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LEGISLATIVE ALERT - CMS Rules on Physician Fee Schedule - 8-27-21

30 Aug 2021 10:58 AM | CSWA Administrator (Administrator)


As you know, each August CMS puts out changes to the rules that govern the Physician Fee Schedule (PFS).  These changes affect our practices and CSWA sends comments on the rules, which go into effect the following year.

Below please find the comments which CSWA has sent on the PFS 2022, a 1747-page document.  CSWA chose three areas for comment, Mental Health Disparities, Telemental Health Coverage, and Telemental Health Parity in reimbursement.  CSWA encourages all members to send their individual comments on any or all of these areas.  CMS is asking that members not send a standard message.  Use any of the language in the CSWA comments for your own comments.  Send them by September 13, 2021, to https://www.federalregister.gov/documents/2021/07/23/2021-14973/medicare-program-cy-2022-payment-policies-under-the-physician-fee-schedule-and-other-changes-to-part .

As always, let me know when you have sent your comments and send a copy.  Thanks for your help.

Laura W. Groshong, LICSW, Director, Policy and Practice  
Clinical Social Work Association  
lwgroshong@clinicalsocialworkassociation.org


August 27, 2021

Centers for Medicare and Medicaid Services
Department of Health and Human Services
RE: Comment on Physician Fee Schedule 2022
https://www.federalregister.gov/documents/2021/07/23/2021-14973/medicare-program-cy-2022-payment-policies-under-the-physician-fee-schedule-and-other-changes-to-part

The Clinical Social Work Association (CSWA) is pleased to have the opportunity to submit comments on the proposed Physician Fee Schedule for 2022 (PFS2022).  We also want to take this opportunity to thank CMS for covering mental health treatment provided through videoconferencing and audio-only delivery during this Public Health Emergency (PHE).

We will be commenting on three major areas of the bill which are of particular interest to Licensed Clinical Social Workers (LCSWs). These areas are 1) addressing mental health disparities; 2) telemental health continuation after the Public Health Emergency; and 3) reimbursement parity between in-person mental health treatment and telemental health treatment.

Mental Health Disparities

The disparities between mental health access, treatment, and outcomes for white populations as compared to Black, Indigenous, and People of Color (BIPOC), have been well-documented and it is past time to address the root causes.  CSWA is pleased to see the request in the PFS2022 for comment on p. 434: “Solicit comments on addressing health disparities and promoting health equity.” 

Health disparities are costly:  approximately 30% of direct medical costs for African Americans, Hispanics and Asian Americans are excess costs due to these health inequities, and the economy loses an estimated $309 billion per year due to the direct and indirect costs of disparities. (Nov. 2012, Henry J Kaiser Family Foundation)

A major root cause driving these inequities lies in Social Determinants of Health (SDOH).  According to the peer reviewed journal,

Health Affairs, disparities may be rooted in differences in insurance coverage, inequalities in access to good providers, or discrimination by health professionals in the clinical encounter.  Disparities may be the result of years of institutional racism, lack of trust due to years of broken promises, cultural traditions, and more.” (Health Affairs, 2008, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.27.2.393)

When it comes to mental health treatment, whites are more likely to receive psychotherapy and medication on an out-patient basis, whereas BIPOC citizens are more likely to be referred to in-patient treatment for the same conditions

(Health Affairs, 2015, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.27.2.393
Yet, the rates of depression are lower in Blacks (24.6%) and Hispanics (19.6%) than in whites (34.7%). Correspondingly, depression in African Americans and Hispanics tends to be more persistent, likely due at least in part to difficulties accessing effective and affordable out-patient care.

Further, since untreated mental health issues tend to exacerbate physical health issues, treatment costs related to physical health tend to rise as well.  Simultaneously, outcomes become less hopeful, and may come to include disability, addiction, homelessness, and incarceration - again disproportionately affecting BIPOC communities.

