ED). In fact, the roadmap only includes one example of a program aimed at supporting mental care services delivered in EDs.
Although ACEP is still refining our overall strategy to address the multitude of issues around mental health care in the ED setting (and we are continually reevaluating our potential strategy as new challenges present themselves), we do lay some groundwork for potential areas for reform and advancement in a February 2022 response to a Congressional request for information on mental health care. In this response, we highlight the following five key areas that we believe policymakers must address:
- Strengthening the Mental/Behavioral Health Workforce: Due to the fragmented nature of the mental health care infrastructure in the U.S., persistent lack of sufficient resources, and longstanding shortages of mental and behavioral health professionals, far too many Americans have limited options for longer-term follow-up treatment. These challenges contribute to long ED wait times and aggravate “boarding” issues, a scenario where patients are kept in the ED for extended periods of time due to a lack of available inpatient beds or space in other facilities where they could be transferred. I have discussed the issue of ED boarding in a previous Regs and Eggs blog post, and I don’t have to tell you that ED boarding is as bad as it has ever been. ED boarding challenges disproportionately affect patients with behavioral health needs who wait on average three times longer than medical patients because of these significant gaps in our health care system.
Another significant issue impacting the health care workforce is the increased risk of violence against physicians, nurses, and other health care workers, especially those who care for psychiatric patients. ACEP, along with Marketing General Incorporated* (MGI), just released results from an August 2022 survey today that shows that 85 percent of emergency physicians believe the rate of violence experienced in ED has increased over the past five years, with 45 percent indicating it has greatly increased. Over half (55 percent) of emergency physicians report they have been assaulted while working in the ED, while nearly 80 percent have witnessed an assault in the ED. Emergency physicians report that psychiatric patients and those seeking drugs or under the influence of drugs or alcohol are most often responsible for the assaults experienced (42 percent and 40 percent, respectively).
This increased risk of violence, along with many other factors, is leading to an extremely high level of burnout among physicians. In fact, the American Medical Association (AMA) recently released a study showing that 62.8 percent of physicians felt burned out in 2021. Further, despite the passage of the monumental Dr. Lorna Breen Health Care Provider Protection Act, many health care workers are still hesitant to seek mental health treatment. This past Saturday was National Physician Suicide Awareness Day, marking an opportunity to underscore how crucial it is to come together to break down the culture of silence around mental health and suicide.
- Increasing Integration, Coordination, and Access to Care: ACEP believes that improving coordination of care across the health care continuum must be one of the highest priorities for any mental health reform effort. The ED serves as the critical health care safety net not only for acute injuries, but for psychiatric emergencies as well. However, most EDs are not ideal facilities to provide longer-term care for patients experiencing a mental health crisis – they are often hectic, noisy, and particularly disruptive for behavioral health patients. Across the country, communities have adopted innovative alternative models to improve emergency psychiatric care and reduce psychiatric patient boarding. The ultimate success of any model hinges on the availability of resources, whether monetary, staffing, or access to follow-up services and patient access to long-term mental and behavioral health care.
Another longstanding barrier to providing adequate mental health treatment services is the Medicaid Institutions for Mental Disease (IMD) exclusion that prohibits the federal government from providing Medicaid reimbursement to states for care provided to most patients in an inpatient psychiatric or SUD facility with more than 16 beds. Though this longstanding policy was intended to reduce the number of people committed to long-term psychiatric treatment facilities without receiving appropriate care, it has perpetuated the problem of disparate treatment of mental health and has stood as a major barrier in the effort to provide necessary non-hospital inpatient psychiatric care options. As a limited workaround, states have been able to apply for Section 1115 Medicaid waivers to receive matching federal funds for short-term residential treatment services in an IMD. ACEP has long advocated for full repeal of the IMD exclusion and strongly urges Congress to rescind this policy either as a standalone effort or as a cornerstone of any comprehensive mental health reform legislation.
