Mental illness among young people in the United States was at a crisis point even before COVID-19. The pandemic exacerbated it, and the already overstretched mental health workforce has been unable to meet the growing need for care. Nearly 40 percent of young people receiving behavioral health care are Medicaid beneficiaries. Many mental health providers don’t accept Medicaid. As a result, young people — especially those living in rural areas and those of color — often can’t get the care they need.
Addressing this crisis will require a comprehensive, long-term approach, but there are immediate opportunities to address access challenges. One is the use of digital mental health technology (DMHT), which is used to assist clinicians in detecting, monitoring, and treating mental health challenges. While a variety of DMHTs exist, in this blog post we focus on those that use evidence-based interventions (e.g., cognitive behavioral therapy) and are used in conjunction with clinician-based care to extend, rather than replace, the behavioral health workforce.
If properly deployed, DMHT tools could bolster the mental health workforce, improve access to care, and support providers. While using DMHT can help increase access to care for people of all ages, it presents especially promising opportunities for young people, who tend to be avid users of digital technologies. Resources have been poured into the development of novel DMHTs, such as mobile applications that help people measure changes in their mental health symptoms or access treatment tools. Unfortunately, we lack policies to foster effective integration of these tools into the continuum of care and ensure clinical efficacy.
Obstacles to Scaling Digital Mental Health Technology
Federal regulation of DMHTs is minimal and their coverage under Medicaid and Medicare is limited. Confusion about when DMHTs warrant regulation is one reason these tools are underutilized in clinical care.
Uncertainty about reimbursement is among the biggest challenges. The rapid development of software, the slow pace of research, and the fact that digital technology often does not fit squarely into reimbursement categories makes payers hesitant to approve payment mechanisms.
There are also few reliable mechanisms to determine which DMHTs are safe, secure, and high-quality in an oversaturated market. The vast majority of DMHTs fall outside the scope of oversight by the Food and Drug Administration (FDA) — the primary agency tasked with ensuring the safety and efficacy of consumer products — leaving patients and clinicians to decipher which tools are best.
Emerging Federal and State Efforts
Federal and state policymakers have made incremental progress toward enabling reimbursement. The Centers for Medicare and Medicaid Services (CMS) is laying the groundwork for a “coverage with evidence development” process to enable reimbursement for digital tools with initial evidentiary support while research is conducted to develop a stronger evidence base. A few state Medicaid programs, such as Washington and Louisiana, have started developing coverage determination processes that are more suitable to the rapid development of digital tools. CMS and state Medicaid programs will need to implement ongoing monitoring of the cost and outcomes of DMHTs.
Efforts to support the adoption of DMHTs across other federal agencies are in early stages. The FDA is taking steps to facilitate the integration of digital health technologies broadly, but mental health technology has not been its priority. The Substance Abuse and Mental Health Services Administration is developing an advisory committee to help foster greater understanding of DMHTs. The Agency for Healthcare Research and Quality recently developed a framework for evaluating mobile mental health apps. Absent government action, private sector initiatives will seek to fill gaps. These actions, while preliminary, suggest that federal agencies are developing standards that will help providers and patients assess available DMHTs.
Federal Policy Opportunities
Recent research suggests a variety of policy opportunities the Biden administration could leverage to accelerate the adoption of safe and effective DMHTs, including:
- Relevant federal agencies should partner to develop more precise definitions and categories of DMHTs and clarify regulatory pathways to facilitate their safety, dissemination, and appropriate use. The guidance should cover the roles, responsibilities, and processes across federal agencies that are needed to advance access to evidence-based digital solutions. It could include guidelines for developing and evaluating technologies for accessibility, cultural and linguistic competence, capacity to advance health equity, and safety and efficacy for certain populations (e.g., people with cognitive impairment or severe mental illness).
- The Office of the National Coordinator should work across the public and private sectors to advance data security, interoperability, and privacy standards to ensure safe use of DMHT. Data privacy and security standards, designed to protect consumer data, should ensure that consumers of digital tools can easily provide their informed consent. Data interoperability standards should address how to integrate DMHT into clinician workflows and data systems, prioritizing the needs of local health authorities and community health centers.
- CMS should clarify existing state Medicaid authorities and opportunities to support the adoption of appropriate DMHT. Using an informational bulletin to states, CMS could provide guidance on how digital technology can support universal screening for mental health symptoms and reimbursement under Early and Periodic Screening, Diagnostic, and Treatment periodicity schedules. When DMHTs are used to enhance clinician care, providers can use existing reimbursement codes for clinician services. CMS should outline what codes providers can use, such as psychiatric add-on codes, collaborative care codes, or codes to cover patient education. It also could highlight examples from states that have adopted innovative processes for making coverage decisions about medical technologies.
Leveraging DMHT should be part of the immediate and long-term response to the youth mental health crisis. As available technologies rapidly evolve, our regulatory and reimbursement frameworks need to adapt accordingly to empower the mental health workforce to use every evidence-based tool at their disposal to meet young peoples’ needs.
