This analysis was prepared by McDermottPlus Consulting on behalf of AACOM.

The Senate Finance Committee (the Committee) recently released the latest discussion draft in their series for mental and behavioral health reform. This draft, entitled, “Behavioral Health Workforce of the Future Act,” focuses on stabilizing and growing the mental health workforce. Here is the press release, bill text, and summary from the Committee. Below is background on the Committee’s efforts and a detailed summary of the Graduate Medical Education (GME) provisions.

Please note, there are a lot of brackets in the GME section of the draft, including the total number of new psychiatry/psychiatry subspecialty residency spots that would be available, the initial start date for availability of these additional spots, and allocation percentages for the new spots across several categories of hospital applicants. While the Committee is inviting feedback on the whole discussion draft, they specifically ask for feedback on these bracketed portions. These brackets are reproduced (and bolded) in the below summary to aid in identifying potential areas for feedback.

Background

Earlier this year, Chairman Wyden (D-OR) and Ranking Member Crapo (R-ID) announced five key health policy areas that the Committee would be addressing—improving access for children and young people; furthering the use of telehealth; ensuring parity; strengthening the workforce; and increasing integration, coordination, and access—and the bipartisan duos of Committee members that are leading each initiative. The telehealth discussion draft was released in May, and the children/youth discussion draft was released in June. The most recent discussion draft, focusing on the mental health workforce, was released last week. The final two discussion drafts, focused on ensuring parity and increasing integration, could be released in the coming weeks. Further action on a comprehensive Committee mental health package—along with the related efforts of other key congressional committees—is increasingly likely during the lame duck session.

Detailed Summary of the “Distribution of additional residency positions in psychiatry and psychiatry subspecialties” Section

General: Beginning in fiscal year [2025], and for each fiscal year after until the aggregate number of full-time equivalent residency positions distributed under this new category is equal to the aggregate number of the positions made available, the Secretary of Health and Human Services (the Secretary) will increase the applicable resident limit for each qualifying hospital that is awarded any additional residency slots.  

Distribution of new residency slots: The new residency slots must be for psychiatry or psychiatry subspecialty residencies. This is defined as “a residency in psychiatry [as accredited by the Accreditation Council for Graduate Medical Education for the purpose of preventing, diagnosing, and treating mental health disorders].” 

Number of new residency slots: The total number of new residency slots available is [400]. The total number of slots awarded in any given fiscal year cannot exceed [200]. Any given hospital cannot receive more than [10] additional full-time equivalent residency positions. The Secretary will conduct a separate application process for these additional residency slots.  The Secretary will notify hospitals of the number of positions distributed to the hospital by January 31 of the fiscal year, and the resulting increase in the hospital’s otherwise applicable resident limit will be effective on July 1 of that year.

In awarding the additional residency slots, the Secretary has to consider the demonstrated likelihood of the hospital filling those positions within the first five training years beginning after the date the increase becomes effective. Additionally, the Secretary is directed to distribute the total number of available slots among each of the following hospital categories according to prescribed percentages:

• [xx percent] for hospitals in rural areas (or hospitals that are treated as being located in a rural area)
• [xx percent] for hospitals in which the reference resident level of the hospital is greater than the otherwise applicable resident limit
  • The draft defines the reference resident level of a hospital as the resident level for the hospital’s most recent cost reporting period ending on or before the date of enactment for which a cost report has been settled (or, if not, submitted (subject to audit)).
  • In other words, this provision would allocate a certain percentage of the new residency slots to hospitals that are already training more residents than their otherwise applicable resident limit.
• [xx percent] for hospitals in States with:
  • New medical schools that received “Candidate School” status from the Liaison Committee on Medical Education or that received “Pre-Accreditation” status from the American Osteopathic Association Commission on Osteopathic College Accreditation on or after January 1, 2000, and that have achieved or continue to progress toward “Full Accreditation” status (defined by the Liaison Committee on Medical Education) or toward “Accreditation” status (defined by the American Osteopathic Association Commission on Osteopathic College Accreditation)
  • Additional locations and branch campuses established on or after January 1, 2000 by medical schools with “Full Accreditation” status (defined by the Liaison Committee on Medical Education) or “Accreditation” status (defined by the American Osteopathic Association Commission on Osteopathic College Accreditation)
• In other words, this provision would allocate a certain percentage of the new residency slots to hospitals in States with new medical schools or new expansions of existing medical schools.
• [xx percent] for hospitals that serve areas designated as health professional shortage areas
• [xx percent] for hospitals located in States with less than 27 residents per 100,000 people

Requirements of Hospitals: Within the five-year period after a hospital receives an increase in resident slots, the hospital has to ensure that the number of full-time equivalent residents in a psychiatry or psychiatry subspecialty residency, excluding any additional positions attributable to an increase from this new program, is not less than the average number of full-time equivalent residents in such a residency during the three most recent cost reporting periods ending prior to the date of enactment, and that all of the positions attributable to the increase are for psychiatry and psychiatry subspecialty residencies. In other words, this provision requires the hospital to hold the number of full-time equivalent psychiatry/psychiatry subspecialty residents steady (excluding the new resident slots awarded). This provision appears to be included to ensure that the additional psychiatry/psychiatry subspeciality slots are, indeed, “additional” slots, and that the hospital continues to train roughly the same number of residents in these specialties as the hospital did before the increase. The Secretary can determine whether a hospital meets these requirements and can redistribute the hospital’s additional residency slots if the hospital no longer meets the requirements.

Other Provisions

Expanding eligibility for incentives under the Medicare health professional shortage area bonus program to practitioners furnishing mental health and substance use disorder services: Beginning on January 1, 2024, the discussion draft would expand Medicare's Health Professional Shortage Area bonus program to increase bonus payments for psychiatrists who practice in shortage areas and allow for psychologists, clinical social workers, marriage and family therapists, mental health counselors, and other non-physician practitioners to receive bonuses when they practice in shortage areas.

Access to mental health programs for physicians: The discussion draft would add a new exception to the Stark Law to allow for hospitals and other entities to provide evidence-based programs for physicians to improve their mental health, increase resiliency, and prevent suicide among physicians.

Coverage and coding for qualified psychologist services furnished by advanced psychology trainees: Beginning on January 1, 2024, the discussion draft would modify Medicare’s supervision rules to allow for psychologist trainees to provide mental health therapy services under the general supervision of a licensed clinical psychologist rather than direct supervision. This would help expand the available workforce by allowing trainees to provide therapy services without the supervising psychologist being in the room. The supervising psychologist would still be required to review notes, conduct follow up, and ensure continuity of care.

Please contact AACOM Government Relations at aacomgr@aacom.org with questions or for further information.

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