Recently, U.S. Senate Finance Committee Chairman Max Baucus (D-MT) and Ranking Member Orrin Hatch (R-UT) reached out to the behavioral health community with three questions: What are the barriers in Medicare and Medicaid for consumers seeking behavioral health care? What policies are leading to improved outcomes for consumers in integrated care models? How can Medicare and Medicaid be cost-effectively reformed to improve access and quality for people with behavioral health needs? According to their letter, the senators interest in behavioral health services stems from the number of veterans returning home with post-traumatic stress, and the fact that so many Americans—one in four—are impacted by mental health issues every year. It is also likely Senators Baucus and Hatch were influenced by the tragedy in Newtown, Connecticut.

Our response focused on substance use disorders provisions, our main area of expertise. Below are highlights of Community Catalyst’s response:


Medicare and Medicaid need better ways to find early signs of substance use disorders. The U.S. Preventive Services Task Force, an independent panel of experts that makes evidence-based recommendations about preventive services, recommends that “clinicians screen adults aged 18 years or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse.” This protocol is known as SBIRT (Screening, Brief Intervention, and Referral to Treatment). Medicare and Medicaid will pay for SBIRT services, but federal and state rules limit the ability of SBIRT to reach patients. For example, Medicare will only pay for an intervention that lasts at least 15 minutes, even though effective screening can take much less time. Also, each state decides for itself whether to pay for SBIRT, and many do not. In addition, some that do pay require the screening to be performed by physicians or other licensed clinicians. Because most of these clinicians are already stretched in providing other services, and the cost of their labor is expensive, few clinicians are administering SBIRT. Either the reimbursement falls short of the labor costs, or in many cases, no insurance reimbursement is available.

Integrated Care Models

Missouri’s Medicaid Health Homes. The Missouri experience with Medicaid health homes has a number of lessons for how successful integrated models can be replicated. The state opted to build two health homes: “Primary Care” is for Medicaid beneficiaries with chronic physical ailments; “Community Mental Health Center (CMHC) Healthcare Home” is for beneficiaries with mental illnesses or substance use disorders, many of whom also have significant chronic physical ailments. This is a key point, as people with serious mental illnessdie 25 years earlier on average than their peers, the majority from preventable physical diseases. Early evidence that this approach is effective for CMHC Healthcare Home patients includes more patients appropriately using their asthma medications. Missouri health homes for physical and behavioral health saved Medicaid $1.48 million per month after the cost of the monitoring was subtracted. More on Missouri’s project is available here.


Encourage SBIRT use and expand authorized providers of SBIRT. At a minimum, the federal government could do more to encourage states to agree to fund and promote SBIRT Promotion, which could include federal webinars and educational materials, including letters directed at state Medicaid officials. (SBIRT has been proven to be a cost saver; in one study, Washington State Medicaid saved more than $2,000 per patient annually due to fewer hospitalizations.) States could also be encouraged to make the administrative decision to allow trained paraprofessionals (non-clinical workers that assist licensed professionals such as doctors) to conduct SBIRT. Wisconsin has developed a model that makes performing SBIRT economically viable by focusing their SBIRT efforts on paraprofessionals. Other states are investigating using peer recovery specialists to deliver SBIRT; peer recovery specialists are people who are in long-term recovery from addiction and are trained to help others learn to live a life in recovery.

Absent from the senators’ request was mention of the two most important behavioral health laws since the widespread sale of color televisions: the Mental Health Parity Act (2008) and the Affordable Care Act (2010). Only one of these leaders, Senator Baucus, supports both of these laws. However, implementation of these laws is of the utmost importance for people with behavioral health issues, even if these laws (especially the ACA) are at times controversial.

Beyond parity and the ACA, this input could lead to more broad based support of behavioral health improvements in Medicare and Medicaid. It is optimistic, but the Senate Finance Committee could have members of both parties agree to improve behavioral health services in Medicare and Medicaid, such as the screening and brief intervention services described above. The Senate Finance Committee oversees legislation on Medicare and Medicaid, and it is likely that the two leaders are considering what new legislation is needed to reduce the impact of SUD and mental illness on society.

For those of you looking for the whole album, not just selections from our playlist, you can find thefull letter submitted by Community Catalyst here, and the letter from Senators Baucus and Hatchhere.

– Tom Emswiler, Policy Analyst