With policymakers focused on mental health, care providers hope for real change

December 1, 2022

By LISA EISENHAUER

The federal government is allocating funding and drafting policy initiatives to address mental health and substance abuse at a rate that executives in the field within the Catholic health ministry extol as unprecedented, laudable and long overdue.

Even so, they are unsure if the cash infusion and legislative action will end what they see as a crisis level of mental and behavioral health needs and they worry the current focus won't last. They also say it's unclear if health systems will be able to tap any of the expanded funding to sustain and grow their services.


Morrow

Patty Morrow, operational vice president for behavioral health at St. Louis-based Mercy, says the federal effort is direly needed to address gaps in access, especially for vulnerable and rural communities, and to improve the system of mental and behavioral health care delivery.

She adds that to ensure the increased funding and revised policies address the crisis will require a "well-coordinated strategic plan" that puts the resources behind proven approaches to meeting needs within communities. "It's not just the dollars, but the planning around the dollars and the spend that I think is a really critical issue," Morrow says.

Big money, tragic trends
The stream of federal funds pouring into mental and substance abuse programs includes $3 billion in block grants to states as part of the American Rescue Plan Act approved in 2021. The Bipartisan Safer Communities Act passed in June added $100 million for states to cover mental health emergency preparedness, crisis response, and services around the 988 Suicide & Crisis Lifeline, which went national in July.


This room at The Link in Sioux Falls, South Dakota, is for people who are sobering up from alcohol and other intoxicants under the observation of staff. The Link is a center where people experiencing a nonviolent behavioral health crisis or needing care for substance abuse disorders can access immediate treatment and get referrals to follow-up services. It opened in June 2021 and is operated and partially funded by Avera Health.

The financial boost comes at a time when studies show many Americans' mental health is fragile and the scourge of substance misuse and addiction is worsening. The National Alliance on Mental Illness says 21% of U.S. adults, or 52.9 million people, experienced mental illness in 2020 and 6.7%, or 17 million, had a co-occurring substance use disorder and mental illness. The Centers for Disease Control and Prevention says opioid overdose deaths hit a record of 80,816 in 2021, up 15% from the year before.

Last year, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry and the Children's Hospital Association jointly issued a "Declaration of a National Emergency in Child and Adolescent Mental Health." It cited "soaring rates of mental health challenges among children, adolescents, and their families over the course of the COVID-19 pandemic."

In October, the groups behind that declaration along with CHA and 130 other organizations sent a letter to President Joe Biden urging him to issue a national emergency declaration. The letter said such a declaration would "galvanize existing critical funding streams and support to help ensure that all children and adolescents can access the full continuum of mental and behavioral health care."

Heightened needs
Thomas Otten, assistant vice president of behavioral health at Avera Health, says stressors and disruptions related to the pandemic — such as grief, isolation, school closures and socioeconomic challenges — have led to a spike in the number of people with depression, anxiety and other mental and behavioral health challenges. He credits that increase for policymakers' recognition of the impact of untreated mental illness on individuals and communities.


Otten

"I would say it's perhaps a silver lining of COVID that there's been a lot more attention focused on mental health and the well-being of people," Otten says. Historically, he says, mental health has been viewed by policymakers as "something different than medical care," a view he hopes is changing.

Otten adds that Sioux Falls, South Dakota-based Avera has responded to an increased demand for mental and behavioral health care in several ways. One has been to become a partner in and operator of The Link, a "community triage center" that opened in Sioux Falls in June 2021. The center is open to anyone regardless of ability to pay. It provides withdrawal management for substance abusers, observation for people who are intoxicated, and crisis stabilization for those with acute mental illness who don't need hospitalization. It is open around the clock.

The Link's annual operations budget of about $2 million is funded by Avera and three partners — the city, the county and another health care system.

Otten says he's unsure if the partnership will be able to tap any of the newer federal allocations to fund The Link, even though such funding could help ensure the long-term sustainability of a program that is meeting a critical need and diverting many patients away from more costly emergency room care.

State discretion
The federal government appears to be giving states wide latitude in the use of the block grants for mental health and substance abuse programs. Morrow says states could use that discretion to direct the funding only to state-run programs and facilities and community-based programs, such as alcohol and drug treatment centers.

Those programs are vital, Morrow says, but so are the services that Mercy provides, such as inpatient and virtual behavioral health care, that don't typically get state grants. "We will not necessarily be the recipients of this funding even though we have a significant mission-driven focus on serving people with mental health needs," she notes.


John

Policy changes around mental health services have proven beneficial to Mercy and other health systems in recent years. Dr. Kyle John, Mercy's clinical vice president of behavioral health, cites, by way of example, some of the temporary federal rules put in place because of the pandemic. One of those revisions has allowed mental health care providers to expand virtual access to all Medicaid and Medicare recipients. Most private insurers have followed suit.

