The last few months have seen significant movement across a broad array of issues.
Executive Branch Activities
HHS Naloxone Education Training Event
On September 9th, APA member and co-chair of the Maryland Psychiatric Society’s Legislative Committee, Michael Young, MD, MS, DFAPA, attended the Department of Health and Human Services’ (HHS) Naloxone Demonstration event. The event included remarks from administration leadership including HHS Secretary Xavier Becerra, ONDCP Director Dr. Rahul Gupta, HHS Assistant Secretary Admiral Rachel Levine, HHS Deputy Secretary Andrea Palm, and SAMHSA Assistant Secretary Miriam Delphon-Rittmon, highlighting the severe nature of the opioid epidemic, and how making naloxone over-the-counter and widely available will decrease the number of people dying from opioid overdoses. The event also included a live demonstration by Roz Pichardo, Founder, Operation Save our City, of how to assess a person suspected of overdosing on opioids and how to administer naloxone nasal spray if indicated.
SAMHSA’s Harm Reduction Framework Encourages Direct Investments
APA supports the Substance Abuse and Mental Health Services Agency’s (SAMHSA) draft harm reduction framework (.pdf), encouraging increased direct investment into programs, sites, and services. Despite the substantial evidence base for the effectiveness of harm reduction, the legality of, access to, and training opportunities for harm reduction approaches remain underutilized. APA’s letter supports many crucial harm reduction modalities included in the framework, while also providing suggestions for additions and improvements. Most notably, APA called for the inclusion of safe injection sites and consumption facilities, the development of clear action plans, and evaluations on funding and maintaining State, Local, Territorial, and Tribal (STLT) programs and work guided by Persons Who Use Drugs (PWUDs).
APA Urges FDA and CMS to Maintain High Standards of Safety and Effectiveness for Digital Health Interventions
Consistent with APA’s App Evaluation Model, APA urges caution and maintaining high standards of evidence in approval and coverage of medical devices and other digital mental health interventions without clinician involvement. In a letter to CMS about the proposed Transitional Coverage for Emerging Technologies program, which would cover FDA-designated Breakthrough Devices, APA advised that, given the relatively low threshold of evidence required for FDA’s Breakthrough Device designation, CMS should exercise caution in allocating Medicare resources for coverage of these devices. In a separate letter to the FDA responding to a request for information about increasing patient access to at-home use of medical technologies, APA noted the importance of ensuring device safety and effectiveness before approving devices for at-home use without the supervision of a clinician. While these interventions are often described as “low risk” by federal rulemakers, there is significant risk in falsely leading a person with mental illness to believe that they are receiving an effective treatment, particularly when this treatment replaces treatment by a clinician.
APA Encourages NIDA to Support Health Care Policies that Safely Facilitate Access to Quality Care
APA maintains its support for continuity of quality care, whether in-person or enabled by technology, in a response to the National Institute of Drug Abuse’s (NIDA) request for data on the impact of telehealth initiation of controlled substances. APA urges NIDA to be cautious in their framing of harms associated with telemedicine prescribing of controlled substances, since telehealth treatment has been found to be as safe and effective as in-person care even for high-acuity psychiatric concerns and increases access to care in instances of stigma, rural location, mobility challenges, and other health-related social needs. The continuity of care, whether through in-person or enabled by technology, can prevent population health risks by maintaining standard care among those for whom controlled substances are clinically appropriate, but must be supported through investment on digital literacy resources and infrastructure. APA continues to advocate for persons with mental health and/or substance use disorders to be seen via audio and/or video in a non-clinical location with no in-person evaluation required, at the discretion of the treating psychiatrist.
APA Supports Universal Suicide Screening in the Emergency Department
Through its comments to CMS on considering a measure related to universal suicide risk in the ED or other interventions or measurement approaches targeted at suicide prevention in a proposed rule, APA advocated for universal suicide screening, as it doubles the number of identified cases of individuals at genuine risk for death from suicide. As the lack of inpatient beds in many hospitals is a barrier to improving care for these patients, APA also advocated for CMS to fund crisis stabilization facilities, which can provide a safe and therapeutic alternative to hospital EDs and inpatient admission. These facilities are a critical component of SAMHSA’s vision for crisis systems in which everyone has someone to call (988), someone to respond (mobile crisis teams), and a safe place to go (crisis facilities). While facility-based crisis care is associated with reduced hospitalization and ED boarding, they vary widely in scope, capability, and populations served because they are not currently reimbursed by Medicare and most private insurance plans, but rather financed and regulated at the state level by Medicaid and block grant funds. APA urged CMS to develop standard definitions for facility-based crisis care and reimbursement for these services.
