Behavioral Health

Connecticut’s top law enforcement official is coming out swinging against big rate hikes requested by health insurers that sell plans in the state’s individual and small-group markets. In an Aug. 15 letter to Connecticut Insurance Commissioner Andrew Mais, Attorney General William Tong points out that the state’s Insurance Dept. may only approve rates that are not “excessive, inadequate or unfairly discriminatory,” and insurers must provide “transparent, factually supported actuarial analysis” to justify their rates. “In at least the case of Cigna’s 14.9 percent increase in the small group market, Anthem’s 9.8 percent increase in the individual group and 14.9 percent increase in the small group market, and ConnectiCare’s 17.5 percent increase in the individual market, the insurers have failed to meet that burden and their requests must be rejected,” Tong wrote.

Vermont’s all-payer accountable care organization (ACO), OneCare Vermont (OCV), has reduced Medicare costs but has had minimal impact on the state's Medicaid and commercial segments, a new report commissioned by CMS says. However, the state’s largest carrier — nonprofit commercial insurer Blue Cross and Blue Shield of Vermont (BCBSVT) — withdrew from the program at the end of the 2022 plan year and does not currently plan to return.

The report, prepared by NORC at the University of Chicago on behalf of the CMS Center for Medicare and Medicaid Innovation (CMMI), focused most of its cost and quality improvement analysis on Medicare. The report did not make any quantitative assessments of OneCare Vermont’s impact on the commercial market. NORC found that the ACO reduced gross spending for Medicare enrollees by $686.40 per member per year, or 6.2% per year, during the first four years of implementation, resulting in a $124.9 million net reduction of Medicare spending during those years, a drop of 5.7%. However, quality improvement and utilization assessments were more difficult to make due to the COVID-19 pandemic, which distorted utilization patterns during 2020 and 2021.

The federal government on July 25 issued proposals to strengthen the Mental Health Parity and Addiction Equity Act (MHPAEA) and ensure that health plans are complying with the mandate of providing fair and equal access to mental health and substance use disorder treatment. JoAnn Volk, the founder and co-director of Georgetown University’s Center on Health Insurance Reforms, says HHS and the Labor and Treasury departments are particularly interested in addressing health plans’ reporting and comparative analyses of nonquantitative treatment limitations (NQTLs).

The MHPAEA was enacted in October 2008 and built upon the Mental Health Parity Act of 1996, which prohibited large group health plans from having different annual and lifetime limits for mental health and medical/surgical benefits. However, the agencies did not publish final regulations implementing the MHPAEA until November 2013.

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.”

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 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.

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).

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.

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.

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.