Nearly four years after the 988 Suicide & Crisis Lifeline launched, states, payers and county systems still define behavioral health crisis care inconsistently, and Medicare offers limited coverage for community-based crisis stabilization services — leaving safety-net funding, Medicaid, federal block grants, and state and local dollars to carry the cost for nearly 200 million Americans.
Congress previously introduced the CARE for Behavioral Health Act, which would have created a Medicare demonstration pilot for crisis stabilization services and established more consistent national definitions.
Now, closing those gaps will take new legislation, an evolving national conversation around crisis care and alignment among a sprawling network of stakeholders — state legislators, payers, law enforcement, health system CEOs and community providers — around a shared standard of care.
Chris Santarsiero, vice president of government affairs at Phoenix-based Connections Health Solutions, joined Becker’s “Behavioral Healthcare Podcast” to discuss the national conversation around crisis care, reimbursement gaps and uniting stakeholders.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: You helped contribute to the Substance Abuse and Mental Health Services Administration’s National Guidelines for Behavioral Health Coordinated System of Crisis Care. How has the national conversation around behavioral health crisis response evolved in recent years from your perspective? And where do you believe the greatest opportunities for improvement still exist?
Chris Santarsiero: That’s a great question, and it’s why SAMHSA’s new guidelines are so important. We’ve scaled our model to new states and communities. Many leaders throughout the country told us they want the “No Wrong Door” model for mental health and substance abuse treatment. However, it became clear very quickly that most didn’t understand what that meant in practice or policy. My work on SAMHSA’s updated national guidelines for crisis care focused on acknowledging that fact and clarifying the many different safe places for help that exist throughout the country today.
There’s been a lot of inconsistency in how we define behavioral health crisis services. When you look at emergency crisis and crisis residential care, the terminology and expectations can vary widely depending on the state, county and especially the payer. That variability creates real confusion about what the services actually include, how they should be delivered and what should be covered. It’s also made it harder for states, tribal communities, local systems and public and private insurers to align around clearer standards.
The updated guidelines and model definition have brought clarity and consistency to the system. We need alignment on a shared understanding of what these services are, along with recommended minimum expectations for how they should be delivered, to help improve quality, standardize services and ultimately support broader payer coverage.
At its core, this effort is about access, ensuring that people in any setting can get timely, high-quality crisis support when they need it. When we talk about behavioral health crisis services, we’re really talking about rapid, responsive and intensive support designed to stabilize someone in the moment or prevent a crisis from escalating, so that they can continue functioning in their daily life, whether that’s at home, school, work or in the community. That consistency, combined with clearer standards, is what really helps transform crisis care into a continuum that supports the physical health system to work better for everyone.
Q: Throughout your career, you’ve worked extensively on Medicare, Medicaid and value-based care initiatives. How do you see reimbursement and policy influencing organizations’ ability to expand access to behavioral health services and improve patient outcomes?
CS: Comprehensive reimbursement is one of the most important factors in shaping access right now. One of the biggest challenges we face is that Medicare still provides limited coverage for community-based crisis stabilization services. What that means in practice is that crisis care for almost 200 million Americans is largely being subsidized by safety-net funding, Medicaid, federal block grants and state and local dollars. When federal programs don’t establish a clear reimbursement pathway, commercial insurers are hesitant to follow. This results in fragmented funding that slows innovation and limits access.
That’s why efforts in Congress, like the CARE for Behavioral Health Act, are so important. It would have created a Medicare demonstration pilot for crisis stabilization services and developed more consistent definitions around crisis stabilization centers, which is really needed. The bipartisan legislation would have also helped establish a sustainable model for scaling behavioral healthcare nationally and would have addressed existing gaps in reimbursement.
At the end of the day, a behavioral health crisis is a health emergency. It can be life-threatening, and it should be treated and reimbursed the same way we treat many other health emergencies.
The absence of Medicare reimbursement makes it difficult to fully fund medically led, interdisciplinary, recovery-based care that high-acuity crisis centers can provide. Ultimately, if we treat behavioral health crises like health emergencies from a reimbursement standpoint, we’ll see better outcomes for individuals and communities, and reduced costs across the care continuum.
Q: As we know, behavioral health is increasingly requiring collaboration between healthcare providers, community organizations, government agencies and payers. What are some of the most effective strategies you’ve seen for bringing these stakeholders together to create a more coordinated system of care?
CS: In government affairs, where there’s an unmet need, there’s always a way. First, let’s acknowledge that the network of stakeholders engaged in behavioral health is both extensive and diverse. It spans governors, their health secretaries and commissioners, state legislators, payers, county commissioners, law enforcement leaders, prison wardens, district attorneys and increasingly education officials. It also encompasses health system CEOs, mental health and substance use providers, and a wide range of social service organizations and housing authorities. The sheer breadth of this coalition emphasizes the necessity of a coordinated campaign to address existing gaps in behavioral healthcare.
The key is getting everyone focused on the North Star of establishing the “No Wrong Door” model of treatment — this will ensure these life-saving services remain available to everyone, regardless of insurance status or time of day. Most communities know that the current way of caring for people with mental health and substance abuse issues is not humane or effective.
Our approach at Connections realizes better health outcomes, significantly lower average length of stay, and reduces the reliance on hospital emergency departments, long-term inpatient psychiatric care and jail. When stakeholders see both better outcomes for individuals and their communities and systems efficiencies, alignment becomes much, much easier.
At the Becker's Fall Behavioral Health Summit, taking place November 4–5 in Chicago, behavioral health leaders and executives will explore strategies for expanding access to care, integrating services, addressing workforce challenges and leveraging innovation to improve outcomes across the behavioral health continuum. Apply for complimentary registration now.
