Transcripts For CSPAN3 Physicians 20240704

Committee here from physicians and Mental Health advocates who raced to hold Physician Health accountable in space for rural health areas. As which was not represented initially in this way. The fact is, these americans are being ripped off by what the government in office has described as a Ghost Network. Not my language, but the language of the Government Accountability office. To me, but a Ghost Network is all about is essentially selling Health Coverage under false pretenses. Because, the providers that have been advertise are not picking up the phones. There are not taking patients. In any other business, if a product or service does not meet expectations, consumers get a refund. In my view, it is a contractor breach. Insurance Companies Sell their plans for thousands of dollars each month, while their product is unusable. Unusable due to a Ghost Network. I am going to work with all my colleagues on both sides, democratic and republican, to get real accountability for these patients who paid good money for Mental Health coverage and find there is very little there. In a moment of National Crisis about Mental Health, at a problem growing at such a rapid rate, the Ghost Network is unacceptable. If someone is worried about their Mental Health or the Mental Health of a loved one, it is hard to work up the courage. Hard to work up the courage to step up and try to coordinate their care. If they cannot get help, the last thing they need from a Big Insurance Company is a symphony of please hold music when they call and nonworking numbers and rejection. We can all imagine because we are all hearing from our constituents. I am looking at my republican colleagues. I have talked to almost all of them personally about the Mental Health challenge, and we are working on it together. What i describe is not a hypothetical better matter. My constituents and i did a secret shopper and looked at 12 Medicare Advantage Insurance Plans in 60. Our secret shoppers could get an appointment. This was after people had paid vast sums of money. They could get an appointment only 18 of the time. That means more than eight out of 10 Mental Health providers listed in the Insurance Company or curios were an accurate or not taking appointments assertively time, the phone number they called was a dead and. In one instance, a staff trying to reach a Health Provider was connected to a High School Research Health Center. Cassidy is a real pro at all these Health Issues and both of us would say that we laugh when he really feel like crying for the patients. I think that is representative of it. In my home state, i am not proud of what our investigators found there. My staff did not find that we can make one successful opponent appointment. Other secret shopper studies looked and found the same thing in 2017, but researchers posing as pears seeking care for a child with depression. They got care about 70 of the time. Ghost networks are an ongoing persistent problem and financers are looking close at this issue. You put a lot of equity into developing red legislation to improve Mental Health care for all americans from telehealth to youth health. I can look down the road starting with my republican colleagues because we have been working on this in a bipartisan basis. We have plenty more to do. Looking at the Ghost Network issue, it is a three leggett approach. Or oversight, transparency, and serious concert answers for companies clicking on american consumers. Greater transparency ought to be an easy one for members of this community to get around. I want to work with my colleagues on this issue, on the accountability questions. I want to look at this across the board. Not just with respect to medicare, medicaid, and many of my colleagues who have expressed interest in providing testimony. There is not anything partisan about it. Let me yield to my friend. Thank you senator wyden. It is no secret that you and i have prioritized Mental Health liberty in america. We have a number of major initiatives through in the last congress. But there are a number of major issues like this one that we still have work to do. I appreciate the opportunity to work with you on it. Last time, we came together to enact dozens of bipartisan policies to expand access to Mental Health care service. These reforms will increase the number of providers dissipating in medicare and allow patients to read care in more convenient locations, including through telehealth. In order for these improvements to its youth and uptodate information on their health care options. I have long champions Medicare Advantage for its ability to offer patients choice and control over their health care. Through robust competition and innovative benefit offerings, Medicare Advantage provides consumer focus Health Coverage to millions of american. As enrollment continues to grow, including improving the accuracy could further strengthen Medicare Advantage. The patient provider relationship is the foundation of the Health Care System. Whether a patient is suffering a Mental Health crisis or just read a troubling diagnosis, directories should serve as a crucial tools to help seniors across the country. While we work to better align incentives to improve providerdirectory accuracy, you must also do so without including burdensome requirements that will only weaken our Mental Health workforce. Regulatory red tape and reimbursement strain, among others, can also decrease patient access, exacerbating physician shortages, compounding burnout, and eroding health care axes and quality. Congress should build on their targeted release painters like the ones we had last year, including to marie physician fee schedule supports, and medicare telehealth expansion, to address these on a bipartisan and sustainable basis. Position payment stabilization at teleHealth Coverage for seniors have received strong support for members of both parties in both chambers. As we look to enhance that a care, we should prioritize these and other bipartisan goals. You must do so in a fiscally responsible manner. I look forward to hearing from witnesses about opportunity to streamline and improve provider reporting requirements, empower patients, and to give them Accurate Information and advance more Transparent Health care system. Thank you. Thank you, senator crapo. You have listed a number of areas where we can continue bipartisan conversations with our colleagues. My Vice President , a partnership that is working to improve Mental Health care. We welcome you. I know that you are a leading Mental Health advocate and decking it. Dr. Jack resnick is here, a president of the american medical organization. It is seeing dr. Resnick. In mark professor in the department of german polity in San Francisco germatology in San Francisco. You come at the recommendation of the psychiatric organization and have been at the forefront of Mental Health parity. We welcome you dr. Trust men with a long relationship with American Psychiatric association. Mary gill liberty serves as chief Public Policy officer for Mental Health america and has also done a important blood series looking at how these powerful special interests determine the quality and accessibility of so much Mental Health care in america. Then, we are glad to have dr. Jeff riedel, president and ceo of the health care association. He is walking nice for his work in Data Management. That is a mouthful. In plain english, making sure there is a focus now, where there is so much content making sure it is presented in an incredible way. Glad you are here. Lets begin with you ms. Myrick. Thank you for conducting this hearing today and providing the honor of testifying regarding Ghost Network directories. I am Vice President of partnerships, from a nonprofit working to advance policy that reflects the belief the health of our mind and bodies is inseparable. I am also a Mental Health advocate and survivor with limited steering is of ghost that and health plans. I am here to share my story and bring attention. It is invisible affected systems within our Health System, preventing people from accessing the care they need. They are particularly damaging for those of us living with serious Mental Health conditions, like me, as they can result in delayed or inadequate treatment or even going without. Any of which can be devastating and have devastating consequences. My First Experience occurred when i had to change my Health Insurance due to a new position with the federal government in 2014. Navigating the Blue Cross Blue Shield provider directory to find a psychiatrist in the d. C. Or maryland area turned into one rejection after another. Call after call resulted in the following types of responses. Who . Hmm . She does not work here. I dont know who they are. I dont know who that is. I am not sure they ever worked here. Hold please, dialtone. Or a recorded message that the doctor is no longer accepting new patients, if this is an emergency, hang up and dial 911. I spent countless days and hours scouring the networks and finally found a psychiatrist that was taking new patients. The success was shortlived. In a call to set up an appointment, i was asked about my diagnosis never a responder without any hesitation, schizophrenia. A pause, a long silence, and then, i do not take patients with schizophrenia. I asked if they had suggestions or referrals to help me find a doctor who does it the answer is, check the provider directory. Going back to the directory was like looking for a needle in a haystack. Lots of hay, very few needles in snow that could stick together the needs of my freddy a. Finally, i contacted my psychiatrist in california and asked if and how he could remain my doctor. I and flying regularly to los angeles on my own expense for over a four year period to enshrine can be and they well. I also paid high outofnetwork copays but at least i had a provider. On the same fan, when i needed a doctor for what turned out to be by word cancer, i was able to find an endocrinologist the same day but for Mental Health, it was a different story that continued throughout my career. In 2018, i began working for the Los Angeles Department of Mental Health. I then had to find another psychologist. I searched the provider directory with trepidation and received jet and responses. In 2020 and 2022, i dealt with new Insurance Plans any directories. Each time felt like the groundhog day movie with the layer responses that there is no provider here, nobody by that name, they are retired or not taking new patients. Unfortunately, my story is not unique. Many of my peers with Mental Health diagnoses they similar challenges, regardless of whether they are covered by medicare, medicaid or private insurance. Even today, despite having Health Insurance that is otherwise considered excellent, have no ongoing psychologist which leads me to Ongoing Society about ongoing anxiety about what would happen if i cannot get the care in. I have had involuntary hospitalzations and do not ever want to go through that again because i am not able to find a provider through my health plans directory. And do not have to worry about this for my thyroid condition. I have a specialist readily available under everett Insurance Plan. Why do i not have the same for my Mental Health . Senator wyden, you said too often americans who need Affordable Health care hit a dead end when they try to find a provider that is covered by their insurance. Ghost networks means the list of Mental Health providers and insurance of Company Directories are almost useless. Never a truer word. As a consumer with lived experience of Ghost Networks, i urge the committee to act on issues through the policies. One, provide the oversight enforcement and initiatives necessary to and incentives necessary. Two, require subdirectories and specialties. Three, lament an online recording system or dedicated 1800 number for consumers to report their experiences of Ghost Networks and to use the information to enforce policy, and form policy, and enforcement actions. Thank you for the opportunity to share my story today. I would be happy to answer any questions you may have for me. It is clear that she will get plenty of questions. We thank you very much for being here. Thats go to dr. Resneck let us go to dr. Resneck. Inky for the opportunity to dissipate. I am a practicing physician and chair of the department of dermatology in San Francisco. Physician provided directories are clinically important tools. They help patients to shop for and elect Insurance Products that cover physicians already part of their health care team, and find in Network Coverage they need once they are covered. They serve as a representation of a planted Network Adequacy for regulators. When directory information is incorrect, results are costly and devastating for patients as you heard from ms. Myrick and her lived experience. In a time when our nation is fighting a mental and Behavioral Health crisis, and accurate directories are not only an infuriating barrier for patients and families already in great periods of stress you must waste time calling practice after practice to find when actually in network and accepting new patients, but they mask the fact and shores consistently and egregiously mask insurance consistently and egregiously. It causes harm to millions of americans. The problem is not limited to Mental Health. Not only have i read many studies showing the scope of problems with provider directories, i conducted one myself. This is of particular interest to me. If you years ago, i had been students call every dermatologist listed in directories for many of the largest Mental Health plans largest medicaid plans. The results were dismal. Of 4754 listings, almost half represented duplicates. Among the remaining, many practices did not exist, had never heard of the listed position, or reported they had died, retired, or moved away. Others were not accepting new patients or were in the wrong subspecialty. In the end, just 27 of listings were unique and offer an appointment. Sadly, more recent studies, including your own, demonstrate these problems persist and are maybe