Behavioral Health: Patient Access, Provider Claims Payment, and the Effects of the COVID-19 Pandemic

What GAO Found

GAO found that there have been longstanding concerns about the availability of behavioral health treatment, particularly for low-income individuals. According to a review of federal data, one potential barrier to accessing treatment has been shortages of qualified behavioral health professionals, particularly in rural areas. Stakeholders that GAO interviewed—officials from the National Council for Behavioral Health (NCBH) and from hospital associations and insurance regulators in four states—cited additional contributing factors such as provider reimbursement rates and health system capacity. Additionally, recent reports from Pennsylvania and Oregon further documented longstanding problems with meeting the need for behavioral health services in their states.

Evidence collected during the pandemic suggests the prevalence of behavioral health conditions has increased, while access to in-person behavioral health services has decreased:

  • Centers for Disease Control and Prevention (CDC) survey data collected from April 2020 through February 2021 found that the percentage of adults reporting symptoms of anxiety or depression averaged 38 percent. In comparison, using similar questions, CDC found that about 11 percent of U.S. adults reported experiencing these symptoms from January to June 2019.
  • An analysis of CDC data found that the share of emergency department visits for drug overdoses and suicide attempts were 36 and 26 percent higher, respectively, for the period of mid-March through mid-October 2020 compared to the same time period in 2019.
  • In a February 2021 survey of its members, NCBH found that in the 3 months preceding the survey, about two-thirds of the member organizations surveyed reported demand for their services increasing and having to cancel or reschedule patient appointments or turn patients away. The survey also found that during the pandemic, 27 percent of member organizations reported laying off employees, 45 percent reported closing some programs, and 35 percent decreased the hours for staff.

Officials GAO interviewed from provider organizations offered anecdotal examples of problems with payments for behavioral health services, including examples suggesting that denials and delays were more common for these services than they were for medical/surgical services. However, most officials were not aware of published data that could confirm their concerns, and data from reports from two states on claims denials either did not support their concerns or were inconclusive. In addition, a report in one state that examined mental health parity—requirements that behavioral health benefits are not more restrictive than medical/surgical benefits—found that the rate of complaints associated with behavioral health services was notably lower than those for medical/surgical services.

The lack of available data confirming stakeholder concerns could be related to potential challenges consumers and providers face in identifying and reporting mental health parity violations, as previously reported by GAO. Specifically, in 2019, GAO found that complaints were not a reliable indicator of such violations, because consumers may not know about parity requirements or may have privacy concerns related to submitting a complaint. GAO recommended that the federal agencies involved in the oversight of mental health parity requirements evaluate the effectiveness of their oversight efforts. As of March 2021, the agencies had not yet implemented this recommendation.

Why GAO Did This Study

Behavioral health conditions, which include mental health and substance use disorders, affect a substantial number of adults in the United States. For example, in 2019, an estimated 52 million adults in the United States were reported to have a mental, behavioral, or emotional disorder, and 20 million people aged 12 or older had a substance use disorder. Experts have expressed concerns that the incidence of behavioral health conditions would increase as a result of stressors associated with the COVID-19 pandemic. Even before the pandemic, longstanding questions have been raised about whether coverage or claims for behavioral health services are denied or delayed at higher rates than those for other health services.

GAO was asked to examine several issues about the demand for behavioral health services, as well as coverage and payment for these services. GAO examined (1) what is known about the need for and availability of behavioral health services, and how these have changed during the COVID-19 pandemic; and (2) what issues selected stakeholders identified regarding the payment of claims for behavioral health services.

GAO reviewed survey data and other relevant analyses focused on the need for and availability of behavioral health services prior to and during the COVID-19 pandemic. GAO also reviewed reports from two states that compared claims for behavioral health services with those of other health services; interviewed officials from NCBH; and interviewed officials from hospital associations and insurance regulators in Oregon, Pennsylvania, Texas, and Virginia.

For more information, contact John E. Dicken at 202-512-7114 or dickenj@gao.gov.

