Policy event this week will explore issues and identify next steps to strengthen behavioral health care access, workforce
BOSTON — Today, the Massachusetts Health Policy Commission’s (HPC) Behavioral Health Workforce Center released its first publication, Examination of Payments for Behavioral Health Care Services, which explores rates paid for behavioral health services by both private and public payers and how payments can support access to quality behavioral health services in the Commonwealth. This legislatively-mandated report is one of a number of studies being conducted by Behavioral Health Workforce Center.
The Commonwealth’s ability to meet increasing behavioral health (BH) needs is under threat, as organizations report ongoing staff vacancies as well as recruitment and retention challenges amid inpatient psychiatric facility and intensive outpatient program closures. Over 25% of BH therapists in Massachusetts exclusively accept cash pay for psychotherapy, in part due to public and private payer reimbursement rates being lower than cash-pay rates.
BH providers have raised concerns about inadequate payment rates for BH services, which contribute to the difficulties they face with hiring and retention of experienced clinicians, and ultimately worsen access challenges. The HPC found that physicians were paid less for performing BH services than for comparable office-based health care services. The commercial reimbursements for primary care evaluation and management visits and medical specialty visits were 2.6 and 6.0 times more, respectively, than for psychotherapy visits for an equivalent amount of physician time. Additionally, between 2019-2023, commercial rates grew more slowly for psychotherapy (10.7% growth) than both inflation (16% growth) and rates paid for primary care (19.4% growth).
The HPC also found notable differences in commercial payment by BH provider type. Master’s-level clinicians, such as licensed social workers and licensed mental health counselors, often received the lowest reimbursement for psychotherapy and psychiatric evaluation services. Notably, master’s-level providers, delivered the majority of such services for commercially insured patients (performing over 70% of commercial psychotherapy visits for adults and children and 81% of adult, non-medical psychiatric evaluations). For most office-based BH services, physicians are paid the highest rate by commercial and public payers
“The current rates for behavioral health care services do not reflect the critical nature of the work our behavioral health practitioners are providing – for our residents’ wellbeing, and for the health and stability of the Commonwealth’s health care system,” said Martin Cohen, HPC Vice Board Chair. “Unless we reassess our behavioral health care rates, we risk more providers shuttering, fewer future clinicians choosing to enter the field, and ultimately, fewer residents able to access the critical behavioral health care they need.”
“With increasing need for behavioral health care services, it’s clear that the Commonwealth needs to act to strengthen our behavioral health care system, and this should begin with strengthening our workforce,” said David Seltz, HPC Executive Director. “The HPC’s Behavioral Health Workforce Center has outlined actionable policy interventions that can bring us closer to our shared goal of a resilient behavioral health care system and more equitable, accessible behavioral health care for all of our residents.”
“This research provides key insights into the Commonwealth’s behavioral health care system. Our master’s-level clinicians performed the majority of our psychotherapy care and were paid the least for it, and our commercial rates for psychotherapy grew more slowly than both inflation and the price growth in primary care,” said Amy Doyle, HPC Behavioral Health Workforce Center Director. “The HPC’s Behavioral Health Workforce Center will continue to assess the challenges facing our behavioral health workforce, working alongside our partners in EOHHS and stakeholders across the health care system, to help the Commonwealth define a path forward.”
Key Findings
Social workers, mental health counselors, and other master's-level providers are licensed to provide psychotherapy and evaluations when a patient does not also need medical evaluation or management. In 2023, master's-level clinicians performed 73% of commercial psychotherapy visits for adults and children and 81% of adult, non-medical psychiatric evaluations.
Master’s-level clinicians often received the lowest reimbursement for those services. For most office-based services, physicians are paid the highest rate by commercial and public payers.
- Differences in the rates paid between provider types for common office-based BH services were greatest among commercial payers. Commercial payers reimbursed master’s-level clinicians at 66% the rate of physicians for 60-minute psychotherapy and 70% the rate of physicians for psychiatric evaluations. In contrast, MassHealth paid master’s-level clinicians at 93% and 81% the rate of physicians for these services.