worsening. Achieving directory accuracy is not simple insight knowledge Physician Practices have a role to play. But the responsibility of directory accuracy ultimately lies with the plans being listed correctly in the directory as a fundamental component of a Physician Health care there contra health plan contract. I work at a big academic medical center. You would think are a big staff devoted to this work would equate to more accurate listings, but health plans typically take six to eight months to add or delete physicians after we notify them of changes. They do not use standardized formats so we have to send different rosters with different formatting to each and everyone. Big and small practices, with 20 or more plans, amounts to a costly and demoralizing administrative burden. It happens at a time when we are emerging from the pandemic with skyrocketing levels of burnout. Facing a web of growing and wasteful obstacles from these same health plans. Author often was like prior authorization. My physician colleagues need to be free to spend time doing what drew us to medicine in the first place. Taking great care of our patients. What are some solutions . In 2021, the ama collaborator with caqh to look at health plans and achieve directory accuracy. I am talk about taking a more active role in regulating regularly reviewing the accuracy of directories. Regulators require health plans to submit accurate directories every year. This is what patients deserve. To take enforcement action against plans that fail to maintain complete and accurate directories with monetary penalties. Encourage stakeholders to update standards so practices like mind to not have 20 different methods. Require plans to immediately remove physicians who no longer participate in their network. My study was in 2014, and here we are today. Enough is enough. We can fix this. I urge policymakers to continue examining the issues that phantom networks may be masking. Problems like overall Workforce Shortages, a lack of Network Advocacy adequacy, plans and rapid failures. Thank you so so much for considering my comments. I am happy to take questions. Great. Dr. Trestman . Chairman wyden, Ranking Member crapo and members of the Senate Finance committee, on behalf of the American Psychiatric association, i want to thank you for conducting this hearing and all the work you have been doing. We greatly appreciate your continuing bipartisan efforts to confront the Mental Health and Substance Use crises in our country. We are grateful for the opportunity to give testimony today. Those networks affect private Sector Health plans purchased by individual and layers, and public plans like medicaid and Medicare Advantage. By written testimony references data from several studies about the ubiquitous nature of directory and adequacy and accuracies. These include misrepresentations that clinicians are accepting new patients, wrong phone numbers, and listings for clinicians who are no longer in this week. I would like to speak to you about my personal experience with how phantom networks affect our patients. Brilliant physicians and other providers and increased costs. My department at my clinic is in rural virginia. We deliver over 90,000 care visits per year to individuals living with a broad range of complex Mental Illnesses and substance disorders. Access to care in rural settings like mine is particularly challenging. These areas are physician shortage areas to begin with and patients can be required to travel for hours for psychiatric care. Finding anyone accepting new patients can be nearly impossible. This clinic is the regions only tertiary center. We function as the Public Health point of access for so many people. My clinic is in almost all networks and our waiting list for patients currently numbers over 800 people. For those who are healthy and well educated, going through an an accident provider list and being told you that we are not taking new patients, this provider is retired, we no longer accept your insurance, means we are leaving a message that no one returns is frustrating. For people experiencing significant Mental Illness or Substance Use disorders, the process, at best, is demoralizing. At worst, it is a setup for clinical deterioration in a preventable crisis. Many are already experiencing profound feelings of worthlessness, grief from loss and trauma, and the impact of Substance Use. Patients have shared with me that they felt themselves repeatedly rejected. And somehow, the fact they could not find a provider was their fault. Some give up looking for care. At this clinic, keeping our credentials updated with Insurance Plans is timeconsuming and expensive. We have multiple fulltime employees doing nothing but maintaining our credentials with Insurance Companies and public players, including medicaid and Medicare Advantage. This is a bargain Insurance Companies, i believe, should bear. Knots those of us trying to provide desperately needed care. The National Administrative burden for Physician Practices to send directory updates to ensures through disparate technologies, schedules, and romance, is 2. 76 billion annually. Not all Mental Health clinicians practice on settings like mine. Are willing and able to invest resources needed to participate in the networks. Private practitioners make up a significant portion of the psychiatric workforce. Many do not participate in the networks because of the administrative burden. Ghost networks are both a cause and a symptom of a system that is shortchanged, Mental Health care for decades. We need the help of congress to change this. I written testimony includes recommendations that we ask committee to consider. Many of which we are already pursuing. It is time to hold plans accountable for maintaining accurate directories and making accurate representations to patients, to clinicians, and to employers. Our patients also need privatesector plans to be held accountable to the Mental Health parity law. Further investment in expanding the workforce, particularly in underserved areas, is vital. Congress might further incentivize the adoption of models, of integrated care, like the collaborative care model that improves outcomes and expands access, while furthering the support of our primary care physicians in their ability to deliver a loss of care. Thank you for the opportunity to testify. I look forward to your questions. Thank you, doctor. Ms. Giliberti. Mers of the Senate Finance committee, thank you for the opportunity to testify regarding provider accuracies in Ghost Networks, issues organizations have been working on for over a decade and caused rate harm. My name is mary gililberti. My testimony details helping friends, family and Mental Health Community Members access Mental Health providers. The first question i ask them is do you need the Services Covered by insurance. I ask this question because i know it is quicker and less effort if they can pay outofpocket, but much more expensive. I was helping young one young woman who, like many others, found her Mental Health was dwindling during the pandemic. She wanted to pay a minimal copay and not hundreds of dollars each visit so i hope to make a list of recommended psychiatrists on her direct. By now, you heard the story many times. She started making calls. Some did not call back. Others said they were not on her network even though they were on her directory. Weeks went by and her condition only worsened. Fortunately, someone at work knew of a telehealth option and she was to get help in network but only after a very painful delay. Some people give up entirely after making unsuccessful calls. When you are experiencing symptoms like lack of motivation, anxiety, and psychosis, and you are getting worse, you are least able to navigate these directories. Fortunately, chair wyden, your state did not very well in this either. Using claims data, researchers found two thirds of Mental Health subscribers listed in plan directories were phantoms who were not fulfilling the plan. Two thirds. The views of advantage medicare plans also show high levels of inaccurate. What can be done . We know from studies of state statutes, it is not enough to require accurate directories. That has been done and over the decades, it does not work. We have three recommendations. The data must be verified by a reliable message like independent audit and claims data. Nonprofit organizations cannot just submit our financial data, but have to submit it to somebody. We need a row requiring states to use secret Shopper Service by an independent entity. The surveys will determine the accuracy and wait times for Mental Health services and others. This policy is an important step further forward entities needs to be finalized. We also need a Medicare Advantage plan for its overview. Plans should also be required to use their claims data to periodically reconcile these directories. He Workforce Shortages behalf if they are not seeing somebody, or not filing claims, they are not seeing people and they are not in the directory. Second, the information should be transparent. In other areas of health care, cms requires transparency. This area needs more sunlight. Terry will require it will require people to use sunlight and all plans to be regulated by cms so we can see what is going on by plan. Not in the aggregate. Third and most importantly, plans have to be physically incentivized to provide accurate directories. This provides carries and states. On the carrot side, we can incorporate accuracy rates that affects which plants consumers choose and bonus payments like the star rating system. It is important he plans doing well are rewarded for doing well. Then, we should have penalties for those not doing well. Similar to hippo provisions hipaa provisions that are enough to change behavior. An individual should always have protection if they rely on an inaccurate directory. In my testimony, there were other areas that would also affect directories including reimbursement rates, interactive care, telehealth and expanding advantage to medicaid service. In conclusion, there will always be some provider directory in adequacy but the high rates consistently rebuild in recent studies are not minimal errors, they are consumer and government conception, this representing the values of the plan, undermining consumer choice, and causing suffering. With the right to verification of data, transparency requirements, and fiscal incentives, we can do much better. Thank you. Thank you. You will have questions for sure. Dr. Rideout. Good morning chairman wyden, vice chair crapo and ricky nevers of the committee. I am part of a california Leadership Group whose members include physician group, health plan, hospital system, regulatory agencies and other health care stakeholders. Among our many programs, our team manages a countywide Data Management program called symphony which is the focus of my mark today. Providing professional accuracy is of great concern to me. Prior to this, i was the first senior medical advisor california and our team oversaw the launch and the wind out of its first directory. I am familiar with the challenges of creating accurate provider information. The problem is real. The key question is how to solve for it . The actress each fund is exposed in the early california effort led to regulatory acquirement in california and also lead to a comprehensive industry effort to address longstanding challenges in provided data accuracy which became a simple program. Symphonys goal is to and unify how providers share, reconcile and validate provider directory information. But our Technology Partner available, we created a steel utility designed to be the primary source of information which will replace existing and between providers. As an output of the process, symphony creates a golden record by providing a strict set of agreedupon roles providing what the best information is when information from multiple organizations is conflicting. It is a form of machine learning. The more organized, the greater chance of finding errors before it goes back to providers. It has 17 contracted health plans, more than 100 organizations, and is engaged with california. Participation in symphony is a california contractual environment for all participating plans. They currently maintain over 170,000 unique provider records and support support more than three elements such as verification and accepting new patients. Ultimately, sustainable provider data improvement requires a collaborative solution. The centers for medicaid medicaid said it best that it has become clear a centralized depository for provider data is a key component missing from the accurate provider information. Symphony is that exactly. What did we learn so far . Providers and data encompasses hundreds of specific Data Elements and most need to be verified on a frequent basis. We need more Data Elements related to lgbt support and more Data Elements related to rates and ethnicities. This problem of Data Elements will grow, not shrink. In addition to the data, providers need to attest to the accuracy of the information every 90 days. Under these conditions, providers are much more willing to do so if they can attest once. It is provider data that is populating the directory and is the ultimate source of accuracy. Based on the number of different data must, all stakeholders have agreed to prioritize the elements most important to consumers assessing new patients. Symphony is a dynamic process that continues to adapt. Before symphony could begin processing data, we have to create standards of processing and regulatory requirements which includes for timeliness, data these are the same across areas. This allows us to identify and consistency. Identifying inaccuracies and correcting them is necessary and feasible. In the last 30 day period, provided data from a hundred 69,000 eight providers identified over 30,000 unique and consistent Data Elements which we call corrections that require health plan and provider changes. Of these, 5000 rares in the physical Office Address which is an active issue, while 2200 were related to license improving provider data accuracy