Re: Requirements Related to the Mental Health Parity and Addiction Equity Act (CMS-9902-P)<br />

Office of Health Plan Standards and Compliance Assistance
Employee Benefits Security Administration
Room N–5653, U.S. Department of Labor
200 Constitution Avenue NW
Washington, DC 20210,
Attention: 1210–AC11

Re: Requirements Related to the Mental Health Parity and Addiction Equity Act (CMS-9902-P)

Dear Ms. Gomez:

On behalf of the Dr. Lorna Breen Heroes’ Foundation, we would like to express our strong support for the proposed rule, “Requirements Related to the Mental Health Parity and Addiction Equity Act”, implementing the Mental Health Parity and Addiction Equity Act of 2008 and expanding access to mental health treatment and care through modifications to the non quantitative treatment limitation (NQTL) comparative analyses requirements. Given the impact of health care provider burnout on physicians and other health workers across the country, these changes will help address a significant unmet need by expanding access to mental health and substance use disorder benefits and removing existing barriers to care for clinicians. We would also ask that you consider the provider-specific barriers to seeking care, including burdensome disclosure requirements, in the final rule to further build on the strong provisions contained in the proposed rule.

Health worker burnout is a serious issue that affects many healthcare professionals, including doctors, nurses, and mental health clinicians, particularly given the additional burdens that clinicians face during the past few years. Rates of burnout have serious consequences for the capacity of the U.S. health system, particularly in regard to employee retention. From 2018 to 2023, the average U.S. hospital turned over 105% of its workforce, with the highest rates of turnover occurring in the Southeastern United States. 47% of U.S. health care workers plan to leave their current role within the next 2 to 3 years.

According to the 2023 Medscape Physician Burnout and Depression Report, 53% of physicians reported experiencing burnout, driving physician shortages in critical areas like emergency medicine. Furthermore, almost two-thirds of nurses reported experiencing burnout during the COVID-19 pandemic, driving a significant number of them to leave the profession entirely and exacerbating a historic workforce shortage. For physicians and other clinicians that remain in medicine, burnout can lead to decreased job satisfaction as well as increased medical errors, impacting the quality of care that patients receive as a result. In addition to the rise in burnout, the same Medscape study reports that 23% of physicians are suffering from depression; an 8% increase in the past five years. With suicide rates among physicians, particularly female physicians, higher than the general population and higher than physicians in other countries and with female nursing suicide rates 8.5 times higher than the general female population, the mental health crisis among health workers is at a crisis level.

The proposed rule will play a key role in reducing healthcare provider burnout by minimizing the administrative burden on healthcare clinicians. Currently, many healthcare clinicians are required to spend a significant amount of time and resources navigating complex insurance regulations and negotiating with insurance companies to ensure that their patients receive the care they need. In fact, a 2022 survey from the Physicians Foundation found that 85% of the physicians who reported staff shortages rated administrative burdens as impactful. This problem is particularly acute for referral and authorizing care for mental health issues and substance use disorders, where existing barriers like excessive reauthorization requirements both pose a barrier to care for patients and exacerbate the existing administrative burden on physicians. The proposed rule’s streamlining access to care is a “win-win” for both patients and physicians by improving access to care while reducing these bureaucratic administrative burdens. By providing clear and transparent information about the limitations of insurance coverage, these regulations will help to reduce the time and resources that clinicians need to spend navigating insurance regulations and negotiating with insurance companies.

In addition to reducing the administrative burden on clinicians, the proposed rule will also streamline access to behavioral health care for those physicians and other clinicians seeking care for depression and other mental health conditions.. Given the unique stresses and burdens that clinicians face, it is critical that they be able to receive the treatment they need without facing bureaucratic delays or undue authorization requirements. The proposed rule’s crackdown on plans and issuers from using NQTLs to place undue limits on access to mental health and substance use disorder benefits will significantly help in this regard by ensuring that clinicians are able to receive the care that they are entitled to under existing law. Health care workers also face an additional barrier: they are often forced by their insurance to receive mental healthcare from their work colleagues. We ask that clinicians have the option to receive in-network care that includes clinicians outside of the health care system where they work.

While the proposed rule is a strong start, there remain important barriers to care for physicians and licensed health workers that we ask be addressed in any final rule. Notably, these barriers have been identified as the primary driver of suicide of health workers in a recent study published by the American Hospital Association. These barriers most commonly appear on state licensing applications and hospital credentialing applications for doctors, nurses, and other licensed healthcare professionals. The questions that appear in these applications use invasive or stigmatizing language requiring applicants to disclose any history of mental health diagnosis or treatment, or to explain why they have taken breaks from work, including past episodes going back decades. In addition to raising privacy concerns under existing law, there is strong evidence that they deter clinicians from seeking the care they need, further exacerbating the growing mental health crisis among health workers. Stigma associated with seeking behavioral health care can lead to tragic consequences and is one of the primary drivers of suicide. NIOSH and the Dr. Lorna Breen Heroes’ Foundation recently issued a Joint Statement calling on all hospitals to take immediate action to address this issue. Given this, we would ask that this issue be addressed using existing statutory authority in any final rule, replacing such language with either questions about current impairment for any reason or by eliminating these questions altogether.

The Dr. Lorna Breen Heroes’ Foundation appreciates the opportunity to share our feedback on this important proposal to strengthen access to mental health care and address the epidemic of provider burnout. Thank you for your consideration of these issues.


The Dr. Lorna Breen Heroes’ Foundation
The Schwartz Center for Compassionate Healthcare The Physicians Foundation
American College of Emergency Physicians American Society of Health-System Pharmacists ALL IN: Wellbeing First for Healthcare
Medicine Forward
Moral Injury