Amber Thomas

All right, excellent. Well, welcome to Think Therapy podcast. I’m Amber Thomas, the Chief Compliance Officer here at Therapy Brands. And I’m guest hosting today with our very special guests, Chuck Igingolia, who is the President and CEO of National Council for Behavioral Health, where he leads the national charge to ensure people have access to quality, affordable mental health care and addiction services.

To accomplish this, he harnesses the voices and support of more than 3,400 National Council members who serve over 10 million individuals nationwide. So Chuck, it’s so good to see you again. How are you?

 

Chuck Ingoglia

Great, it was great to see you too, Amber, and I’m so happy to be here with you on this podcast.

 

Amber Thomas

Thank you. We’re so grateful. So it’s been an active last couple of weeks in the regulatory space. Can you talk about some of the exciting final rule changes we’ve seen in the Medicare program?

 

Chuck Ingoglia

Well, I mean, who ever thought that we get excited about changes in the Medicare program and they don’t happen very often, right? And I think for almost 30 years, at least 25 years, I’m not gonna be over dramatic. Let’s say 25 years, we’ve been working with Congress to try to make sure that marriage and family therapists and licensed professional counselors, mental health counselors can bill Medicare for their services.

And we’ve heard over and over again, every part of the country that I go to, people, our members, providers, desperate for this change. And it finally happened. Last year, Congress included this in an end of the year package. And last Congress and CMS, the Centers for Medicare and Medicaid Services have now made it possible. So organizations can now, and individuals can start enrolling in Medicare.

And as of January 1 Medicare will start paying for this service So that is one of the most exciting kind of developments We’ve seen on the Medicare front in a long time. We know it’ll be a big help to senior citizens to older adults to people living in rural communities where there aren’t necessarily social workers and or Psychologists so excited about that and that’s not where it ends, right? There’s some other cool things in there, new benefit for intensive outpatient programs that will be available through either CMHCs or rural health centers or federally qualified health centers. We’re still trying to understand exactly what this will mean, but again, it’s a great indication of a extension of a benefit. And also I think an important clarification, there’s been some misunderstanding that Medicare partial hospitalization and intensive outpatient programs were only for people with mental health disorders. And this has not ever been true and CMS went out of their way to clarify it in this rulemaking that people with substance use disorders can take advantage of these programs as well. So those are some of the, did I hit all the highlights here or was there anything else that you were excited about?

 

Amber Thomas

I’m very excited about the new classification providers that can enroll in Medicare. And I started my career helping providers enroll when I was very fresh out of law school. It can take a while, the process, so I encourage anyone looking to begin providing services to Medicare beneficiaries to start that process now. But that’s…

 

Chuck Ingoglia

So Amber, somewhere on the internet, you will find, I wrote some article years ago about enrolling in Medicare, and I still get people send me, find this article and they send me questions about it still today. So that’s not my specialty, don’t reach out to me. And if you see that article, just delete it.

 

Amber Thomas

Yeah, the regulations may have changed the requirements. I don’t know how old this article is, but Pico’s not sure if that was around back then. But that’s what I’m really, really excited about. And is there anything as exciting on the Medicaid side? I know I’m kind of throwing you a curveball. OK.

 

Chuck Ingoglia

Thank you.

 

Chuck Ingoglia

Ah, well, let’s just stay with Medicare for good. I did forget one thing. Medicare has also clarified that you can bill for crisis services in Medicare, which is interesting. You know, so there’s been a general movement in both Medicaid and Medicare the last few years to try to create reimbursement for crisis services.

Now I have to admit, I am still, I talk to our members who operate mobile crisis teams. They’re still trying to figure out how to operationalize this because when someone’s in the middle of a crisis, you’re not gonna be asking them for their Medicaid or Medicare card. And so we’re still trying to figure all of that out, but those are some of the exciting things there. On the Medicaid front, the big change last year that we’re excited about,

is the expansion of the certified community behavioral health clinic demo, and that it will be available to all states over the next 10 years. And we’ve seen a lot of interest this year. We’re waiting to see what happens with planning grants and then selection into the demo. But I think that’s probably the most exciting thing there.