- Commercial reimbursement to physicians performing BH services was lower than commercial reimbursement to physicians performing comparable office-based health care services. Physicians were reimbursed for primary care evaluation and management visits and medical specialty visits 2.6 and 6.0 times more, respectively, than for psychotherapy visits for an equivalent amount of clinical time.
- This lower reimbursement is mirrored in wages -- advance practice registered nurses (a medical non-physician) earned 1.4 times more per hour than psychologists in 2023.
Average commercial payments per diem for inpatient BH admissions and PHP visits were lower for non-acute hospitals than general acute care hospitals (GACs). Most commercial behavioral health inpatient days took place at non-acute hospitals (76% for adults and 70% for children), but non-acute hospitals received lower payment rates than GAC hospitals.
Commercial payers paid GAC hospitals an average of $2,547 per adult inpatient day. Non-acute hospitals that had commercial adult inpatient stays were paid $1,377 per day (54% of GAC rate).
- Commercial rates for psychotherapy grew more slowly than both inflation and the price growth in primary care. Between 2019-2023, price growth for the physician rate of 60-minute psychotherapy (10.7%, or 2.6% per year) lagged behind the consumer price index for Boston (16%, or 3.8% per year), and the commercial price growth for primary care for E&M visits (19.4%, or 4.6% per year).
- Payments for common psychiatric services for adults were higher for out-of-network versus in-network. About 15% of adult, in-person visits for common psychiatric services paid for by commercial insurance were out-of-network. For these services, commercial insurers paid out-of-network providers 114%-150% more than in-network providers.
Policy Recommendations
- Reduce payment differentials among provider and facility types for the same services. The Legislature should consider establishing limits on commercial payment differentials, ensuring master’s-level providers are paid 90-100% of the rate paid to doctoral-level providers for the most common office and telehealth BH services. Commercial payers should consider adjusting per diem payment rates for inpatient psychiatric admissions by increasing rates for stays in non-acute hospitals. Rate increases should not lead to increased premiums, deductibles, cost-sharing, or treatment limitations for patients.
- Establish a minimum commercial payment level for common behavioral health services. The Legislature should consider establishing BH minimum payment levels for commercial payers, equivalent to 150% of the Medicare rate for office and telehealth BH services covered by Medicare, or 150% of the Medicaid rate for office and telehealth BH services not covered by Medicare.
- Adjust behavioral health payment increases by economic measures. Both commercial payers and MassHealth should adjust payments to BH providers and facilities in alignment with reasonable and known cost increases, including cost of living and provider wages.
- Strengthen state investment into MassHealth, sustaining efforts to increase reimbursement for BH providers. The Executive Office of Health and Human Services (EOHHS) should also consider authorizing MassHealth to implement annual BH rate increases in alignment with reasonable and known cost increases, including cost of living and provider wages benchmarked at or above the 75th percentile from the most recently available Massachusetts data from the Bureau of Labor Statistics (BLS).
- Investigate the capacity and sustainability of the behavioral health markets, including cost-sharing, out-of-network payments, and cash payments for BH services, and monitoring data to identify any changes to consumer costs.
- Sustain support for the work of the HPC’s Behavioral Health Workforce Center. Future reports should investigate the relationship between commercial rates, cash pay rates, and BH workforce salaries. The Legislature should additionally ask the HPC to convene a task force focused on assessing BH service delivery costs across care settings and developing recommendations to inform payer methodologies.
This research will be discussed further at the HPC Behavioral Health Workforce Center’s inaugural event, Behavioral Health Care Under Pressure in Massachusetts: Policy Solutions for a Sustainable Workforce, on Thursday, May 7th from 9:00 am – 12:00 pm at Suffolk University Law School, Boston, MA and livestreamed on the HPC’s website.
The event will feature a research presentation of key findings and policy recommendations as well as a panel discussion with behavioral health leaders, identifying next steps for the Commonwealth’s behavioral health care system.