Physician Fee Schedule and Quality Payment Program
APA supported a number of proposed provisions put forward by CMS regarding the Physician Fee Schedule including: support for the continuation of telehealth flexibilities around payment for telehealth and virtual supervision of residents as well as a request to drop the requirement for an in-person visit prior to telehealth; payment for mobile crisis services as well as an additional payment for providing care to chronically ill patients. APA suggested an alternative approach to proposed increases to timed psychotherapy codes used by non-physician clinicians without a corresponding increase to the psychotherapy codes used along with an evaluation and management service to ensure services are paid for equitably. APA provided additional information regarding increasing access to mental health services including how to encourage psychiatrists to participate in Medicare. We also provided comments regarding suicide safety planning as well as a detailed response to an RFI regarding digital therapies. Within the quality payment program section, APA did not support the Mental Health and Substance Abuse MIPS Value Pathway (MVP) proposed by CMS in the 2024 Quality Payment Program section of this rule for several reasons. First, the MVP does not align quality with cost and simply serves to limit the number of measures available for behavioral health reporting, which adds administrative burden. Second, the cost measures proposed for inclusion, especially the psychosis cost measure are problematic and confounded by the limited ability of inpatient psychiatrists to influence care or outcomes outside of the hospital setting. APA did respond favorably to the proposed inclusion of the 2 new measures for suicide safety planning and reduction of suicidal ideation and the measure of improved functioning developed under the MACRA grant over the last 4 years.
Congressional Activities
APA Supports Behavioral Health IT Grant Program
On July 28, APA joined the Behavioral Health Information Technology Coalition in a letter to express our support of H.R. 5116, the Behavioral Health Technology Coordination Act. This legislation would expand access to health information technology among behavioral health providers. Specifically, the bill proposes the authorization of an Office of the National Coordinator gram program facilitating health IT incentives for a range of mental and behavioral health providers, including psychiatric hospitals, psychiatrist, and addiction medicine physicians, psychologists, social workers, Community Health Centers, and substance use treatment providers. Without the proper technology, it is difficult to integrate mental health services into primary care when behavioral health care workers are still reliant on phones, faxes and emails to exchange patient data. Providing behavioral health providers with proper health IT is instrumental as a means of coordinating care for patients.
APA Supports Conrad State 30 and Physician Access Reauthorization Act
On August 1, APA joined letters of support to both the House and the Senate in support of H.R. 4942 and S. 665, the Conrad State 30 and Physician Access Reauthorization Act. The Conrad State 30 waiver program provides waivers to states that exempt international medical graduate (IMGs) physicians with J-1 visas from the requirement to return to their home country in exchange for three years of service in a rural or underserved community. Without the program, IMGs would have to return to their country of origin and must wait at least two years before applying for another visa or green card. In the letters, we urge Congress to again reauthorize this program to ensure that rural and underserved communities can continue to access health care.
APA Supports Medicare Billing Code G2211 Implementation
On September 6, APA signed a letter to House and Senate leadership in support of the Centers for Medicare and Medicaid Services (CMS) fully implementing Medicare billing code G2211 in 2024. The G2211 code is designed to address the evaluation and management associated with medical care for patients with complex medical conditions. The code was initially finalized in the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS), but Congress imposed a moratorium on full implementation until January 1, 2024. In the letter, we express our support for Congress to fully implement this code as CMS has again included the code in the 2024 MPFS rule.
APA Urges Support for Workforce Programs
In September, APA joined the Group of 6 in a letter to House and Senate leadership urging lawmakers to continue supporting key workforce programs. According to the Association of American Medical Colleges, the U.S. is expected to face a shortage of 124,000 physicians by 2034, while the Health Resources and Services Administration estimates a shortage of 250,000 mental health professionals by 2025. In order to address these projected shortages, we urge Congress to prioritize workforce programs, including reauthorizing the Conrad State 30 program for Fiscal Year 2024 as well as supporting programs that defer interest on student loans during a medical or dental internship or residency program.