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    GAO's previous work has shown that a number of opportunities exist for the Department of Defense (DOD) to strengthen management of defense spending, which would help the department address the challenges it faces, especially in a constrained budget environment. These opportunities include: Improving budgeting execution of funds. DOD does not fully obligate the funds appropriated to it and can improve both its budgeting for and its use of the resources that are provided to it. For example, GAO found that DOD has left billions of dollars in appropriated amounts unspent over the past 10 fiscal years. Better estimating annual budget requirements and obligating appropriations provided by Congress within the period of availability established by Congress would help DOD minimize these cases of under-execution. More clearly determining future resource requirements related to overseas contingency operations. DOD and Congress need a clearer determination of DOD's future resource requirements, in particular how and whether to incorporate enduring Overseas Contingency Operations (OCO) costs—costs that will endure beyond ongoing contingency operations—into DOD's base budget. These costs could total tens of billions of dollars a year. However, few details exist as to what makes up these enduring costs or how they were derived, raising questions about how much should be included as future requirements. Reducing improper payments. Addressing improper payments—payments that should not have been made or were made in an incorrect amount—is an area where better financial management could save DOD billions of dollars. In its fiscal year 2020 agency financial report, DOD estimated that it paid about $11.4 billion in improper payments, or about 1.7 percent of all payments it made that year. DOD has taken steps to reduce improper payments in some areas, but DOD's estimates of its improper payments in other areas indicate more remains to be done. Sustaining and refining department-wide business reform efforts. DOD must transform its overall business operations so that it can more efficiently and effectively use its resources. In recent years, DOD reported notable achievements from its most recent department-wide business reform efforts, including $37 billion in savings from fiscal years 2017 to 2021 as a result of these efforts. However, GAO previously found that while DOD's reported savings were largely reflected in its budget materials, the analyses underlying these estimates were not always well documented and the savings were not always the result of business reform. Moreover, uncertainty about the leadership structure at DOD for overseeing and reforming business operations, including the recent elimination of the Chief Management Officer position, calls into question whether efforts to fundamentally transform how the department does business can be realized and sustained. GAO has previously highlighted the importance of DOD providing clear department-wide guidance on roles, responsibilities, authorities, and resources for business reform efforts will be necessary for DOD to make progress in these efforts. Decisions by DOD and Congress regarding long-term defense needs will have a meaningful impact on the nation's fiscal future. As the single largest category of discretionary spending, defense spending is likely to play a large role in any discussion of future federal spending. GAO and others have found that DOD faces challenges that are likely to put pressure on its budget moving forward. DOD is the only major federal agency that has been unable to receive a clean audit opinion on its financial statements. This testimony provides information on how DOD can better manage defense spending, specifically related to its ability to (1) accurately estimate its budgetary requirements and execute its appropriated funds, (2) determine resource requirements related to overseas contingency operations, (3) reduce improper payments, and (4) sustain and refine department-wide reform efforts. For this testimony, GAO reviewed and summarized its recent work on DOD budget and financial management issues and departmental reform efforts. In prior work on which this testimony is based, GAO made recommendations that DOD take steps to better estimate its annual budget requirements and future fiscal needs for OCO, reduce improper payments, and refine and formalize its departmental reform efforts. DOD generally concurred with these recommendations and is working toward implementing them. For more information, contact Elizabeth A. Field at (202) 512-2775 or fielde1@gao.gov.
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  • Secretary Michael R. Pompeo, Secretary of Defense Mark Esper, Indian Minister of Defense Rajnath Singh, And Indian Minister of External Affairs Subrahmanyam Jaishankar Opening Statements at the U.S.-India 2+2 Ministerial Dialogue
    In Crime Control and Security News
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  • Secretary Michael R. Pompeo Remarks at the Florida Family Policy Council Dinner Gala: Respecting Life in America’s Foreign Policy
    In Crime Control and Security News
    Michael R. Pompeo, [Read More…]
  • Kansas Man Indicted on Federal Child Pornography Charges
    In Crime News
    A resident of Topeka, Kansas, has been indicted by a federal grand jury in the U.S. District Court for the District of Kansas on federal child pornography charges, Acting Assistant Attorney General Brian Rabbitt of the Justice Department’s Criminal Division announced today.
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  • Florida Tire Importer Pleads Guilty in Tax Conspiracy
    In Crime News
    A Miami, Florida, tire importer pleaded guilty today to conspiracy to defraud the government, announced Principal Deputy Assistant Attorney General Richard E. Zuckerman of the Department of Justice’s Tax Division and U.S. Attorney Ariana Fajardo Orshan of the Southern District of Florida.  
