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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    What GAO Found The Protecting Access to Medicare Act of 2014 (PAMA) established the Certified Community Behavioral Health Clinics (CCBHC) demonstration and tasked the Department of Health and Human Services (HHS) with its implementation. CCBHCs aim to improve the behavioral health services they provide, particularly for Medicaid beneficiaries. Initially established for a 2-year period, the demonstration has been extended by law a number of times; most recently, it was extended to September 2023. States participating in the demonstration can receive Medicaid payments, consistent with federal requirements, for CCBHC services provided to beneficiaries. PAMA also required HHS to assess the effect of the demonstration on service access, costs, and quality. HHS's preliminary assessments of the demonstration in eight states, with 66 participating CCBHCs, found the following: Access. CCBHCs commonly added services related to mental and behavioral health, such as medication-assisted treatment, and took actions to provide services outside the clinic setting, such as through telehealth. Costs. States' average payments to CCBHCs typically exceeded CCBHC costs for the first 2 years of the demonstration. CCBHC payments and costs were more closely aligned in the second year for most states, better reflecting the payment methods prescribed under the demonstration. Quality. States and CCBHCs took steps, such as implementing electronic health records systems, to report performance on 21 quality measures. GAO found data limitations complicated—and will continue to affect—HHS's efforts to assess the effectiveness of the demonstration. For example: Lack of baseline data. PAMA requires HHS to assess the quality of services provided by CCBHCs compared with non-participating areas or states. The demonstration marked the first time these clinics reported performance on quality measures, so no historical baseline data exist. HHS officials noted that with time, additional data may provide insight on the quality of services. Lack of comparison groups. PAMA requires HHS to compare CCBHCs' efforts to increase access and improve quality with non-participating clinics and states. HHS was unable to identify comparable clinics or states due to significant differences among the communities. Lack of detail on Medicaid encounters. PAMA requires HHS to assess the effect of the demonstration on federal and state costs and on Medicaid beneficiaries' access to services. HHS plans to use Medicaid claims and encounter data to assess such changes. However, GAO has previously identified concerns with the accuracy and completeness of Medicaid data and has made numerous recommendations aimed at improving their quality. HHS's decisions in implementing the demonstration also complicated its assessment efforts. HHS allowed states to identify different program goals and target populations, and to cover different services. HHS also did not require states to use standard billing codes and billing code modifiers it developed. The lack of standardization across states limited HHS's ability to assess changes in a uniform way. Why GAO Did This Study Behavioral health conditions—mental health issues and substance use disorders—affect millions of people. HHS estimates that 61 million adults had at least one behavioral health condition in 2019—41 million of whom did not receive any related treatment in the prior year. Many individuals with behavioral health conditions rely on community mental health centers for treatment, but the scope and quality of these services vary. To improve community-based behavioral health services, PAMA created the CCBHC demonstration and provided HHS with $25 million to support its implementation. PAMA directed HHS to assess the demonstration and to provide recommendations for its continuation, modification, or termination. To date, HHS has issued three annual reports assessing the initial demonstration period, which ran from 2017 to 2019. HHS plans to issue a fourth annual report and a final report by December 2021. This report describes HHS's assessment of the demonstration regarding access, costs, and quality. Under the CARES Act, GAO is to issue another report on states' experiences by September 2021. GAO reviewed federal laws and regulations; HHS guidance; and HHS's assessments of the demonstration, including three issued reports, interim reports, and the analysis plan for future reports. GAO also interviewed HHS officials and officials from organizations familiar with community health clinics. HHS provided technical comments, which GAO incorporated as appropriate. For more information, contact Carolyn L. Yocom (202) 512-7114 or yocomc@gao.gov.
