THE BEHAVIORAL HEALTH WORKFORCE

The behavioral health workforce includes many different types of clinicians, each with their own unique approach to training and profession norms and identity. Many provide similar sets of services such as therapy and counseling. To deliver that care, the workforce must have some sort of licensing, registration, certification, or credentialing that requires an appropriate level of education and training (Box 3-1). Behavioral health professionals are subject to unique state or territorial licensure requirements, which may include minimum requirements on education and clinical practice hours, exams, and background checks. Health care providers are expected to maintain and renew their licenses, which often requires an annual fee, continuing education, and self-reporting disciplinary actions.

BOX 3-1

Workforce Standards and Definitions.

Behavioral health care providers in the United States include prescribers, like psychiatrists and psychiatric mental health nurse practitioners (PMHNPs) who primarily oversee medication management, and those who perform therapy and counseling services, including psychologists, social workers, and licensed therapists and counselors.

There are approximately 45,000 psychiatrists and 35,000 PMHNPs in the U.S. who assess, diagnose, and treat mental illnesses and SUDs through a combination of psychotherapy and medications (American Psychiatric Association, 2023; Delany, 2023). All psychiatrists complete a 4-year residency program once they graduate from medical school, and they often complete additional specialized fellowship training in sub-specialties such as child and adolescent psychiatry. Every state mandates that practicing psychiatrists obtain licensure (HRSA, 2017). The behavioral health system is increasingly reliant on Psychiatric–Mental Health Advanced Practice Nurses (PMHNPs) to meet growing demand for mental health and substance use services. PMHNPs also diagnose and treat individuals and have the authority to prescribe and manage psycho-active medications for behavioral health conditions (Delaney, 2023). PMHNPs have completed a graduate degree focused on developing competencies in these practice areas and leading to national certification and licensing as care providers by state boards of nursing. Upon receiving their graduate degree, all advanced practice psychiatric nurses and psychiatric nurse practitioners must take a national certification examination (Hanrahan and Staten, 2017). Recent evidence suggests that the number of PMHNPs serving Medicare patients increased 162% during 2011–2019 and provided nearly 1 in 3 mental health prescriber visits to Medicare patients nationally in 2019, offsetting the drop in psychiatrists treating this population (Cai et al., 2022).

Importantly, primary care clinicians are also playing a growing role in the delivery of behavioral health services, thanks in part to challenges in accessing specialists and a trend towards integrating behavioral health with physical health care. From 2006 to 2018, the proportion of adult primary care visits that addressed mental health concerns increased by approximately 50% (Rotenstein et al., 2023). Primary care includes family medicine, general internal medicine, or general pediatrics physicians; nurse practitioners; and physician assistants who advise range of health-related issues and may also coordinate care with specialists (CMS, 2024e). Primary care clinicians have become the primary behavioral health care provider for many patients. One study found that approximately 40 percent of office visits for mental health concerns such as depression and anxiety occur in primary care offices and 47 percent of prescriptions for any mental illness are written by primary care physicians (Jetty et al., 2021). Addiction medicine physicians are credentialed clinicians that subspecialize in addiction medicine to provide prevention, evaluation, diagnosis, and treatment services for patients with SUD or substance-related health conditions. Physicians who are certified in any primary specialty can become certified in the subspecialty of addiction medicine (NIDA, 2018).¹

Complementing medication management are therapy and counseling (psychotherapy) services, which are delivered by a wide swath of specialized behavioral health providers. Clinical psychologists hold doctoral degrees in psychology and assess, diagnose, and treat mental disorders and learning disabilities, as well as cognitive, behavioral, and emotional problems using a variety of evidence-based therapeutic approaches.^2,3 Mental health counselors are licensed professionals who work with individuals, couples, and groups to deal with anxiety, depression, grief, stress, suicidal impulses, and other mental and emotional health issues. While licensing requirements vary from state to state, mental health counselors generally hold an accredited master’s degree in counseling and have 2–3 years of supervised counseling practice. Social workers similarly diagnose and treat mental illnesses and SUDs in the form of individual or group counseling, crisis management, case management, client advocacy, and preventive service, either by working directly with clients or by working as part of a health care team. All clinical social workers have a master’s degree, are licensed, and meet certain additional requirements. Social workers with a graduate degree are employed in mental health and substance use treatment centers, physicians’ offices, clinics, hospitals, and colleges, as well as in private practice, research, planning, or teaching (HRSA, 2017; Lombardi et al., 2017).

There are important subsets of behavioral health professionals that may specialize in certain areas of clinical practice. For example, marriage and family therapists may be psychologists or social workers by training but specialize in diagnosing and treating behavioral health conditions in marriage and family relationships. Marriage and family therapists can help individuals, couples, and families address issues such as low self-esteem, stress, substance use, eating disorders, and chronic illness that can lead to marital or family distress. Addiction counselors provide treatment and support to people who suffer from addiction to alcohol or other drugs and other behavioral health problems, such as gambling addiction. School counselors guide students through academic, emotional, and social challenges, fostering healthy behaviors and essential life skills such as collaboration and perseverance.

Finally, the behavioral health workforce also includes community health workers and behavioral health paraprofessionals who provide unique sets of services, engender community engagement and trust, and support and complement the activities of other behavioral health professionals. Community health workers (CHWs) are frontline public health workers who are typically trusted members of the community and have a close understanding of the community served. The CHW serves as a liaison, link, and intermediary between health and social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery (APHA, 2023). Licensing and certification vary by state in the U.S., hindering the full integration of roles into healthcare due to the absence of national uniformity. Peer support specialists leverage their personal experiences with mental health or substance use disorder to provide empathetic support and practical guidance, acting as advocates and role models to empower individuals in their recovery. Most states require a certification for peer support specialists. Certified prevention specialists focus on educating communities, especially at-risk youth, about healthy lifestyles and steering them away from substance abuse. Psychiatric rehabilitation counselors, psychiatric technicians/aides, and mental health paraprofessionals work under licensed professionals and connect individuals to resources to help facilitate treatment engagement, and teach coping skills, enhancing support for those in need. With varying certification requirements and duties, these professionals collectively contribute to holistic behavioral health care, addressing diverse needs and extending support amid workforce constraints.

Although the number of people treated for behavioral health conditions has risen each year, the capacity and distribution of behavioral health services in the United States is insufficient to deliver care for all who need it, given the ongoing increase in demand (Reinert et al., 2022). There has been consistent policy attention on the supply side of the behavioral health sector, with focus on reported workforce shortages. While some specific behavioral health professions, such as child and adolescent psychiatrists, are in short supply (Tobin-Tyler et al., 2017, p.1)., the Committee notes that there is general disagreement among experts regarding the extent to which there is an aggregate shortage of behavioral health providers in the U.S., particularly given known geographic maldistribution, low provider participation in insurance programs, and the possibility for complementary and even substitutable care among provider types (Glied and Aguilar, 2023). (See Table 3-1 for professional licensing and credentialing qualifications.) Compounding these workforce concerns is a persistent lack of diversity among behavioral health professionals that is needed to reflect the growing heterogeneity of the U.S. population. While the behavioral health workforce remains disproportionately White (Buche et al., 2017), relative to the general population, research has shown that providers from diverse backgrounds, and language and cultural affinities, are more likely to enhance patient satisfaction, build trust with diverse populations, improve service engagement, strengthens therapeutic alliances, and enhance the effectiveness of care (Liang, 2022; NASEM, 2022). Access to these services will improve through increasing the benefits that racially, ethnically, culturally and linguistically diverse populations derive from behavioral health services (Liang, 2022; Saha et al., 2006; Sullivan Commission on Diversity in the Healthcare Workforce, 2004). It should be noted that the need for increased diversity of the workforce does not diminish the importance of ensuring that providers, regardless of race, ethnicity, or other forms of diversity are striving to be culturally competent.

TABLE 3-1

Professional Licensure and Credentialing Qualifications in Behavioral Health Care.

Growing the workforce in the long run is a necessary approach to addressing supply-side challenges in behavioral health, as are additional levers to better utilize the existing behavioral health workforce in the service of care access, quality, and equity. The committee’s statement of task is centered on behavioral health provider participation in Medicare, Medicaid, and Marketplace. Thus, we focus on current systems of financing, payment, and delivery for Medicare, Medicaid, and Marketplace enrollees, and set the foundation to identify policy responses to improve behavioral health provider participation in these programs under the existing total supply of providers. Given that the persistent geographic maldistribution of the behavioral health workforce and the lack of diversity disproportionately affect Medicare, Medicaid, and Marketplace beneficiaries, we do consider these issues in scope.

MEDICARE, MEDICAID, AND MARKETPLACE INSURANCE PROGRAMS

As of January 2024, 67 million Americans were enrolled in Medicare, and 84.5 million Americans were enrolled in Medicaid and CHIP (CMS, 2024d; Medicaid.gov, 2024c). In addition, nearly 13 million dual-eligible Americans were enrolled in both Medicare and Medicaid in 2022. As of early 2024, about 21.6 million people had individual health insurance coverage via the Marketplace. While policies during the COVID-19 pandemic led to increases in Medicaid enrollment, there has since been widespread Medicaid disenrollment, affecting millions. Income fluctuations, administrative obstacles, and shifts in state policies have left approximately 23 percent of those disenrolled currently uninsured (KFF, 2024).