 

Amber Thomas

Awesome. So I’ll have to, you know, you know, this is an area that I have a particular interest in. And it’s very exciting for me, which is, can you share a little bit of history about the Mental Health Parity and Addiction Equity Act, or MEPIA as some refer to it, and the changes Congress made in 2020, and some of the recent Department of Labor proposed rulesand what you think this means for the industry.

 

Chuck Ingoglia

Well, I’m going to go back a little bit further and then we’ll fast forward to there. So I just want to, for context, remind folks that in the 1990s, the Clinton administration was trying to do health care reform and they got into a lot of detail about what the benefit package would be. And one thing was clear, mental health and substance use was not going to be included at parity with physical health conditions. And that then led to a whole movement over many, many years for our field to say that mental health and substance use should be treated just like the rest of healthcare. Ultimately then in 2008, October 3rd, to be precise, I don’t know why I remember that, but it was October 3rd, 2008, Congress passed the Mental Health Parity and Addiction Equity Act. And I would say most of us have been underwhelmed with the effect that it has had on access to care for vulnerable people. Various administrations have tried. I do think though that the rules that are out now, the comment just closed a few weeks ago. If you would judge by the reaction by the health insurance community, I think you get a sense that…this is a pretty strong rule, you know, because they’re really pushing back hard on the new disclosure requirements, the compliance requirements that they’re going to have to meet. And we hope that the new requirements around network adequacy, we hope that those combination of factors will actually lead to increased access for people who need it. I do think that in this country, if you are very rich, you can…

pay for mental health and substance use treatment out of pocket. If you’re very poor, we are lucky that we have safety net programs like Medicaid that offer a robust mental health and substance use benefit. And if you’re in the middle and you’re privately insured, sometimes it’s really difficult to get care. And we’re really hoping that this most recent rulemaking will start to turn the, start to improve that situation.

 

Amber Thomas

I listened to a webinar that the Department of Labor did on this topic and one of the biggest pieces of takeaways for me, of course I work in compliance, is that they were unable to find a single health plan that could demonstrate compliance with the old requirements, not one. And one of the nuggets was if 96% of your mental health claims are paid out of network, we don’t care how good your network adequacy directories are. That tells us there’s something wrong. And so I’m really excited for that level of skepticism that the Department of Labor is taking. And this new proposed rule, if finalized, hopefully give them the compliance tools to really enforce it. So.

 

Chuck Ingoglia

And that whole auto network thing is really interesting, right? There’s a variety of reasons that people, that providers might want to be out of network. The most prominent one is that you can get higher reimbursement, right? And, and we shouldn’t, we shouldn’t have to create more barriers for folks in order to get care. And so hopefully this also lead to some incentives for plans to think about their reimbursement approaches and being trying to be more inclusive of providers.

 

Amber Thomas

completely agree. If you’re going to have network adequacy requirements, you may have to pay a higher premium to get those providers in your network. So I think that’s fantastic for the field. Excellent. Okay. So another regulatory update that we saw recently was the second temporary extension of the COVID-19 telemedicine flexibilities for prescription of controlled substances.

Do you have any predictions when A, we’ll see a final rule, or just how that will play out? We got a lot of questions at peer to peer about that.

 

Chuck Ingoglia

Yeah. Well, Amber, so forgive me. I want to try to give some context for this. So, you know, the reason that we’re having to extend public health emergency flexibilities and reason this is even an issue is another federal law, the Ryan Haight Act, which was passed by Congress after the death of a young man named Ryan Haight who had obtained…

 

Amber Thomas

Yeah, please. Please.

 

Chuck Ingoglia

medication through an unregulated online pharmacy. So Congress responded by creating guardrails for online pharmacies, including that you have to see a person in person before you can dispense controlled substances. And this then was never intended to have a, you know, remember this was passed years before

 

Chuck Ingoglia

COVID-19 outbreak before telehealth was really a common delivery modality and meant to address a specific problem. There was a provision in that original law that allowed the Department of Justice to create an exception for telehealth and a whole registration process. We helped get legislation passed. What year was that? Was that 20?

2018, 2017, we got language passed by Congress telling the DOJ to actually, telling the DEA to actually write rules to operationalize that exception. They ignored it. Congress reminded them again about this responsibility. They ignored it again. And so here we are, where writing prescriptions for controlled substances requires an in-person evaluation before that can happen.

