Expert Consensus on the Impact of COVID-Response Medicare Policies on Mental Health, Substance Use Care, and Costs

Abstract

Issue: Medicare policy changes made in response to the COVID-19 pandemic may have important implications for the accessibility, quality, and affordability of mental health and substance use disorder care. Evidence is needed to inform decisions on sustaining these policies for the long term.

Goals: To characterize evidence and expert consensus on how sustaining pandemic-related Medicare policy changes might influence care and costs for beneficiaries with mental illnesses or substance use disorders.

Methods: We conducted an evidence review and a modified Delphi expert consensus process to examine experts’ opinions on whether to sustain COVID-response Medicare policies relevant to mental health or substance use disorders.

Key Findings and Conclusions: A policy waiving discharge planning requirements is likely harmful to care quality. However, policies expanding telehealth coverage, relaxing Part D restrictions, and increasing staffing flexibility likely increase Medicare beneficiaries’ access to mental health and substance use disorder care. Sustaining these three policies could improve beneficiaries’ access to mental health and substance use disorder care. Additional research is needed to understand how to best leverage these policies to achieve high-value care.

Introduction

Gaps in Medicare mental health and substance use coverage make high-quality mental health and substance use disorder care inaccessible and/or unaffordable for many beneficiaries.¹ Multiple Medicare policy changes made in response to the COVID-19 pandemic — for example telehealth coverage expansions and relaxation of staffing requirements — have potentially important implications for the accessibility, quality, and affordability of mental health and substance use disorder care.² While these policy changes were designed as short-term pandemic responses, there is ongoing dialogue regarding whether, and in what form, these COVID-related policy changes should be made permanent.

Many pandemic-driven policies are tied to the COVID-19 public health emergency issued by the U.S. Department of Health and Human Services. Some policy changes made in response to the COVID-19 public health emergency could, if sustained long term, benefit Medicare beneficiaries with mental illnesses or substance use disorders. However, other policies could have detrimental effects or unintended adverse consequences. To learn more, we reviewed evidence and sought experts’ opinions on 36 COVID-response policies that apply directly or indirectly to beneficiaries with mental health and substance use disorders (Appendix).

Key Findings

Four categories of COVID-response policies emerged as having likely effects on Medicare beneficiaries with mental illnesses or substance use disorders: telehealth policies, Medicare Part D policies, staffing flexibility policies, and a policy waiving hospital discharge planning.

Expert panelists viewed the four groups of policies as likely to have similar effects on both mental health and substance use treatment. Thus, we do not distinguish between the two behavioral health conditions in the presentation of results.

Telehealth Policies

We identified 14 policies related to Medicare coverage of mental health and substance use disorder services delivered via telehealth (Appendix). For illustrative purposes, we present expert consensus on the likely effects of five of these policies (Exhibit 1).

Most expert panelists viewed policies expanding Medicare telehealth coverage as likely to increase access to services for mental health and substance use disorders. While more access does not necessarily lead to better outcomes — if care is of low value or quality — experts expected that, given the significant mental health treatment gap, a higher volume of services delivered should increase desirable outcomes and increase insurer spending on behavioral health. These expert perspectives are supported by published evaluations of telehealth policies.¹⁰

However, during the panel discussion, experts emphasized the need for research to better understand the effects of telehealth policies on access to care among subgroups of beneficiaries. Panelists highlighted the importance of understanding whether telehealth policies benefit beneficiaries who would not typically get treatment or get less treatment in the absence of these government actions, or whether the policies lead to increased treatment utilization among Medicare beneficiaries who would ordinarily get similar in-person treatment regardless of these policies.

These pending questions contributed to low consensus among experts on the effects of telehealth policies on beneficiary out-of-pocket spending. If these policies lead beneficiaries to substitute telehealth services for a similar volume of in-person services, then their out-of-pocket spending should not change, although they may spend less on transportation, childcare, and other services needed to attend in-person treatment. On the other hand, if these policies lead beneficiaries to access new or additional services via telehealth, then their out-of-pocket spending may increase. However, taking a longer-term perspective, increased access to treatment may reduce both beneficiary out-of-pocket and insurer spending by preventing inpatient hospitalizations and other costly service utilization for high-acuity behavioral health problems.