is a complex undertaking for independent providers of which Mental Health providers are more likely to be. This can be cost prohibitive without a centralized Data Repository that supports a multi plan provider, Directory Health plans and providers will be unable to maintain accurate provider, data and directories individually, even with the best of intentions. This is critical for mental and behavioral Health Providers who are increasingly less likely to be in health plan networks, making it even more critical for them to be able to update their data in a convenient single centralized repository. Thank you for your attention. Thank you very much, ms myrick. I was listening to your eloquent statement and i was saying to myself, what is it like in america when someone like you who is in the Obama Administration who specializes in Health Care Gets bounced around the Mental Health system, the way you describe, i just kept thinking to myself, whats it like for the typical person and the typical family . If they go through what you describe . And i think the question i have for you because i think your exhibit a for why we so desperately need reform. Whats gonna be the consequence of doing nothing . What if the Insurance Companies is to keep doing business as usual . What are going to be the consequences because it seems to be the problem. You describe intersecting with the tremendous increase in demand is a big problem for the country. So just if you would paint the picture of what happens if we dont do the kinds of reforms that you and your colleagues are talking about . Thank you for the question. I am not a soothsayer but i think about the consequences of much of what i talk about my testimony that if you are going without health care or Mental Health care, the consequences are dire. We see them in our statistics related to people with Mental Health conditions who become unhandled, who are criminalized, who end of own lives, and so really i think the consequences at the end of the date are about the difference between life and death. And that is pretty dire. We may have to put you in charge of the federal government by the way, when you are making those comments. You want to be in california when uh when you are making those comments, your colleagues, particularly the physicians on the panel, everybodys nodding. So, thank you for that. Let me go to you, uh miss gilberti with respect to the financial burden of these Ghost Networks. As i mentioned, you know, the finance committee made, felt like a gazillion calls, but 100 120 looked for an appointment for a senior with depression. The vast majority of cases, the vast majority be one thing. If it was incidental resulted in a dead end phone call, we were able to make an appointment 18 of the time after hours and hours on the phone. And the reason i wanted to talk to you because it reminded me a little bit of my Great Panther experiences, what you were talking about and kind of crunching some of the numbers for some patients who are able to make an appointment they , found out that the provider they saw who was listed in their directory was actually out of network. So the patient gets stuck with the bill. Now, why should the patient be on the hook here . The Insurance Company is not doing what they purported to do when they were taking the consumers money. And yet the patient in what youve been describing and, and others who are advocating for consumers seems to me actually backwards is the Insurance Company hasnt done what they indicated that they would do, but its the patient whos on the hook when they desperately need coverage and they have to reach out of network. What should the committee do in a situation like this . I wanna, my friend, senatoro has always been so constructive on this. We work in a bipartisan way. So when we see a problem, we say, hey, wheres the Common Ground . We can get democrats and republicans to be for. What is that kind of Common Ground here so that we can actually help that patient who in my view is just being fleeced. Thats what we used to say it back when i was codirector of the Great Panthers. You know, we didnt talk health lingo. We said this person is just being fleeced, but now we got to figure out how to navigate reforms. What kind of reforms should senator and i pursue here. It should not be the responsibility of the individual, right. In my view, they should be compensated for the stress that comes when you get a bill like that, you open the paper and its like, you know, hundreds of dollars, you expect a 25 copay and youre looking at hundreds of dollars, they should compensate you for that stress. And instead youre expected to pay that. So if the directory is inaccurate, the consumer should pay in network prices. So their regular old co pay and the plan should have to cover the rest of that cost because their directory was inaccurate. So it should not fall the person whos least able to bear this cost. Right . I mean, if you think about these companies whos in the best position to bear the cost, the individual or the company that, for the mistake that was made and they represent this network, thats part of what youre paying for. Right . I mean, when you choose that plan, when a consumer goes to the website, they choose a Medicare Advantage plan and thats one of the advantages, right . They can pick one, but they pick based on what they see and then if its not accurate, that shouldnt be their problem, they shouldnt have to pay for that. Im over my time. Thank you. All the panel has been excellent. Senator. Thank you, senator wyden and doctor redout. Id like to start with you and im gonna ask a question similar to the one that, uh senator wyden just asked m g be. And that is, uh, well, first of all, thank you for the work that youve done on the ground in terms of helping to improve the accuracy of provider directories. Uh you talked about a lot of important things in your testimony. What if you could just summarize for us . What are some of the key practices that we need to be focusing on here as the solution . Bring it down to some of the best. Well, i think youve, youve highlighted several of them um transparency being one um better auditing being another potentially penalties being another. My concern would be if um this is done without sort of an on the Ground Operational solution, you will double down on bad practices. We will get more intensity from health plans to avoid penalties. Well get more suppression of networks. Potentially, we will get more urgency and challenges for the physicians and other providers who cant afford and are really being distracted from what theyre doing. So i think ultimately having a Single Source of truth, however, thats organized, whether by state or nationally gives everybody a fighting chance to say this problem is about intentions or it is about accuracy or its a combination of both. So i would say its hard work, but youve got to kind of get that part fixed as well or else well just double down on whats happening now. Well, thank you and doctor resnick again, following up on the same thing you mentioned in your testimony that the physicians are facing a crisis here themselves trying to deal with this solution. And were seeing a lot of unprecedented stress and burnout exacerbated by administrative burdens. We dont want another Government Program or another government mandate that just puts burdens on everybody and doesnt get to the solution. What could you do if you could just concisely bring it down to . Whats the best, what are some of the best things we should consider here to achieve this objective without causing the damage that that could be caused . We appreciate your leadership on this and the bipartisan engagement. There are some things we think you can do and while there are some uh excess regulations, wed love to talk about in another hearing to reduce. This is one area where we actually need congressional help. And, and i think there are some straightforward things we hear from hhs that they dont think they have the tools to audit and enforce and impose monetary penalties on the ma plans and the Exchange Plans that they have oversight of. I know it may not be in this committees jurisdiction, but the department of labor needs Additional Authority around erisa plans. And then we at the American Medical Association are putting in a lot of work with our colleagues in state medical associations and special societies, going to states to make sure that Insurance Commissioners also at the state level, have, have increased authority if we dont have monetary penalties on these plans for continuing to put out these Fake Networks to make their, these fake directories to make their networks look bigger than they are. Were not going to make progress. Well, thank you and doctor according to the National Institutes of Health Americans in Rural Communities, as as you indicated in your testimony, experience a significant disparity in Mental Health outcomes even though the rates of Mental Illness are consistent in rural and metropolitan areas. Over the course of the past two congresses, weve explored how different problems within our Mental Health care system disproportionately impact Rural Communities. Uh could you just tell us from your experience in practicing psychiatry in a Rural Community . How do inaccurate provider directories and other access issues impact these areas differently than metropolitan areas . Thank you, senator. I think many of the issues are identical. The challenge is the provider directories are even more sparse for us. And the geography is really challenging. The challenges that our patients have faced have been, have driven us to many limited resolutions. Oftentimes their primary care physicians have been tasked to take care of the psychiatric issues because theres no one else available helping us to empower them is really critical as well. So i think that, that telehealth has been another extraordinary advantage for people with Broadband Access and the ability to afford uh data plans. They have telehealth with video, which is wonderful. But in many rural areas including mine, i do this last week. I did some of my visits by audio only because thats all that was available. Thank you. Thank you very much, very important point. During our telehealth discussion, we heard consistently from Rural Communities that they uh support broadband, but if they dont have it, they want audio only. Senator cornyn is next. Thank you, mr chairman for uh for this hearing today. Thanks to all the witnesses. This is a disturbing um issue of, of Ghost Networks. Uh i want to ask though that um theres a, a bill that senator cortez masto and i have introduced and doctor truman, you happen to mention this in the uh in your written testimony. Um the complete care act. I know the nature of uh practicing medicine is, has evolved a lot probably during your professional career, both yours and and doctor res. But one of the things that seems to make a lot of sense to me is we now are embracing the whole person and not just dealing with physical health, but Mental Health too, to find ways to integrate uh Mental Health into Physician Practices. Um could you share more about how you think the bill might be uh able to help doctor truman. Absolutely. And thank you so much for your work on this. You know, as i understand the bill, the opportunity is with the partnership between primary care and psychiatry. The challenge that weve seen over the years and i worked closely with our colleagues who developed the collaborative care model at the university of washington. Ive worked with people around the country and ive tried to implement the collaborative care model in my own Health System. Its challenging and frankly, the challenge isnt so much on the side of psychiatry. The challenge is on the side of primary care. Its hard to change work flows. Its hard to have an integration and support system. So i think that the complete proposal that you and senator uh oh forgive me, cortez Masto Cortez Masto have developed is critical because it front loads, reimbursement and support for primary care to make this real for the first few years. Thats central and a wonderful opportunity. Well, we look forward to working with you and others on that. Um i know the chairman and Ranking Member have talked about things that the congress has done recently in the Mental Health area. And certainly i agree with them that the status quo was completely unacceptable. Weve failed to provide that Mental Health safety net. But one of the things that i i would just draw your attention to or refresh your memory on is we passed the bipartisan Safer Communities act last year. It was uh senator tillis and i were involved in a hot and heavy negotiations with senator cinema and senator murphy on this, uh after this terrible shooting in uvalde. But one of the most overlooked aspects of that i think happens to be one of the most important aspects of it that is expanding the Certified Community Behavioral Health clinics and the funding for that. Um as you know, there had been a pilot program, senator stabenow and senator blunt have been taking the leadership on that for many years and i congratulate them for that. Theyve really led the way. But we made, i think the single largest investment and uh Mental Health delivery in american history, um which is incredible and great. But heres, heres the challenge. Doctor resnick. Um where are we going to find the workforce . Where are we going to try to find the trained physicians, psychologists, counselors . And uh the like, its a great question and im, im glad you brought it up, senator. Um as you all probably know and weve talked with all of you about over the years and many of you have led in this area. We have a graduate medical education crisis in the United States as well and, and psychiatry is a part of it, but its really across all specialties where we are now seeing shortages, patients are facing long wait times. I think about this in a few ways. So theres the front end, as you mentioned, training more physicians and and non physician clinicians and nurses, et cetera. We need more g m e dollars. We need support for that big bill