The pandemic has exacerbated psychological well being and substance use points and 90% of Individuals imagine the nation is within the midst of a psychological well being disaster. Regardless of will increase in want, knowledge present that remedy charges throughout all payers are low. Documented workforce challenges contribute to limitations in entry to care and practically half of the US inhabitants – 47% or 158 million folks – dwelling in a psychological well being workforce scarcity space. Behavioral well being situations (i.e. psychological well being and substance use issues) are most prevalent in Medicaid enrollees, with knowledge from 2020 displaying that roughly 39% of Medicaid enrollees have been dwelling with a psychological well being or substance use dysfunction. Workforce challenges are widespread and transcend Medicaid, however shortages could also be exacerbated in Medicaid. On common, solely 36% of psychiatrists settle for new Medicaid sufferers – decrease in comparison with different payers and in comparison with charges for physicians general (71%). Even when suppliers settle for Medicaid, they could solely take a number of sufferers or will not be presently taking new Medicaid sufferers. There’s consideration on the federal degree to handle workforce shortages—and states are additionally taking motion to handle these points for Medicaid enrollees and extra broadly. The Consolidated Appropriations Act handed in December 2022 approved further provisions to handle workforce shortages, together with new psychiatry residency positions, removing of further necessities for suppliers who need to prescribe sure drugs for opioid use dysfunction (OUD), necessities for improved Medicaid supplier directories, and new funds that can be utilized towards workforce initiatives for peer assist suppliers.
We surveyed state Medicaid officers about their state’s methods for addressing behavioral well being workforce shortages that have been in place in state fiscal 12 months (FY) 2022 or applied/deliberate for FY 2023. These questions have been a part of KFF’s Behavioral Well being Survey of state Medicaid applications, fielded as a complement to the 22nd annual price range survey of Medicaid officers performed by KFF and Well being Administration Associates (HMA). A complete of 44 states (together with the District of Columbia) responded to the survey, however response charges various by query.
State methods to handle the behavioral well being workforce scarcity fall into 4 key areas: rising charges, lowering burden, extending workforce, and incentivizing participation. We requested states about their methods to handle behavioral well being workforce shortages. Almost all states indicated utilizing at the very least one specified technique to extend behavioral well being workforce, with nearly half of states endorsing at the very least one technique in all 4 key areas. This concern transient describes these 4 classes of behavioral well being workforce methods and summarizes state Medicaid program exercise in every space.
Growing Reimbursement Charges
Gaps in entry to sure suppliers, particularly psychiatrists, are an ongoing problem in Medicaid and infrequently within the broader well being system on account of general supplier shortages and geographic maldistribution of behavioral well being suppliers. Decrease Medicaid fee charges (relative to different payers) in addition to disparities in pay between bodily and psychological well being suppliers might restrict participation in Medicaid and additional exacerbate current workforce shortages. Psychiatrists, for instance, obtain decrease Medicaid reimbursement than major care suppliers for related companies. States have appreciable flexibility to set supplier fee charges in fee-for-service. Managed care plans, which now serve most Medicaid beneficiaries, are accountable underneath their contracts with states for making certain ample supplier networks and setting charges to suppliers, however states have a number of choices to make sure that price will increase are handed to the suppliers that contract with managed care organizations (MCOs). The American Rescue Plan Act (ARPA) gave states momentary funding (primarily via a rise within the Medicaid match price for house and neighborhood primarily based companies (HCBS)) to extend sure supplier charges or present funds to draw or retain staff. COVID-19 Medicaid public well being emergency (PHE) authorities gave states further flexibility to undertake momentary price will increase.
To draw or retain Medicaid behavioral well being professionals, practically two-thirds of responding states (28 of 44) applied fee-for-service (FFS) price will increase in FY 2022 or plan to take action in FY 2023 (Determine 1). Of those, 19 states reported price will increase in FY 2022 and 23 states reported plans to extend charges in FY 2023. Sixteen states reported no price will increase for 2022 and 2023.
