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Advocacy Update: August 2020

August 25, 2020

The last few months have seen significant movement across a broad array of issues.

APA-Led Activities

APA Urges Congress to Support Mental Health and Substance Use Disorder Programing in Fifth COVID Response Package

Over 88,000 Americans have been screened for anxiety or depression over normal baseline screening numbers during the COVID pandemic. APA urged congressional leadership to provide a robust investment in the mental health care delivery system in the fifth COVID relief package. Specifically, APA recommended that Congress prioritize resources to support healthcare services in underserved communities and direct HHS to study the health disparities related to COVID. APA also recommended that Congress permanently remove certain telehealth restrictions, extend other flexibilities beyond the public health emergency, and study telehealth’s role in healthcare delivery. APA requested additional long- and short-term funding for mental health programs including additional support for mental health providers. Finally, APA promoted the Collaborative Care Model as an innovative way to increase access to mental health providers and requested support for International Medical Graduates (IMG).

APA President Testifies Before Congress

APA President Dr. Jeffrey Geller testified before the Energy and Commerce Health Subcommittee as it considered 22 pieces of legislation of priority to the mental health community. The bills under consideration covered a broad range of topics including telehealth, crisis interventions, suicide prevention, racial disparities and justice in healthcare, and mental health parity. APA priority bills on mental health parity, telehealth, emergency room suicide screenings, health disparities and crisis services were included in the hearing. Ultimately, the committee approved 17 bills including several that APA supports:

  • H.R. 5201, the “Telemental Health Expansion Act of 2019,” introduced by Reps. Doris Matsui (D-CA) and Bill Johnson (R-OH). The legislation would permanently include a patient’s home as an eligible originating site for mental health services delivered via telehealth and remove Medicare’s geographic restrictions for certain mental health services.
  • H.R. 7539, the “Strengthening Behavioral Health Parity Act,” introduced by Reps. Joe Kennedy III (D-MA), Bilirakis, Katie Porter (D-CA) and Fred Upton (R-MI), which would help improve and strengthen enforcement of existing mental health parity laws.
  • H.R. 1646, the “Helping Emergency Responders Overcome (HERO) Act of 2019” introduced by Rep. Ami Bera, MD (D-CA), which would address trauma experienced by public safety officers by tracking suicide incidences and supporting peer support behavioral health and wellness programs within fire departments and emergency medical service agencies.
  • H.R. 4564, the “Suicide Prevention Lifeline Improvement Act of 2019,” introduced by Reps. John Katko (R-NY), Don Beyer (D-VA) and Grace Napolitano (D-CA). The legislation would increase funding levels of the National Suicide Prevention Lifeline program so that it can launch pilot programs to better promote suicide prevention.
  • H.R. 4585, the “Campaign to Prevent Suicide Act,” introduced by Reps. Beyer and Greg Gianforte (R-MT). The legislation would establish a public awareness program promoting the new 9-8-8 suicide prevention hotline.
  • H.R. 5619, the “Suicide Prevention Act,” introduced by Reps. Chris Stewart (R-UT) and Matsui, which establishes grant programs to prevent self-harm and suicide.

The Committee also considered legislation APA ardently opposes, H.R. 884, which would change Medicare’s definition of physician to include psychologists. Thanks in large part to the advocacy efforts of over 3,000 APA members who used APA’s action center to write their members of Congress, the committee did not pass that dangerous legislation.

Newly Launched App Advisor

APA recently launched App Advisor, a new initiative geared toward helping psychiatrists and patients alike navigate the ever-expanding world of digital mental health apps. App Advisor builds on APA's previous App Evaluation Model by offering both comprehensive and a streamlined frameworks to help users pick an app that is right for them. App Advisor is steered by an Expert Panel composed of APA member psychiatrists; psychologists; social workers; informaticists; medical students, and patients with lived experience of mental illness. The site offers sample app evaluations to demonstrate how the App Model and its framework can be used to find important information about apps when guiding decision-making about whether to use them in practice. Visit APA App Advisor for more information.