that will help, that will help to accomplish that. Training physicians does take a while. We need Immigration Reform and Additional Resources for the conrad 30 program to help to grow that as well. That provides critical physician access in cities around the country. I also think about workforce at sort of the tail end of the pipeline. Im worried because as i look at my colleagues around the country, these soaring rates of burnout in the last few years and we know all the things that contribute to that. But if we continue to have health plans, adding burdens to physicians, whether its prior off, whether its inaccurate directories, weve got one in five physicians telling us that theyre likely to retire in the next two years so we could acutely lose a lot of that workforce too. So its important that we think both about the sort of training and and about getting those obstacles and burdens out of the way. So we retain the workforce. We have. Thank you. And of course, that applies as you indicated, not just to physicians but to allied Health Care Professionals and even School Counselors where part of the problem that we made an investment in safer schools too because thats where most of the Mental Health problems i believe are likely to be identified. And then, and then referred for the kind of care that these kids need in order to get well and not get sicker and sicker and be a danger to themselves and perhaps others. Thank you, mr chairman. I thank my colleague and my colleague who spent a lot of time on these Mental Health issues and with senator stabenow has been doing some good work, is making a very important point. And that is, weve got a big uh challenge ahead of us some serious lifting with respect to workforce. And thats why senator crapo and i so appreciated the chance to work with the two of you, senator stabenow and yourself on those workforce issues. And the fact is in the gun safety bill, the reason we were able to get it uh in was we had taken the time to write black letter law and we were ready to go and the two of you spearheaded the effort were going to build on it. I do want to make sure that a of my approach to this is im going to be all in all in on these workforce issues, but that is not the same thing as running a Ghost Network which is misrepresentation. So we got to deal with both of these issues and i look forward to working with my colleagues in a bipartisan way on both of these questions, senator grassley is next. Can you get me . Well, of course. No, we got plenty of people. Um, what, what well do because senator grassley has strong views on these issues. Uh, we will have senator tillis now and then senator stabenow and, uh, if other colleagues are on, on the way, uh, lets, lets get senator tillis and senator stabenow and senator grassley in and then i hope other colleagues will come. Senator tillis. Thank you, mr chair. Thank you all for being here. Im glad that senator cornyn brought up the Safer Communities act. People call it a gun safety bill. I call it a Mental Health and Safer Communities bill because it, it is an extraordinary investment and im proud that North Carolina is one of the 1st 10 states to receive the tranche of funding to expand um Behavioral Health access, particularly in, in Rural Communities. But uh but a across the board, um miss my uh back in 2007, i was diagnosed with an illness that required me to take uh medications that caused me to have pharmacologically uh induced mania, followed by clinical depression. So i got a window into Mental Health that i consider to be a blessing. Um had i not had a wife, uh you know, when im in mania, i felt i felt like i could fix any problem anyway, i simply would not have sought a health care or Behavioral Health professional. And when i was in depression, if i went to a website, went through what you did, id have said whats the use. Um, so we need to understand this has real life consequences and, and, uh, youre in the worst possible state to have the complexity and maybe even have it in, in, in the middle of depression. Uh, finding out that you have to pay out network costs. So now youve got financial stressors, youve got whatever the underlying condition is, the insurers, the providers, everybody need to understand that i want to get to getting regulations. Right. Um, i think if were punitive then the resources uh to the health care uh to the insurers is gonna come from somewhere and most likely its gonna come from the pockets of patients at the end of the day are from providers by lower provider rates. So we have to get this right. But we have to do something. And, um, im sorry, how do you pronounce your last name right up . No, im sorry, i got yours. Ok. Um, what would be wrong with, uh, hhs and c ms. Uh, i, i work for, uh, big four audit, uh and Management Consulting firm for most of my professional career. And, um, for one thing, it, its shocking to me that the insurers would have this as part of their annual audit regimen that, that they already dont have within their, all of them have internal audits. They have the skill, they have to have it and compliance. Its shocking to me that they dont have uh an Audit Program of record, uh where theyre going through their, uh provider, uh networks. Um so, rather than mandating that why couldnt we move towards mandating to c ms and giving c ms the technology, the resources necessary to do it that were gonna perform audits . Were gonna determine. I think in, in one example of, of medicare provider, uh uh information that theyre about 50 accurate. But what would be wrong with an audit or a review by c ms giving them an f because they have a failing grade and having published that on the website, uh, a part of the carrot and, and i think a competitive advantage for the insurers would be go to the c ms website c r rating. Weve got an abc grade one star, two star, but why not a kind of an incentive for them to just make this a part of Standard Operating Procedure a auditing it and then getting the underlying Information Systems that they have in place to get a higher grade rather than because if we come down with a heavy hammer, theyre going to comply. But thats also taken their attention away from finding additional providers, uh driving down cost of insurance and a number of other things. Uh, what, what would be wrong with the light regulatory regimen is a way to start that. I think that generally would get bipartisan support. Well, i think that that is absolutely an important uh component. So it would be a great advance forward. Um you know, obviously wed like the whole piece, but i think that having that would be very, very helpful. C ms has done some auditing, but they didnt identify the plans, which i think is what youre saying. But i think if you do that, that youre gonna find the audit uh and a test ecosystem very quickly come up with Advisory Services that are going to go after these companies and figure out how they can accelerate it, get that integrity right. Get out of the over promising and under delivering that we have today. Uh and i also think you said something thats very important if you have somebody select a plan, maybe because they looked and saw a very Large Provider Network and that proves not to be the case and they have to go out of that work. I think thats a legitimate case where the, the, the the person who sold you the expectation that you had these options and when you came into crisis, you have those that should be the insurers problem, not the insured, the insurers problem. But to me, those are relatively modest changes that if theyre implemented properly, i think could have a significant behavioral impact that benefits the insurer. Um i, i dont have, i, i have no more time left but on the workforce thing, if, if we wanna get this right, it cant be just about educating more doctors because we simply wont get the pipeline. I spend a lot of time. Ive got a couple of schools. You may have heard of duke uh uh chapel hill. Uh they train a lot of doctors that they tell me that the outlook is bleak. So if we not to cover off the ball, were still not gonna have enough and were not gonna knock to cover off the ball of getting people into this profession. If we dont deal with a number of other underlying reasons why people are leaving earlier and not getting into the profession. So those are the things we have to talk about if were seriously gonna get it done. Thank you, mr chair with you, senator grassley. Im ready now, im a strong supporter of telehealth. And when i was finance committee chairman, i helped make it a permanent in medicare. Several states have followed suit in their Medicaid Program while i supported making telehealth permanent for all services. Mental mental telehealth is an important tool to improve access, especially in Rural America. So im going to give one question to miss gilberti and another question to doctor tress. Uh the question im going to state both of these. Now. Uh miss gilberti, in your written testimony, you said nearly half of the adults and youth with Mental Health needs dont receive treatment, access to care can have many challenges. Has telehealth and investments in broadband helped improve the access issue. And for mr tress, in your written testimony, you said access to care in rural settings is challenging, you specifically highlighted how telehealth improves access to more timely care. Given the recent expansion of telehealth, our patients getting the best uh Mental Health care and if not, what can we do to improve the quality of care . This is, yes, absolutely. Telehealth has had a tremendous effect on access. In fact, the story that i told the young woman actually finally got care using telehealth. So it has disproportionately affected the Mental Health community. You want to have access to in person as well. But having telehealth particularly in rural areas has definitely been a game changer. We need to extend those flexibilities and make them permanent. We also need to worry about licensing between states because that becomes a problem as the emergency ends. Senator, thank you and thank you for your work on this issue. It is enormously challenging. And as ms gilberti had said the benefits of telehealth during the pandemic have been demonstrated, they are substantial. Many people are in rural areas simply unable to meaningfully come to us without telehealth without taking off days of work. Many dont have paid medical leave, they lose a lot of money coming to see us. The opportunity with telehealth is really substantial in providing appropriate care. The data is still evolving as to who is best served in person who is adequately or appropriately served by video uh and who is adequately served by audio only in what conditions. But in my own experience, and i still see a lot of patients. I have had insights into peoples lives by seeing them in their homes that i otherwise never would have gotten if they traveled to me. Will traveled to me. So ive had opportunities that have benefited both me as the doctor, as well as our patients by having access to them in a timely way, in a way that doesnt put additional burdens of cost and time on them. And that get allows me to see them in the environment in which they live. Thank you. Ive heard from iowans about the challenges finding in Network Providers including Mental Health services. There are many reasons for the bad provider, uh directories, even the best information may not be user friendly patients may have to navigate pages and pages of information for any of you. Witnesses that want to comment on this question are government regulations or incentives preventing the private sector from solving this problem . And i dont care which one of you comment on it. I would say the lack of, of standardization is, is, is a problem. So, um and several Panel Members uh discuss this. The fact that a provider may have to, whether its a physician provider or a Mental Health provider of any type may have to deal with literally dozens of Health Plan Requirements that come at them different elements, different times, different submission, standards, different expectations and then have to repeat that over and over again. Every time something is potentially wrong, its just a burden that they cant absorb even the largest organizations. And thats what we see in our, in our work. We have to fix the accuracy problem together. Thank, thank you, senator grass. So we have to call a lot of audibles around here and because of senator caseys graciousness, senator stabenow will go next. Well, thank you so much and thank you to all of you. This is so important that we actually have accurate provider, directories and this is just part of the whole big picture. I remember back in this committee when we were writing the Affordable Care act and i authored the provisions on Mental Health parity and that were still finding this. And i mean, its just, its in every way we, we, we are coming back all the time, health care above the neck, not being treated as well as health care below the neck. And uh miss mike, thank you for your testimony and sharing with us. Im sorry, youve had to go through all of this. Um i do want to expand a couple of things because im im all in mr chairman and what you want to do. Absolutely all in. I do want to stress as um senator cornyn was talking about that we have made progress and frankly, one of the alternatives i would love ms wright for you to be able to contact your local Certified Community Behavioral Health clinic. Theyre in areas now where we have them fully funded. Theyre funded like health care. You can walk in the door. A third of the time in michigan, one of the 10 states where were fully funding. At a third of the time, people are seen immediately and people are seen within 10 days with and, and required and theres a whole bunch of things there. But uh we have 10 more states coming out at the beginning of the year. Were moving to get all the states engaged, largest investment in permanent Mental Health funding ever for the country that is, that is coming. And so step by step by step, this is part of the answer. Its not the whole answer. But, but you know, if they want to put up ghost registries, go to your c c b h c and well get you some care. And so as a start. So, um so, but i wanna talk, uh and certainly can, we can come back to that. But i wanted to follow up also on the issue of providers because we have the Provider Networks. We have these ghost list and then we just dont have enough providers, right . And so, and we know this and one of the things i so appreciated that we worked on last year, senator danes and i as cochair of a workforce. Working group, uh, that senator wyden center re set up a really important part of our Mental Health work. We actually did a few things but theres some, theres more things to do. We were able to get a small number of graduate medical education slots. 