While Medicare, Medicaid, and Marketplace insurance programs provide behavioral health coverage or insurance benefits for children and adults, enrollees struggle to find care providers that accept their insurance. A recent Department of Health and Human Services (HHS) Office of the Inspector General report found that only one-third of the total behavioral health care workforce accepted Medicare or Medicaid enrollees and one-quarter of the counties surveyed had fewer than one active care provider per 1,000 enrollees in traditional Medicare and in Medicaid (OIG, 2024).

Throughout this report, the committee focuses on the role of managed care organizations (MCOs) as they play a major role in Medicare, Medicaid, and Marketplace insurance programs. For the purposes of this report, MCOs are insurance companies that provide managed care plans to Medicare and Medicaid beneficiaries and sell health plans in the Marketplace. We take an inclusive view of managed care plans. They are any type of public or private health coverage that uses a network of contracted care providers to direct enrollees to effective health care services that offer value and affordability. For the purposes of this report, the term includes health maintenance organizations, preferred provider organizations, and exclusive provider organizations.

MEDICARE AND MEDICARE ADVANTAGE

In 2023, Medicare provided health insurance coverage to over 65 million people in the United States, including 57 million older adults and nearly 8 million younger adults with disabilities that qualified for Social Security disability insurance (SSDI) (Worstell, 2024). Traditional Medicare benefits include three parts: hospital insurance (Part A), supplementary medical insurance (Part B), and the outpatient prescription drug benefit (Part D). Medicare Part A covers inpatient hospital care, skilled nursing facility care, hospice care, lab tests, and surgery, while Part B covers physician services and the services of other practitioners, preventive and screening services, outpatient hospital care, care in other outpatient settings, other medical services and supplies, and drugs that people cannot self-administer. Part A and Part B also cover up to 28 hours a week of post-acute home health care if an individual requires part-time or intermittent skilled services and is homebound.⁴ Some 31.6 million adults aged 65 years and older are enrolled in Medicare Advantage plans, which cover Part A and Part B; most plans also include Part D coverage (MedPAC, 2024). The Medicare Advantage program spends significantly more per average Medicare Advantage enrollee than the average cost of coverage for a similar traditional Medicare enrollee (Fuglesten Biniek et al., 2024). The Medicare Shared Savings program is another Medicare program that promotes accountability for a population of Medicare beneficiaries and improves the coordination of fee-for-service (FFS) items and services. In this program, care providers participating in an accountable care organization (ACO) continue to receive traditional Medicare FFS payments under Parts A and B, and ACOs that meet quality and savings requirements share a percentage of any savings realized with Medicare.

Medicare covers inpatient mental health services under Part A and outpatient mental health services, including evaluation and visits with a mental health care provider, under Part B. Part B covers 80 percent of the cost for outpatient mental health services provided by a psychiatrist or other doctor, clinical psychologist, clinical social workers, clinical nurse specialist, nurse practitioner, or physician assistant (Table 3-2). Starting January 1, 2024, Medicare Part B also began covering mental health services provided by marriage and family therapists, and mental health counselors. Medicare will only cover 190 days of care in a lifetime in a hospital that specializes in treating mental health conditions, with days spent in a general hospital being treated for a mental health condition not counting toward the 190-day limit (CMS, 2023a). Table C-2 in Appendix C provides a list of behavioral health and wellness services covered by Medicare.

TABLE 3-2

Medicare Provider Payment Rates for Mental Health and SUD Services.

A 2022 analysis found that 60 percent of psychiatrists were accepting new Medicare patients, compared with 81 percent of general and family practitioners (Freed et al., 2023). In addition, 7.5 percent of psychiatrists opted out of Medicare in 2022, the highest rate of any medical specialty. Physicians, including psychiatrists, who opt out of participating in Medicare contract directly with their Medicare patients and bill them any amount they determine is appropriate. Because of the high demand for behavioral health services and the limited access to behavioral health care providers, many care providers can choose to only accept patients who pay directly, out of pocket. Behavioral health care providers can charge patients who pay directly more than the amount that Medicare would pay while also avoiding the administrative requirements for billing Medicare. One challenge for individuals enrolled in Medicare Advantage plans is that they often lack access to in-network behavioral health providers and instead must turn to more expensive out-of-network care (Zhu et al., 2023). One analysis found that, on average, only 23 percent of psychiatrists were in-network for Medicare Advantage plans (Jacobson et al., 2017).

In 2021, Medicare Advantage enrollees were more likely to be Black or Hispanic, have incomes below $20,000 per person (Figure 3-1), live in urban areas, and have lower levels of education in contrast with traditional Medicare beneficiaries (Clerveau et al., 2023). As of 2020, approximately 55 percent of Hispanic or Latina/o Medicare enrollees and 54 percent of Black Medicare enrollees choose Medicare Advantage plans.

FIGURE 3-1

Income range of Medicare enrollees by coverage type. SOURCE: AHIP, 2023.

MEDICAID AND CHIP

Medicaid and CHIP are federal–state programs that cover medical costs for individuals with limited income. Administered by states and territories under federal guidelines, Medicaid is the largest payer for behavioral health services in the United States, with increasing reimbursements for SUD services (CMS, 2022). As of 2019, nearly a quarter of adult Medicaid and CHIP beneficiaries received mental health or SUD services, with almost four times as many beneficiaries receiving mental health services as SUD services (CMS, 2022).

The CHIP program extends low-cost health coverage to children in families above Medicaid income thresholds. States can choose to structure a CHIP program as an expansion of Medicaid, a separate program, or a combination, with different federal rules applying. As of January 2024, slightly more than 7 million individuals were enrolled in CHIP, for a total of 37.8 million enrollees under Medicaid and CHIP combined (Medicaid.gov, 2024c).

Medicaid rules ensure that mental health and substance use services are covered equally for those enrolled in Medicaid managed care and those in alternative benefit plans, regardless of how the services are provided. Similar parity standards apply to CHIP coverage. Medicaid excludes certain inpatient services because of its “institutions for medical disease” exclusion, which parity regulations do not address (Pestaina, 2022). To help children and youth receive the appropriate preventive, dental, behavioral health, and developmental health services they need through the Medicaid program, states are required to comply with the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program under the federal EPSDT law.⁵ Under the EPSDT program, states are “to provide comprehensive services and furnish all Medicaid coverable, appropriate, and medically necessary services needed to correct and ameliorate health conditions.” The EPSDT program helps to pay for behavioral health care services for Medicaid-covered children and youth up to age 21 (Medicaid.gov, 2024b), but remains an underused resource, with half of all eligible Medicaid beneficiaries not receiving services under the EPSDT benefit in 2017.

The Center for Medicaid and CHIP Services has started several Medicaid and CHIP inititives aimed at making mental health and SUD treatment more readily available at nonspecialized health care settings, including primary care, and at nontraditional settings such as schools, jails, and prisons. These initiatives are intended to increase access to treatment in nonspecialized settings with the hope of also addressing health-related social needs and reducing stigma associated with mental health and SUD conditions (CMCS, 2023).

Demographically, Medicaid/CHIP enrollees come from diverse racial and ethnic backgrounds. In 2020, 43043 percent of Medicaid/CHIP enrollees were non-Hispanic White, 28 percent were Hispanic, 21 percent were Black, and 5.55 percent were Asian (Medicaid.gov, 2020). Medicaid/CHIP enrollees are slightly more likely to reside in rural areas than the total U.S. population, with enrollees in rural areas more likely to be non-Hispanic White and non-Hispanic American Indian and Alaska Native than enrollees in non-rural areas. Medicaid/CHIP enrollees with a primary language other than English are more likely to be Hispanic or non-Hispanic Asian/Pacific Islander compared with enrollees whose primary language is English. Disability-based eligibility is significant with most but not all recipients also receiving Supplemental Security Income (Proctor, 2023). While states have been expanding coverage of behavioral health care services under Medicaid, accessibility remains a challenge because of workforce shortages, despite efforts to provide more widespread coverage of services (Guth et al., 2023a).

DUALLY ELIGIBLE BENEFICIARIES

Individuals enrolled in both Medicare and Medicaid are known as dual eligibles. Medicare is the primary payer for dual-eligible beneficiaries, covering medical services such as professional services provided by a physician, inpatient and outpatient acute care, and post-acute skilled-level care. Dual-eligible beneficiaries are eligible for the same Medicare benefits as other Medicare beneficiaries, but they have lower incomes that make it difficult to afford the Medicare-required premiums and services not covered by the Medicare program (MedPAC, 2022). As of 2022, 87 percent of dual eligibles had an income of less than $20,000, and 40 percent had an income of less than $10,000, compared with 20 percent of all Medicare beneficiaries without Medicaid coverage (MedPAC, 2022). Medicaid supplements Medicare’s coverage by providing financial assistance to dually eligible beneficiaries, who receive different levels of Medicaid assistance, depending on household income. Medicaid covers services like case management, nursing home care, and psychosocial rehabilitation services.

About half of all dual eligibles had a mental health issue, compared with 24 percent of Medicare beneficiaries without Medicaid coverage (Figure 3-2) (Nardone et al., 2014; Peña et al., 2023). 40 percent of partial-benefit dual-eligible enrollees had a mental health condition. Dually eligible beneficiaries receive a diagnosis of having a serious mental illness three times more often than Medicare beneficiaries who are not dually eligible (CBO, 2013).