Executive Branch Activities

2021 Medicare Physician Fee Schedule Proposed Rule

Physician Fee Schedule: The CMS proposed rule on the 2021 Physician Fee Schedule and Quality Payment Program was released on August 3 and included a number of proposals favorable to psychiatrists. CMS will be moving forward with the coding and documentation structure developed by the CPT Editorial Panel for office Evaluation and Management (E/M) Services. Key changes include increased values -- an 8% increase overall for psychiatry -- and decreased documentation requirements for the office E/M, and the option of billing office E/M services on time alone.

Because of budget neutrality, the increase in the office E/M services, which is significant, will result in cuts across the board for all other services, as well as a proposed conversion factor for 2021 that is $3.83 less than the current conversion factor. Additionally, CMS has increased the valuation of specific psychiatric services that they believe are analogous to the office E/M visits. This includes the psychiatric diagnostic evaluation and psychiatric diagnostic evaluation with medical services, and the three stand-alone psychotherapy services (90832, 90834, 90837). However, CMS is not proposing to extend the increase to the psychotherapy add-on codes used by psychiatrists when providing psychotherapy along with E/M services. It appears the increase in values for select psychiatric services was done to mitigate the cuts psychologists and social workers would experience from the budget neutrality adjustment. APA recently signed on to an AMA letter to CMS asking that budget neutrality be waived given the potential for significant negative impacts on those groups (including psychologists and social workers) that do not or cannot bill E/M services. The increase to the total allowed charges for psychiatry is estimated to be 8% and 0% for psychologists and social workers. The overall impact of these proposals on individual psychiatrists will depend on their coding patterns.

In addition, APA has worked for several years to promote improved access to care through early identification, intervention and treatment in a primary care office, with consultation from psychiatrists. CMS has increased payments for psychiatric collaborative care management (CoCM) and transitional care management codes. They have also proposed to add a shorter-timed code to the CoCM family of codes for those months that require less time.

Quality Payment Program: In recognition of the need for clinician focus on the response to COVID-19, the 2021 Medicare Physician Fee Schedule Proposed Rule (MFPS) does not make significant changes to quality programs. The MIPS Value Pathway (MVP) initiative, which intends to establish specialty-specific sets of conceptually- and clinically-aligned measures that more comprehensively assess the ‘value’ of clinician activity across the domains of quality, cost, and improvement, was planned for implementation in the 2021 performance period. However, CMS will now introduce no new MVPs, instead further developing the guiding principles for the MVP program.

The Proposed Rule also introduces a new quality reporting option, the APM Performance Pathway (APP), which will apply the MVP concept to clinicians participating in Alternative Payment Models (APMs) and/or the Medicare Shared Savings Program (MSSP). CMS states that the APP program is being implemented in service of a transition from MIPS to APMs.

The weighting of MIPS performance categories will be adjusted to increase the weight of cost measures in relation to the weight of quality measures. This moves toward a statutory mandate to bring the cost and quality dimensions into equal weighting by the 2022 performance period. No changes are proposed to the weighting of the Improvement Activities and Promoting Interoperability categories.

With regard to measures in the MIPS program, CMS proposes to replace the current All-Cause Unplanned Readmission measure, which was originally developed to assess hospital performance, with a re-specified measure designed to attribute outcomes to MIPS-participating clinician groups and assess performance at the clinician group level. The All-Cause Readmission measure is automatically applied to MIPS-eligible groups meeting clinician and patient minimums. The Proposed Rule would not add any measures specific to mental or behavioral health for the 2021 performance period. A set of measures related to potential opioid misuse are being removed from the program because they are no longer in alignment with the guidelines and are topped-out in performance.

Telehealth: During the COVID-19 PHE, CMS waived the geographic and site of service "originating site" restrictions for Medicare telehealth services, allowing Medicare beneficiaries to receive care while at home. These flexibilities were extended by HHS by continuing the PHE declaration through Oct. 23, 2020. Within the PFS, CMS does not propose to permanently waive these restrictions, stating that it lacks the authority to do so, and that such a change must occur through an Act of Congress. APA continues to advocate for this change to be made permanent.