200 and half of those for psychiatrists, small. But first time we designated psychiatric slots. And so that was something we were able to get medicare, Medicare Coverage for licensed professional counselors and marriage and family therapists. But i wanted to ask uh miss uh gilberti, um one of the things that senator uh barrasso and i have introduced and been around for a long time relates to social workers. Um and we have the improving access to Mental Health act as it relates to Medicare Beneficiaries being able to access social workers and the complete set of services they provide as well as appropriately compensating social workers. And so one of you might speak to that, that seems to me thats a big hole we have here when were talking about providers in Mental Health as well. And, and how could this help meet the demand on Behavioral Health . Oh, absolutely. Social workers are critical. You know, as i talked about how hard it is to find providers, theyre particularly helpful if you have a Chronic Health condition or you have a disability and youve got to find multiple providers. Social workers can help you with that coordination. They provide treatment as you mentioned and we dont have enough people doing that. So they provide an Important Role there. Theyre very important with the social determinants of health, right . We know that housing, food insecurity, transportation, all those things affect people. Social workers can help people get connected and really serve underserved communities who disproportionately are not able to access those kinds of things and it affects health and Mental Health and they are important and integrated care, which weve talked about today, they provide some of those services, they coordinate care. So social workers have an Important Role to play and we definitely need them in that continuum of care. Thank you so much and limited time. Uh doctor uh just a couple of things. One in our discussion draft on workforce senator deans and i propose raising physician bonus payments in shortage areas and allowing non physician providers to receive bonus payments really focused on rural and and and underserved areas. Um any thoughts on that and also c c b h cs. Um you know, any comments you would have on on that as part of what we need to be doing. Senator stabenow. Yes and yes. The short answer clearly having additional compensation and encouragement for people to join us in rural areas is phenomenally valuable, helping them pay down their sometimes profound student loans. Hundreds of thousands of dollars is an enormous incentive to allow them to do what they want to do in the first place. But frequently cant because of their financial status and with regard to the, the new access issues and opportunities. Uh these are phenomenal programs. Our challenge will be, where do you go for an f q h c . Where do you go to these, you know, when do you go in uh network . When do you go for medicaid helping us understand whats right. Well, the great thing is f q h cs and our mouthful c cv h cs are now funded structurally the same. Its the same high quality standards for medicaid reimbursement and so on. And what were seeing is that they are oftentimes together at the same site, which is really the longterm goal. Thank you, mr chairman. I thank my colleague, senator casey is gonna be next and just so were clear after senator casey. Uh the next would be senator brown and senator bennett in order of appearance, senator casey, mr chairman. Thanks very much and happy birthday. Thank you. I know that might have been indicated earlier. I wont sing, dont worry about it. I want to thank the panel for being here and ill, ill direct my, i, i think i have two questions for um miss uh gilla and i just wanted to, to thank you and, and the whole panel for the work youre doing. As many of, you know, so many of our colleagues in both parties support making investments to shore up the number, the number of Mental Health providers and integrate physical and Mental Health. Last year. For example, last congress, i should say senator cassidy and i introduced a bill called the Health Care Capacity for pediatric Mental Health act. It was a bipartisan bill to increase investment in childrens Behavioral Health integration, also Workforce Development and Health System and infrastructure. As your testimony indicated, so many people dont have access to that integrated care yet, in the process of finding a Mental Health provider can be overwhelming for people suffering from Mental Health challenges. Someone who needs help has to sort through provider lists and make lots of phone calls to find a provider with affordable pricing and availability. I know youve covered this. Its especially hard when these lists have countless errors in them. One constituent who reached out to my office was already very well acquainted with the with a top Health System, but it still took her months to find a Mental Health provider for her daughter. As you indicated, you get calls from family and friends for that kind of help. So i guess my first question is how can we Work Together to help find, to help people find the provider who has both availability as well as one that accepts insurance. And i know this is by way of reiteration, but i think it bears emphasis. Yeah, i think that well, just to talk about integrated care for a moment, if you go to primary care, most of those are in network. Right. So thats a way that if we could expand that we would have more providers that it would be easy for a family with a child, theyd already be there to be able to get that care in network. So that would be one way. But then of course, we need these directories to be accurate. So we need audits, we need them to be using their claims data. If theres no claims, theres, theyre not seeing people, right . With the shortages that we have and the Mental Health crisis for children, in particular, if theyre not seeing patients, we know that theyre not in network. So they need to clean up those provider, directories make them very clear and that will help people find care. And then we need to expand integrated care because i think most families would just love to be able to go to their pediatrician and get the care. The other question i had was how can we help people find primary care practices that offer this integrated Mental Health care such as practices that have telehealth partnerships with Mental Health providers . I think that would be very helpful to have on the directory is when a primary care practice has integrated care capacity. And i think that the barriers that we see often are just that the rates at this point, we just need to put more financing into integrated care as well if we really want to see it happen. Great mr chairman. Thanks. Ill yield back my time. I i thank my colleague. The next three in order of appearance would be cardin brown and bennett and those three are not here. Lets see. That would then mean senator cassidy is next. Hey, yall, thank you for being here. Um it seems like we actually have two issues here. One is the Ghost Networking which could be false advertising and miss my, your experience is so typical. Thank you for sharing it. It takes courage to do so, but just thank you for doing so. Um second is access itself because m m my speaks of both the false advertising and the lack of access. And i think you set the tone for the, for the questions if you will. Now, one thing that im struck by dr tress is when i would speak to im a physician. So id speak to my colleagues back home who were in psychiatry and they would say that medicaid medicare rates were so poor that they got to pay the bills, et cetera. So they typically went to either private insurance or to cash pay. Then ive heard the reimbursement has been mentioned. But one thing thats not been mentioned in this is that traditional medicare, which actually doesnt have a Provider Panel per se that the access is equally poor for the uh traditional medicare if youre speaking about. Um uh something such as Mental Health providers is, is that a fair statement. Yes, sir. It is. I asked my staff because we did a literature review beforehand, but they werent quite sure if there had been kind of a cross tab if you will of access for medicare patients ma versus traditional medicare. And i wouldnt be surprised if theyre kind of roughly the same uh, your thoughts on that. I, i expect that they are, sir. Uh the, the challenge in so many situations really is once you, its the administrative burden, its the access, the management. Uh and so i think that uh the ma versus medicare plans traditional have some of the same challenges. Now, theoretically, an ma plan, if theyre challenged to increase their Provider Panel, they could actually pay better than medicare rates in order to achieve that if you will, the medicare ma model if done, right . Actually addresses the market issue. Correct. Absolutely true. And supply and demand is what this country was built on. But i dont think that that has applied appropriately to Insurance Plans. You know, i think that part of the challenge for us is to come up with an appropriate strategy where people, i mean, psychiatrists have told me repeatedly that, you know, i wish i could afford to be in the Insurance Plans in medicare in ma, but they, it cost me more to deliver the no, i get that, no, i get that, believe me, you know, i, i, i, i hear that too. Uh so um so im not disputing that doctor resnick as you kind of representing the entirety of health care. At least physicians of it, you could speak to this. Theres also a little bit of a quandary that uh a doctor will see a medicaid patient because her friend asked her if she will see the medicaid patient, she doesnt really see medicaid, but shes gonna see this particular medicaid patient because her friend asked her to. And so she remains on the medicaid Provider Panel, but she doesnt really see it. I think miss joe bertie said something along the lines of theyre not seeing patients. So therefore, theyre not in network. Technically, thats not necessarily true if i will see three patients a month on medicaid because my friend who ive known since we were both in kindergarten together calls me and says, please see this patient for me. Uh would you accept that as a valid kind of occasionally occurs at least . Yeah, i think thank you, doctor senator cassidy. I i um you know, i have such pride in my colleagues on the front line around the country who are doing their best every day to take care of their communities and, and the patients who present and and the primary care colleagues who call to refer those patients. But as you have identified payment rates are an issue and you know, we have, as weve talked about two decades of stagnant rates in traditional medicare, we have Medicare Advantage plans in some markets, theyre so consolidated that theyre playing, paying less than medicare. So let me ask you this. You know, my wife whos a retired general surgeon once said, if they pay you below your cost, you cant make it up on volume. That is, that is true. And so uh so, but to that point, um and knowing that there are people who yes, i am on the Provider Panel because i still have some patients whom i see and i will occasionally see a new patient under certain circumstances. It almost seems though that we have to have some sort of threshold to, to analyze this. Uh does a patient . Yes, theyre open for new patients. But how many new patients will they receive a year from this particular payment plan . Uh because i think we have to bring sophistication to this analysis as opposed to Insurance Plans are all bad. For example, your thoughts on that. Well, i i there are physicians on panels who have not seen any patients i get. And so thats, thats fixable by the health plan. If its a small number, then i think we need to turn to the physician and theres a difference between being contracted. So and we see this also with physicians at multiple locations, right, where they get, theyre contracted at 30 spots in case they go there, but they wouldnt want to be listed on the directory because they literally go cover for a colleague every couple of years. So i think this is were having a low burden way for physicians to have input and actually be able to tell the plans when and if they want to appear on those directories based on whether theyre accepting new patients in that plan. Well, so with my last, im over here over time in five more seconds, send me that low burden way. If youve got, if a ma has got a way to do that, we could somehow add sophistication to this analysis, we would like to hear from the front line providers. We will be convening stakeholders to help you to that point. I appreciate that. Thank you, doctor cassidy, senator cortez masto. Thank you, mr chairman and thank you to the panel. Its a great discussion. Um i had the opportunity to listen in my office uh to a lot of the discussion this morning, um particularly the integrated model concept that we are talking about today. And it was so appreciative of my colleague, senator cornyn asking doctor the question about why its important and thats where we need to start, obviously, but let me ask you this, uh doctor tress, how would this integrated model uh help us alleviate the existing Workforce Shortage . Would it . I think itd go a long way to helping senator and thank you for all of your work in this domain. The opportunity is this if we partner psychiatrists with appropriate support staff embedding into