Introduced by Reps. Kristi Noem, R-S.D., and Jan Schakowsky, D-Ill., and Senators Sherrod Brown, D-Ohio, and Susan Collins, R-Maine, the Medicare Mental Health Access Act (H.R. 1173/S. 448) would remove a roadblock to mental health treatment for Medicare beneficiaries in certain treatment facilities. Although psychologists are licensed to practice independently in all U.S. states and jurisdictions, Medicare still requires unnecessary physician sign-off and oversight of their services in some settings, hampering or even preventing delivery of needed care. H.R. 1173 and S. 448 would remove this barrier.

Medicare beneficiaries desperately need better, faster access to psychologists:

  • Only 1 in 3 older adults with a mental disorder receives any mental health treatment. The Institute of Medicine reports that the situation “borders on a crisis.”
  • Making patients wait for mental health treatment worsens outcomes and increases costs. For Medicare beneficiaries with a chronic condition like diabetes or congestive heart failure, comorbid depression doubles the rate of hospitalization and emergency room use.
  • Physicians — and especially psychiatrists — are often in short supply, particularly in rural and underserved areas, and thus not available to oversee psychologists’ services, oversight which is unnecessary in the first place. In 2015 an executive with a leading physician search and consulting firm stated that “finding a psychiatrist willing to practice in an inpatient setting is like looking for a needle in a haystack.” Psychiatrists are more than 30 percent less likely than other physicians to accept Medicare.
  • Physician oversight is usually provided by general practitioners, who have very little training in treating mental disorders. Primary care physicians detect and adequately treat or refer only 40-50 percent of patients with mental health problems.
  • Behavioral health services are an essential component of treatment for many mental disorders, and psychologists provide more than 70 percent of these services in facilities.
  • Medicare doesn’t require physician sign-off or certification for psychologists’ services provided in an office, so it is inconsistent to require it in outpatient rehabilitation facilities, home health agency programs, partial hospitalization programs and other settings in which psychologists are authorized to practice independently by state law.
  • Private sector health plans, TRICARE, the VA and Medicare Advantage plans let clinical psychologists practice independently in all treatment settings, without requiring physician oversight or prior authorization.
  • Medicare is moving toward integrated care systems, and giving psychologists the same autonomy they enjoy in other health systems will facilitate this trend. Improving beneficiaries' access to behavioral health services is essential to improving outcomes and reducing costs.
  • Psychologists are not currently eligible for the same mental health professional shortage area (MHPSA) bonus payments Medicare pays to psychiatrists and other physicians. These 10 percent bonus payments are an important incentive to provide services in rural and underserved areas. Psychologists were also excluded from receiving Medicare electronic health records (EHR) incentive payments, limited to physicians.

U.S. Health Service Use for Individuals Rating Themselves as in Poor Mental Health
Petterson S, Miller BF, Payne-Murphy JC, Phillips RL Jr. Mental health treatment in the primary care setting: Patterns and pathways. Fam Syst Health 2014;32:157– 66
Here’s how the current referral/supervision requirement affects treatment: 

“I serve a Skilled Nursing Facility in California.  I receive patient referrals from nurses, social workers and families.  These are sent to attending physicians for orders.  Often it takes from 3 - 4 weeks for approval and sometimes never.  There have been several incidents where due to lack of consultation the patients have been sent to the ER for evaluation and treatment.”
— Hugh Pates, Ph.D., San Diego

“[W]ith Medicare patients…I find treatment almost invariably delayed when waiting for approval or authorization action from a referring physician. It is most concerning when the patient is suicidal which is common when they are seeking help for depression and anxiety. It is common for treatment to be delayed for two to six weeks waiting for physician approval during which time the client is not seen or if seen is not reimbursable because the authorization was not finalized.  
— John Griffin, Ph.D., Arlington, Wash.

The Medicare Mental Health Access Act removes the unnecessary physician oversight requirement by adding clinical psychologists to the list of providers in Medicare’s definition of a “physician,” which already includes podiatrists, chiropractors, optometrists and dentists. Psychologists are the only doctoral-level provider not included.

H.R. 1173/S. 448 would not change state licensure laws, and would not add coverage for any new services for which psychologists could bill Medicare.  

Consumer and Provider Organizations endorsing the “Medicare Mental Health Access Act”:

  • American Association of Pastoral Counselors
  • American Board of Professional Neuropsychology
  • American Foundation for Suicide Prevention
  • American Group Psychotherapy Association
  • Association for Ambulatory Behavioral Healthcare
  • Association for Behavioral and Cognitive Therapies
  • Brain Injury Association of America
  • Center for Medicare Advocacy, Inc.
  • Mental Health America
  • National Academy of Neuropsychology
  • National Association for Rural Mental Health
  • National Council for Behavioral Health
  • National Register of Health Service Psychologists
  • Paralyzed Veterans of America
  • TASH