Indeed, the prison population has become the largest group of people with diagnosable mental health disorders, between 45-60% (When Did Prisons Become Acceptable Mental Health Facilities?, Stanford Law School, 2017.)   Lack of critical mental health care during incarceration has been persistent, as are the difficulties accessing mental health care through Medicaid upon release. Here, then, is another example of the SDOH role in exacerbating disparities, especially given the excessively high numbers of brown and Black people incarcerated in the US.

CSWA would be happy to provide additional data on how SDOH factors are connected to mental health disparities and need to be addressed.

Telemental Health Coverage

When the Public Health Emergency was implemented in March, 2020, most LCSWs began providing psychotherapy through virtual telemental health (videoconferencing) and audio-only (telephone).  The decision by CMS to cover these new delivery systems during the PHE has been crucial to the wellbeing of Medicare beneficiaries living in areas without local mental health services or accessible transportation to more remote care.  Previously unable to obtain in-person psychotherapy, they finally have the needed treatment because of the new delivery systems.  It is unrealistic to expect them to begin treatment in person when the PHE ends unless SDOH transportation and other barriers to access are addressed.

CSWA therefore recommends that all three forms of treatment delivery be approved and reimbursed at the rate being paid for in-person treatment.   LCSWs who provide services through videoconferencing and audio-only are working as hard, if not harder, than when they see patients in person.  Further, even the requirement that patients being treated via videoconferencing and audio-only must be seen in person every six months is highly problematic; certainly it would be a huge barrier to seeing patients who can ONLY access treatment through virtual means.

The elderly - the main group of Medicare beneficiaries - are chronically underserved when it comes to mental health treatment.  Not all Medicare beneficiaries have access to Rural Health Centers and Federally Qualified Health Centers; many had the opportunity to establish virtual  psychotherapy relationships with independent LCSWs as a result of the PHE.  However, the biannual in-person requirement has created a barrier to virtual treatment.  If it is not eliminated, these beneficiaries may well find themselves back among the “chronically underserved”.

Telemental Health Parity

As noted in the Proposed Rule, “the estimated cost impact of this proposal is unclear, the proposed requirement that a modifier be appended to the claim to identify that the service was furnished via audio-only communication technology would allow us to closely monitor utilization and address any potential concerns regarding overutilization through future rulemaking” (p.1198).  This comment applies to videoconferencing as well.

 In fact, LCSWs and other mental health clinicians have been involved in an in vivo application of these two delivery systems throughout the pandemic.  We ask that this data be collected and analyzed to see how much these services are being utilized and how their use affects cost offsets of medical conditions before CMS moves forward on plans to limit or eliminate them.

CSWA recommends that all three forms of treatment delivery be approved until CMS completes such a study, and that all three be reimbursed at the rate being paid for in-person treatment.   LCSWs providing mental health treatment through videoconferencing and audio-only means are working just as hard, if not harder, providing professional clinical treatment virtually as when they provide services in person.

LCSWs have been long been called the backbone of psychotherapy services, and with more than 250,000 licensees, LCSWs are the largest mental health provider group in the country.  However, as you know, LCSWs are reimbursed by Medicare at 25% less than psychologists for providing the same services, with the exact same CPT psychotherapy codes.  LCSWs have equivalent clinical training, experience, client overall satisfaction, and provide long-term relief of emotional problems.  The reimbursement disparity for LCSWs has not gone unnoticed and the number of LCSW Medicare providers has continually dropped. Lowering reimbursement for telemental health services would likely result in even fewer LCSW Medicare providers.

CSWA hopes that these comments are helpful developing the Proposed Rule and would be happy to discuss them with you further.

Sincerely,

Kendra C. Roberson, PhD, LCSW, President  
Clinical Social Work Association  
kroberson@clinicalsocialworkassociation.org

Laura Groshong, LICSW, Director, Policy and Practice  
Clinical Social Work Association  
lwgroshong@clinicalsocialworkassociation.org 


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