primary care. We can keep people in primary care without them having to physically be seen by psychiatry, one psychiatrist for two or three hours a week can review a panel of between 40 and 60 patients to provide adequate support to the primary care team so that we can give guidance and support them. Additionally, something that was already addressed was workforce burnout, keeping people in play, keeping them satisfied with their work. Its morally frustrating not to be able to refer someone to care if youre the primary care. Do you see someone who needs care . Its beyond your scope and you cant do it. These, the collaborative care model and other potential models allow primary care to do what they want to do. Thank you and, and doctor, i appreciate your comments regarding the burnout issue and the preauthorization. I just had some doctors in my office talking about the concerns about this prior preauthorization requirement and how frustrating it can be. So, thank you. But can i jump to, i only have about five minutes . I want to jump to rural nevada um which is similar to northern california. Uh and so um let me uh doctor, right, let me ask you this because as with the integrated primary care telehealth has proven to be valuable tool for rural nevada in my state and essentially to also extend our Mental Health workforce. And while were making steps in the right direction, i am concerned that the telehealth and expanded primary care alone will not meet our workforce needs, particularly in our Rural Communities when it comes to Behavioral Health professionals in the long term. So, in your view, how are contracting issues driving the supply problem in rural areas . How do we address that . Well, i would agree with you that despite the huge up uptick in tele health visits, its not gonna be enough to solve the supply problem. And as i think a number of panelists have mentioned primary care physicians who and im one of them do provide a certain level of Mental Health care, but they too were burning out. They too are aging out. So youve got essentially stop gap measures. And i think the in terms of contracting in my experience across plans, purchasers and providers, its the conditions of participation, including rates but not limited to rates that really drives whether people want to participate or not. Weve heard psychiatrists which are actually a relatively small percentage of the total Mental Health providers. Um it just costs too much to do it. I would bring back a thought of integrated care. Weve talked a lot about integrated care in terms of uh uh medical and behavioral integration. Theres also an integrated care model where physicians of multiple specialties practice under one organizational structure in an organization thats large enough to provide telehealth, large enough to provide Data Analytics and large enough to essentially cover some of the shortages through better contracting or better load management within the group. So i think thats hard in a rural area because people dont concentrate that way in terms of practice. Um very, very well. Thank you, dr resnick. Did you have a comment . Well, senator, im really glad you brought up contracting because when we look at the data and a ma does produces these data every year. Most areas around this country have highly concentrated Insurance Markets where one or two plans cover the vast majority of patients in that area. So theyre really in rural nevada or in big urban centers, theres not meaningful contracting. And we have physicians who have a big panel of patients and the insurer just sends them a letter at the end of the year that says, thanks very much. Youre were done with you or its really take it or leave at contracts that they present that increasingly are lower and lower percents of, of medicare. So it is not a level Playing Field between the physicians who actually want to be contracted to be able to take care of their patients and the health plans. Well, and, and it sounds like we need another panel of Health Plan Providers to be able to talk to. And i look forward to that opportunity. Thank you, mr chairman. Thank you. Thank you, senator brown will be next and i understand one of our colleagues on the republican side is coming back as well, but uh with that. Unless there are people we dont know about, we will wrap up and theres a vote on senator brown. Uh thank you, mr chairman and im glad i got here in time. Welcome all of you. Thanks for joining us and for the service youve provided to so many people. And its, its more important ever. I mean, we all living through the pandemic, we all saw different parts of the Health Care System perhaps. And its more important than ever that people in my state in nevada and oregon and idaho get the Mental Health care when they need it. And we know that we didnt pay enough attention to Mental Health during the pandemic and Mental Health. Thats fundamental basic health care. It works, it saves lives too many families though, as you know, cant get this life saving care. Finding someone to help is hard enough trying to call for an appointment with a doctor who doesnt exist or it doesnt exist at this number and is a, you know, a so called ghost. We agree, we spend too much time trying to schedule doctors visits for most people. Its far too troubling and difficult. And Rube Goldberg like to get through the problem worsens when we cant be sure that the doctor listed in the insurance direct is actually practicing medicine in the place that, that that person that we think that person is and doctors listed arent taking patients. Sometimes other cases of doctors have retired or practicing an all together different locations sometimes in a different state. Uh, the, and so i, i, i mean, its infuriating, its also preventable. So, doctor tres, what should congress do to make it easier for you to work with plans to make sure they have the right information . Uh how would you feel if you tried to call doctor . Only to realize the number . I mean, you know, where im going on this . So talk to me. Thank you, senator. You know, i this to be very trite, this is complicated. There are many, many opportunities. But i do think some of the things weve heard today are really critical. The first we if congress could pass a standard that everyone shares to reduce the inconsistencies in format and reporting time and sequence, the more we can have consistency and essentially interoperability, making it electronic, making it as close to real time as possible would be of enormous benefit to everyone. So i think that some of the things that dr ridout mentioned in one form or fashion could be transformative for our nation if we have a standard that would really reduce some of the challenges, sharing the burden between the physicians and the Insurance Plan, so that, you know, we own responsibility of, you know, how much, how many patients can we see, you know, how much can we afford to see of which plans . So, but i think that a standard that would be federally structured and guided, would help all of us. Thank you. Thank you, ms meyer. Kind of along those lines. Lets continue down that path first. Thank you for sharing your story uh to this committee that always takes guts to talk about personal stories and in, in public and congress. Uh, no one should have to fly. Of course, no one should have to fly across the country at her own expense because she cant find a psychiatrist to treat them. Ohioans just want to get the treatment they need using the benefits that they actually paid for. Several years ago. We passed a law making sure patients are held and patients are held harmless when they relied upon an incorrect insurance directory. Sadly, patients must file an appeal with their insurer, the same insurer that made the error. Uh so miss gilberti, isnt this approach in this appeals process . Just one more annoying, time consuming. I hate to use the word Rube Goldberg again, but kind of is a hurdle that ohioans and others shouldnt have to face when they want to get Mental Health treatment. These kinds of processes can also be very difficult for people. So we talk a lot about making sure people know their rights. Its clear, you know, weve been talking about financial protection. If you use somebody in a directory, you know, that should be really clear to you that you have a right to get that reimbursed. So we need to make things clear to people and i agree that a lot of these procedures wind up making it difficult for the person rather and the Insurance Companies really need to bear the burden here. Thank you for that mr chair. Thank you. Thank my colleague, senator lankford is next. Oh, excuse me, senator warner is next and uh were gonna go in order of appearance, senator warner is next. Well, thank you mr chairman and im sure others have already mentioned this but happy birthday. Um and uh, you know, i really do appreciate the fact that you and senator crapo are holding these hearings. I mean, this issue around Mental Health. Uh i think we always knew it was a huge issue but in the post covid world, i dont know any family, including mine that didnt have some challenges around our Mental Health. I want to also uh acknowledge m g and doctor tres who are both uh service in virginia. Um and weve got a lot of great talent there. Uh i wanted to raise quickly. Im gonna go to doctor out on a question, but i, i wanna brag for a moment about something. We started in virginia way back in the nineties. Um i started something called the Virginia Health care foundation. And then subsequent to that, uh seeing how my dad was trying to take care of my mom and access services. We started something called senior navigator of how you can, you know, provide in a, in the kind of directory issues were talking about on a real time basis, uh, linking up services that virginia Senior Navigator Program grew into something called virginia navigator. And, you know, its now up to 9000 Service Providers who provide 26,000 programs. And weve kind of taken this high tech high touch approach. And, um, you know, it, its one of the things that kind of makes me crazy that these Insurance Companies and providers you dont update. I know everybody thats been the focus of the whole whole hearing about how you update these directories. How do we make sure theres, theres there is that navigator role rather than simply putting, putting out um a tech site. Um doctor. I know youve, youve had some experience in this and how do you, how do we do a better job on these high tech high touch approaches um that so we can get the incentives right, so that people can access these services out of these directories in a user friendly way. I would answer that senator warner by saying, i dont think its the tech or the touch that matters. Its the quality of the information and the willingness of the participants to share that information before it gets published. Um i know there are many ways to do that, but in our experience with symphony, you have to get it right before you start pushing it back to the plans or the providers as right. And then if the patient is experiencing a disconnect, they arent taking a new patient when they said they were, then you can resolve those. I think on more of these in one, on one basis. But i think if the core problem is 80 of the information is wrong to begin with, um, i dont know that technology is going to solve that. And i think navigators are great. Weve used those in many settings in health care and housing and other things. Um but then you have is the energy of the individual to kind of hang in there of the navigator better than the patient. And the answer may be yes, but they may not have any more success. But, but dont you think even if you get the information right, the amount of time that that information stays right is gonna be a short term. So one of the things i think that is important is, you know, i agree with you, you got to get the information right. But boy, boy, you also got to make sure that there is an update process. Um and have you found experience with symphony . How you, how you uh make sure that data is constantly updated . We update um pretty much weekly and then physicians to test at least every three months because they only have to attest once. Um imagine if you were having every health plan and every provider large Provider Organization asks the same physicians, the same information over and over and over again. A lot of times theyll just stop providing it. So i think you have to do it very frequently. Not quite real time, but, um, pretty much closer to that to get it. And i, i was interested in your testimony when you said that, um, um, there was a California Consumer protection law that basically said, you know, if you, if a plan doesnt provide these Mental Health services, theres almost a Consumer Protection law that says the plan has an obligation to define that services. Has that been a good way to keep the plans a bit honest . I think its a relatively new requirement, senator, but the idea is that they have to arrange for it. Um and then if they cant find it in network, they have to pay the out of Network Charge for the person that, that they found the provider that they found. So, like youre saying, it takes the burden again off the person, shift the burden to the plan to help you find it again though, it has to be really clear on your directory that they can provide this help to you, right . Because otherwise people wont know about it. So i think its really important that people know about it and then, you know, theyre actually gonna be able to get that kind of help. Well, i do think and, and again, were, i may take a little issue with doctor position because i do think you gotta get the information right. But lord knows there are plenty of user friendly sites that invite a user in. Dont make it this technology opaqueness. And i think again, there are examples across the spectrum that we can look at for best practices. But i do appreciate that the chair and vice chair, this chair. Thank you, senator warner. And youre being logical and heaven forbid that logic should break out over this because i, i do believe in these navigator approaches. So were going to