Many states report the usage of ARPA HCBS funds to briefly improve behavioral well being supplier charges. For instance, behavioral well being suppliers in Ohio have been accepted to obtain a one-time fee equal to 10% of claims paid in FY 2021. In some states, price will increase have been focused to particular supplier varieties, akin to will increase to residential degree of take care of SUD or will increase for utilized behavioral analysts. Different states applied will increase that have been extra widespread. For instance, the state of Oregon directed its Medicaid coordinated care organizations to extend the charges of behavioral well being suppliers: a 30% improve for suppliers who obtain 50% or extra of their income from Medicaid; 15% improve for suppliers who obtain lower than 50% Medicaid income; and extra differentials for sure forms of care (akin to culturally or linguistically particular companies). Missouri and Oklahoma are rising some supplier charges to be extra in keeping with Medicare charges. In most states that contract with MCOs, states reported that they might require MCOs to implement the FFS price will increase (for instance, via a state-directed fee). A smaller share of MCO states don’t require, however could encourage, MCOs to implement FFS price will increase.
Extending the Workforce
Given the substantial behavioral well being workforce scarcity, many state methods concentrate on choices that stretch the workforce akin to reimbursing for brand new supplier varieties, including supplier varieties that may invoice with no supervising practitioner, loosening restrictions on in-person necessities (akin to telehealth or interprofessional codes), or reimbursing for care delivered by trainees or the license-eligible workforce. Every state has its personal set of legal guidelines and laws that set requirements and specify the scope of apply for various supplier varieties. Medicaid businesses have flexibility to resolve which forms of suppliers and companies are eligible for reimbursement, in addition to the settings through which these companies have to be supplied, although there could also be some variation throughout MCOs.
Almost all responding states reported they’d at the very least one technique in place or deliberate for FY 2022/2023 to develop the workforce, akin to extending the forms of suppliers that would invoice for companies, utilizing inter-professional session codes, or participating in outreach efforts to recruit new suppliers (Determine 3). Most states with MCOs reported that necessities in FFS have been additionally required for MCOs. Including peer or household specialists as suppliers was essentially the most generally reported technique for increasing the workforce. As well as, some states reported extending direct reimbursement privileges to different forms of psychological well being practitioners. For instance, New Jersey now consists of licensed medical social staff as a sort of supplier that may invoice independently. Almost two-thirds of responding states reimburse companies delivered by people who’re license-eligible and practising underneath supervision as of FY 2022. Much less widespread methods included Medicaid reimbursement for inter-professional consultations and focused recruitment efforts, with round one-third of reporting states having both of those methods in place as of FY 2022. Interprofessional session codes can lengthen the workforce by permitting normal suppliers to be reimbursed for consultations with specialists. For instance, with this code, a rural major care supplier might get reimbursed for a session with a psychiatrist to debate medicine administration for a affected person with a critical psychological sickness. State curiosity in interprofessional consultations could improve following latest CMS steering stating that interprofessional session may be coated as a definite service.
Telehealth may additionally deal with behavioral well being workforce shortages and improve entry to care. States have broad authority to cowl telehealth in Medicaid with out federal approval. To extend well being care entry and restrict danger of viral publicity in the course of the pandemic, all 50 states and DC expanded protection and/or entry to telehealth companies in Medicaid, together with expansions aimed toward rising entry to telehealth supply of behavioral well being care. As of July 2021, most states reported large protection of telehealth companies in each FFS and managed care applications. In FY 2022, greater than three-quarters of states reported that behavioral well being companies have been amongst these with the best utilization. Within the present survey, the state of Nebraska famous that telehealth was the simplest technique for addressing its behavioral well being workforce challenges.
Lowering Administrative Burden
Supplier administrative burden refers to a variety of administrative actions and might embody prior authorization, prolonged kinds or documentation necessities, unclear processes to navigate, prolonged credentialling course of, and unclear causes for denials or auditing. Analysis signifies that administrative burden can impede supplier insurance coverage acceptance, notably if the executive burdens are disproportionate for Medicaid relative to different payers. Suppliers contracting with a number of MCOs could discover that administrative necessities and processes range between MCOs as a result of lack of standardization on the state degree. Various administrative burdens could also be notably difficult for smaller behavioral well being suppliers/organizations. Thus, addressing administrative burdens might scale back time related to unbillable supplier time and sources and lead to increased charges of Medicaid acceptance.