FIGURE 3-2

Share of Medicare beneficiaries with mental health conditions by Medicaid coverage status, 2020. SOURCE: Peña et al., 2023.

MARKETPLACE PLANS

ACA Health Insurance Marketplaces are run by the federal government in 32 states, with 18 states and the District of Columbia running their own Marketplaces. The Marketplace enables consumers to shop for coverage if they need to buy health insurance on their own. Income-based premiums and cost-sharing subsidies are available through the Marketplace to make coverage affordable for individuals and families (CMS, 2024c).

As of January 2024, 21.3 million people enrolled in Marketplace plans, including 5 million who were first-time enrollees (CMS, 2024a,c). All Marketplace plans must cover behavioral health treatment, including mental health and SUD inpatient and outpatient treatment, as one of 10 essential health benefits that all Marketplace plans must include. However, the behavioral health services included in Marketplace plans benefits vary across states. States select a state-specific “benchmark plan,” such as the state’s largest small group market plan. Marketplace plans must then provide benefits that are substantially equal to the benefits the benchmark plan offers, often aligning those benefits with the state’s small group commercially insured health plan with the largest enrollment. This requirement does not extend to large employer plans under the ACA’s essential health benefits mandate. Self-insured private employer plans, commonly offered by large and some small employers, are not obligated to cover behavioral health services as they can be exempt from these state mandates and the ACA’s essential health benefit requirements. Parity protections only come into effect if these plans offer behavioral health coverage.

PAYMENT MODELS FOR BEHAVIORAL HEALTH SERVICES

There are three approaches that Medicare, Medicaid, and Marketplace plans use to pay for behavioral health services: FFS, capitated payment, and value-based payment (VBP). FFS,⁸ the traditional model of health care reimbursement, is the most common. FFS payments reward care providers for doing more and tend to be very restrictive with respect to the definitions of services that a FFS plan will cover. This can limit the ability of care providers to tailor care to individual needs. Most payments to health plans are based on a fixed amount per person (capitated), but some plans pay doctors and hospitals based on the services they provide (fee-for-service). Different payment programs, such as Accountable Care Organizations (ACOs), focus on improving care at the plan level, while others like the Merit-based Incentive Payment System (MIPS) aim to improve care by rewarding individual providers.

Capitated payment is a population-based payment in which payers often make a risk-adjusted, prospective payment for each enrolled person to a health plan regardless of the costs actually incurred. For Medicare Advantage plans, that amount is frequently risk-adjusted to account for the health status and complexity of the population of patients insured; plans are paid more for enrolling sicker people. In a capitated payment system, the entity receiving the fixed monthly payment bears the risk of spending more than it receives and realizes any savings that result from spending less than the fixed amount. Many state Medicaid agencies also operate a capitation system in which the state pays MCOs a fixed, monthly amount per enrollee.

VBP programs reward health care providers for both achieving savings and for the quality of care they provide to Medicare beneficiaries rather than the quantity of services they provide. Through financial incentives and other methods, value-based care programs aim to hold health plans and care providers more accountable for the quality of care, along with spending, while also giving them greater flexibility to deliver the right care at the right time. An example of a VBP is the voluntary Medicare Shared Savings program. This program allows care providers to form ACOs that can share in savings from efficient management of care if they reach quality-of-care thresholds. One of CMS’s attempts to develop a value-based approach began in 2024 with the Innovation in Behavioral Health (IBH) model. With this approach, care can be more targeted to Medicaid and Medicare beneficiaries dealing with moderate to severe mental health conditions and SUD by providing those individuals with better access to treatment programs and safety net providers (CMS, 2024b). One goal of the IBH model is to mitigate frequent emergency department visits and hospitalizations by offering outpatient mental health and SUD services to more vulnerable populations, since emergency department visit rates for adults with mental health disorders reached 52.9 per 1,000 people from 2017 to 2019 (Santo et al., 2021).

Medicaid Managed Care

Historically, Medicaid paid for services, including those for behavioral health conditions, on a FFS basis; Medicaid then paid providers for each distinct billable service they delivered. Over the past several decades, however, Medicaid payment has shifted to managed care arrangements, through which state Medicaid programs pay health plans based on capitation. Health plans in turn contract with care providers for services provided to Medicaid recipients (Figure 3-3).

FIGURE 3-3

MCO coverage of behavioral health services as of July 2022. NOTE: MCO = managed care organization. SOURCE: Guth et al., 2023b.

In 2022, the majority of Medicaid beneficiaries (74%) received care through comprehensive, risk-based MCOs (Hinton and Raphael, 2023a,b; KFF, 2021). Behavioral health services are mostly provided through managed care arrangements, and though some states “carve out” behavioral health services from their MCO contracts, there is evidence that more states are moving to integrate, or “carve in,” behavioral and physical health care (Hinton and Raphael, 2023a). However, some states carve out coverage for serious mental illnesses specifically. As of 2023, behavioral health managed care companies administered 42 state Medicaid programs (Kaye and Wilkniss, 2023). While the majority of Medicaid-reimbursed services are FFS, several states have implemented alternative payment models for specific services, such as case management, or for high-risk populations, such as individuals with schizophrenia (Gifford et al., 2019).

SETTINGS FOR DELIVERING BEHAVIORAL HEALTH CARE

The behavioral health workforce functions in a wide range of prevention, health care, and social service settings. These settings include prevention programs, community-based programs, inpatient treatment programs, primary care health delivery systems, private practitioners’ offices, emergency rooms, criminal justice systems, schools, or higher education institutions (Figure 3-4). Estimates place the number of U.S. behavioral health treatment facilities at over 12,000 (SAMHSA, 2020). In addition, there are designated rural health centers (RHCs), Indian Health Service clinics, and Tribal health centers that offer behavioral health services in their respective communities (Box 3-2).

FIGURE 3-4

Number of U.S behavioral health facilities by facility type, 2020. NOTE: CMHC = community mental health center; RTC = residential treatment center; VAMC = Veterans Affairs Medical Center. General hospitals include only non-federal general hospitals with (more...)

BOX 3-2

A Note on Rural Health Centers, Indian Health Services, and Tribal Health Clinics.

Community-Based Settings

Community-based behavioral health care is delivered in a number of settings, many of which are described below. Community-based care addresses population needs in ways that are accessible and acceptable to members of the community; builds on the goals and strengths of people who experience mental illnesses; promotes a network of supports, services, and resources; emphasizes evidence-based, recovery-oriented services; and uses peer expertise in service design and delivery (Keet et al., 2019; Thornicroft et al., 2011). For example, Medicaid launched a new program in 2021 to support community-based mobile crisis intervention services. These services, staffed by both behavioral health professionals and paraprofessionals, meet people experiencing mental health or substance use crises where they are and connect them to a behavioral health specialist 24 hours per day, 365 days a year (CMS, 2021). This new option gives states the flexibility to design programs that work for their communities.

A considerable portion of individuals with Medicaid or Medicare coverage seek care in community health settings, which have become integral components of the nation’s health safety net system. For the purposes of this report, the following overview will focus on community mental health centers (CMHCs), federally qualified centers (FQHCs), certified community behavioral health clinics (CCBHCs), and school-based health centers (SBHCs) as examples of the community-based settings in which people can receive behavioral health care. Though the federal government supports a variety of different approaches to providing community-based care, some states are also funding experiments in this area. Box 3-3 provides an example of a state-organized demonstration project.

BOX 3-3

An Example of Promising State Practices in Behavioral Health.

Community Mental Health Centers

CMHCs are mostly nonprofit, community-based programs that offer a variety of services to support mental health. CMHCs primarily offer outpatient behavioral health services, though some CMHCs also offer inpatient psychiatric hospitalization, residential care, and crisis stabilization. The centers treat both children and adults, including individuals who are severely and persistently mentally ill or have been discharged from an inpatient mental health facility. The specific clinical services that CMHCs offer include diagnostic evaluation, screening and triage, crisis intervention, individual and group psychotherapy, psychiatric medication management, partial hospitalization or day treatment, psychosocial rehabilitation, SUD treatment, and case management. Additional services include vocational rehabilitation, training and education, and collaboration with schools, social service agencies, law enforcement, and community-based organizations.

CMHCs originated with the Community Mental Health Act of 1963.⁹ Community mental health was envisioned to be an inclusive, multidisciplinary, systemic approach to providing publicly funded behavioral health services to everyone living in a given geographical locale and without consideration of ability to pay (Beck, 2008). Before the act’s passage, individuals with mental illness in the United States were frequently institutionalized for their lifetime, and the quality of the treatment they received varied significantly. The act called for establishing and funding a network of behavioral health centers meant to provide care within one’s community, as opposed to in an institution. The Community Mental Health Act helped to facilitate the closure of many state-run mental hospitals, as patients were transferred to community-based care. The policy initiative transformed the landscape of behavioral health treatment in the 20th century and laid the groundwork for all of the country’s CMHCs, of which there were 2,548 as of 2020 (SAMHSA, 2020).

