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

Doctor talking to senior female patient in a home visit
Toplines
  • The approaching end of temporary COVID-era changes to Medicare policy could have important implications for the accessibility, quality, and affordability of mental health and substance abuse care

  • Experts agree that some temporary Medicare policies during the pandemic, especially expanded telehealth coverage and the relaxation of restrictions on prescription drug access, should be continued

Toplines
  • The approaching end of temporary COVID-era changes to Medicare policy could have important implications for the accessibility, quality, and affordability of mental health and substance abuse care

  • Experts agree that some temporary Medicare policies during the pandemic, especially expanded telehealth coverage and the relaxation of restrictions on prescription drug access, should be continued

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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).

Mental Illness and Substance Use Disorders in Medicare Beneficiaries

Prevalence of Mental Illness

  • About one in four Medicare beneficiaries have a mental illness.3 Prevalence is particularly high in two subgroups:
  • Medicare beneficiaries under age 65 who qualify because of disability: an estimated 60 percent have a mental illness.4
  • Medicare–Medicaid dual-eligible, low-income beneficiaries: an estimated 40 percent have a mental illness.5

Prevalence of Substance Use Disorders

  • Approximately 3 percent of Medicare beneficiaries overall and 6 percent of dual-eligible beneficiaries have a substance use disorder.6
  • The percentage of beneficiaries with opioid use disorder increased more than threefold from 2013 to 2018, from 4.6 cases per 1,000 beneficiaries in 2013 to 15.7 in 2018.7

Medicare Spending Implications

  • More than 30 percent of high-cost Medicare beneficiaries — those in the top 10 percent of total spending — have a serious mental illness.8
  • Medicare beneficiaries with a substance use disorder have 70 percent higher costs than beneficiaries without a disorder.9

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).

McGinty_expert_consensus_impact_covid_medicare_mental_health_substance_use_Exhibit_01

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.

McGinty_expert_consensus_impact_covid_medicare_mental_health_substance_use_Exhibit_02

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).

McGinty_expert_consensus_impact_covid_medicare_mental_health_substance_use_Exhibit_03

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.

HOW WE CONDUCTED THIS STUDY

We identified a set of 36 policies from the Medicare COVID-19 policy tracker.17 All of these policies either a) pertain directly to mental health or substance use or b) include, but are not specific to, mental health or substance use. We then conducted an evidence review, including scholarly and gray literature, and a modified Delphi panel with 20 experts in Medicare mental health and substance use policy to gauge consensus on how sustainment of policies would influence care access, quality of care, insurer spending, out-of-pocket spending, and health outcomes.

The Delphi panel process involved three steps. First, panelists completed a survey in May 2022 asking for their expert opinions on how each policy would impact care access, quality, spending, and health outcomes for beneficiaries with mental illness or substance use disorders. Second, panelists convened for a six-hour virtual session in June 2022 to review evidence summaries of each policy and then discuss each policy in-depth. Third, immediately following the panel discussion, panelists re-rated each policy in a second survey. Panelists could provide separate ratings for policies’ effects on mental health treatment versus substance use disorder treatment.