look at it, senator langford. Thank you, mr chairman. Happy birthday as well. And uh thanks for holding the hearing. Yeah, so yall thank you for the testimony today. Uh exceptionally important to be able to get out there. All of us deal with this. We all have casework staff that try to help chase through i wanna try to drill down a little bit from the physician side of this. Uh so Insurance Plan reaches out, lets say early summer and says were looking to be able to put all our networks together for next year, you want to be in network or out of network, they negotiate you, they tell you this is what were going to pay you flat out and no, we wont negotiate with you and you go through all that back and forth on it. Finally resolve it. By the end of the summer, they put out their open season plan with their list of all their providers on it for the next year. People select their plan based on who their providers are. If its near them where their own physician is there and then they pick up the phone and start calling people, is there a requirement for physicians if they, if they say im going to be in a plan to actually be in that plan for the next year or can a physician say . Yeah, ill be in the plan and then lets say january february march decide. No, i really dont feel like being in this plan. Are they locked in typically . And again, company to company may be differently. But is there a commitment on the physician side if i set up gonna be in this plan for a year . Im actually gonna be in general physicians contract on an annual basis. But i think, uh, this probably is the other, the other piece of that as well, but well get back to you with more information. Thats right. That, that, thats helpful because thats one of the areas that weve got to be able to resolve. Is, is there a commitment from the physician also being the plan weve heard several times from different plans that will say, or from individuals that will say by the time that pursued the plan and got into the plan and start in january. February started calling people. They said, oh no, i actually dropped out last year, but theyre still listed or i just changed and shipped it over and were trying to figure out the mechanics of and where all the players. And if you talk to that physician, they probably called the plan just like your office staff, helping, helping people in your district in your state have and probably sat on hold for three hours and then got disconnected, trying to update the directory themselves. The plans have made it really difficult for the docs. Yeah, really difficult for the patient and for the docs on it. Thats whats been the challenge on this. The next layer in this doctor, let me ask you about this as well. From the industry side and youre dealing with this. Theres a lot of uh Insurance Companies right now that arent following the current c ms regulations even. So the issue always comes back to us. Theyre not following currently, lets add one more and see if theyll follow that one as well. What do you see as the solution here in this process . Because i dont want a single constituent to be able to call and say, i dont know who that is. Ms maris testimony was powerful to be able to say, i dont know who that is. That person died. Sorry, we dont take people anymore. We havent been on that for years. Thats plans just not updating and doing their work, but theyre already violating cms rules. So from an industry perspective, what is the answer on this . Standardization across the board. And thats a challenge because most plans are, are regulated on a state basis and states have their own variations on what they do or dont want. But i think it starts with very, very detailed aligned standards. You know, in the old adage is standards are great because theres so many of them. And thats the problem, were now dealing with, you know, medicaid standards, c ms standards Medicare Advantage, state standards. There are state regulations, but this is a Medicare Advantage. This is a unique, this falls right into this committee of whats happening in medicare and Medicare Advantage and such. So to create that, that centralized standard for that. Your colleague earlier mentioned carrots and sticks and liking carrots. I completely agree, transparency would be great. Carrots are very helpful. My fear is were gonna, im gonna be Walking Around with a backpack of carrots for another 10 years and theyre going to rot in my backpack because i wont have any to give out. The plans are so consolidated and have such an incentive to look like they have a full network when they dont, that i think in the Medicare Advantage space that you have jurisdiction over and in the Exchange Space that you have jurisdiction over, we do need some sticks, we do need monetary fines. These are big plans with big resources that have the capability and responsibility to put out accurate. So the sense would be like the chairman was saying before, if we end up calling secret shopper type calls or whatever process that we do from a third party or whether it be a federal agency and find out these folks dont actually exist, then they get a fine to be able to come in. Its a requirement on them to be able to fulfill that. Theres always going to be a little background noise and a few inaccuracies. But when 80 of the directory is inaccurate, i think you can say that is a plan failure. Thats a massive issue. And its a big issue for us in rural oklahoma that there will be companies that will put out a plan and that everyone looks at it, selects a plan, then they get into that plan in january and find out its not real and they cant go anywhere or if theyre going to go anywhere, theyre going to have to drive 150 miles to be able to get to someone. They assume the people that were listed locally actually existed and accepted the process. So appreciate, appreciate your testimony today. And, and senator lankford, you have just given a snapshot of why this issue is so important in Rural America and i appreciate it. Senator menendez is next. Excuse me, senator whitehouse is next. Thanks. Ill be very brief because i know senator menendez has a lot to do, but i wanted to flag. Its not exactly the topic of this hearing, but its been extremely important in uh rhode island to have had Mental Health access through covid through telehealth. Its been extremely important with people who are in recovery to be able to talk to their peer recovery coaches and to the people who are providing them treatment. Um and i just wanted to take a moment. Im seeing a lot of heads nodding that this is a good thing that we need to extend those telehealth protections and waivers because the information that i have is not only did compliance attendance improve compared to having come into the office, but i know this is anecdotal and theres no way to put a scientific proof behind it. But over and over again, ive heard from the professionals in the community that the quality of the engagement increased with telehealth. And i suspect thats just the human aspect of not having to drive some place, not having to wait in a waiting room, not having to fill out a clipboard, not having to be in unfamiliar territory. Instead, you just go to your quiet place in your own residence, you click on and there you are. So i wanted to make that pitch. I also wanted to try to make the point that this problem of required networks and Fake Networks in essence, is part of a suite of payment and cost saving strategies that have developed in our current Health Care System. They include just plain payment, denial and delay. We have an enormous armada of insurance effort to slow or deny payment to providers obliging providers to then stand up a whole countermeasures apparatus. I remember years ago going to the Cranston Community Health Center and finding out that they actually had more personnel on staff who are devoted to trying to get paid than they had devoted to providing the health care that the Cranston Community Health Center provided. So there is an enormous enormous burden of unnecessary administrative cost from that. Theres an enormous burden of administrative cost and pain from these Fake Networks. And i think that prior authorizations are another vehicle frequently used by the Insurance Industry to evade and avoid payment for services that are pretty clearly required. And what i would really like to have anyone whos interested do and you can do this as a response in writing. Consider this a question for the record. I think the way out of most of those problems is comprehensive payment reform. The more we get away from fee for service, the less their ability there is to deny and delay the payments for those services to shrink networks and to um impose prior authorization restrictions that foul up treatment. So, uh were continuing to work to get that done here. I think the ac os, the Accountable Care organizations provided a good lead that have provided particularly in rhode island through coastal medical and integra some really good results showing whats possible. But id love to have your careful thoughts on that. And is this area of reducing the dead weight cost burden of the administrative warfare between insurers and providers likely to be alleviated by payment reform . And if so what payment reforms are likely to alleviate it most . And with that, i yield back to senator menendez. Im not sure whos next, senator cardin. Were going right up the line here. First, i want to thank you all for your testimony. Now, i just really want to add one other dimension to these Ghost Networks. My colleagues have heard me talk frequently about the tragedy in dental care with the monte driver losing his life in 2007. A 12 year old because he couldnt get access to dental care. I know that our focus here is on a broad range of services, particularly Mental Health services. But the monty drivers death was many contributing factors. One was that his mom really could not find a dentist who would treat him. There was not an accurate directory available that could provide guidance where she could find a dentist who would be willing to provide services. And i guess what i just want to underscore is that this topic is critically important for health care throughout our country, but particularly in underserved communities, they need help. And if we dont have accurate directories, if they have a list that is not accurate telephone numbers or the the person, the provider is not taking any new uh patients and it may be somewhat red line, it makes it even more challenging. So i just really wanted to add that into the record and i thank you all for your, for your participation. But as we look at ways to solve the issues, let us not lose sight of the fact that its not equal throughout this country, underserved communities are suffering the most. And with that, ill yield back. Thank you very much. The problem of Ghost Networks is particularly harmful in Mental Health care and one arguably made worse in recent years amid the nations ongoing Mental Health crisis. Though the pandemic and beyond those desperate for help continue to get ghosted. And reality is that there just arent enough providers. I was proud to secure my colleagues on the committee 100 new graduate medical education slots reserved for psychiatry. And last years consolidated appropriations act. Last week, i reintroduced my resident physician shortage reduction act alongside senators bodman schumer and collins. Its a bipartisan bill would raise the number of g m e positions by an additional 14,000 over seven years. So doctor resnick, would you agree that increasing graduate medical education positions would complement efforts to improve provider directories and Mental Health access overall . Senator i cannot thank you , enough and agree enough that and the 100 additional slots for psychiatry, every little bit helps, but the larger act is absolutely necessary as we face an aging population. We need more physicians for this country. So thank you. Thank you. Dr. Trust men, for children in need, the problem is even worse. According to the data by the American Psychological association, only 4000 out of more than 100,000 u. S. Clinical psychologists are child and adolescent clinicians. What can congress do to specifically address the Workforce Shortage of child and adolescent Mental Health clinicians . Senator, i think that the trajectory that you and your colleagues have started has been wonderful. We need to think broadly about the needs of health care in this society. And so training at the uh the Community College level, the College Level getting people in the pipeline for allied health professions, whether its nursing, social work, um Community Health workers, as well as psychologists and physicians. We need to think broadly so that we can provide adequate care and many professions other than physicians can be trained in a more timely way and any of the ability that they have to provide care, whether through social work or others can make a profound difference and really expand and leverage the care that only phy physicians can provide. Thank you. Well, imagine for a moment that you or someone you love is in the midst of a Mental Health crisis. You call 70 plus doctors listed in your Insurance Plans network. Not one is available for an appointment within two months. Most never call you back. Some are retired, others are deceased. Some phone lines are disconnected. This is the reality for far too many people seeking Mental Health Care Services in new jersey and across the country. Its critical that people seeking Mental Health services have access to accurate up to date provider directories. This outdated information hurts people when they are desperate to get help for themselves or a loved one. Miss gilberti. What mechanisms can federal regulators use to hold those responsible for provider list accountable . How can we highlight how c ms can better enforce regulation and oversight of provider directors . I think they could do several things. One, we could have audits of these plans for their Behavioral Health networks and those audits could be done either by cms itself or by a third party, and transparency. The results of that. Weve