Medicaid and state mental health agencies using federal grants and state revenue funding are the primary payers for services within CMHCs, with a small proportion of a CMHCs funding coming from private commercial insurance, sliding scale fee payment for uninsured individuals, and donations. Depending on the services and populations covered in a state’s Medicaid program, a sizable percentage of the revenue at a CMHC may be from Medicaid reimbursements. Medicare participation is minimal unless individuals are dually enrolled in Medicaid and Medicare.

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the main federal agency responsible for administering federal grants funding community behavioral health services via two block grant programs: the Community Mental Health Services Block Grant and the Substance Use Prevention, Treatment, and Recovery Services Block Grant. SAMHSA distributes funds to each state to support a state behavioral health system. State mental health agencies distribute these grant funds, often along with other state and federal funds, through grants or contracts with CMHCs or local government entities. The architecture of CMHC government funding, therefore, varies significantly by county and state based on the state Medicaid program and on state programs for behavioral health services and public health. A county may contract with a CMHC to provide school-based behavioral health services, for example, and a state mental health agency may fund behavioral health programs for specific populations, such as those who are unhoused or under/uninsured, through these grants and contracts.

Federally Qualified Health Centers

FQHCs are nonprofit primary care organizations that provide accessible, comprehensive care, particularly to under-resourced populations such as people experiencing homelessness, people who work in agriculture, and veterans. They are typically in areas characterized by economic, geographic, or cultural barriers that limit access to affordable health care. In 2021, FQHCs provided care for 18 percent of all Medicaid beneficiaries, while accounting for only 2.1 percent of Medicaid spending, and also provided care for 22 percent of all uninsured individuals (NACHC, 2023b). FQHCs offer many services, including preventive care, chronic condition management, and mental health support, and often provide enabling services such as case management and legal aid.

Governed by community-led boards and overseen by the Bureau of Primary Health Care within the Health Resources and Services Administration (HRSA), FQHCs play a crucial role in the health care safety net, serving millions of individuals across diverse communities. FQHCs have expanded behavioral health services over the years, integrating them into primary care to enhance accessibility and coordination. Together, these sites serve approximately 1 in 11 people in every U.S. state, the District of Columbia, Puerto Rico, the Virgin Islands, and the Pacific Basin. In 2022, these sites employed over 285,000 staff, including 18,800 behavioral health specialists, and provided care for 3 million individuals with behavioral health issues (NACHC, 2023a).

Today, virtually all FQHCs provide behavioral health services either directly or through referral, in large part as a result of significant investments by HRSA to increase access to mental health and SUD services. In fact, the capacity of FQHCs to provide behavioral health services increased from over 5,000 behavioral health specialists in 2010 to almost 18,800 in 2021. FQHCs employ a variety of licensed behavioral health care providers, including clinical social workers, psychiatrists, psychologists, advanced practice registered nurses and nurse practitioners, professional counselors, marriage and family therapists, and other professionals, who collectively constitute an average 11.7 percent of the health care team at FQHCs nationally (NACHC, 2023b).

Although the growth and integration of behavioral health professionals at FQHCs is a vital part of improving the behavioral health landscape, it addresses only a fraction of the overall care needed. Research has shown that people with mental illnesses are at higher risk for deaths from physical ailments, pointing to the importance of whole person care (Momen et al., 2022; Prior et al., 1996; Tan et al., 2021). Studies have also shown this integrated approach improves access and treatment for children of color (Sheldrick et al., 2022).

While Medicaid is a major source of funding, FQHCs also rely on Medicare, commercial insurance, and other grants to sustain their operations, with payment structures such as the Prospective Payment System (PPS) supporting their services or other approved alternative payment models (MACPAC, 2017). PPS is a method of reimbursement in which the Medicaid and Medicare payment is made according to a predetermined, fixed amount based on a per visit rate predicated on the cost of services. The payment rate is typically higher than the usual and customary reimbursement and is designed to cover a broader, more flexible range of clinical services. While these rates are updated annually to reflect inflation and the costs of new services, the payment amounts have fallen behind the cost of providing care (NACHC, 2023b).

Certified Community Behavioral Health Clinics

CMHCs evolved from federally mandated guidelines to services provided by state mental health agencies that are supported by ongoing federal financial aid such as SAMHSA block grants for community mental health and substance abuse services.¹⁰ The Protecting Access to Medicare Act of 2014¹¹ sanctioned establishing CCBHCs as a pilot initiative to reform the conventional model of behavioral health service delivery and payment within CMHCs.

CCBHCs are required to provide a range of services, including crisis services that are available 24 hours a day, 7 days a week. Today, there are more than 500 CCBHCs in 46 states, the District of Columbia, Guam, and Puerto Rico, serving about 2.1 million people (National Council for Mental Wellbeing, 2022). CCBHCs are usually CMHCs and show significant outcomes, including reductions in hospitalizations, homelessness, and jail time, with extensive service provision to children and youth, often within the school setting. The centers emphasize collaboration with law enforcement, offer re-entry support, and provide medication-assisted therapy (MAT) for SUD. In 2022, 82 percent of CCBHCs offered at least one type of MAT, compared with 56 percent of behavioral health clinics nationwide (National Council for Mental Wellbeing, 2022). CCBHCs have required collaboration with law enforcement agencies and other partners to improve outcomes for people involved with or are at risk of involvement with the criminal justice system (SAMHSA, 2019). In addition, 65 percent of CCBHCs train law enforcement officers in Mental Health First Aid and other awareness training and 64 percent provide re-entry support to individuals return to the community from incarceration (National Council for Mental Wellbeing, 2022).

One difference between a CMHC and a CCBHC is how they are reimbursed for services rendered. A CMHC bills for and is reimbursed for each service the center provides, while a CCBHC is usually funded through a per-person per-month model that includes administrative costs (Moore and Stangler, 2022). Both SAMHSA and Medicaid have programs to support CCBHCs, though CCBHCs developed under SAMHSA and those created through Medicaid have different funding mechanisms. Medicaid funds demonstrations authorized by Section 223, Demonstration Program to Improve Community Mental Health Services, and participating states receive enhanced reimbursements to support their CCBHCs. States awarded SAMHSA-administered CCBHC expansion grants receive $2 million annually, paid directly to clinics. States receiving Medicaid demonstration funds may not apply for SAMHSA grants (National Council for Mental Wellbeing, 2022). States can also fund CCBHCs independent of these two mechanisms.

School-Based Health Centers

SBHCs provide primary care, behavioral care, and other services in or near schools, reducing scheduling and transportation barriers for students. SBHCs are often in communities with higher rates of free or reduced lunches. According to the School-Based Health Alliance, “SBHCs operate through partnerships between health care organizations, school communities, community-based organizations, families, and youth. This collaboration, care coordination, and youth engagement improves student, school staff, and community health literacy and outcomes and contributes to positive educational results, including reduced absenteeism, decreased disciplinary actions, and improved graduation rates” (Soleimanpour et al., 2023, p. 1). SBHCs offer a variety of services to students including social/emotional well-being counseling, crisis intervention, classroom behavior/learning support, individual counseling, peer mediation/peer group counseling, mental health screenings (e.g., depression, anxiety, attention deficit hyperactivity disorder, trauma), case management, evaluation of need for individualized learning plans, prescribing and managing mental health medications, sexual assault counseling (Foney and Buche, 2018). Approximately 80 percent of schools served by SBHCs are Title 1 schools that receive federal funding to support high percentages of children from families with low incomes, and some 70 percent of students in schools with access to SBHCs are Black, Indigenous, and other people of color. In a 2022 national survey of SBHCs, 75% reported serving populations besides students, compared to 62% in 2017. Of those serving other populations, almost 60 percent of SBHCs reported serving school staff, 47 percent serve students’ family members, and 33 percent serve other community members (Figure 3-5) (Soleimanpour et al., 2023).

FIGURE 3-5

Populations served by SBHCs. NOTE: SBHCs = School-Based Health Centers. SOURCE: Soleimanpour et al., 2023.

Approximately 83 percent of SBHCs offer behavioral health services (Keeton et al., 2012; Soleimanpour et al., 2023). A review of the evidence on SBHCs suggests that they might be well suited to address youth gun violence, adverse childhood experiences, and the health of American Indian and Native American communities (Arenson et al., 2019). In addition to health care, SBHCs provide support that addresses the social determinants of health (Figure 3-6). Most SBHCs screen clients for health and social needs, including 31 percent that screen for adverse childhood experiences or trauma and 30 percent that screen for social determinants of health (Soleimanpour et al., 2023).

FIGURE 3-6

Supports provided to clients and their families to obtain services to address social determinants of health. SOURCE: Soleimanpour et al., 2023.

Academic Medical Center/Teaching Hospital/Regional Health System

Academic medical centers (AMCs) and teaching hospitals provide behavioral health services on both an outpatient and inpatient basis. They also serve as the primary training grounds for the behavioral health care workforce. AMCs and teaching hospitals represent a minority of hospital systems, with AMCs accounting for approximately 6 percent of U.S. hospitals (Burke et al., 2023) and teaching hospitals accounting for approximately 55 percent of U.S. hospitals (Fisher, 2019).