- Ensuring Parity Between Behavioral and Physical Health Care: As with the HHS roadmap, ACEP also does not believe that the Mental Health Parity and Addiction Equity Act and the Affordable Care Act go far enough to ensure parity between behavioral and physical health care. Despite these federal laws, there is no mechanism for the federal government to enforce compliance against plans that continue to violate parity requirements and discriminate against patients with mental health conditions or substance use disorder. ACEP supports legislation that would provide the Department of Labor with the ability to issue civil monetary penalties for violations of the Mental Health Parity and Addiction Equity Act.
Without enforcement penalties and more explicit parity requirements, we will continue to see insurers attempting to limit the coverage available to beneficiaries experiencing mental health crises. As described in a previous Regs and Eggs post, there was a recent example in Maryland where Optum, a subsidiary of UnitedHealthcare, instituted a policy that only allowed certain specialists who identify as “mental health practitioners” to bill for services delivered to patients in the ED who have a primary diagnosis related to a mental health condition. In other words, emergency physicians in Maryland who, as you well know, treat people with mental health disorders on a routine basis, weren’t allowed to bill for any mental health services they delivered to their Medicaid patients! While this issue has mostly (but not completely) been resolved, it represents yet another example of insurers attempting to disregard the Prudent Layperson Standard (PLP). The PLP a longstanding and critical policy that protects patients from retroactive denials of insurance coverage for emergency department visits that are ultimately determined to be non-emergent.
Finally, we believe that ensuring parity for behavioral health care also requires appropriate treatment of substance use and opioid use disorders (SUD/OUD). To help reduce the pervasive stigma associated with SUD/OUD and treatment for these health conditions, ACEP supports the complete elimination of the X-waiver requirement to prescribe buprenorphine for medication assisted treatment (MAT). The Mainstreaming Addiction Treatment (MAT) Act, which would remove the X-waiver requirement, has passed in the U.S. House of Representatives, and ACEP continues working to ensure this legislation also passes the Senate and is signed into law.
- Furthering the Use of Telehealth: Telehealth has helped reduce barriers and increase access to care, especially during the COVID-19 pandemic—and ACEP supports both Congress’ and the Administration’s efforts to expand telehealth flexibilities during the public health emergency (PHE). In fact, a recent study in JAMA Psychiatry demonstrated that there was an increased use of telehealth services during the COVID-19 pandemic for the treatment of opioid use disorder and that these additional services helped individuals stay in treatment longer and reduce their overall risk of medically treated overdose. ACEP supports legislation, the Advancing Telehealth Beyond COVID-19 Act (H.R. 4040), that would extend the telehealth flexibilities and waivers granted during the PHE for two years once the PHE ends.
- Improving Access to Behavioral Health Care for Children and Young People: As the U.S. Department of Education report “Supporting Child and Student Social, Emotional, Behavioral, and Mental Health Needs” notes, children have experienced isolation, bereavement, depression, worry, and other issues throughout the COVID-19 pandemic, leading to reports of anxiety, mood, and eating disorders, as well as increased self-harm behavior and suicidal ideation at nearly twice the rate of adults. Pediatric ED visits related to mental health significantly increased during the pandemic — a 24 percent increase for children 5-11 years of age, and a 31 percent increase for children 12-17. These stressors affect children’s development and ability to learn in both the immediate and long term, with lasting consequences should their mental health needs not be adequately addressed. Given the substantial strains on the health care and social safety nets that existed long before the pandemic hit, it is clear that EDs, child welfare systems, the child and adolescent mental health workforce, and other related services will need considerable investments and significantly expanded resources in order to appropriately address this unprecedented challenge. Thus, as policymakers evaluate suggestions to improve mental and behavioral health access, ACEP believes that they consider the implications such policies would have on pediatric care.
Again, these represent the first set of priorities around addressing the challenges you as emergency physicians face treating patients with mental health disorders in the ED. Stay tuned for more updates on our mental health strategy and our own “roadmap” for tackling these issues in the months ahead!
Before concluding, I have a quick programming note: There will be no Regs & Eggs the next couple of weeks. It will return in full swing Thursday, October 13.
Until then, this is Jeffrey saying, enjoy reading regs with your eggs.