also talked about making sure its included in the star ratings system so that its really, they get incentivized to make those changes. And weve talked about civil monetary penalties which currently dont exist. So thats another way, and they have to be sufficient to affect behavior. So those are array of choices that could make a difference if they were combined together. And finally, we have to address the challenges of Ghost Networks, but we must also prioritize policy to support low income and marginalized populations. Last week, hhs released proposed access and quality standards for medicaid and chip. Among other things, these proposals would require states to conduct secret shopper surveys of medicaid and chip managed care plans to verify compliance with appointment, wait time standards and to identify where provider directories are inaccurate. How would these requirements mitigate impacts of Ghost Networks for low income communities . Thank you very much for asking the question. And i think anything that can help, especially, you know, folks of color, people in low income communities, be able to get the Accurate Information that they need in order to get the care when and where and how they need it is going to be critical. I also added that being able to empower the consumer, i like the word consumer. I know some in our communities dont like it but i like it because i think of John F Kennedys Consumer Rights bill and what he talked about in 1962 about the consumers rights to be heard, the consumers rights to have information to make a choice. And then lastly, the un added to redress. And i think the things that youre talking about give us those rights, especially if we have Something Like a 1800 number or a online portal to report when we are not able to get our needs met because of the Ghost Network. Because we want to be empowered to inform so that either the carrots or the sticks can happen. Thank you very much for your insight. On behalf of the chairman, i call on senator blackburn. And thank you so much. Thank you for sharing your story. I appreciate hearing it. I know were talking about medicare, Medicare Advantage, but senator blumenthal and i have been busy today introducing the kids Online Safety act and ms. Myrick, as i was listening to your testimony, i thought how closely it mirrors what i hear. Not only from moms and parents , but the teenagers themselves. I hear it from the psychiatrist and psychologist, from principals. That there is not enough access , and that there seems to be complete confusion when you call the Insurance Company and say, we are desperate for help, i have my child, we are at the emergency room and we are not getting any answers. And it is just so imperative that we look holistically at this system and i appreciate it appreciated hearing from you on the issue. Dr. Resnick, let me come to you. Telehealth is something even when i was in the house and we were working on 21st century cures and then i didnt get my telehealth bill in there, but we got it across the line during covid. During covid, people really began to use telehealth and what i hear from providers, especially down in Shelby County , memphis, that area where you are dealing with mississippi, arkansas. They talk a lot about interstate licensure requirements. So, just very briefly, if you would talk to me a minute about what you are hearing from providers when it comes to that licensure issue. And also what youre hearing about the Digital Therapeutics and their utilization in these. Thank you, senator. My dad grew up in clarksdale, mississippi. So i know the memphis area. Even though im now a californian and i am always reluctant to use the term bright spot about anything in the pandemic, but telehealth clearly opening up coverage, whether its medicare or commercial insurers. Huge bright spot. Thank you for your leadership in that area. And we have seen not only patients learn how to use it well and discover when its convenient, but weve seen physicians in every specialty , psychiatry included, learn how to integrate it seamlessly into a care plan, because sometimes patients need to be seen in person. And now we know more about when those instances are and when they are not. You mentioned licensure. We still believe in maintaining state licensure and that it exists in the place where the patient is. The reason we believe in that is because if im taking care of a patient in florida, i believe i have a responsibility to follow floridas rules and that that patient needs to be able to go to their state insurance commissioner if i provide lousy care to, to seek redress. But we have some really cool stuff going on to aid in people being able to do telehealth in multiple states. We have the interstate medical licensure compact, where it makes it much easier for many physicians to just click off several states that they want to be licensed in and agree to follow those rules. Is that the reciprocity model . It is not pure reciprocity but its not like the nursing reciprocity model because uh individual states do still maintain the ability to police what happens in their states and take your license away but it makes it much easier to get multiple licenses. The other thing is we have seen the medical boards, the federation of state medical boards agree unanimously nationally and now it has to be implemented on the states on reasonable exceptions. If im taking care of a patient and they go off to college and they happen to be out of state or theyre vacationing or spend three months a year in arizona, thats not really practicing across state lines. I have an established relationship. If a patient needs to go to a center of excellence and wants to do one pre visit via telehealth across state lines, that should be ok. But we do want to protect patients and make sure they have local care. Do you want to weigh in on this . You are not in your head and i thought you might have something to say. Yes. Telehealth has been transformative. The continuing availability particularly in rural areas uh is extraordinarily valuable but also even in urban areas where it may take people two hours to take three buses to get to us. Ok. And, and by the way, i trained at the Elvis Presley Memorial Trauma Center in memphis. Im very glad to hear about the College Students because we hear that all the time about College Students that have a provider and then they lose access to it. And i think that, you know, really this idea really needs to be thought through, particularly for Mental Health where, you know, the issues in the state. I really dont understand why we cant get more reciprocity and more ability to go across street state lines with Mental Health care because it is very problematic. Increasing access is what we ought to do. Thank you, madam chairman. Thank you. So, america is facing a Mental Health crisis. One in five americans live with a Mental Illness and for Medicare Beneficiaries, its one in four. Federal law requires medicare to cover Mental Health services in both traditional medicare and Medicare Advantage. The program that allows private Insurance Companies to offer Medicare Coverage. Now, unlike traditional medicare, the private Insurance Companies in Medicare Advantage can establish networks to restrict the doctors or facilities that beneficiaries can use. So if your doctor is in network, the plan will cover those services for a small copay, but an out of Network Doctor can leave patients with skyrocketing costs. This can be especially devastating for seniors or for people with disabilities who are more likely to be living on fixed incomes. To help beneficiaries avoid these surprise costs in a plans are required to publish directories which enrollees can use to find new doctors or to make sure their existing doctors are covered. Lets start with what we know about the accuracy of these directories. Thereve been some references to them. Ms. Gilberti, what do we know about the accuracy of the provider directories in Medicare Advantage . So cms has done some audits, senator, and what they found was on average, the accuracy rate was about 45 . Does that mean that the accuracy rate is 45 . You know, they, they found in, in 2018, i think it was, you know, almost 50 had at least one inaccuracy. So, you know, were seeing a good deal of inaccuracies thats with physical health care. Just say theres a gap in data because they havent done this for Behavioral Health. Might we surmise that Behavioral Health is always worse . Its always worse. Ok. So you think youve got a list of people you can go to and the odds are actually in favor of the list is wrong and probably even worse on Behavioral Health. All right. So here weve got a patient who does everything right. They still might get hit with a huge bill because a directory has outdated or inAccurate Information. Or they might call up every doctor only to find out that phone numbers dont work. Theyre not accepting new patients. Weve heard the story about this and i appreciate you being here to talk about your story. We know that ma plans use all kinds of tricks and traps to squeeze more money out of medicare. They got a lot of different ways that they do this to boost their numbers. But heres the one i want to focus on. Do these ma plans stand to gain anything from having inAccurate Information . In other words, is it inaccurate because they just havent spent enough money to make it accurate, or is it inaccurate by design . Well, i think there are advantages that they have when their directories unfortunately are inaccurate. If they use those directories for Network Adequacy standards, for example, they might meet the standards, but theyre not accurate. People make choices based on what they see as their network. So if it looks like a bigger network, but its not real, people are choosing a plan. So its a way to defraud consumers, to say i have this really big list of people you could go to if you had a problem and it turns out that really big list, if it were accurate is actually the little tiny list. Right. So thats one way its to the advantage of the Medicare Advantage plan. In order to be inaccurate. They get paid. They make more money by being inaccurate. I think its about 60 of the plans dont have out of Network Coverage. So if you get really frustrated and you pay on your own, then theyre not paying anything. So the more i can frustrate you, the more that i, meaning the Medicare Advantage plan, the more the Medicare Advantage plan can frustrate you, the more youll just go somewhere else. And that means its not money out of their pockets. Did we get the two main ones . Yes. We see this all the time. This is how plans delay and deny care. That same patient once they find the needle in the haystack and even get to a physician whos in network and sit down and get a diagnosis and a treatment plan, then goes to the pharmacy and discovers the health plan has requires prior authorization for the treatment for that condition, which then it takes weeks to get approved. Sometimes they never go back to the pharmacy. They give up. There Mental Health or other condition gets worse. So conditions get worse and they dont have to pay for the treatment. This Medicare Advantage plan. So look what were really saying here is that it is in the financial interests of these Medicare Advantage plans to discourage beneficiaries from accessing care. We also know that the Medicare Advantage plans are paid a set amount per beneficiary, which can be dialed up if the beneficiary is sicker. So the more diagnosis codes that a beneficiary has, the higher the payment, the Insurance Companies have built entire businesses around making these beneficiaries look as sick as possible and then overcharging taxpayers by hundreds of billions of dollars. Here is the key that underlines this. Whatever insurers dont spend on care as a result of tactics like outdated provider directories or overly restrictive networks or inAccurate Information, whatever they dont spend on care, they get to keep. So let me ask you one last question on this. What penalties, ms gilberti, do ma plans face for being out of compliance with regulations and provider directories and Network Adequacy . We got a bunch of rules. When they are in violation of the rules, whats the consequence . Im not aware of any penalties. The audit that i mentioned earlier talks about like notices of non compliance and warning letters, but they dont mention anything about penalties. So i know theres been some legislative proposals to that effect, but im just not aware of any penalties that are being assessed. I tell you, nobodys jumping in with any other answer. You know, this is the part that just drives me crazy. People look at the regulation and think, we are going to be ok because it is regulated. But we are not ok if there is no enforcement. Now to the extent they have enforcement tools cms really needs to step up the enforcement. At a minimum beneficiaries , should not be on the hook for out of network costs that were incurred because of the inaccurate directories. Thatd be a nice starting place on this. Cms should also penalize Medicare Advantage plans that are out of compliance. Just put penalties on these guys. And its congresss job to put tougher regulations in place. And i also want to say this, if these Medicare Advantage plans continue to mislead beneficiaries about covered providers at the same time that they are overcharging taxpayers for this crummy coverage, then we should be taking another look at whether or not ma plans should continue to enjoy the privilege of restricting Provider Networks at all. Now, theres a serious question that should be on the table. If they cant do better in managing these restricted networks, then maybe they ought to have to cover anyone whos a licensed practitioner that you go to see. So with that, i will now say im finished, and i will put on the hat of the chair and say without objection, i would like to submit the majority staff report into the record. Anybody object . No. Senators have one week from today to submit questions for the record. They will be due at 5 00 p. M. And this hearing stands injured. Thank you all stands adjourned. No objection. With that,