Though not specific to behavioral health, data from the American Association for Medical Colleges indicate that Medicare payments represent over 30 percent of the net patient revenue mix for AMCs and teaching hospitals, with Medicaid payments accounting for another 17 to 18 percent (AAMC, 2023). Several studies have found that teaching status is associated with better clinical outcomes in the hospital setting for Medicare beneficiaries and that a larger number of AMCs in an area may be associated with better clinical outcomes in neighboring non-academic hospitals (Burke et al., 2023).

REFERENCES

• AAMC (American Association for Medical Colleges). Teaching hospital characteristics. Chicago, IL: Association of American Medical Colleges; 2023.
• AAMFT (American Association for Marriage and Family Therapy). About marriage and family therapists. 2023. [June 7, 2024]. https://www​.aamft.org​//About_AAMFT/About​_Marriage_and_Family_Therapists.aspx .
• ASCA (American School Counselor Association). State/territory certification requirements. 2023. [June 20, 2024]. https://www​.schoolcounselor​.org/About-School-Counseling​/State-Requirements-Programs​/State-Licensure-Requirements .
• Abed Faghri NM, Boisvert CM, Faghri S. Understanding the expanding role of primary care physicians (PCPs) to primary psychiatric care physicians (PPCPs): Enhancing the assessment and treatment of psychiatric conditions. Mental Health in Family Medicine. 2010;7(1):17–25. [PMC free article: PMC2925161] [PubMed: 22477919]
• AHIP (America’s Health Insurance Plans). Medicare Advantage demographics. Washington, DC: AHIP; 2023.
• Alakeson V, Pande N, Ludwig M. A plan to reduce emergency room “boarding” of psychiatric patients. Health Affairs (Millwood). 2010;29(9):1637–1642. [PubMed: 20820019]
• Andrews CM, Grogan CM, Westlake MA, Abraham AJ, Pollack HA, D’Aunno TA, Friedmann PD. Do benefits restrictions limit Medicaid acceptance in addiction treatment? Results from a national study. Journal of Substance Abuse Treatment. 2018;87:50–55. [PMC free article: PMC5826552] [PubMed: 29471926]
• American Psychiatric Association. The psychiatric bed crisis in the U.S.: Understanding the problem and moving toward solutions. Washington, DC: American Psychiatric Association; 2022. [PubMed: 35921395]
• American Psychiatric Association. What is psychiatry. 2023. [July 3, 2024]. https://www​.psychiatry​.org/patientsfamilies​/what-is-psychiatry#:~:text=There​%20are​%20about%2045%2C000​%20psychiatrists%20in%20the%20U.S.
• APA Services. RxP: A chronology. 2024. [June 7, 2024]. https://www​.apaservices​.org/advocacy/issues​/prescriptiveauthority​/prescription-chronology .
• APHA (American Public Health Association). Community health workers. 2023. [June 7, 2024]. https://www​.apha.org​/apha-communities/member-sections​/community-health-workers . [PubMed: 20943481]
• Arenson M, Hudson PJ, Lee N, Lai B. The evidence on school-based health centers: A review. Global Pediatric Health. 2019;6:2333794–19828745. [PMC free article: PMC6381423] [PubMed: 30815514]
• Bashshur RL, Shannon GW, Bashshur N, Yellowlees PM. The empirical evidence for telemedicine interventions in mental disorders. Telemedicine and e-Health. 2016;22(2):87–113. [PMC free article: PMC4744872] [PubMed: 26624248]
• Becerra X, Palm A, Haffajee RL, Contreras J, Barkoff A, O’Connell D, Valdez RO, Walensky RP, Brooks-LaSure C, Califf RM, Johnson C, Tso R, Tabak LA, Levine RL, Tripathi M, Delphin-Rittmon M, Murthy VH. Health Affairs Forefront. Dec 2, 2022. Addressing the nation’s behavioral health crisis: An HHS roadmap to integrate behavioral health.
• Beck BJ. Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL. Massachusetts General Hospital comprehensive clinical psychiatry. Philadelphia: Mosby; 2008. Chapter 67: Community psychiatry; pp. 917–926.
• Bishop TF, Press MJ, Keyhani S, Pincus HA. Acceptance of insurance by psychiatrists and the implications for access to mental health care. JAMA Psychiatry. 2014;71(2):176–181. [PMC free article: PMC3967759] [PubMed: 24337499]
• BLS (Bureau of Labor Statistics). Occupational outlook handbook, substance abuse, behavioral disorder, and mental health counselors. 2022. [June 7, 2024]. https://www​.bls.gov/ooh​/communityand-social-service​/substance-abuse-behavioral-disorder-and-mental-health-counselors.htm .
• BLS. Occupational employment and wage statistics. 2024. [July 5, 2024]. https://www​.bls.gov/oes​/current/oes211013.htm .
• Buche J, Singer PM, Grazier K, King E, Maniere E, Beck AJ. Primary care and behavioral health workforce integration: Barriers and best practices. Behavioral Health Workforce Research Center. 2017;1(1):1–16.
• Burke LG, Frakt AB, Khullar D, Orav EJ, Jha AK. Association between teaching status and mortality in U.S. hospitals. JAMA. 2017;317(20):2105–2113. [PMC free article: PMC5815039] [PubMed: 28535236]
• Burke LG, Burke RC, Orav EJ, Duggan CE, Figueroa JF, Jha AK. Association of academic medical center presence with clinical outcomes at neighboring community hospitals among Medicare beneficiaries. JAMA Network Open. 2023;6(2):e2254559. [PMC free article: PMC9892959] [PubMed: 36723939]
• Cai A, Mehrotra A, Germack HD, Busch AB, Huskamp HA, Barnett ML. Trends in mental health care delivery by psychiatrists and nurse practitioners in Medicare, 2011–2019. Health Affairs. 2022;41(9):1222–1230. [PMC free article: PMC9769920] [PubMed: 36067437]
• Cantor J, McBain RK, Kofner A, Hanson R, Stein BD, Yu H. Telehealth adoption by mental health and substance use disorder treatment facilities in the COVID-19 pandemic. Psychiatric Services. 2022;73(4):411–417. [PMC free article: PMC10695271] [PubMed: 34407631]
• Cantor JH, McBain RK, Ho P-C, Bravata DM, Whaley C. Telehealth and in-person mental health service utilization and spending, 2019 to 2022. JAMA Health Forum. 2023;4(8):e232645. [PMC free article: PMC10457709] [PubMed: 37624614]
• Cavale S, Vanaik G. Walmart to shut all health clinics in us over lack of profitability. 2024. [June 7, 2024]. https://www​.reuters.com​/business/healthcare-pharmaceuticals​/walmart-close-51-us-health-centers-2024-04-30 .
• CBO (Congressional Budget Office). Dual-eligible beneficiaries of Medicare and Medicaid: Characteristics, health care spending, and evolving policies. Washington, DC: Congressional Budget Office; 2013. [June 7, 2024]. https://www​.cbo.gov/publication/44308 .
• Clerveau G, Ochieng N, Cubanski J, Neuman T. A snapshot of sources of coverage among Medicare beneficiaries. San Francisco. CA: KFF; 2023.
• CMCS (Center for Medicaid and CHIP Services). Mental health and substance use disorder action plan. 2023. [June 7, 2024]. https://www​.medicaid​.gov/medicaid/benefits​/downloads/cmcs-mntl-helthsubstnce-disrdr-actn-plan.pdf .
• CMS (Centers for Medicare & Medicaid Services). New Medicaid option promotes enhanced mental health, substance use crisis care. 2021. [June 7, 2024]. https://www​.cms.gov/newsroom​/pressreleases​/new-medicaid-option-promotes-enhanced-mental-health-substance-use-crisiscare .
• CMS. Medicaid and CHIP and the COVID-19 public health emergency: Preliminary Medicaid and CHIP data snapshot. Baltimore, MD: Centers for Medicare and Medicaid Services; 2022.
• CMS. Medicare & mental health coverage. Baltimore, MD: Centers for Medicare and Medicaid Services; 2023a.
• CMS. The Mental Health Parity and Addiction Equity Act (MHPAEA). 2023b. [June 7, 2024]. https://www​.cms.gov/marketplace​/private-health-insurance​/mental-health-parity-addiction-equity .
• CMS. Historic 21.3 million people choose ACA Marketplace coverage. 2024a. [June 7, 2024]. https://www​.hhs.gov/about​/news/2024/01/24​/historic-21-million-people-choose-aca-marketplace-coverage.html .
• CMS. Innovation in Behavioral Health (IBH) model. 2024b. [June 7, 2024]. https://www​.cms.gov/priorities​/innovation​/innovation-models/innovation-behavioral-health-ibh-model .
• CMS. Marketplace 2024 open enrollment period report: Final national snapshot. 2024c. [June 7, 2024]. https://www​.cms.gov/newsroom​/fact-sheets​/marketplace-2024-open-enrollment-period-report-final-national-snapshot .
• CMS. Medicare monthly enrollment. 2024d. [May 2, 2024]. https://data​.cms.gov​/summary-statistics-onbeneficiary-enrollment​/medicare-and-medicaid-reports​/medicare-monthly-enrollment/
• CMS. Primary care. 2024e. [May 7, 2024]. https://www​.cms.gov/priorities​/innovation​/key-concepts/primary-care .