Since March 2020, physicians and Medicare beneficiaries have relied on telehealth services, which have been dramatically expanded during the COVID-19 PHE. In the PFS, CMS has proposed to permanently keep several codes that were temporarily added to the Medicare telehealth list. These include the prolonged office or outpatient E/M visit code and certain home visit services. CMS also proposes to keep certain emergency department visits on the list of covered telehealth services until the end of the calendar year where HHS ends the PHE to allow more time to study the benefits of having provided these services. Finally, the proposed rule also provides some details about allowing physicians to supervise non-physicians in rural areas via telehealth beyond the PHE.

APA Responds to Executive Order on Regulatory Relief to Support Economic Recovery

APA submitted comments in response to President Trump’s Executive Order 13924, issued on May 19, 2020: Regulatory Relief To Support Economic Recovery. APA applauded the Administration and Congress for the rapid and decisive government action to make needed regulatory changes during the COVID-19 public health emergency, including improved access to telehealth. APA highlighted its concern that if our nation is to be successful in recovering economically from COVID-19, we must also ensure we have the ability to most efficiently accommodate the expected rise in demand for mental healthcare at all levels of the healthcare system. These efforts include: Improving Access to Mental Health and Substance Abuse Care in Primary Care; greater transparency and streamlining of all prior authorization processes; permanently expanding telehealth services; issuing waivers for telehealth prescribing of controlled substances; prioritizing the enforcement of mental health parity; and providing ligature risk reduction guidance and relief.

NIDA Strategic Plan

APA provided feedback to the National Institute on Drug Abuse (NIDA) 2020 Strategic Plan for Research. We urged NIDA to prioritize your focus on developing strategies for medication adherence and prevention of poor outcomes such as relapse and overdose. We specifically asked them to address: substance use disorders and suicide, workforce develoment, overdoes prevention and delivery of virtual care for SUD and harm reduction during the COVID-19 pandemic.

42 CFR Part 2 Member Education

On July 15, 2020, a final rule revising the federal regulations governing the Confidentiality of Substance Use Disorder Patient Records, 42 CFR Part 2 (Part 2), was released by the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services. The rule will go into effect on August 14, 2020. Between the time the Part 2 proposed rule was released and the final rule was promulgated, Congress included legislation to align 42 CFR Part 2 with HIPAA for the purpose of treatment, payment and operations in section 3221 of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). The CARES Act became law on March 27, 2020. SAMHSA will release new regulations to implement the law, which are required no earlier than March 27, 2021. The SAMHSA regulations going into effect on August 14, 2020 do not include provisions from the CARES Act.

In preparation for the final rule to go into effect and to educate members about the changes included in the CARES Act, the APA jointly hosted a webinar, Understanding the Final Rule for 42 CFR Part 2 and Next Steps, with the American Academy of Addiction Psychiatry and the American Society of Addiction Medicine on August 12, 2020.

Congressional Activities

House of Representatives Determines 2021 Funding for Mental Health

The American Psychiatric Association (APA) applauded the U.S. House of Representatives for passing the Labor-Health and Human Services-Education FY2021 appropriations bill that includes much needed funding for mental health care and medical research. The bill, which includes a total of $96.4 billion for the Department of Health and Human Services, was part of a seven-bill spending package (HR 7617). Among the provisions supported by the APA are:

  • $6 billion for the Substance Abuse and Mental Health Services Administration (SAMHSA), an increase of more than $100 million over the previous fiscal year for mental health and substance use-related programs. The APA effectively worked with mental health partners resulting in a $35 million increase to the SAMHSA budget to improve mental health crisis systems and suicide prevention at the state and local level, as well as $25 million for the national suicide prevention lifeline.
  • $8 billion for the Centers for Disease Control and Prevention (CDC), an increase of over $250 million from the previous fiscal year. The CDC budget includes $25 million for firearm injury and mortality prevention research. The National Institutes of Health also would receive $25 million for such research.
  • $66.95 million for the CDC Racial and Ethnic Approaches to Community Health (REACH) program; a 14% increase in funding for the Minority Fellowship Program (MFP); and a request that the National Institute of Mental Health develop a 10-year strategic plan to eliminate racial mental health disparities in youth by 2030.
  • An increase of over 40 percent for funding for the loan repayment program for the Substance Use Disorder Treatment Workforce Program through the Health Resources and Service Administration.
  • A total of $550 million for the National Institute on Alcohol Abuse and Alcoholism; $1.47 billion for the National Institute on Drug Abuse and $2.06 billion for the National Institute of Mental Health, all increases.

