Mental Health Service Use, Spending Jumped During Pandemic, Remain Elevated

Spending on mental health services among Americans with private health insurance has surged since the beginning of the COVID-19 pandemic, a research letter published today in JAMA Health Forum has found. The results suggest that spending on mental health services is continuing to rise even as the use of telehealth has plateaued.

Jonathan H. Cantor, Ph.D., of the RAND Corporation and colleagues examined data from 1,554,895 mental health service claims to ascertain trends in mental health services use and spending during three periods:

• Pre-pandemic, before the declaration of the public health emergency (January 1, 2019, to March 12, 2020).
• Acute phase of the pandemic, before vaccines were available (March 13, 2020, to December 17, 2020).
• Post-acute phase of the pandemic (December 18, 2020, to August 31, 2022).

The researchers found that during the acute phase, in-person visits decreased by 39.5% and telehealth visits increased roughly 1,019.3% (roughly tenfold) compared with the year prior. Jointly, this represented a 22.3% increase in overall service use. During the post-acute phase, telehealth visits stabilized at approximately 1,068.3% of pre-pandemic levels, whereas in-person visits increased 2.2% each month over the period. By August 2022, in-person visits reached 79.9% of pre-pandemic levels, and overall mental health service use was 38.8% higher than before the pandemic.

During the acute phase, per capita expenditures for mental health services were 29.5% higher compared with the year prior. During the post-acute phase, spending for telehealth services remained stable, and spending for in-person care decreased to pre-pandemic levels. However, the average spending rate on mental health services was $3,547,424 per 10,000 beneficiaries per month in the post-acute phase, compared with $2,308,247 during the pre-pandemic phase, a 53.7% increase.

“These findings suggest that telehealth utilization for mental health services remains persistent and elevated. If this increased utilization affects spending, insurers may begin rejecting the new status quo,” Cantor and colleagues wrote. “This concern is particularly relevant when considered against the backdrop of telehealth policies that expired alongside the national [public health emergency] declaration.”

For related information, see the Psychiatric News article “Expect a ‘Long Tail’ of Mental Health Effects From COVID-19.”

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Hospital Incentive Program Found to Increase Buprenorphine Prescriptions for Patients With OUD

Pennsylvania patients with opioid use disorder (OUD) were more likely to receive a prescription for buprenorphine within 30 days of a visit to the emergency department (ED) if they were seen at a hospital participating in the state’s Opioid Hospital Quality Improvement Program than those seen at a hospital that did not participate in this program. These findings are described in a recent report in JAMA Health Forum.

“With surging rates of opioid overdose deaths, ED encounters present a crucial opportunity to engage patients with OUD treatment,” wrote Keisha T. Solomon, Ph.D., of Howard University and colleagues. “The [Opioid Hospital Quality Improvement Program] may be a new policy approach to expanding access to evidence-based treatment for OUD across a diverse and large population of hospitals.”

In response to high opioid overdose death rates, the Pennsylvania Department of Human Services in 2019 implemented the Opioid Hospital Quality Improvement Program—a statewide program that provides financial incentives to any hospital in the state that agreed to implement changes to increase the number of OUD patients who transition from the ED to follow-up OUD treatment, including buprenorphine.

The researchers analyzed data on 17,428 adults (about 57% male) who were enrolled in Medicaid and were seen in an ED for an opioid-related cause (for example, opioid withdrawal or opioid overdose) between January 1, 2016, and December 31, 2020. The main outcome was patients’ receipt of buprenorphine within 30 days of their ED visit.

A total of 14,585 patients with OUD sought care at a hospital ED that was participating in the Opioid Hospital Quality Improvement Program; 2,843 patients sought care at a hospital ED that was not participating in the program. Prior to the Opioid Hospital Quality Improvement Program, the baseline rate for patients prescribed buprenorphine within 30 days of their ED visit for an opioid overdose was similar between hospitals that were and were not participating in the program (5.0% and 5.7%, respectively), Solomon and colleagues noted. However, the researchers found that patients who visited an ED at a hospital participating in the program in 2020 were 3.6 percentage points more likely to receive buprenorphine treatment within 30 days than patients treated at nonparticipating hospitals.

“State programs that use financial incentives to drive OUD treatment practice changes in hospitals may be effective in improving quality and care transitions,” Solomon and colleagues wrote. “Similar programs across the nation should be considered as part of a multifaceted approach to mitigating the opioid epidemic.”

For related information, see the Psychiatric News article “High-Dose Buprenorphine in the ED Effective for OUD.”

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More Research Needed on Appropriateness of MIPS Measures for Psychiatrists, Study Shows

Psychiatrists score lower than other physicians on Medicare’s Merit-Based Incentive Payment System (MIPS) and are more likely to incur negative payment adjustments than other physicians who participate in the system, a study published today in JAMA Health Forum has found. The findings suggest more research is needed to evaluate the appropriateness of MIPS measures for psychiatrists.

MIPS—a mandatory, outpatient value-based payment program that ties reimbursement to performance on cost and quality measures—was “designed to assess performance for a broad range of outpatient clinicians, although different clinicians practice in widely disparate settings and elect to report different quality measures,” wrote Andrew C. Qi, M.D., of Washington University School of Medicine in St. Louis and colleagues. “Psychiatrists represent one group for whom MIPS may be particularly poorly suited to adequately assess care quality.”

The researchers analyzed data from 9,356 psychiatrists and 196,306 other outpatient physicians who participated in the 2020 MIPS, which covered performance in 2018. The mean final MIPS performance score for psychiatrists was 84.0 compared with 89.7 for other physicians. Furthermore, 6.1% of psychiatrists received a penalty compared with 2.9% of other physicians, 92.6% of psychiatrists received a positive payment adjustment compared with 96.3% of other physicians, and 82.0% of psychiatrists received a bonus payment adjustment compared with 88.7% of other physicians.

MIPS adjusts Medicare Part B payments based on performance in four performance categories: quality, cost, promoting interoperability, and improvement activities. Most of the performance disparities were driven by lower scores in the quality and interoperability domains. For example, psychiatrists performed more poorly on measures such as participation in health information exchanges; documentation of patient medications in medical records; and preventive measures that are not related to psychiatry, such as cancer screening. Regarding the measures that appear most relevant to the practice of psychiatry, psychiatrists had higher reporting rates and better performance, including for depression screening and follow-up, and screening for future fall risk, the authors noted.

“Ideally, each specialty would be judged on measures of greatest relevance to the patients treated by that specialty,” Qi and colleagues wrote. “The fact that just as many psychiatrists in our exploratory analysis reported on quality measures for cancer screening and flu shots as for depression care suggests that MIPS performance reflects multispecialty group performance as opposed to quality of psychiatric care.” They added that most measures included in the mental/behavioral health specialty set were almost entirely unreported, which points to a need to develop and encourage the use of measures relevant to psychiatric care in MIPS.

“The increased administrative and financial burdens introduced by MIPS may further disincentivize psychiatrists from treating Medicare patients, resulting in an even greater number of psychiatrists who require patients to pay out of pocket for services,” they wrote. “This factor has concerning implications for access to mental health care for Medicare beneficiaries.”

They concluded, “[Medicare] may want to reconsider the use of many current MIPS measures for assessing the performance of psychiatrists,” the researchers concluded.

For related information, see the Psychiatric News article “PsychPRO Reaping Benefits for Clinicians Reporting MIPS Data.”

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