• CMS. Shared savings program/ACOs: About the program. 2024f. [May 6, 2024]. https://www​.cms.gov/medicare​/payment/fee-for-service-providers​/shared-savings-program-ssp-acos/about .
• CMS. Tribal behavioral health coverage. 2024g. [June 7, 2024]. https://www​.cms.gov/training-education​/partneroutreach-resources​/american-indian​/alaska-native/behavioral-health​/tribal-behavioral-healthcoverage .
• CMS Medicare Learning Network. Information for rural health clinics. Baltimore, MD: Centers for Medicare & Medicaid Services; 2024.
• Collins C, Hewson DL, Munger R, Wade T. Evolving models of behavioral health integration in primary care. New York: Milbank Memorial Fund; 2010. [June 7, 2024]. https://www​.milbank.org​/publications/evolving-models-of-behavioral-health-integrationin-primary-care/
• Crocker AM, Kessler R, van Eeghen C, Bonnell LN, Breshears RE, Callas P, Clifton J, Elder W, Fox C, Frisbie S, Hitt J, Jewiss J, Kathol R, Clark/Keefe K, O’Rourke-Lavoie J, Leibowitz GS, Macchi CR, McGovern M, Mollis B, Mullin DJ, Nagykaldi Z, Natkin LW, Pace W, Pinckney RG, Pomeroy D, Pond A, Postupack R, Reynolds P, Rose GL, Scholle SH, Sieber WJ, Stancin T, Stange KC, Stephens KA, Teng K, Waddell EN, Littenberg B. Integrating behavioral health and primary care (IBH–PC) to improve patient-centered outcomes in adults with multiple chronic medical and behavioral health conditions: Study protocol for a pragmatic cluster-randomized control trial. Trials. 2021;22(1):200. [PMC free article: PMC7945346] [PubMed: 33691772]
• CRS (Congressional Research Service). Medicaid’s Institution for Mental Diseases (IMD) exclusion. 2023. [June 7, 2024]. https://crsreports​.congress​.gov/product/pdf/IF/IF10222 .
• Cummings JR, Ji X, Allen L, Lally C, Druss BG. Racial and ethnic differences in ADHD treatment quality among Medicaid-enrolled youth. Pediatrics. 2017;139(6):e20162444. [PMC free article: PMC5470500] [PubMed: 28562259]
• Curtis SE, Hoffmann S, O’Leary Sloan M. Prescriptive authority for psychologists: The next step. Psychological Services. 2023;20(2):363–381. [PubMed: 35511569]
• Davenport S, Darby B, Gray TJ, Spear C. Access across America: State-by-state insights into the accessibility of care for mental health and substance use disorders. Seattle, WA: Milliman; 2023. [June 7, 2024]. https://www​.milliman​.com/en/insight/access-across-america-state-insights-accessibility-mental-health-substance-use .
• Delaney KR. Inclusion of psychiatric–mental health advanced practice nurses in federal behavioral workforce planning. Psychiatric Services. 2023;75(6):594–596. [PubMed: 38088040]
• Emerson J. Optum shutting down telehealth business. 2024. [June 7, 2024]. https://www​.beckershospitalreview​.com/disruptors​/optum-shutting-down-telehealth-business.html .
• Federation of State Medical Boards. About physician licensure. [Juy 7, 2024]. n.d. https://www​.fsmb.org/u​.s.medical-regulatory-trends-and-actions​/guide-to-medical-regulation-in-the-united-states​/about-physician-licensure/
• Fisher K. Academic health centers save millions of lives. 2019. [June 7, 2024]. https://www​.aamc.org​/news/academic-health-centers-save-millions-lives#:~:text​=In​%20addition%2C%20major​%20teaching%20hospitals,of​%20all%20inpatient​%20psychiatric%20beds .
• Foney DM, Buche J. Behavioral health services in school-based settings. Ann Arbor, MI: University of Michigan School of Public Health; 2018.
• Fortney JC, Bauer AM, Cerimele JM, Pyne JM, Pfeiffer P, Heagerty PJ, Hawrilenko M, Zielinski MJ, Kaysen D, Bowen DJ, Moore DL, Ferro L, Metzger K, Shushan S, Hafer E, Nolan JP, Dalack GW, Unützer J. Comparison of teleintegrated care and telereferral care for treating complex psychiatric disorders in primary care: A pragmatic randomized comparative effectiveness trial. JAMA Psychiatry. 2021;78(11):1189–1199. [PMC free article: PMC8387948] [PubMed: 34431972]
• Freed M, Cubanski J, Neuman T. KFF. 2023. [June 7, 2024]. FAQs on mental health and substance use disorder coverage in Medicare. https://www​.kff.org/mental-health​/issue-brief​/faqs-on-mental-health-and-substance-use-disorder-coverage-in-medicare/
• Fuglesten Biniek J, Freed M, Neuman T. KFF. 2024. [June 7, 2024]. Gaps in Medicare Advantage data remain despite CMS actions to increase transparency. https://www​.kff.org/medicare​/issue-brief​/gaps-in-medicare-advantage-data-remain-despite-cms-actions-to-increase-transparency/
• Gajarawala SN, Pelkowski JN. Telehealth benefits and barriers. Journal for Nurse Practitioners. 2021;17(2):218–221. [PMC free article: PMC7577680] [PubMed: 33106751]
• Galbreath L, Wilkniss S, Rohrer J. Behavioral health system modernization: Comprehensive approaches and cross-cutting tools. 2024. [June 7, 2024]. https://nashp​.org/behavioral-healthsystem-modernization-comprehensive-approaches-and-cross-cutting-tools/
• Gale JA, Croll Z, Croom J, Munk L, Jonk Y. Community characteristics and financial and operational performance of rural health clinics in the United States: A chartbook. Portland, ME: University of Southern Maine; 2022.
• Gifford K, Ellis E, Lashbrook A, Nardone M, Hinton E, Rudowitz R, Diaz M, Tian M. A view from the states: Key Medicaid policy changes: Results from a 50-state Medicaid budget survey for state fiscal years 2019 and 2020. 2019. [May 8, 2024]. https://www​.kff.org/report-section​/a-view-from-the-states-key-medicaid-policy-changes-delivery-systems/
• Gliadkovskaya A. Fierce Healthcare. 2023. [June 7, 2024]. Report: Retailers are vying for “a piece of the medical pie.” How should traditional providers respond? https://www​.fiercehealthcare​.com/providers​/definitive-healthcare-report-retailers-healthcare-how-should-providers-respond .
• Glied S, Aguilar K. USC–Brookings Schaeffer Initiative for Health Policy. 2023. [June 7, 2024]. The behavioral health workforce shortage: Can we make better use of the providers we have? https://www​.brookings​.edu/articles/the-behavioral-health-workforce-shortage-can-wemake-better-use-of-the-providers-we-have/
• Guth M, Saunders H, Corallo B, Moreno S. KFF. 2023a. [March 17, 2023]. Medicaid coverage of behavioral health services in 2022: Findings from a survey of state Medicaid programs. https://www​.kff.org/mental-health​/issue-brief​/medicaid-coverage-of-behavioral-health-servicesin-2022-findings-from-a-survey-of-state-medicaid-programs/
• Guth M, Saunders H, Niles L, Bergefurd A, Gifford K, Kennedy RE. How do states deliver, administer, and integrate behavioral health care? Findings from a survey of state Medicaid programs. 2023b. [June 7, 2024]. https://www​.kff.org/mental-health​/issue-brief​/how-do-states-deliver-administer-and-integrate-behavioral-health-care-findings-from-a-survey-of-state-medicaid-programs/
• Han X, Ku L. Enhancing staffing in rural community health centers can help improve behavioral health care. Health Aff (Millwood). 2019;38(12):2061–2068. [PubMed: 31794314]
• Hanrahan N, Staten T. Common questions about advanced practice psychiatric nurses. 2017. [June 7, 2024]. https://www​.apna.org​/about-psychiatric-nursing/faqs/#1 .
• Harati PM, Cummings JR, Serban N. Provider-level caseload of psychosocial services for Medicaid-insured children. Public Health Reports. 2020;135(5):599–610. [PMC free article: PMC7485049] [PubMed: 32645279]
• Poll Harris. Industry workforce shortages research. Washington, DC: National Council for Mental Wellbeing; 2023. [June 7, 2024]. https://www​.thenationalcouncil​.org/news/help-wanted/
• Heisler EJ. Congressionional Research Service report R43255. 2018. [June 7, 2024]. The mental health workforce: A primer. https://sgp​.fas.org/crs/misc/R43255.pdf .
• HHS (U.S. Department of Health and Human Services). Calendar year (CY) 2023 Medicare physician fee schedule final rule. 2022. [June 7, 2024]. https://www​.hhs.gov/about​/news/2022/12/02​/hhs-roadmap-for-behavioral-health-integration-fact-sheet​.html .
• HHS. About telehealth. 2024. [June 7, 2024]. https://telehealth​.hhs.gov/about .
• Hinton E, Raphael J. 10 things to know about Medicaid managed care. 2023a. [June 7, 2024]. https://www​.kff.org/medicaid​/issue-brief​/10-things-to-know-about-medicaid-managed-care/
• Hinton E, Raphael J. A closer look at the five largest publicly traded companies operating Medicaid managed care plans. 2023b. [June 7, 2024]. https://www​.kff.org/medicaid​/issue-brief​/a-closerlook-at-the-five-largest-publicly-traded-companies-operating-medicaid-managed-care-plans/
