Behavioral Health

At AHIP, Medicaid MCOs Talk Behavioral Health Value-Based Contracts

To succeed with value-based behavioral health care contracts, Medicaid managed care plans need to tailor those pacts to the unique needs of a given provider, MCO executives say. And plans may not be able to use risk-based contracts with individual practitioners and other small providers — especially if network adequacy is at stake.

“We really try to think about it in three broad categories: Are we bringing clinical value, operational value or financial value” as a result of a value-based contract? posed Kevin Wheeler, M.D., medical director for practice transformation and value-based contracting strategy at AmeriHealth Caritas, during a June 14 session of the AHIP 2023 conference in Portland, Oregon. “And we’re thinking about this in terms of our relationships with our providers and with our members.”


Behavioral Health Workforce Shortage Is Exacerbated by Poor Reimbursement

The behavioral health workforce isn’t large enough to meet current demand, according to experts, and it is particularly under-resourced for LGBTQ+ patients and people of color, who are not adequately represented in the current workforce despite disproportionate need for treatment. Meanwhile, poor pay and too-high workloads offer little incentive for behavioral health providers to enter insurance networks, driving up costs for patients and stymieing plans’ attempts to comply with mental health parity and network adequacy requirements.

George Washington University (GWU) researchers maintain the only comprehensive database tracking the number of behavioral health providers in the US. They released their first data in 2022 and published an article in Health Affairs that August. According to an April slide deck prepared by GWU researchers Clese Erikson and Randl Dent, Ph.D., there are currently 1.3 million mental health care providers in the U.S. — a figure that includes over 600,000 prescribers of psychotropic drugs and medications for opioid use disorder (MOUD).


Pear Bankruptcy Filing Highlights Reimbursement Barriers for Digital Therapeutics

Pear Therapeutics, Inc. this month filed for Chapter 11 bankruptcy, saying that it had laid off about 92% of its staff but would still pursue a sale of the company or its assets. Health care insiders tell AIS Health, a division of MMIT, that the announcement by one of the pioneers in the prescription digital therapeutics (PDT) industry highlights the challenges such companies face getting their products reimbursed. The difficulties are exacerbated by investors being wary of backing companies that promise future growth but have yet to turn a profit.

In 2017, Pear’s reSET digital app to treat patients with substance use disorder became the first FDA-approved PDT, which are software-based therapies to treat medical and behavioral conditions. Since then, the FDA has approved more than 40 DPTs, according to Brandon Aylward, Ph.D., director of digital health for RTI International, a nonprofit research institute.


New Prison Medicaid Waiver Offers Opportunities, Challenges for MCOs

The Biden administration will make Medicaid coverage available to incarcerated people for the first time through a new category of Section 1115 waivers, building on a demonstration program that has been active in California since January. Experts tell AIS Health, a division of MMIT, that the waiver poses notable challenges to Medicaid managed care organizations, which will have to coordinate with the carceral system and community providers to meet the needs of a disproportionately vulnerable and sick population.

States that apply for the waiver, dubbed the Reentry Section 1115 Demonstration Opportunity, will provide Medicaid coverage to incarcerated people who are on the verge of returning to the community. According to an HHS press release, states will be allowed “to cover a package of pre-release services for up to 90 days prior to the individual’s expected release date that could not otherwise be covered by Medicaid.” The package of services includes providing formerly incarcerated people with a 30-day supply of medication on release, case management, and medication-assisted treatment (such as prescribing methadone) for substance use disorder (SUD).


Better Perinatal Care Means Closing Coverage Gaps, AHIP Panelists Say

With the maternal mortality rate in the U.S. notoriously higher than many other developed countries and care access issues a perennial concern, payers can play an important role in efforts to improve perinatal care. During a recent session at AHIP’s Medicare, Medicaid, Duals & Commercial Markets Forum in Washington, D.C., panelists discussed how a deeper understanding of coverage data can fuel those efforts.