The Senate must now negotiate and finalize their funding proposal for FY2021, which is expected to be lower than the House’s proposal. Then the two bodies will negotiate final funding levels.

Congress Addresses Youth Suicide and Mental Health

Legislation to address the issue of suicide and mental health in youth populations was recently introduced in both the House and Senate. APA served on the task force that helped develop the bill, which is geared toward minority youth in socially and economically disadvantaged communities. The Mental Health Equity Act (Senate bill) and Pursuing Equity in Mental Health Act of 2019 (House bill) would provide grants for culturally competent mental health services, increase authorized funding levels for research and the Minority Fellowship Program, direct research and resources through agencies like the Department of Health and Human Services to establish a Commission on the Effects of Smartphone and Social Media Usage on Adolescents.

APA Sounds the Alarm in Support of the USUHS

The Military Health System is responsible for the care of more than 1.4 million active-duty and 331,000 reserve personnel, their families and retired members. The Uniformed Services University of the Health Sciences and Department of Defense (DoD) graduate medical education programs play a critical role in developing the future of military medical professionals as well as ensuring that our Nation’s service members receive high quality medical care. Recently, APA members have expressed concern to the Department of Government Relations that DoD leadership was considering cuts in funding for key research centers and training programs. In response to these concerns, APA led a letter endorsed by six other physician organizations, that emphasized the importance of these programs and urged the DoD not to make significant cuts to the university.

TREATS Act Would Improve Access to Telehealth

APA joined the Coalition to Stop Opioid Overdose and other health groups in sending a letter to the Hill urging inclusion of telehealth flexibility legislation in the next COVID-19 package. The Telehealth Response for E-prescribing Addiction Therapy Services (TREATs) Act would permanently allow for an audio and video telehealth evaluation exception under Ryan Haight's in-person evaluation requirement for SUD services. In addition, the bill would clarify CMS authority to allow for reimbursement of audio-only telehealth services for SUD and co-occurring mental health services.

Bipartisan Effort to Address Physician Burnout

Senators Tim Kaine (D-VA), Todd Young (R-IN), Jack Reed (D-RI), and Bill Cassidy, M.D. (R-LA) introduced the Dr. Lorna Breen Health Care Provider Protection Act, which aims to reduce and prevent suicide, burnout, and mental and behavioral health conditions among health care professionals, with APA’s support. The bill helps provider organizations offer their workers more options for mental and behavioral health assistance, specifically geared towards those working on the frontlines of the pandemic. It also supports suicide and burnout prevention training in health professional training programs and increases awareness and education about suicide and mental health concerns among health care professionals.

988 Suicide Hotline Moves Closer to Reality

The Federal Communications Commission (FCC) unanimously voted to designate 988 as a new dialing short-code, like 911, to help individuals easily reach the National Suicide Prevention Lifeline. Under the proposal, telecom companies would have to implement the 988 short-code by July 16, 2022. APA has monitored and supported this effort since the National Suicide Hotline Improvement Act became law in 2018. Over the next two years, phone companies will be required to broadly roll out the 988 number.

State Activities

APA Works to Ensure Access to Telehealth

During the early days of the pandemic federal and state governments acted quickly to ease certain restrictions on telehealth ensuring that it could serve as a vital resource in treating patients with mental illness and substance abuse disorders. To ensure continuity of care and to allow policymakers time to study telehealth’s positive role in the healthcare delivery system, APA’s Committee on Telepsychiatry worked with its Department of State Government Affairs to draft telehealth model legislation that would ensure fair reimbursement for providers and audio-only serve delivery. The department and its regional directors are currently working with over 20 states to introduce this legislation either this year or when state legislative bodies open early next year. Is your state on the list or do you want to know more? Email [email protected].

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