Congress should include in pending Medicare legislation provisions to protect the Medicare mental health benefit
by Government Relations Staff
Congress should restore reimbursement cuts to psychologists' and social workers' services in Medicare legislation to protect the mental health benefits that Medicare patients receive-
• Representatives in the House should continue to support efforts to restore mental health cuts. The House has already passed a provision in Section 610 of the Children's Health and Medicare Protection Act (CHAMP) to restore critical Medicare reimbursement funding beginning in 2008.
• As the Senate considers Medicare legislation, Senators should support Senator Jeff Bingaman's (D-NM) efforts to protect Medicare mental health benefits. The Bingaman proposal would restore reimbursement cuts to psychologists' and social workers' services and make psychologists eligible for E&M reimbursement for the services they provide within their licensure.
The Centers for Medicare & Medicaid Services (CMS) slashed Medicare part B reimbursement for psychologists and social workers effective January 1, 2007. Because psychologists and social workers provide almost all of the Medicare psychotherapy and testing services, many senior citizens may lose access to these services, as psychologists and social workers have indicated they may have to reduce their caseloads or leave the Medicare program all together.
This cut is attributable to the recent CMS "5-year review" (71 Fed. Reg. 37170). Under the 5-year review rule, CMS increased payments for physician E&M codes, raising Medicare costs by $4.5 billion. Required by law to keep its costs budget neutral, CMS offset the higher E&M payments by reducing the work relative value units (RVUs) for all Medicare services.
The 5-year review cut is different from pay adjustments related to the Sustainable Growth Rate (SGR). Congressional action late last year to avert the scheduled 10.1% pay decrease under the SGR formula and replace it with a 0.5% increase through June 30th was critically important to keeping psychologists' and other provider payments from plummeting further. Congress should continue to stop cuts through this year.
Mental health and psychological testing services are hardest hit by the 5-year review cut since reimbursement values for these services are heavily weighted by work RVUs. E&M services are important, but E&M payments should not be increased at the sacrifice of Medicare mental health services. Psychologists and social workers are not eligible for E&M reimbursement and should not shoulder the burden for the increase in physician E&M payments.
CMS does not, but should reimburse psychologists for the E&M services they provide within their licensure. Psychologists perform many E&M services now, including providing consultations, establishing diagnosis and treatment options, analyzing tests and records, and counseling and coordinating care, but CMS prohibits psychologists from billing for E&M services under a vaguely described rationale that these are "medical" services. Since psychologists can and do provide some of these services now, they should be permitted to provide them to Medicare beneficiaries in accordance with their licensure. In this way, psychologists will be able to more accurately bill for the actual services that they provide.
The cost is very low to protect mental health. Removing psychologists and social workers from the cut would reduce CMS's budget neutrality adjuster by a mere $30 million per year of the $4.5 billion 5-year review costs associated with E&M payments. Making psychologists eligible for E&M reimbursement will increase Medicare costs by approximately $6 million per year.
Lack of Medicare Parity: A Significant Barrier to Care
Members should cosponsor and pass outpatient mental health coinsurance parity as proposed by Representatives Tim Murphy and Grace Napolitano (H.R. 1571) and Senators Olympia Snowe and John Kerry (S. 1715). These bills phase out the discriminatory 50% coinsurance requirement, moving to a parity requirement of 20% in six years. The House approved an immediate 20% requirement when it passed the CHAMP Act last year.
Medicare beneficiaries in need of mental health treatment services face financial discrimination that contributes to their inability to receive needed care. Medicare reimburses 80% of the cost for most services, but only 50% for the outpatient mental health services of a psychologist or other mental health provider in the program. For many elderly and disabled people this high coinsurance requirement makes it extremely difficult or impossible to get needed care.
This higher out-of-pocket expense is a barrier to cost-effective outpatient psychological services, particularly for the great majority of beneficiaries who do not have expensive Medigap insurance to pay the difference. In addition to the discriminatory 50% mental health requirement, Medicare also has a discriminatory lifetime cap on inpatient psychiatric facility days, but no cap on other inpatient services.
Importance of Access to Quality Mental Health Care for the Elderly and Disabled
The mental health needs of the nation's elderly are great. According to the U.S. Surgeon General, 37% of seniors in primary care settings display symptoms of depression. In addition, older people have the highest rate of suicide of any age group, accounting for 20% of all suicide deaths. Approximately 17% of adults over 65 suffer from addiction or substance abuse, particularly alcohol or prescription drug abuse. For Medicare beneficiaries receiving Social Security Disability Insurance mental illness represents the single largest diagnostic category (27%).
The need for mental health services for the nation's elderly will increase significantly as the baby boom generation ages. Many will face stress due to physical health problems and limitations. Changes such as retirement or relocation to a different community can disrupt seniors' intellectual and social activities-factors that the Surgeon General recognized as important for maintaining mental health in later life. The loss of family members and friends will test coping abilities as well as affect overall wellbeing.
Psychological intervention can improve quality of life, mental health, and potentially reduce overall medical costs for this population. For those with dementia, psychological services can alleviate or control many of the serious emotional/behavioral problems that accompany this disorder.
Research shows that lack of quality and timely mental health treatment can lead to increases in medical costs associated with misdiagnosed conditions, inappropriate treatment or overmedication. For example, patients suffering from untreated depressive and anxiety disorders often do not respond well or quickly to medical and physical rehabilitation and recover more slowly after medical interventions such as surgery.
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