A study conducted on data from 20 selected counties across the country by the Department of Health & Human Services Office of Inspector General found that, despite unprecedented demand for services, only one-third of the total behavioral healthcare workforce actively serves Medicare and Medicaid enrollees.
This review focused on providers with a specialization and training in behavioral health in 20 selected counties. OIG selected a diverse group of 10 urban and 10 rural counties from 10 states that are geographically dispersed throughout the country. It determined the ratio of providers to enrollees in each of the three programs as a key measure of provider availability. It based these ratios on providers who actively served enrollees in the selected counties. It considered a provider to actively serve Medicare or Medicaid enrollees if the provider had at least one outpatient behavioral health service with an enrollee at a location in the enrollee’s county of residence in 2021.
The OIG report describes the scope of the problem. More than 160 million people live in federally designated mental health professional shortage areas, and in 2021, fewer than half of those with a mental illness were able to access timely care. Medicare spends more than $27 billion annually on behavioral health services. However, although one in four Medicare enrollees are living with a mental illness, less than half of them receive treatment.
Many behavioral health providers may be accepting new patients, but do not participate in programs such as traditional Medicare, Medicare Advantage, or Medicaid. For example, a recent study found that almost two-thirds of Medicare Advantage plans had fewer than a quarter of the counties’ available psychiatrists in a plan’s network. Additionally, less than 55 percent of the nation’s psychiatrists accept traditional Medicare, compared to more than 85 percent for other types of physicians.
A number of reasons could explain why certain providers did not serve Medicare and Medicaid enrollees, the report says. Research suggests that reasons can include burdensome administrative requirements for providers and low payment rates. Further, in Medicare and Medicaid, either CMS or state Medicaid agencies will determine what types of providers and services are eligible for reimbursement, which can affect whether providers are able to serve enrollees. Licensure and other supervision requirements can also impact whether providers are able to serve enrollees.
Network adequacy standards
The OIG report notes that Medicare and Medicaid do not have uniform network adequacy standards to ensure that an adequate number of behavioral health providers meet the needs of enrollees. In Medicare Advantage, the network adequacy standards vary by specialty and location. For example, in a large metropolitan county, 90 percent of Medicare Advantage enrollees must have a psychiatrist within 20 minutes or 10 miles of their home. Prior to 2024, these standards applied only to psychiatrists and did not apply to other types of behavioral health providers; however, as of Jan. 1, 2024, the standards were expanded to include clinical psychologists and clinical social workers.
In traditional Medicare, because an enrollee can see any provider participating in Medicare, there are no similar quantitative standards to measure whether there are an adequate number of providers to meet the needs of enrollees. In Medicaid, states must set a quantitative standard for behavioral health providers—such as a time and distance standard—to measure the adequacy of their managed care networks; however, these standards vary across states, and states may define behavioral health providers differently. Additionally, these standards are typically calculated based on data from plan provider directories; however, a number of researchers have found that these directories contain inaccurate or out-of-date information.
On average, in the selected counties, there were fewer than five active behavioral health providers per 1,000 enrollees in each program.
The report noted that the need for behavioral health services increased dramatically during the emergence of COVID-19, and many enrollees experience difficulties accessing timely care.
Prior OIG work has found that similar ratios of active providers to enrollees resulted in challenges for enrollees, who were often unable to receive timely access to care. For example, OIG’s evaluation of New Mexico’s Medicaid program found that there was an average of four behavioral health providers per 1,000 enrollees, and almost three-quarters of the state’s key behavioral health providers reported that they did not have enough behavioral health providers in their counties to meet the needs of enrollees.
These providers also reported difficulties finding and retaining staff, a lack of timely access to care, and difficulty arranging or making referrals for key behavioral health services, largely because of the lack of available providers.
When enrollees are not able to find available providers, they may face higher healthcare costs, delays in receiving care, and difficulty finding a provider close to home. Such challenges could cause enrollees to forego treatment altogether.
Some counties had no providers or very few providers who actively served enrollees. Notably, in traditional Medicare and in Medicaid, a quarter of the counties had fewer than one active provider per 1,000 enrollees, and in Medicare Advantage, three counties had fewer than 1 active provider per 1,000 enrollees. Enrollees in these counties may have to seek providers located in other counties and may need to travel significant distances to see a behavioral health provider.
Within Medicare Advantage and Medicaid, there were also a number of managed care plans offered in the selected counties that had no active providers serving enrollees in that county. In Medicare Advantage, there were 35 plans with no active providers serving enrollees in the county in which they lived. Similarly, in Medicaid, two managed care plans had no active providers in the county.
The report found that rural counties had fewer active providers than urban counties On average, rural counties had fewer than half the number of active providers per 1,000 enrollees, compared to the number of active providers in urban counties. Traditional Medicare had the largest difference.
There were almost three times as many urban providers as rural providers, with an average of 4.4 providers per 1,000 enrollees in urban counties compared to an average of 1.5 providers in rural counties.
Very few providers who could prescribe medication actively served Medicare and Medicaid enrollees. Behavioral health providers who can prescribe medications— such as psychiatrists or psychiatric advanced practice nurses—are critical to behavioral health care. Growing research suggests that medication is most effective when used in combination with therapy and when prescribed and monitored by providers with expertise in behavioral health.
On average, in the selected counties, there were fewer than two active providers who could prescribe medication per 1,000 enrollees in each program. In addition, there were three counties with no active providers who could prescribe in Medicaid, two counties with no active providers who could prescribe in traditional Medicare, and one county with no active providers who could prescribe in Medicare Advantage. Similarly, there were 61 Medicare Advantage plans and 20 Medicaid managed care plans offered in the selected counties that had no active prescribers in that county.
Among the steps OIG recommends CMS take in response is encouraging more providers to serve Medicare and Medicaid enrollees and using network adequacy standards to drive an increase in behavioral health providers in Medicare Advantage and Medicaid. It said CMS should also increase monitoring of Medicare and Medicaid enrollees’ use of behavioral health services and identify vulnerabilities.
The report noted that CMS concurred with or concurred with the intent of all four recommendations.
