Author: Nora Brunner

Mental health is receiving more attention across healthcare and as President Biden unveils broad changes in his budget bill released in March. Many see the pandemic as both a crisis and an opportunity to strengthen the nation’s mental health system.

Some strategies under consideration include payers being required to offer three behavioral health sessions at no charge to patients in private health plans. Another shift would be to apply the 2008 Mental Health Parity and Addiction Equity Act to Medicare. Recent administration moves seek larger networks of behavioral health providers built into benefit plan design and training for the mental health workforce.

Parity is a hot topic in Congress. Payers are required to cover mental health to the same extent they cover physical health under the Parity Act. However, three federal agencies recently reported to Congress that 30 health plans and issuers were out of compliance with the law.

Provider shortages contribute to this picture, with mental health professionals remaining out of network at a rate of five times higher than other provider types. Consumers are often discouraged by delays in getting first appointments or in facing out-of-network fees. Payers say they need more guidance on mental health parity rules and clarity on how to document compliance to the satisfaction of regulatory agencies.

The Senate Finance Committee may be the driver of change as members of both parties search for ways to strengthen access to care, especially post-pandemic. Levers for change could come through the modification of Medicare and Medicaid policies. Other momentum could come from pandemic advances in the use of telehealth and a trend to integrating primary care with behavioral healthcare. While there are issues in prescribing medications to parse, most parties agree that the telehealth flexibilities of the pandemic should be extended. Legislation may come as early as this summer, potentially creating a bipartisan win. Previous mental health parity bills have largely been supported by both parties.

Mental healthcare may be having its moment as the nation appears to unwind from the prolonged pandemic. Experts have expressed concern about the nation’s total health after events that are unprecedented in the modern era.

The non-profit organization CAQH® has been issuing a steady drumbeat of reports over the years about how much money and time could be saved across the healthcare industry by switching transactions from paper-based to electronic. It’s fascinating to see the progress over the years as the industry transitions, yet despite obvious savings, many think progress is still much too slow. The 2021 CAQH Index is just out in early 2022, reporting that important shifts have taken place in healthcare administrative operations during the pandemic. These are hopeful indicators.

Prior authorization is an area that changed dramatically during the pandemic, as the requirements were mostly suspended or waived during the urgency of providing care to jampacked healthcare facilities. The volume of elective procedures also decreased as consumers shied away, lowering the rate of prior authorizations by 23 percent. Automation of prior authorizations in general also lowered the time providers spend on this process. Overall automation of prior authorizations has increased from 21 to 26 percent, lowering the cost to the system by 11 percent to $686 million.

Prior authorizations help providers and health plan members stay within the rules and criteria governing their plans. They ensure that providers operate within the most up-to-date and respected clinical decision-making criteria. But they do create payer-provider friction that can ultimately filter down to health plan members in some form.

Last year, the GuidingCare business unit of HealthEdge worked with a valued customer, Priority Health, to develop an automated prior authorization process under a unique set of circumstances. Priority is part of the Spectrum Health System, which means that the GuidingCare® implementation team was able to solicit the direct and specific input of Spectrum physicians as to what would be most helpful in a portal for prior authorization. The teams worked together to create a provider-friendly solution that dramatically reduced the time spent on prior authorizations. The portal allows providers to receive authorizations in a matter of moments, allowing more complex requests to be routed quickly for review of medical necessity. One-click messaging offers document and image upload on both ends. With 80 percent of requests being approved at some point, valuable data is being generated about which prior authorizations could be eliminated altogether.

The power of automation and data are changing the landscape. Payers and providers both need to jump on board and help CAQH turn out an even more encouraging reports in the future.

Learn more about GuidingCare here.

With the Omicron variant starting to recede and political pressure starting to build to end the Public Health Emergency (PHE), various sectors of healthcare are starting to prepare for the end of the emergency period. Currently slated to come to a close April 16, the PHE has been extended eight times since it was declared in January of 2020 and could very well be extended again for three months at a time. However, the end is in sight and the pressure is building. The implications to the larger economy and the healthcare system are significant. Payers will see a shift in their member mix due to Medicaid disenrollment, among other changes.

A feature of the PHE was to halt all Medicaid disenrollment, regardless of changes to member eligibility. Those covered by Medicaid who are no longer eligible due to changed circumstances stand to be disenrolled when the PHE expires. One estimate reckons 15 million people younger than 65 could lose coverage, even though some will become eligible at the same time for Exchange plans or other programs. However, the educational task to convey this is huge with this traditionally difficult-to-reach audience because of SDOH barriers. Many who qualify for Medicaid often fall off the rolls because they cannot or do not complete the renewal process. Changes of address, disability, illiteracy, language barriers and other challenges contribute to incomplete renewals.

The Centers for Medicare and Medicaid Services (CMS) has issued guidance for states on “unwinding” the requirements and sorting out who continues to be eligible among 76.7 million currently enrolled individuals – nearly one in four Americans. The federal money allotted to maintain continuous coverage is likely to run out before this task is completed, even with the current administration allowing states a year to finish redeterminations. States will be under significant budgetary pressure.

The industry will get 60 days’ notice before the PHE ends, according to the U.S. Department of Health and Human Services (HHS). The agency often waits until just a few days before the expiration date to extend the PHE, shortening the window for state agencies and others to notify beneficiaries that their coverage may end.

Medicaid disenrollment is just one challenge of many ahead, as grants to local governments, providers and other groups dry up. With an unprecedented worldwide pandemic in modern times, the after-effects are bound to be significant and long-lasting, but may reveal opportunities to improve the system.