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  • Commercial Shipping: Information on How Intermodal Chassis Are Made Available and the Federal Government’s Oversight Role
    In U.S GAO News
    What GAO Found Containerized shipping—performed by oceangoing vessels using standardized shipping containers—accounted for approximately 60 percent of all world seaborne trade, which was valued at approximately $12 trillion in 2017. At a port, shipping containers are placed on "intermodal chassis" (chassis), standardized trailers that carry shipping containers and attach to tractors for land transport. Multiple entities are involved in the movement of shipping containers, including intermodal equipment providers (IEP) (which own and provide chassis for a fee); ocean carriers (which transport cargo over water); and motor carriers (which transport shipping containers over land via chassis). Four distinct models are used in the U.S. to make chassis available to motor carriers (see table), each with benefits and drawbacks according to the entities GAO interviewed. While chassis are generally provided to motor carriers using one of these four models, more than one model may be available at a port. Chassis Provisioning Models Model 1: Single chassis provider An individual intermodal equipment provider (IEP) owns chassis that are directly provided to shippers or motor carriers. Model 2: Motor carrier-controlled A motor carrier owns or is responsible for a chassis that it has procured under a long-term lease. Model 3: Gray pool A single manager, often a third party, oversees the operations of a pool that is made up of chassis contributed by multiple IEPs. Model 4: Pool-of-pools Each IEP manages its respective chassis fleet, but each allow motor carriers to use any chassis among the fleets and to pick up and drop off chassis at any of the IEPs’ multiple locations. Source: GAO.  |  GAO-21-315R Entities GAO interviewed identified multiple benefits and drawbacks to each of the chassis provisioning models. Regarding benefits, for example, both the single chassis provider model and the motor carrier-controlled model allow IEPs and motor carriers to have direct control over the maintenance and repair of their chassis, something these entities potentially lose under other chassis provisioning models. Further, the gray pool and the pool-of-pools models can resolve many of the logistical concerns regarding the availability of chassis, leading to operational efficiencies for port operators and the ability of motor carriers to choose whatever chassis they wish. Regarding drawbacks, cost considerations were identified in some cases. For example, under the single chassis provider model, two IEPs told us that while an expected part of the business, repositioning chassis to ensure there is a sufficient supply of chassis where they are needed can be costly to the IEPs. The federal government provides oversight of chassis safety but has a limited economic oversight role regarding chassis. The Federal Motor Carrier Safety Administration (FMCSA) employs several inspection methods to help oversee chassis safety and compliance with regulations. For example, inspectors perform roadside inspections on commercial vehicles, including chassis, in operation. FMCSA also performs investigations of individual IEPs to oversee chassis safety. While one stakeholder GAO spoke with stated that FMCSA should consider maintaining safety ratings for IEPs—as is currently done for motor carriers—FMCSA officials told us that the current processes provide sufficient information to select IEPs for investigation. The Federal Maritime Commission (FMC) oversees ocean carriers that provide service to and from the U.S. and works to ensure a competitive and reliable ocean transportation supply system. Entities may file complaints with FMC to allege violations of the Shipping Act of 1984, as amended. One such complaint was filed in August 2020, in which the complainants allege, among other things, that although ocean carriers do not own chassis, they still control the operation of chassis pools at ports. An initial decision on this complaint is expected in August 2021. None of the entities GAO spoke with identified additional actions they would like for FMC to take regarding chassis. Why GAO Did This Study Senate Report 116-109—incorporated by reference into the explanatory statement accompanying the Further Consolidated Appropriations Act, 2020—contained a provision for GAO to study intermodal chassis. Within the U.S., some entities have expressed concerns about chassis, including limited availability of chassis in some circumstances, as well as the age and safety of chassis. This report describes selected stakeholders' views on: (1) the ways in which chassis are made available for the movement of shipping containers and the benefits and drawbacks of those models, and (2) the federal government's role in the chassis market. To address these objectives, GAO reviewed relevant reports on chassis provisioning and federal oversight. GAO interviewed representatives from FMC, FMCSA, five industry associations, and the three largest intermodal equipment providers. GAO also interviewed three ocean carriers, five port operators, and a motor carrier selected, in part, for their large number of container movements. The information obtained from these interviews provides a broad perspective of relevant issues but is not generalizable to all entities. For more information, contact Andrew Von Ah at (202) 512-2834 or vonaha@gao.gov.