Now you’re asking me for predictions. You know, that’s always a tricky thing living in Washington. I would say if I had a crystal ball, I’d live in Las Vegas, not in Washington, D.C. But I think that there has been such a ground swell on this issue. I do think that they’re regarding to see change, but it’s hard, right? The DEA is an enforcement organization. They’re worried about diversion.

I’m not saying they’re right, but that is their mindset. That’s how they’re thinking about it. We’re thinking about access to care for vulnerable individuals. Their mindset is very different. And I do believe that there is kind of a lot of discussion happening, let’s say a friendly way, between the DEA and HHS on this issue. I am hopeful that it will get resolved and that people will continue to have access to care.

But I have said from the beginning, it’s not a slam dunk, right? It’s gonna take a lot of back and forth. And if the DEA moves, and we’ve seen right there, their moves so far have been cautious. And I think they will continue to be cautious.

 

Amber Thomas

Yeah, that has been my kind of take on this is that there’s maybe some tension between DEA, Department of Justice and HHS, because they have very different mandates, right? And one is in the business of creating public health policy, and the other is, well, enforcing drug laws. And so, interesting.

 

Chuck Ingoglia

And look, we could have a whole separate conversation about our approach to drug use and people who use drugs in this country and drug laws. That’s a really worthy debate. It’s beyond the scope, right, of this conversation, but certainly that does influence the situation that we’re in.

 

Amber Thomas

Yes.

 

Amber Thomas

Agreed, agreed. So it’s an interesting time to do this podcast because we had elections throughout the country yesterday, which has me already thinking about the upcoming 2024 election season. I think in 2020 mental health was part of the dialogue between the candidates. Do you think that’ll also be the case in 2024?

what kind of issues you think you’ll see the parties talking about as it relates to mental health and substance use recovery.

 

Chuck Ingoglia

Well, you probably know, right? It’s always tricky to be part of the conversation or not. I’d say in general, whether or not the issues that we care about are part of the debate in 2024 is really up to us, right? Elected officials.

get interested in things because they hear from their constituents that it’s important from them. The reason Congress cares about the number of people dying from overdose in this country is not just because it’s terrible, regrettable, it’s because when they go home, they hear about it. They know somebody, people come up to them. So to the extent that we want our issues to be front,

and center for people in this next election cycle, it’s up to us and people we know to bring it up, to have meetings, to be at town halls, to engage in candidate forums, right? And to, that that’s really how this is going to happen. Now, I would predict, you know, the economic fallout of COVID is, is affecting communities around the country in different ways.

And certainly one of the things we’re seeing, and especially in a lot of urban cores, is an increase in homelessness. And so I do think that there might be some, especially state elections, where homelessness and mental illness will be a bigger deal in those conversations too. And also gonna be important for folks to be engaged in that, because we wanna make sure we have policies that make sense and aren’t kind of, vindictive or kind of fostering a lot of coercion.

 

Amber Thomas

Excellent. So maybe I’ll just have one last question. Are there any initiatives that the National Council is working on that you’re working on in the next year that you’re excited about that you want to talk about here on this podcast?

 

Chuck Ingoglia

Well, I would just say, you know, for folks in healthcare right now, not just in healthcare, but in our country broadly, we have a terrible labor challenge in this country. We have more jobs than we have workers. That is particularly acute across healthcare. And so National Council is engaged in a number of initiatives to try to retain existing workforce.

recruit additional workforce, get more people interested in our field. And those are some of the things that I’m most passionate, excited about. And, you know, I know none of them are going to happen soon. So we, you know, we’ve just stood up recently a new center of excellence on workforce and folks can come to our website and get information about how our, how, how are other organizations approaching this challenge? We have a series of recommendations for.

regulators at the state and county level about investments and changes they can make. And we have legislation that we’re pursuing. So we’re working on a number of fronts. And we’re certainly interested in hearing from listeners about what are some of the challenges that they’re confronting? What are some of the ideas that they have? And we know that this is going to be, this is going to require attention and investment over a long period of time.

 

Amber Thomas

Well, thank you so much, Chuck, for being here today. It is a pleasure, as always. We love working with the National Council here at Therapy Brands. So thank you, and thank you for our listeners for joining Think Therapy podcast. I’m Amber Thomas. It was a pleasure to guest host as well, and we look forward to seeing you back in Think Therapy podcast again. Thank you.