• Hoff T, Lee DR. Physician satisfaction with telehealth: A systematic review and agenda for future research. Quality Management in Health Care. 2022;31(3):160–169. [PubMed: 35132008]
• Horton EM. The role of accreditation in validating population-based practice/programs. In: Curley AL, editor. Population-based nursing: Concepts and competencies for advanced practice. 3rd ed. New York: Springer Publishing; 2019.
• HRSA (Health Resources and Services Administration). Behavioral health workforce projections, 2017–2030. Rockville, MD: Health Resources and Services Administration; 2017.
• IHS (Indian Health Service). Indian Health Service fact sheet. Rockville, MD: Indian Health Service; 2023.
• Jacobson G, Rae M, Neuman T, Orgera K, Boccuti C. Medicare Advantage: How robust are plans’ physician networks. San Francisco, CA: KFF; 2017.
• James S. What works in group care? A structured review of treatment models for group homes and residential care. Child and Youth Services Review. 2011;33(2):308–321. [PMC free article: PMC3314708] [PubMed: 22468014]
• Jetty A, Petterson S, Westfall JM, Jabbarpour Y. Assessing primary care contributions to behavioral health: A cross-sectional study using medical expenditure panel survey. Journal of Primary Care & Community Health. 2021a;12:215013272110238. [PMC free article: PMC8202306] [PubMed: 34109860]
• Jolly JB, Fluet NR, Reis MD, Stern CH, Thompson AW, Jolly GA. Review of behavioral health integration in primary care at Baylor Scott and White Healthcare, central region. Proceedings (Baylor University Medical Center). 2016;29(2):131–136. [PMC free article: PMC4790545] [PubMed: 27034543]
• Kaye N, Wilkniss S. State approaches to behavioral health measures in Medicaid managed care. Washington, DC: National Academy for State Health Policy; 2023.
• Keet R, de Vetten-Mc Mahon M, Shields-Zeeman L, Ruud T, van Weeghel J, Bahler M, Mulder CL, van Zelst C, Murphy B, Westen K, Nas C, Petrea I, Pieters G. Recovery for all in the community; position paper on principles and key elements of community-based mental health care. BMC Psychiatry. 2019;19(1):174. [PMC free article: PMC6558752] [PubMed: 31182058]
• Keeton V, Soleimanpour S, Brindis CD. School-based health centers in an era of health care reform: Building on history. Current Problems in Pediatric and Adolescent Health Care. 2012;42(6):132–156. discussion 157–138. [PMC free article: PMC3770486] [PubMed: 22677513]
• KFF. Total Medicaid MCO enrollment. 2021. [June 7, 2024]. https://www​.kff.org/other​/state-indicator​/totalmedicaid-mco-enrollment/
• KFF. Nearly a quarter of people who say they were disenrolled from Medicaid during the unwinding are now uninsured. 2024. [June 21, 2024]. https://www​.kff.org/medicaid​/press-release​/nearly-a-quarter-of-people-who-say-they-were-disenrolled-from-medicaid-during-the-unwinding-are-now-uninsured​/#:~:text=With​%20the%20end%20of​%20continuous,people​%20(46%25)%20have%20had .
• Larson C. Mind 24-7 aims to bring retail behavioral health to the masses, wants to become the “Starbucks of mental health”. 2022. [June 7, 2024]. https://bhbusiness​.com​/2022/02/03/mind-24-7-aims-to-bring-retail-behavioral-health-to-the-masses-wants-to-become-thestarbucks-of-mental-health/
• Lee EC, Grigorescu V, Enogieru I, Smith SR, Samson LW, Conmy AB, De Lew N. Updated national survey trends in telehealth utilization and modality (2021–2022). Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, U. S. Department of Health and Human Services; 2023. [PubMed: 38913813]
• Liang JA. IFDHE Blog. Chicago, IL: AHA Institute for Diversity and Health Equity; Jul 26, 2022. [June 7, 2024]. Increasing diversity among mental health care providers improves trust and reduces cultural stigma. https://ifdhe​.aha.org​/news/blog/2022-07-26-increasing-diversity-among-mental-health-care-providers-improves-trust-and .
• Lombardi BM, de Saxe Zerden L, Richman EL, Sheps CG. Toward a better understanding of social workers on integrated care teams. Chapel Hill, NC: University of North Carolina; 2017.
• MACPAC (Medicaid and CHIP Payment Access Commission). Medicaid payment policy for federally qualified health centers. Washington, DC: Medicaid and CHIP Payment and Access Commission; 2017.
• MACPAC. Implementation of the mental health parity and addiction equity act in Medicaid and CHIP. 2021. [June 3, 2024]. https://www​.macpac.gov​/publication/implementation-of-the-mental-health-parityand-addiction-equity-act-in-medicaid-and-chip-2​/#:~:text=The%20Paul​%20Wellstone%20and​%20Pete,the%20coverage​%20generally%20available%20for .
• Maeng DD, Poleshuck E, Rosenberg T, Kulak A, Mahoney T, Nasra G, Lee HB, Li Y. Primary care behavioral health integration and care utilization: Implications for patient outcome and healthcare resource use. Journal of General Internal Medicine. 2022;37(11):2691–2697. [PMC free article: PMC9411292] [PubMed: 35132550]
• Mark TL, Olesiuk W, Ali MM, Sherman LJ, Mutter R, Teich JL. Differential reimbursement of psychiatric services by psychiatrists and other medical providers. Psychiatric Services. 2018;69(3):281–285. [PubMed: 29191138]
• McBain RK, Cantor JH, Eberhart NK, Huilgol SS, Estrada-Darley I. Adult psychiatric bed capacity, need, and shortage estimates in California—2021. RAND Health Quarterly. 2022;9(4):16. [PMC free article: PMC9519097] [PubMed: 36238001]
• McBain RK, Cantor J, Pera MF, Breslau J, Bravata DM, Whaley CM. Mental health service utilization rates among commercially insured adults in the U.S. during the first year of the COVID-19 pandemic. JAMA Health Forum. 2023a;4(1):e224936. [PMC free article: PMC9857246] [PubMed: 36607697]
• Medicaid.gov. Inpatient psychiatric services for individuals under age 21. [June 7, 2024]. n.d. https://www​.medicaid​.gov/medicaid/long-term-services-supports​/institutional-long-term-care​/inpatientpsychiatric-services-individuals-under-age-21/index.html .
• Medicaid.gov. 2020 race and ethnicity data brief. 2020. [June 3, 2024]. https://www​.medicaid​.gov/medicaid/datasystems​/macbis/medicaid-chip-research-files​/transformed-medicaid-statistical-informationsystem-t-msis-analytic-files-taf​/index.html .
• Medicaid.gov. About section 1115 demonstrations. 2024a. [May 2, 2024]. https://www​.medicaid​.gov/medicaid/section-1115-demonstrations​/about-section-1115-demonstrations​/index.html .
• Medicaid.gov. Early and periodic screening, diagnostic, and treatment. 2024b. [June 7, 2024]. https://www​.medicaid​.gov/medicaid/benefits​/early-and-periodic-screening-diagnostic-and-treatment​/index.html .
• Medicaid.gov. January 2024 Medicaid & CHIP enrollment data highlights. 2024c. [May 3, 2024]. https://www​.medicaid​.gov/medicaid/program-information​/medicaid-and-chip-enrollment-data​/report-highlights/index.html .
• Medicare.gov. Mental health care (inpatient). [June 7, 2024]. n.d. https://www​.medicare​.gov/coverage/mentalhref="https://www​.medicare​.gov/coverage/mentalhealth-care-inpatienthealth-care-inpatient .
• MedPAC. Data book: Beneficiaries dually eligible for Medicare and Medicaid. Washington, DC: Medicare Payment Advisory Commission and the Medicaid and CHIP Payment and Access Commission; 2022.
• MedPAC. Chapter 7 in March 2024 report to the Congress: Medicare payment policy. Washington, DC: MedPAC; 2024. [June 7, 2024]. Home health services. https://www​.medpac.gov​/document/march-2024-report-to-the-congress-medicare-payment-policy/
• MHA (Mental Health America). Residential treatment for children and adolescents with serious mental health and substance use conditions. 2015. [June 7, 2024]. https://www​.mhanational​.org/issues/residential-treatment-children-and-adolescents-serious-mental-health-and-substance-use .
• Momen NC, Plana-Ripoll O, Agerbo E, Christensen MK, Iburg KM, Laursen TM, Mortensen PB, Pedersen CB, Prior A, Weye N, McGrath JJ. Mortality associated with mental disorders and comorbid general medical conditions. JAMA Psychiatry. 2022;79(5):444–453. [PMC free article: PMC8968685] [PubMed: 35353141]
• Moore M, Stangler C. Briefing Book 2022. Topeka, KS: Kansas Legislative Research Department; 2022. Differences between community mental health centers and certified community behavioral health clinics.
• Mundt AP, Rozas Serri E, Irarrázaval M, O’Reilly R, Allison S, Bastiampillai T, Musisi S, Kagee A, Golenkov A, El-Khoury J, Park SC, Chwastiak L, Priebe S. Minimum and optimal numbers of psychiatric beds: Expert consensus using a Delphi process. Molecular Psychiatry. 2022;27(4):1873–1879. [PMC free article: PMC8780043] [PubMed: 35064234]