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  • 5G Wireless: Capabilities and Challenges for an Evolving Network
    In U.S GAO News
    Fifth-generation (5G) wireless networks promise to provide significantly greater speeds and higher capacity to accommodate more devices. In addition, 5G networks are expected to be more flexible, reliable, and secure than existing cellular networks. The figure compares 4G and 5G performance goals along three of several performance measures. Note: Megabits per second (Mbps) is a measure of the rate at which data is transmitted, milliseconds (ms) is a measure of time equal to one thousandth of a second, and square kilometer (km²) is a measure of area. As with previous generations of mobile wireless technology, the full performance of 5G will be achieved gradually as networks evolve over the next decade. Deployment of 5G network technologies in the U.S. began in late 2018, and these initial 5G networks focus on enhancing mobile broadband. These deployments are dependent on the existing 4G core network and, in many areas, produced only modest performance improvements. To reach the full potential of 5G, new technologies will need to be developed. International bodies that have been involved in defining 5G network specifications will need to develop additional 5G specifications and companies will need to develop, test, and deploy these technologies. GAO identified the following challenges that can hinder the performance or usage of 5G technologies in the U.S. GAO developed six policy options in response to these challenges, including the status quo. They are presented with associated opportunities and considerations in the following table. The policy options are directed toward the challenges detailed in this report: spectrum sharing, cybersecurity, privacy, and concern over possible health effects of 5G technology. Policy options to address challenges to the performance or usage of U.S. 5G wireless networks Policy Option Opportunities Considerations Spectrum-sharing technologies (report p. 47) Policymakers could support research and development of spectrum sharing technologies. Could allow for more efficient use of the limited spectrum available for 5G and future generations of wireless networks. It may be possible to leverage existing 5G testbeds for testing the spectrum sharing technologies developed through applied research. Research and development is costly, must be coordinated and administered, and its potential benefits are uncertain. Identifying a funding source, setting up the funding mechanism, or determining which existing funding streams to reallocate will require detailed analysis. Coordinated cybersecurity monitoring (report p. 48) Policymakers could support nationwide, coordinated cybersecurity monitoring of 5G networks. A coordinated monitoring program would help ensure the entire wireless ecosystem stays knowledgeable about evolving threats, in close to real time; identify cybersecurity risks; and allow stakeholders to act rapidly in response to emerging threats or actual network attacks. Carriers may not be comfortable reporting incidents or vulnerabilities, and determinations would need to be made about what information is disclosed and how the information will be used and reported. Cybersecurity requirements (report p. 49) Policymakers could adopt cybersecurity requirements for 5G networks. Taking these steps could produce a more secure network. Without a baseline set of security requirements the implementation of network security practices is likely to be piecemeal and inconsistent. Using existing protocols or best practices may decrease the time and cost of developing and implementing requirements. Adopting network security requirements would be challenging, in part because defining and implementing the requirements would have to be done on an application-specific basis rather than as a one-size-fits-all approach. Designing a system to certify network components would be costly and would require a centralized entity, be it industry-led or government-led. Privacy practices (report p. 50) Policymakers could adopt uniform practices for 5G user data. Development and adoption of uniform privacy practices would benefit from existing privacy practices that have been implemented by states, other countries, or that have been developed by federal agencies or other organizations. Privacy practices come with costs, and policymakers would need to balance the need for privacy with the direct and indirect costs of implementing privacy requirements. Imposing requirements can be burdensome, especially for smaller entities. High-band research (report p. 51) Policymakers could promote R&D for high-band technology. Could result in improved statistical modeling of antenna characteristics and more accurately representing propagation characteristics. Could result in improved understanding of any possible health effects from long-term radio frequency exposure to high-band emissions. Research and development is costly and must be coordinated and administered, and its potential benefits are uncertain. Policymakers will need to identify a funding source or determine which existing funding streams to reallocate. Status quo (report p. 52) Some challenges described in this report may be addressed through current efforts. Some challenges described in this report may remain unresolved, be exacerbated, or take longer to resolve than with intervention. GAO was asked to assess the technologies associated with 5G and their implications. This report discusses (1) how the performance goals and expected uses are to be realized in U.S. 5G wireless networks, (2) the challenges that could affect the performance or usage of 5G wireless networks in the U.S., and (3) policy options to address these challenges. To address these objectives, GAO interviewed government officials, industry representatives, and researchers about the performance and usage of 5G wireless networks. This included officials from seven federal agencies; the four largest U.S. wireless carriers; an industry trade organization; two standards bodies; two policy organizations; nine other companies; four university research programs; the World Health Organization; the National Council on Radiation Protection and Measurements; and the chairman of the Defense Science Board's 5G task force. GAO reviewed technical studies, industry white papers, and policy papers identified through a literature review. GAO discussed the challenges to the performance or usage of 5G in the U.S. during its interviews and convened a one-and-a-half day meeting of 17 experts from academia, industry, and consumer groups with assistance from the National Academies of Sciences, Engineering, and Medicine. GAO received technical comments on a draft of this report from six federal agencies and nine participants at its expert meeting, which it incorporated as appropriate. For more information, contact Hai Tran at (202) 512-6888, tranh@gao.gov or Vijay A. D’Souza at (202) 512-6240, dsouzav@gao.gov.
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