The rule change is set to end when the public health emergency declaration around the COVID pandemic does. Keeping that revision and other pandemic-related policies in place could go a long way toward making mental health services financially viable, John says.

Support for integrated care
Mercy also is advocating for states to revise their Medicaid codes to cover the provision of mental health services in primary care settings. This is a model of care sanctioned by the Centers for Medicare and Medicaid Services, and most behavioral health care is delivered in primary care settings, John says. Even so, he points out, fewer than half of states have revised their Medicaid billing codes to support this approach. Three states in Mercy's four-state footprint — Missouri, Arkansas and Oklahoma — are among those that have not.


Waghray

Dr. Arpan Waghray, chief executive of Well Being Trust, says he would like to see some of the new federal funding allocated to support the kind of integration of mental health care into primary care settings that many health providers have been implementing in recent years.

Well Being Trust is a foundation that was created with an endowment from Providence St. Joseph Health. It is focused on advancing mental, social and spiritual health. Providence is among the systems that have moved toward mental health and medical care integration, including screening patients in primary care clinics for signs of depression, anxiety and drug abuse and offering treatment.

Waghray says the lion's share of behavioral health resources are concentrated in specialty mental health services yet only about one-third of patients with mental health concerns receive care in that setting. The vast majority of those with mental illness, he says, get treatment in family, pediatric, maternity and other primary care clinics.

Counting on partnerships
Michelle Schafer, SSM Health regional vice president of behavioral medicine, says SSM Health has many partnerships with community organizations to address mental illness and the social determinants that affect patients' health. One such partner program is Places for People, a nonprofit in St. Louis that helps people with mental illness and people in recovery from substance use disorders develop skills to manage their conditions and lead meaningful lives.


Schafer

Even if most of the direct federal funding bypasses SSM Health, she says it is likely to boost some of the system's partners and help sustain their joint efforts with SSM Health.

SSM Health Behavioral Health Urgent Care, which the system opened in August 2020 on the campus of SSM Health DePaul Hospital — St. Louis, works with several community mental health agencies. These community-level providers promote clients' use of the urgent care facility for episodic treatment, and they take referrals for follow-up care from the urgent care clinic.

Schafer says that if some of the increased federal funding flows to community-based programs for patients with mental illness, the investment will address patients' needs upstream before their issues reach a crisis point and acute stabilizing care is more difficult and more costly to provide.

Schafer is co-chair of a statewide collaborative in Missouri that includes members of the state legislature. The collaborative is taking a coordinated approach to deciding how best to meet the demand for behavioral health services. She says the work includes evaluating funding, legislative initiatives, Medicaid's structure and other factors with the goal of creating a coherent system of care that is effective and that provides access to anyone in need of mental or behavioral health care.

Schafer thinks unified efforts like this one along with the heightened federal focus and increased funding could bring needed change to how, where and at what point in a patient's illness mental health care is delivered.

"We have a real window of opportunity for the first time in my career, and I've been doing this a long time. I've been in this world for 30 years," she says. "I don't want us to lose traction. I don't want our legislators to lose interest or to move on to a different thing."

Comprehensive mental health package moves toward approval in Congress

Clay O'Dell, who tracks initiatives around mental health care as part of his work as director of advocacy for CHA, says a comprehensive package of mental health care legislation is being drafted by the Senate finance committee. The package will address a range of issues including workforce, telehealth and insurance coverage, but is unlikely to make it to the finish line in the current Congress. Nevertheless, O'Dell says the prospect for its passage is good.

"The long and short of it is, everybody thinks, and I agree, that this work is going to continue into the next Congress," he says. "The good news is that all of the work that's been done so far by the committee has been bipartisan."

Several of the legislative proposals that the committee's five working groups have released align with what CHA and its members have been seeking, O'Dell says. Those requests are outlined in a policy brief created by CHA and posted on its website, chausa.org.

Among the working groups' proposals are:

  • Removing the requirement for Medicare patients to receive an in-person visit with a provider prior to receiving mental health services through telehealth. The requirement has not been in force during the COVID-19 public health emergency.
  • Allowing Medicare beneficiaries who seek treatment for mental health disorders to receive their care through audio-only services.
  • Providing incentives to states to use their Children's Health Insurance Program to address behavioral health needs in schools, including through telehealth.
  • Allowing providers to receive Medicaid reimbursement for behavioral and physical health services delivered on the same day.
  • Issuing Medicaid guidance to states to clarify allowable payments, identify strategies to reduce administrative burdens, and improve access to mental health and substance use disorder services to children and young adults, including strategies to deliver services in home or community-based settings.

— LISA EISENHAUER

 

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