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Best Remedy for Medicare’s Underutilization is a Virtual EAP Model
Medicare beneficiaries experience highly fragmented care. CMS traces this largely to an abundance of specialty services—40% of Medicare patients see 7 or more specialists a year. Yet they get relatively few outpatient behavioral services. This needs to change, but it would be inadvisable to increase those services by implementing a new detection and referral system. There is a better way.
The Centers for Medicare & Medicaid Services (CMS) is betting on value-based care (VBC) to transform care delivery and reduce fragmentation. It ideally means care will be better integrated and coordinated. Improving access to behavioral services may be core to VBC, but we know people routinely fall through the cracks with referral protocols. We need a more reliable method of getting people engaged in behavioral healthcare.
We should let Medicare beneficiaries have therapeutic conversations from home. Let them engage licensed therapists virtually, by phone or video, for services that are more employee assistance program (EAP)-like than diagnostically grounded. This approach would cast a wide net, reach seniors with diverse issues, and direct those with serious disorders to appropriate care. Initial access is the primary problem needing to be solved.
Numbers Tell the Story
The focus here is on Medicare seniors (now at 56 million), not disabled or “dually eligible” people who qualify for Medicare. Nearly half of those eligible opt for Medicare Advantage (MA) plans versus Original Medicare (OM). The MA plans are often more tightly managed, but CMS will move all OM members into “accountable care relationships by 2030” to ensure better care coordination.” Outpatient behavioral care is underutilized within MA and OM.
Let us dig into the MA data by studying Massachusetts, a state surpassing others in “measuring behavioral health expenditures.” The state is also striving to increase access. Its largest insurer recently expanded its provider network by 50% and doubled spending on behavioral services. These efforts should be copied by every state. Nonetheless, their reporting exposes the Medicare underutilization problem.
Behavioral costs are quite different for commercially insured versus MA members. Behavioral health was 6.1% of total healthcare costs for commercial members in 2019, compared to only 1.8% for MA members. The percentage increased in 2020 with the pandemic. The commercial rate grew to 7.0%, while MA crept to 1.9%. Level-of-care costs are even more revealing than aggregate costs.
Outpatient behavioral services are the largest category of spending for commercial members in Massachusetts, at 55% of the total in 2019 and 60% in 2020. Yet outpatient costs for MA members never reach 25% in either year. The largest category of behavioral health spending for MA members is inpatient care. The lack of outpatient visits likely contributes to some inpatient admissions.
Virtual Care in an EAP Framework
We know many people in need do not access outpatient behavioral care due to cost, stigma, and convenience. It is also likely some Medicare beneficiaries are too preoccupied with their chronic medical conditions. Their doctors may not think they need or want a therapy session. Yet unmet needs are probably substantial given that utilization for Medicare is a fraction of that for people under 65.
We learned during the pandemic that virtual care is a viable modality. The strategy recommended here is to use virtual modalities in an EAP model where everyone gets 3 (or more) visits on demand at no copay. This is a direct and simple way to overcome Medicare’s chronic underutilization. Screenings and referrals can delay or impede access. This approach gives every member open access to virtual care.
While some Medicare beneficiaries may have little need for behavioral counseling, the priority now should be attraction and engagement. We can expect many are overwhelmed by life circumstances, others are coping with loss and loneliness, and many others are dealing with undiagnosed behavioral disorders. EAP has another positive feature: Innovation is expected every year to increase service use.
Hurdles for Behavioral Executives
This care deficit has not been properly prioritized. Why? The reasons are partly scientific and partly related to health plan competition. CMS bases its actions on research evidence and would likely want clinical trials to validate every element of the plan outlined here. The wheels of research turn slowly. The medical model also demands a grounding in detection and diagnosis, which this plan abandons.
MA competition is a separate problem. Plans must attract members each year. They must either lure people away from other MA plans or convince OM beneficiaries to join. Plans incentivize consumers with dental, vision, and other supplemental benefits. Would behavioral visits be appealing? Marketing experts should be able to make 3 free virtual visits on-demand enticing—it might even become popular.
The task of moving such an idea forward sits with behavioral executives. They must articulate for local MA plan leaders how this could be both an attractive benefit and a service that reduces other healthcare costs. We must end an access failure that has been ignored for too long. Seniors are entitled to appropriate levels of outpatient care. We can start by meeting them where they are—at home.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
References
Making Care Primary (MCP) Model. Centers for Medicare & Medicaid; 2023.