About three-quarters of responding states reported at the very least one technique in place or deliberate for FY 2022/2023 to scale back supplier administrative burden each in FFS and/or MCOs (Determine 4). States most steadily reported in search of behavioral well being supplier suggestions on administrative processes, adopted by implementing centralized or standardized credentialling. Notably, a number of states reported plans to implement centralized or standardized supplier credentialing in FY 2023, suggesting development within the adoption of this technique. Considerably fewer states reported standardized prior authorization, remedy plan kinds, or preliminary variety of items or days for prior accepted companies.
Notably, the authority of state Medicaid applications to independently scale back administrative burden could range by state, with some Medicaid applications having this authority unbiased of different state businesses, and others sharing it. For example, one state famous that their state’s behavioral well being authority additionally regulates documentation, so efforts to streamline documentation require collaboration between the 2 businesses.
Delays in reimbursement have been proven to scale back supplier participation in Medicaid, main some Medicaid businesses to undertake immediate fee insurance policies to incentivize supplier participation (along with federal immediate pay necessities). In North Carolina, as an example, well being plans should notify suppliers inside 18 calendar days of any further data wanted to course of a declare they usually should pay for accepted clear claims inside 30 calendar days. Some states could select to make use of monetary incentives to encourage suppliers to take part in built-in bodily and behavioral well being programs, with some incentives aimed toward rising behavioral well being screenings or creating the workforce. Monetary incentives for built-in care could lead to extra services offering behavioral well being care. Supplier participation may additionally be inspired via pupil mortgage compensation applications or different efforts to develop the workforce.
Most states reported immediate fee insurance policies in place in FY 2022 or deliberate for FY 2023, however fewer reported monetary incentives for built-in behavioral well being care (Determine 5). As of FY 2022, about two-thirds of reporting states have immediate fee insurance policies in place in FFS and/or MCOs. Fewer states reported offering monetary incentives to suppliers to take part in bodily and behavioral well being integration, with lower than one-fifth of responding states reporting doing so for FFS and/or MCOs in FY 2022.
Some states reported methods to develop the workforce or to create new coaching alternatives, together with efforts akin to pupil mortgage compensation, outreach, and medical supervision. For instance:
- Massachusetts is leveraging varied funding streams to implement pupil mortgage compensation applications in trade for 4 years of service in a community-based well being care setting; improve household nurse practitioner residency slots; and assist peer specialist coaching to extend the variety of licensed friends.
- Washington launched a marketing campaign to extend curiosity in behavioral well being careers, in addition to a pilot and coaching program to encourage behavioral well being suppliers to extend internships in FY 2022.
State Medicaid program efforts to bolster the behavioral well being workforce observe with continued efforts on the federal degree. In December 2022, Congress handed the Consolidated Appropriations Act, which approved the funding for at the very least 100 new residency positions devoted to psychiatry. Moreover, provisions within the Act will considerably improve the variety of suppliers approved to prescribe buprenorphine for the remedy of OUD by eliminating further administrative necessities to prescribe buprenorphine to sufferers with OUD. The Act may even require further coaching on treating and managing sufferers with OUD or SUD for all prescribers of managed substances. Different related provisions embody grants for psychological well being peer assist suppliers and necessities to enhance the accuracy and value of Medicaid supplier directories, which have been proven to be notably inaccurate for psychological well being. Quite a lot of these provisions have been included in bipartisan legislative drafts produced by the Senate Finance Committee.
This work was supported partly by Nicely Being Belief. KFF maintains full editorial management over all of its coverage evaluation, polling, and journalism actions.
This transient attracts on work executed underneath contract with Well being Administration Associates (HMA) consultants Angela Bergefurd, Gina Eckart, Kathleen Gifford, Roxanne Kennedy, Gina Lasky, and Lauren Niles.