NOTES
  1. Beth McGinty, Medicare’s Mental Health Coverage: How COVID-19 Highlights Gaps and Opportunities for Improvement (Commonwealth Fund, July 2020); and Deborah Steinberg and Ellen Weber, Medicare Coverage of Substance Use Disorder Care: A Landscape Review of Benefit Coverage, Service Gaps, and a Path to Reform (Legal Action Center, Feb. 2021).
  2. Pauline Andersen, “COVID-19: An Opportunity, Challenge for Addiction Treatment, NIDA Boss Says,” Medscape, Apr. 28, 2020; Ermal Bojdani et al., “COVID-19 Pandemic: Impact on Psychiatric Care in the United States, a Review,” Psychiatry Research 289 (July2020): 113069; Stuart M. Butler, “After COVID-19: Thinking Differently About Running the Health Care System,” The JAMA Forum 323, no. 24 (June 23/30, 2020): 2450–51; Coleman Drake et al., “Policies to Improve Substance Use Disorder Treatment with Telehealth During the COVID-19 Pandemic and Beyond,” Journal of Addiction Medicine 14, no. 5 (Sept.–Oct. 2020): e139–e141; Lev Facher, “COVID-19 Has Streamlined Addiction Medicine. Will the Changes Stick?,” STAT, May 12, 2020; and Matthew L. Goldman et al., “Mental Health Policy in the Era of COVID-19,” Psychiatric Services 71, no. 11 (Nov. 1, 2020): 1158–62.
  3. McGinty, Medicare’s Mental Health Coverage, 2020.
  4. McGinty, Medicare’s Mental Health Coverage, 2020.
  5. McGinty, Medicare’s Mental Health Coverage, 2020.
  6. U.S. Department of Health and Human Services, Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health (HHS, Nov. 2016).
  7. Carla Shoff, Tse-Chuan Yang, and Benjamin A. Shaw, “Trends in Opioid Use Disorder Among Older Adults: Analyzing Medicare Data, 2013–2018,” American Journal of Preventive Medicine 60, no. 6 (June 2021): 850–55.
  8. Yongkang Zhang et al., “Developing an Actionable Patient Taxonomy to Understand and Characterize High-Cost Medicare Patients,” Healthcare 8, no. 1 (Mar. 2020): 100406.
  9. Brian J. Fairman et al., “Costs of Substance Use Disorders from Claims Data for Medicare Recipients from a Population-Based Sample,” Journal of Substance Abuse Treatment 77 (Feb. 24, 2017): 174–77.
  10. Jeongyoung Park et al., “Are State Telehealth Policies Associated with the Use of Telehealth Services Among Underserved Populations?,” Health Affairs 37, no. 12 (Dec. 2018): 2060–68; Ateev Mehrotra et al., “Utilization of Telemedicine Among Rural Medicare Beneficiaries,” JAMA 315, no. 18 (May 10, 2016: 2015–16; Ateev Mehrotra et al., “Rapid Growth in Mental Health Telemedicine Use Among Rural Medicare Beneficiaries, Wide Variation Across States,” Health Affairs 36, no. 5 (May 2017): 909–17; Michael L. Barnett et al., “Trends in Telemedicine Use in a Large Commercially Insured Population, 2005–2017,” JAMA 320, no. 20 (Nov. 27, 2018): 2147–49; Jonathan D. Neufeld, Charles R. Doarn, and Reem Aly, “State Policies Influence Medicare Telemedicine Utilization,” Telemedicine and e-Health 22, no. 1 (Jan. 13, 2016): 70–74; Jillian B. Harvey et al., “Utilization of Outpatient Telehealth Services in Parity and Nonparity States 2010–2015,” Telemedicine and e-Health 25, no. 2 (Feb. 5, 2019): 132–36; Jiajia Chen and Angela K. Dills, “Does Telemedicine Save Lives? Evidence on the Effect of Telemedicine Parity Laws on Mortality Rates,” Southern Economic Journal (Feb. 10, 2022); and Anca M. Grecu and Ghanshyam Sharma, “The Effect of Telehealth Insurance Mandates on Health Care Utilization and Outcomes,” Applied Economics 51, no. 56 (July 2019): 5972–85.
  11. Eric T. Roberts and Ateev Mehrotra, “Assessment of Disparities in Digital Access Among Medicare Beneficiaries and Implications for Telemedicine,” JAMA Internal Medicine 180, no. 10, (Aug. 3, 2020): 1386–89.
  12. Consolidated Appropriations Act, 2021, H.R. 133, 116th Congress (2020); and Consolidated Appropriations Act, 2022, H.R. 2471, 117th Congress (2022).
  13. Elena V. Fernandez, Jennifer A. McDaniel, and Norman V. Carroll, “Examination of the Link Between Medication Adherence and Use of Mail-Order Pharmacies in Chronic Disease States,” Journal of Managed Care & Specialty Pharmacy 22, no. 11 (Nov. 2016): 1247–59; Lihua Zhang et al., “Mail-Order Pharmacy Use and Medication Adherence Among Medicare Part D Beneficiaries with Diabetes,” Journal of Medical Economics 14, no. 5 (July 2011): 562–67; and Corey A. Lester et al., “The Influence of a Community Pharmacy Automatic Prescription Refill Program on Medicare Part D Adherence Metrics,” Journal of Managed Care & Specialty Pharmacy 22, no. 7 (July 2016): 801–07.
  14. Nahara A. Martínez-González et al., “The Impact of Physician–Nurse Task Shifting in Primary Care on the Course of Disease: A Systematic Review,” Human Resources for Health 13, no. 1 (July 2015); and Nahara A. Martínez-González et al., “Task-Shifting from Physicians to Nurses in Primary Care and Its Impact on Resource Utilization: A Systematic Review and Meta-Analysis of Randomized Controlled Trials,” Medical Care Research and Review 72, no. 4 (Aug. 2015): 395–418.
  15. Centers for Medicare and Medicaid Services, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers (CMS, Aug. 18, 2022).
  16. Katherine L. Frohlich and Louise Potvin, “Transcending the Known in Public Health Practice,” American Journal of Public Health 98, no. 2 (Feb. 2008): 216–21.
  17. Jennifer Podulka and Jonathan Blum, Regulatory Changes to Medicare in Response to COVID-19 (Commonwealth Fund, Aug. 2020).

Publication Details

Date

Contact

Beth McGinty, Chief, Division of Health Policy and Economics, Department of Population Health Sciences, Weill Cornell Medicine

[email protected]

Citation

Beth McGinty et al., Expert Consensus on the Impact of COVID-Response Medicare Policies on Mental Health, Substance Use Care, and Costs (Commonwealth Fund, Oct. 2022). https://doi.org/10.26099/5vgp-e157