Lynn Cooper was going through an awful time. After losing her job in 2019, she became deeply depressed. Then the covid-19 pandemic hit, and her anxiety went through the roof. Then her cherished therapist — a marriage and family counselor — told Cooper she couldn’t see her once Cooper turned 65 and joined Medicare.
“I was stunned,” said Cooper, who lives in Pittsburgh and depends on counseling to maintain her psychological balance. “I’ve always had the best health insurance a person could have. Then I turned 65 and went on Medicare, and suddenly I had trouble getting mental health services.”
The issue: For decades, Medicare has covered only services provided by psychiatrists, psychologists, licensed clinical social workers, and psychiatric nurses. But with rising demand and many people willing to pay privately for care, 45% of psychiatrists and 54% of psychologists don’t participate in the program. Citing low payments and bureaucratic hassles, more than 124,000 behavioral health practitioners have opted out of Medicare — the most of any medical specialty.
As a result, older adults anxious about worsening health or depressed by the loss of family and friends have substantial difficulty finding professional help. Barriers to care are made more acute by prejudices associated with mental illness and by ageism, which leads some health professionals to minimize older adults’ suffering.
Now, relief may be at hand as a series of legislative and regulatory changes expand Medicare’s pool of behavioral health providers. For the first time, beginning in January, Medicare will allow marriage and family therapists and mental health counselors to provide services. This cadre of more than 400,000 professionals makes up more than 40% of the licensed mental health workforce and is especially critical in rural areas.
Medicare is also adding up to 19 hours a week of intensive outpatient care as a benefit, improving navigation and peer-support services for those with severe mental illness, and expanding mobile crisis services that can treat people in their homes or on the streets.
“As we emerge from the COVID-19 public health emergency, it is abundantly clear that our nation must improve access to effective mental health and substance use disorder treatment and care,” Meena Seshamani, deputy administrator of the Centers for Medicare & Medicaid Services, said in a July statement.
Organizations that have advocated for years for improvements in Medicare’s mental health coverage applaud the changes. “I think we are, hopefully, at a turning point where we’ll start seeing more access to mental health and substance use disorder care for older adults,” said Deborah Steinberg, senior health policy attorney at the Legal Action Center in Washington, D.C.
For years, seniors in need of mental health aid have encountered obstacles. Although 1 in 4 Medicare recipients — including nearly 8 million people under 65 with serious disabilities — have some type of mental health condition, up to half don’t receive treatment.
Cooper, now 68 and a behavioral health policy specialist at the Pennsylvania Association of Area Agencies on Aging, bumped up against Medicare’s limitations when she tried to find a new therapist in 2020: “The first problem I had was finding someone who took Medicare. Many of the providers I contacted weren’t accepting new patients.” When Cooper finally discovered a clinical social worker willing to see her, the wait for an initial appointment was six months, a period she describes as “incredibly stressful.”
The new Medicare initiatives should make it easier for people in Cooper’s position to get care.
Advocates also note the importance of expanded Medicare coverage for telehealth, including mental health care. Since the pandemic, older adults have been able to get these previously restricted services at home by phone or via digital devices anywhere in the country, and requirements for in-person appointments every six months have been waived. But some of these flexibilities are set to expire at the end of next year.
Robert Trestman, chair of the American Psychiatric Association’s Council on Healthcare Systems and Financing, called on lawmakers and regulators to maintain those expansions and continue to reimburse mental health telehealth visits at the same rate as in-person visits, another pandemic innovation.
Older adults who seek psychiatric care tend to have more complex needs than younger adults, with more medical conditions, more disabilities, more potential side effects from medications, and fewer social supports, making their care time-consuming and challenging, he said.
Several questions remain open as Medicare enacts these changes. The first is, “Will CMS pay mental health counselors and marriage and family therapists enough so they actually accept Medicare patients?” asked Beth McGinty, chief of health policy and economics at Weill Cornell Medicine in New York City. That’s by no means guaranteed.
A second: Will Medicare Advantage plans add marriage and family therapists, mental health counselors, and drug addiction specialists to their networks of authorized mental health providers? And will federal regulators do more to guarantee that Medicare Advantage plans provide adequate access to mental health services? This kind of oversight has been spotty at best.
In July, researchers reported that Medicare Advantage plans include, on average, only 20% of psychiatrists within a geographic area in their networks. (Similar data is not available for psychologists, social workers, and psychiatric nurses.) When older adults have to go out-of-network for mental health care, 60% of Medicare Advantage plans don’t cover those expenses, KFF reported in April. With high costs, many seniors just skip services.
Another key issue: Will legislation proposing mental health parity for Medicare advance in Congress? Parity refers to the notion that mental health benefits available through insurance plans should be comparable to medical and surgical benefits in key respects. Although parity is required for private insurance plans under the 2008 Mental Health Parity and Addiction Equity Act, Medicare is excluded.
One of the most egregious examples of Medicare’s lack of parity is a 190-day lifetime limit on psychiatric hospital care, a feature that deeply affects members with serious conditions such as schizophrenia, severe depression, or post-traumatic stress, who often require repeated hospitalization. There is no similar curb on hospital use for medical conditions.
An upcoming Government Accountability Office report examining differences between the cost and use of behavioral health services and medical services in traditional Medicare and Medicare Advantage plans may give Congress some guidance, suggested Steinberg, of the Legal Action Center. That investigation is underway, and a date for the report’s release hasn’t been set.
But Congress can’t do anything about the all-too-common assumption that seniors feeling overwhelmed or depressed should “just grin and bear it.” Kathleen Cameron, chair of the executive committee for the National Coalition on Mental Health and Aging, said “there’s a lot more that we need to do” to address biases surrounding the mental health of older adults.
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