Medicaid pays for more than four in 10 births nationally and more than half of births in some states, said Usha Ranji, associated director for women’s health policy at the Kaiser Family Foundation (KFF). Federal law requires all states to provide Medicaid coverage for pregnancy-related services to women with incomes up to 133% of the federal poverty level and cover them up to 60 days postpartum, but many states have extended the income threshold “well over 200%” of FPL, according to Ranji.


As NC Nears Medicaid Expansion, State Official Has Strong Warning for MCOs

North Carolina at press time was close to passing legislation that would allow it to become the 40th state to expand Medicaid under the Affordable Care Act. The state transitioned to a Medicaid managed care structure in 2021, but recent public comments from one state official suggest that ongoing issues between MCOs and providers could pose challenges as the state prepares for expansion.

House Bill 76, Access to Healthcare Options, would require the state to extend Medicaid coverage to individuals with income at or below 133% of the federal poverty level (FPL) starting Jan. 1, 2024, and establish a fund allowing the state to provide direct payments to acute care hospitals based on assessments of hospital costs. Democratic Gov. Roy Cooper has been advocating for expansion, which could reduce the uninsured population by 30%, or 346,000 people, according to an Urban Institute analysis from November.


Biden Budget Targets Drug Pricing, Enhanced ACA Subsidies, Mental Health Coverage

Although the Inflation Reduction Act (IRA) enacted significant health care provisions, such as giving Medicare the authority to negotiate prices for select prescription drugs and temporarily extending enhanced premium tax credits for Affordable Care Act plans, President Joe Biden in his fiscal year 2024 budget proposal made it clear that those and other health reforms don’t go far enough.

However, the health care industry will have to wait for more granular details about, for example, how many more drugs Biden plans to add to the price-negotiation list, HHS officials indicated during a May 9 call with reporters. And Biden must also convince a divided Congress to put his proposals into legislation.


Employers’ Desire to Shake Up Benefits Vendors Can Be Opportunity for Insurers

Although U.S. employers already contract with a bevy of health and wellbeing vendors, a recent survey found that nearly nine in 10 are planning to make changes to their vendor partnerships in the next two years — chiefly by adding or enhancing current offerings. As companies do so, health insurers have a critical role to play when it comes to integrating various solutions and helping employees find them, an employee benefits expert says.

Employers’ desire to add and enhance health/wellbeing offerings “doesn’t look like it’s going to stop anytime soon,” says Regina Ihrke, senior director and health, equity and wellbeing leader at WTW. Therefore, large medical benefits carriers “are going to have to continue to be nimble and flexible in who they partner with, and then how they also integrate with other carveout solutions that are out there,” she tells AIS Health, a division of MMIT.


ACA Marketplace Plans Deny Over 16% of In-Network Claims in 2021

About 16.6% of in-network claims were denied by non-group qualified health plans (QHPs) offered on in 2021, down from 18.3% in 2020, according to a recent Kaiser Family Foundation analysis. Among the 162 issuers in states with complete data on claims received and denied, 65 of them had a denial rate between 10% and 19%. Only 17 issuers had a denial rate over 30%, compared with 28 in 2020. The majority of denials (76.5%) were classified as “all other reasons,” while 8% were for services that lacked a prior authorization or referral. Of the more than 48 million denied claims in 2021, marketplace enrollees appealed 90,599 claims — a 0.2% appeal rate — and insurers upheld 59% of denials that were appealed.


UnitedHealth, Blues Spinoff Lucet Proffer Behavioral Health Care Access Solutions

With two recently debuted product offerings, a pair of health care companies aim to solve a problem that has been thrown into sharp relief during the ongoing pandemic: highly variable — and often inadequate — access to behavioral health care services. Industry observers say that both solutions are likely a response to employer clients seeking increased care access points for their covered workers.

One of the announcements comes from UnitedHealth Group, which in January rolled out a virtual behavioral health coaching program that’s available to UnitedHealthcare commercial plan members with mild depression, stress and anxiety. Through the Optum-administered program, 5 million eligible fully insured plan members can access support “through digital modules and 1:1 video or telephonic conferencing and messaging with trained coaches” at no additional cost. Self-insured employers may also purchase the virtual behavioral health coaching program for their employees, UnitedHealth said.