• NACHC (National Association of Community Health Centers). America’s health centers: 2022 snapshot. Bethesda, MD: National Association of Community Health Centers; 2023a.
• NACHC. Community health center chartbook. Bethesda, MD: National Association of Community Health Centers; 2023b.
• Nardone M, Snyder S, Paradise J. Integrating physical and behavioral health care: Promising Medicaid models. Menlo Park, CA: KFF; 2014.
• NASEM (National Academies of Science, Engineering, and Medicine). Educating health professionals to address the social determinants of mental health: Proceedings of a workshop. 2020. [PubMed: 33180403]
• NASMHPD (National Association of State Mental Health Program Directors). Trends in psychiatric inpatient capacity, United States and each state, 1970 to 2018. National Association of State Mental Health Program Directors; 2022.
• National Council for Mental Wellbeing. 2022 CCBHC impact report. Washington, DC: National Council for Mental Wellbeing; 2022.
• NIDA (National Institute on Drug Abuse). About the addiction medicine subspecialty. 2018. [August 6, 2024]. https://nida​.nih.gov​/nidamed-medical-health-professionals​/health-professions-education​/adm-fellow-toolkit​/about-addiction-medicine-subspecialty#:~:text=They​%20provide​%20prevention%2C​%20evaluation%2C%20diagnosis,one​%27s%20substance​%20use%20or%20addiction .
• NLM (National Library of Medicine). Credentialing. 2022. [May 3, 2024]. https://www​.ncbi.nlm​.nih.gov/books/NBK519504/
• Nordstrom K, Berlin JS, Nash SS, Shah SB, Schmelzer NA, Worley LLM. Boarding of mentally ill patients in emergency departments: American Psychiatric Association resource document. Western Journal of Emergency Medicine. 2019;20(5):690–695. [PMC free article: PMC6754202] [PubMed: 31539324]
• OIG (Office of Inspector General). A lack of behavioral health providers in Medicare and Medicaid impedes enrollees’ access to care. Washington, DC: U.S. Department of Health and Human Services; 2024. [June 7, 2024]. https://oig​.hhs.gov/reports-and-publications​/all-reportsand-publications​/a-lack-of-behavioral-health-providers-in-medicare-and-medicaid-impedesenrollees-access-to-care/
• OpenLoop. Licensing credentialing 101. 2021. [May 20, 2024]. https:​//openloophealth​.com/blog/licensing-101 .
• Peña MT, Mohamed M, Burns A, Biniek JF, Ochieng N, Chidambaram P. A profile of Medicare–Medicaid enrollees (dual eligibiles). 2023. [May 14, 2024]. https://www​.kff.org/medicare​/issue-brief​/a-profile-of-medicare-medicaid-enrollees-dual-eligibles/
• Pestaina K. KFF. 2022. [June 7, 2024]. Mental health parity at a crossroads. https://www​.kff.org/mentalhealth​/issue-brief​/mental-health-parity-at-a-crossroads/
• Preyde M, Frensch K, Cameron G, White S, Penny R, Lazure K. Long-term outcomes of children and youth accessing residential or intensive home-based treatment: Three-year follow up. Journal of Child and Family Studies. 2011;20(5):660–668.
• Prior P, Hassall C, Cross KW. Causes of death associated with psychiatric illness. Journal of Public Health Medicine. 1996;18(4):381–389. [PubMed: 9023795]
• Proctor K. CMS releases data briefs that provide key Medicaid demographic data for the first time. 2023. [June 7, 2024]. https://www​.cms.gov/blog​/cms-releases-data-briefs-provide-key-medicaid-demographic-data-first-time .
• Reinert M, Fritze D, Nguyen T. The state of mental health in America. Alexandria, VA: Mental Health America; 2022.
• RHIhub. Telehealth models for increasing access to and engagement with care outside of healthcare settings. 2023. [June 7, 2024]. https://www​.ruralhealthinfo​.org/toolkits​/telehealth/2/care-delivery​/nontraditional-settings .
• Rotenstein LS, Edwards ST, Landon BE. Adult primary care physician visits increasingly address mental health concerns. Health Affairs (Millwood). 2023;42(2):163–171. [PubMed: 36745830]
• Rudowitz R, Burns A, Hinton E, Mohamed M. 10 things to know about Medicaid. 2023. [June 7, 2024]. https://www​.kff.org/mental-health​/issue-brief​/10-things-to-know-about-medicaid/
• Saha S, Shipman S., Bureau of Health Professions. The rationale for diversity in the health professions: A review of the evidence. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions; 2006.
• SAMHSA (Substance Abuse and Mental Health Administration). Principles of community-based behavioral health services for justice-involved individuals: A research-based guide. Rockville, MD: Substance Abuse and Mental Health Administration; 2019.
• SAMHSA. Data on mental health treatment facilities annual report. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2020. National mental health services survey (N-MHSS): 2020.
• Santo L, Peters ZJ, DeFrances CJ. Emergency department visits among adults with mental health disorders: United States, 2017–2019. NCHS Data Brief. 2021;426:1–8. [PubMed: 34982662]
• Sheldrick RC, Bair-Merritt MH, Durham MP, Rosenberg J, Tamene M, Bonacci C, Daftary G, Tang MH, Sengupta N, Morris A, Feinberg E. Integrating pediatric universal behavioral health care at federally qualified health centers. Pediatrics. 2022;149(4):e2021051822. [PubMed: 35347338]
• Soleimanpour S, Cushing K, Christensen J, Ng S, Yang J, Saphir M, Geierstanger S, Even M, Brey L. Findings from the 2022 National Census of School-Based Health Centers. Washington, DC: School-Based Health Alliance; 2023.
• Sullivan Commission on Diversity in the Healthcare Workforce. Missing persons : Minorities in the health professions : A report of the Sullivan Commission on Diversity in the Healthcare Workforce. 2004. [June 7, 2024]. http:​//minority-health​.pitt.edu/archive/00000040​/01/Sullivan_Final_Report_000​.pdf .
• Tan XW, Lee ES, Toh M, Lum AWM, Seah DEJ, Leong KP, Chan CYW, Fung DSS, Tor PC. Comparison of mental–physical comorbidity, risk of death and mortality among patients with mental disorders—A retrospective cohort study. Journal of Psychiatric Research. 2021;142:48–53. [PubMed: 34320455]
• Thornicroft G, Szmukler G, Mueser KT, Drake RE. Oxford textbook of community 1381 mental health. New York: Oxford University Press, USA; 2011.
• Tobin-Tyler E, Hulkower RL, Kaminsi J. Behavioral health integration in pediatric primary care: Considerations and opportunities for policymakers, planners, and providers. New York: Milbank Memorial Fund; 2017. [June 7, 2024]. https://www​.milbank.org​/publications/behavioral-health-integration-in-pediatric-primary-care-considerations-andopportunities-for-policymakers-planners-and-providers/
• U.S. Census Bureau. Quick facts. 2023. [June 7, 2024]. https://www​.census.gov​/quickfacts/fact/table/US/PST045223 .
• Wampler KS, Blow AJ, McWey LM, Miller RB, Wampler RS. The profession of couple, marital, and family therapy (CMFT): Defining ourselves and moving forward. Journal of Marital and Family Therapy. 2019;45(1):5–18. [PubMed: 29112773]
• Warren JC, Smalley KB. To the Point blog, June 18.The Commonwealth Fund. 2020. [June 7, 2024]. Using telehealth to meet mental health needs during the COVID-19 crisis. https://www​.commonwealthfund​.org/blog/2020​/using-telehealth-meet-mental-health-needs-during-covid-19-crisis .
• Watts MO, Musumeci M, Ammula M. Medicaid home & community-based services: People served and spending during COVID-19. San Francisco, CA: Kaiser Family Foundation; 2022.
• Wilcock AD, Huskamp HA, Busch AB, Normand S-LT, Uscher-Pines L, Raja PV, Zubizarreta JR, Barnett ML, Mehrotra A. Use of telemedicine and quality of care among medicare enrollees with serious mental illness. JAMA Health Forum. 2023;4(10):e233648. [PMC free article: PMC10611994] [PubMed: 37889483]
• Worstell C. Medicare statistics 2024. 2024 [June 24, 2024]; https://www​.medicareadvantage​.com/resources​/medicare-statistics .
• Young J, Ramachandran S, Freeman AJ, Bentley JP, Banahan BF. Patterns of treatment for psychiatric disorders among children and adolescents in Mississippi Medicaid. PLOS One. 2019;14(8):e0221251. [PMC free article: PMC6695227] [PubMed: 31415651]
• Zhu JM, Charlesworth CJ, Polsky D, McConnell KJ. Phantom networks: Discrepancies between reported and realized mental health care access in Oregon Medicaid. Health Affairs (Millwood). 2022a;41(7):1013–1022. [PMC free article: PMC9876384] [PubMed: 35787079]
• Zhu JM, Myers R, McConnell KJ, Levander X, Lin SC. Trends in outpatient mental health services use before and during the COVID-19 pandemic. Health Affairs. 2022;41(4):573–580. [PMC free article: PMC9056059] [PubMed: 35377763]