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  • Fair Labor Standards Act: Observations on the Effects of the Home Care Rule
    In U.S GAO News
    In response to the Department of Labor's Home Care Rule—which extended Fair Labor Standards Act (FLSA) minimum wage and overtime protections to more home care workers—some states made changes in their Medicaid programs, according to studies and GAO interviews with stakeholders and selected state officials. Many stakeholders said the rule led some states to limit home care workers' hours in their Medicaid programs to avoid overtime costs. For example, in Oregon, newly hired home care workers provided through Medicaid were generally limited to 40 hours per week, according to state documentation. Some states also budgeted additional funds for overtime pay. In addition, according to a few stakeholder groups, some states changed service delivery in their Medicaid programs, for example, by discontinuing services such as live-in care. In contrast, several stakeholders said some states did not make any major changes to their Medicaid programs' home care services. Provider agencies, workers, and consumers experienced changes after the Home Care Rule took effect. Specifically, some provider agencies restricted workers' hours to limit overtime costs, though this can result in the need to hire more workers, leading to increased costs of recruiting, training, and scheduling, according to several stakeholders. GAO's analysis of national survey data found that home care workers, when compared to occupations with similar education and training requirements, were more likely to work full-time but did not earn significantly higher earnings following the Home Care Rule (see figure). Many stakeholders GAO spoke with described ongoing challenges consumers face in obtaining home care services, such as difficulty finding workers to hire. Estimated Median Weekly Earnings of Employed Workers, 2010 through 2019 Note: The margins of error at the 95 percent confidence level are within plus or minus 7.2 percent of the estimate itself. Employment in home care is projected to grow nearly 40 percent over the next decade to meet demand from an increasing population of older adults and people with disabilities. Home care workers help those who need assistance with activities of daily living such as dressing, eating, or bathing. State Medicaid programs may allow home care for eligible individuals as an alternative to institutional care. The Department of Labor's (DOL) Home Care Rule, which went into effect in 2015, extended FLSA protections to more home care workers. GAO was asked to review the implementation and effects of the Home Care Rule. This report examines what is known about (1) changes states made to their Medicaid programs in response to the Home Care Rule; and (2) the Home Care Rule's effect on home care provider agencies, workers, and consumers. To address these objectives, GAO analyzed 2010 through 2019 national survey data on workers' hours and wages; interviewed stakeholders from 15 organizations that represent the different groups affected, DOL officials, and home care program officials from three states selected based on variation in their Medicaid programs and minimum wage levels; and reviewed studies on state strategies to implement the Home Care Rule. For more information, contact Melissa Emrey-Arras at (617) 788-0534 or emreyarrasm@gao.gov.
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  • Statement of Acting Attorney General Jeffrey A. Rosen on the Death of U.S. Capitol Police Officer Brian D. Sicknick
    In Crime News
    Acting Attorney General Jeffrey A. Rosen issued the following statement:
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  • Apply for Preclearance Expansion
    In Travel
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  • Former Cancer Center President Indicted For Participation In Long-Running Antitrust Conspiracy
    In Crime News
    A federal grand jury returned an indictment against Dr. William Harwin, founder and former President of Florida Cancer Specialists & Research Institute LLC (FCS), for conspiring to allocate medical and radiation oncology treatments for patients in Southwest Florida, the Department of Justice announced today.
    [Read More…]
  • Pain Clinic Owner Sentenced for Role in Operating Pill Mills in Tennessee and Florida
    In Crime News
    A pain clinic owner was sentenced today to over 33 years in prison for her role in operating several pill mills in Knoxville, Tennessee, and Hollywood, Florida.
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  • J&F Investimentos S.A. Pleads Guilty and Agrees to Pay Over $256 Million to Resolve Criminal Foreign Bribery Case
    In Crime News
    J&F Investimentos S.A. (J&F), a Brazil-based investment company that owns and controls companies involved in multiple industries, including the meat and agriculture industry, has agreed to pay a criminal monetary penalty of $256,497,026 to resolve the department’s investigation into violations of the Foreign Corrupt Practices Act (FCPA).  The resolution arises out of J&F’s scheme to pay millions of dollars in bribes to government officials in Brazil in exchange for obtaining financing and other benefits for J&F and J&F-owned entities.
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  • Man Sentenced for Engaging in Illicit Sexual Conduct with Minors in the Republic of Kenya
    In Crime News
    A Pennsylvania man was sentenced today to over 15 years in prison plus a lifetime of supervised release, and ordered to pay $16,000 in restitution for engaging in illicit sexual conduct in a foreign place.
    [Read More…]
  • Honduran immigrant convicted of alien smuggling
    In Justice News
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