The U.S. Centers for Medicare and Medicaid Services (CMS) has made behavioral health equity a strategic priority.
In particular, the agency is focused on integrating behavioral health services into a community model. Earlier this month, it proposed a new ruling aimed at addressing workforce shortages and enhancing care coordination.
The changes, if finalized, would also bring medication assisted opioid use disorder treatment into the community through mobile units.
A key player in many of these initiatives is Dr. Meena Seshamani, CMS deputy administrator and director of the Center for Medicare. Behavioral Health Business sat down with Seshamani to talk about behavioral health, equity and policy.
This interview was edited for length and clarity.
BHB: How is CMS addressing social determinants of health when it comes to behavioral health care, specifically with Medicare?
Seshamani: We have made behavioral health a priority. It really crosses all of our strategic pillars: advancing equity; expanding access to coverage and care; driving innovation to reward high-quality, whole-person care; and making our program affordable and sustainable for generations to come.
Key to that is making sure that, as we’re doing all of this, especially with behavioral health, we’re thinking about people as people. People have a myriad of experiences that impact their health. We want to make sure that we are looking at the whole person.
For example, we are now requiring special needs plans to screen for health-related social needs for all of their enrollees. We have comments out on how we can stratify data so that we can better identify disparities among populations, to then be able to encourage fixing those and closing those gaps.
We’re proposing these advanced investment payments to provide to smaller providers in rural and underserved areas to give them funding upfront, so that they can invest in improving care for their communities. And importantly, that money can be used to address health-related social needs.
[Providers] can use it to help with community-based organizations, food, housing and transportation. There’s a lot of work that we’re doing to make sure that we are thinking about people more holistically, and marrying our efforts in physical health, behavioral health, health-related social needs towards that end.
A big part of that, too, is outcomes. What are the main focus areas?
This comes back to how we are looking at our data to make sure that we are identifying where there are gaps and then addressing them. So as an example, we have solicited comments on a health equity index in Medicare Advantage, so that we can see what plans are doing to help some of their underserved populations, those who are dually eligible, low income, disabled. Similarly, we have proposed a health equity adjustment in our Medicare Shared Savings Program.
With our largest Accountable Care Organization (ACO) program, we’re saying, “Those of you who take excellent care of underserved populations will get additionally rewarded.” The idea is to encourage that kind of movement. So data underlies all of that, where you can see what impact you’re having on specific populations.
How does CMS plan to use community resources and health centers to address some of those behavioral health issues?
I think this comes right back to where, particularly with our holistic care models, our ACOs, we really want to be able to grow those models and do so in a way that is addressing rural and underserved populations. So where we can provide this kind of upfront investment, so that smaller providers, FQHCs (Federally Qualified Health Centers), rural health clinics – they can become part of these models. And we’re working very closely with HRSA (the Health Resources and Services Administration) as well, which runs the FQHCs grant programs. We are collaborating very closely with them to marry our efforts in this regard.
What innovations are being considered right now, in terms of closing health equity gaps for behavioral health? And are there any issues with innovation widening that gap?
I wrote a piece in Health Affairs in May on how we can think about technology moving forward, because absolutely, the pandemic opened the door for all of these innovations in care delivery. We think a lot about telehealth, but it’s more than just telehealth. It’s about team-based care. It’s about leveraging community health workers more.
Moving forward, we want to make sure that innovations are driving our strategic pillars for the vision of Medicare: Are they advancing equity? Are they driving innovation towards whole-person, high-quality care? Are they expanding access? Are they promoting sustainability of the program?
As an example, HHS did a report on telehealth … on how in 2020, telehealth utilization went up 63 fold. While there were all these waivers, etc., Black and rural Medicare beneficiaries were less likely to use telehealth than their white and urban counterparts. And Black and Latinx beneficiaries were less likely to use video than their counterparts.
So these are important pieces of data, to your point, that you have to take into consideration, because you want these innovations to address disparities and not exacerbate them. So we’re thinking about broadband access, thinking about cultural responsiveness, thinking about language access, as we are trying to innovate and make sure that all of this work is addressing disparities.
To start, can you tell me a little bit about yourself and your past health care experiences?
I’m an otolaryngologist, an ear, nose and throat surgeon, by training. And I also have a Ph.D. in health economics. I definitely bring both of those perspectives to bear, with all the work that I’ve done.
I’ve led the Office of Health Reform in the Obama administration – so on implementation of the Affordable Care Act, the health care marketplaces, Medicaid, all of the delivery system reform work. That’s when Accountable Care Organizations (ACOs) started.
And then I moved to MedStar Health, which is the largest health system in the D.C., Maryland, Virginia area. That’s a $6 billion health system that’s leading care transformation.
Why is it so important to focus on behavioral health right now, in terms of setting the stage for the national health care policy?
Well, we definitely have a behavioral health crisis in our country. Medicare cares for people aged 65 and older, those with disabilities, those with end-stage renal disease. These are populations that were vulnerable to social isolation, depression, substance use disorder before the pandemic, and even more so now. I mean, people really are in a behavioral health crisis.
Where we are able to leverage what Medicare can do in mobilizing the behavioral health workforce includes extending access for licensed marriage and family therapists, licensed professional clinical counselors, the outpatient hospital departments being able to use telehealth to reach populations who otherwise might not have anybody to take care of them.
Where we’re making care more effective is by providing payment for the integration of behavioral health with primary care, by investing in these holistic care models like ACOs. And then where we’re expanding on substance use treatment. I think our proposal to pay for mobile van use for opioid treatment programs to bring care to where people are, you know, these are all avenues that we’re taking because behavioral health is such a priority.
How do you see the delivery of behavioral health services changing over the next five years?
I think we have to learn from the changes that have occurred with the pandemic, see what has worked, what hasn’t and move forward from there.
We’ve all seen that a team-based approach to care is very important and meeting people where they’re at is important. Where can you engage people in the community? Where can you open the aperture of how we view the health of people, to all the things that impact their health, including social needs? I think that all will continue moving forward.