Meadows Mental Health Policy Institute

Full Testimony

Presented to the U.S. Senate Finance Committee by Andy Keller, President & CEO of the Meadows Institute on March 30, 2022

Quotes from the Testimony

“The simplest explanation for these consistently worsening behavioral health indicators is that we have dramatically cut spending on behavioral health over the last 40 years. In 1986, behavioral health represented 9.3% of all medical spending. But a host of policy decisions, including the shift among insurers to manage behavioral health as a cost-center separate from other health conditions, led to extensive spending reductions. By 1998, behavioral health spending had been reduced by at least 20% more than other health care spending, to just 7.4% of all medical spending, and these decreased spending levels held constant going forward.”

“Nearly four decades of services erosion cannot be fixed overnight, and to offset the trajectory we are on, we will need both the public and private sectors as part of the solution.”

“Despite attention from Congress and Presidential Administrations for decades, parity implementation gaps persist, with millions of Americans unable to access needed behavioral health services. A 2019 Milliman research report detailed widespread network adequacy and reimbursement parity concerns for commercially insured consumers: Commercially insured individuals were between five and six times more likely to use out-of-network providers for their behavioral health needs than for other healthcare.”

“In January of this year, the Department of Labor (DOL), Department of Health and Human Services (HHS), and the Treasury released The Report to Congress on Implementation of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. In what the three departments termed “a failure to deliver parity,” the report found broad non-compliance with MHPAEA’s requirements among health insurance plans, with all 58 plans reviewed failing to meet requirements.”

“Specific alarms were raised regarding the use of non-quantitative treatment limitations (NQTLs),which are non-numerical limits on the scope or duration of benefits for treatment (such as pre-authorization requirements, differences in provider availability, and application of medical necessity standards).”

“There is also a significant issue with SUD network adequacy and a lack of SUD providers covered by Medicare. Providers that are not covered by Medicare include Licensed Professional Counselors, Licensed Addiction Counselors, Certified Alcohol and Drug Counselors, and Peer Support Specialists. As a result, many patients who seek treatment are unable to access it.”

“The primary impediment to parity is the lack of providers to deliver care cost-effectively, and integration of behavioral health providers and care deliver into primary care offers the only path to removing this barrier. To adequately address the magnitude of behavioral health need in America, we must combine enhanced parity enforcement with an aggressive effort to integrate behavioral health into primary care. Broad scale adoption of evidence-based primary care interventions for mental health and substance use disorders are essential to realizing the promise of parity for two reasons. First, decades of research and over 90 randomized control trials have clearly shown that the two-thirds of needs which fall into the mild to moderate range can be better treated in primary care than in specialty care. Second, serving most people in primary care would allow America’s limited specialty care workforce to focus on people with more severe and complex needs.”

“Two models best represent the promise of reaching people in primary care rather than referring them to overwhelmed and understaffed specialty care systems: 1) the Collaborative Care Model (CoCM) and 2) Primary Care Behavioral Health (PCBH). CoCM and PCBH each have th potential to magnify the reach of our limited workforce many times over, and analysis carried out by the Meadows Institute shows that CoCM can leverage psychiatrist time 3.5 times over and PCBH can leverage other licensed practitioner time 2.65 times over.43 In early 2021, comprehensive studies through both RAND and the Bipartisan Policy Center endorsed these strategies, and RAND offered specific recommendations for scaling them nationwide. CoCM is the most extensively researched and evidence-based integration strategy to detect and treat mental health and substance use disorders before they become crises.”

Andy Keller, President & CEO, Meadows Institute