Expert panelists also highlighted the need for future research to understand the effects of Medicare telehealth policies on the quality of mental health and substance use disorder care, including whether care is evidence-based, high-value, person-centered, and culturally appropriate. Additional research also is needed to understand the equity implications of these telehealth policies. A recent study estimated that 26 percent of Medicare beneficiaries lack telehealth readiness because they do not have a computer, high-speed internet access, or a phone with a wireless data plan.¹¹

As of September 2022, most of these telehealth policies were still in place (Appendix). Some of the identified telehealth policies will end when the public health emergency (PHE) expires. When this happens, policy waivers will expire, but some policies will be maintained. For example, the Centers for Medicare and Medicaid Services (CMS) allowed federally qualified health centers and rural health centers to be telehealth distant sites during the pandemic. This policy has been made permanent for mental health services; however, 151 days after the public health emergency expires, these facilities will no longer be able to serve as distant sites for non-mental-health telehealth visits. CMS also waived in-person visit requirements for mental health care delivered via telehealth. Approximately five months after the PHE ends, a modified version of the requirement that patients seeking care via telehealth have an in-person visit within six months of the initial appointment will take effect.¹²

Medicare Part D Policies

We identified three policies related to Medicare Part D (Exhibit 2). These policies were designed to support continuous access to prescription medications in the face of pandemic-related disruptions. Most experts agreed that these policies improve access to behavioral health medications and, as a result, support desirable health outcomes. Panelists also viewed the Part D policies that allow enrollees to obtain the total supply of medications and relax plan-imposed restrictions on mail or home delivery as likely to improve quality of care by supporting medication continuity. However, several panelists noted potential safety concerns and the importance of prescribers adequately informing patients on instructions for use.

There was a lack of expert consensus on how these policies would influence beneficiary out-of-pocket and insurer spending. In the short term, if these policies facilitate significantly easier access to medications, they might increase spending. Longer term, these policies may reduce both beneficiary and insurer spending as increased medication continuity could prevent more costly services.

While our evidence review did not identify studies of these three COVID-response Part D policies, research has shown that policies easing access to prescription drugs can increase adherence to chronic disease medications and, over the long term, reduce hospitalizations and costs among Medicare beneficiaries.¹³

As of September 2022, these Part D policies were still in place and are tied to the public health emergency declaration.

Medicare Provider Flexibility Policies

We identified seven Medicare policies related to how providers serving Medicare beneficiaries are organized (Appendix). Below we present expert consensus on the likely effects of five of these policies (Exhibit 3).

Panelists agreed that the five policies should increase access to mental health and substance use disorder care, though they thought that the gains would be small in magnitude.

Most experts thought that the policies designed to shift service delivery from physicians to less time-stretched providers, such as physician assistants or nurse practitioners, would likely not harm or potentially improve quality of care. Panelists also thought that these policies would likely improve desirable outcomes among beneficiaries by way of enhanced access to care and potentially higher quality of care. These perspectives are supported by research showing that task-shifting from providers with higher-level credentials to those with lower-level credentials can improve access without sacrificing quality.¹⁴

Panelists also largely agreed that the licensure portability policy, which waives in-state licensing requirements for physicians and nonphysician practitioners, increases Medicare beneficiaries’ access to behavioral health services. During the panel discussion, experts noted that sustaining this policy over the long term could be particularly beneficial if telehealth policies, discussed above, are also sustained to support mental health and substance use disorder services.

The lack of expert consensus on the likely effects of these policies on beneficiary and insurer spending were driven by the same considerations described above for telehealth and Part D policies. Specifically, experts point to the need to weigh short-term increases in spending resulting from increased utilization against potential long-term savings stemming from decreases in high-cost, high-acuity care after beneficiaries get needed behavioral health treatment.

Most of these COVID-response policies were still in place as of September 2022, and certain policies or elements of policies have been made permanent. For example, CMS has made permanent a policy allowing all care team members to document in the medical record. In other cases, policy waivers have been modified or revoked for certain facilities. In May 2022, CMS terminated the waiver that allowed physicians to delegate tasks in skilled nursing facilities.¹⁵ In general, the remaining policies will either expire completely or in part when the public health emergency expires.

Medicare Discharge Planning Policy

In response to the COVID-19 pandemic, CMS enacted a policy stating that hospitals, including psychiatric hospitals and critical access hospitals, are not required to provide discharge planning. This policy was still in effect as of September 2022 and is slated to remain in effect until the end of the public health emergency.

Experts concurred that this policy would likely have detrimental consequences for mental health and substance use disorder care:

• 71 percent of panelists agreed that the policy would decrease access.
• 86 percent foresaw a decrease in quality because of this policy.
• 79 percent thought the policy would adversely affect beneficiary outcomes.

Conclusion

Sustaining COVID-era policies that expand telehealth coverage; relaxation of Part D restrictions on prescription supply, refills, and mode of delivery; and grant increased flexibility in how providers are organized could benefit Medicare beneficiaries with mental illness and substance use disorders. However, the CMS policy lifting hospital discharge planning requirements should be revoked.

More research is needed to understand how these policies influence the quality of behavioral health care received by Medicare beneficiaries and the policies’ long-term effects on out-of-pocket and insurer spending. Results of this future research should inform policy updates, as needed. For example, telehealth policies may need to be refined to incentivize or require provision of high-value and culturally appropriate care. In addition, future research should take into account documented disparities in telehealth readiness and past research showing that policies designed to benefit everyone often disproportionately assist the most privileged.¹⁶ Going forward, research should study the effects of policies on health equity and identify strategies to address inequities, if they occur.