I previously reported about psychotherapy utilization in Medicare during the first pandemic year, 2020. Public use data have recently become available for 2021, allowing comparisons and perhaps some insights into psychotherapy in this very large population (62.6 million total enrollees in 2021).

All psychotherapy provided

For this analysis, only procedure codes reflecting 30, 45, and 60 minute sessions are considered (HCPCS/CPTs 90832, 90834, and 90837). Psychotherapy may be provided in the context of other services, for example along with medication-related visits. But the services reflected by the reported codes are visits provided for the specific purpose of psychotherapy.

A total of 10,004,775 sessions were provided to/used by beneficiaries in 2021. Therapy utilization first exceeded 10 million sessions in 2017, continued at that level through 2018 and slightly below in 2019. After a surprising and sharp drop-off in the first pandemic year of about 15% from 2019 — considering the flexibilities, increased needs, and migration to telehealth — therapy use showed a strong increase (12%) in 2021 relative to the first pandemic year, back to pre-pandemic levels.

The pattern of use of different length sessions varied from 2020 to 2021, with about a 5% decrease in 30 minute sessions, about a 6% decrease in use of 60 minute sessions, and a 45% increase in use of 45 minute sessions.

The 2020-2021 pattern shows a noteworthy change in the trend previously occurring from 2013-2018, during which use of 60 minute sessions increased and 45 minute sessions decreased. Use of 60 minute sessions declined from 2019 to 2021, and in 2021, the number of 45 minute sessions rebounded to a level not seen since 2013.

Social workers provided just under half of all psychotherapy sessions for Medicare beneficiaries in 2021. Psychologists provided about 43%, psychiatrists about 5%, and all other specialists about 4%.

These proportions are similar to those seen in 2018, when social workers provided about 48% of all psychotherapy in Medicare, psychologists about 46%, psychiatrists about 5%, and all other specialties about 2%. There does seem to be an increase in non-mental health specialties providing psychotherapy, so it may be of interest to understand which specialties are providing this service.

Specialties Providing At Least 1,000 Units of Psychotherapy

(HCPCS/CPTs 90832, 90834, 90837)

 

Patterns of Psychotherapy Delivery By Mental Health Clinicians

Social workers have substantially increased provision of therapy over the years, by 43% from 2013 to 2021. Psychologists have shown a decrease of 2.6% in provision of these services in the same time span, and psychiatry has reduced use of these services by about 38%. In 2018, social workers became the dominant provder of these psychotherapy services.

The mental health specialities have shown different patterns of use of session lengths over time. Social workers have increased use of all session lengths from 2013 to 2021, with the steepest increase in 60 minute sessions — essentially doubling use during that time period — while increasing use of 30 minute sessions by 35% and 45 minute sessions by 16%.

In contrast, psychologists appear to have made a shift from 30 and 45 minute sessions to 60 minute sessions, with decreases of 32% and 14% in 30 and 45 minute sessions, respectively, and an increase of 66% in use of 60 minute sessions, from 2013 to 2021. Psychologist use of 60 minute sessions exceeded 45 minute sessions for the first time in 2020, with 45 minute session use rebounding to exceed 60 minute sessions in 2021.

Psychiatry has shown decreased use of all session lengths reflected in these service codes, with 25% and 28% decreases in 60 minute and 45 minute sessions, respectively, and a 63% decrease in 30 minute sessions, from 2013 to 2021.

The one commonality among these mental health specialties is that use of 45 minute sessions showed a sharp increase in 2021 relative to 2020 — by 41% for social workers, 39% for psychologists, and 37% for psychiatrists. Forty-five minute sessions exceeded 60 minute sessions for all three specialties in the second pandemic year, a pattern not seen since 2016 for social work and since 2018 for psychiatrists. Psychologist use of 60 minute sessions first exceeded 45 minute sessions in 2020, having shown increased used from 2013-2018, after which a gradual decrease began.

Considerations

• The overall decrease in psychotherapy during the first pandemic year may have occurred due a “lost” quarter or other span of time during the pandemic. Clinicians and patients likely were only gradually moving toward telehealth even in the context of increased flexibilities and needs. This could be further explored by a quarter-by-quarter analysis.
• The volume of psychotherapy in Medicare rebounded to pre-pandemic levels in 2021, after a 15% decrease from 2019 to 2020.
• Recovery to pre-pandemic levels of psychotherapy by 2021 was associated with decreased use of 60 minute sessions and a notable increase in use of 45 minute sessions, both among the mental health specialties and other medical specialties providing these services. The move toward briefer sessions may reflect an adaptation to increased needs of the Medicare population.
• Social workers continue to provide a growing proportion of psychotherapy in Medicare. They provide the greatest share of psychotherapy among the mental health specialties, and have provided just under half of all psychotherapy sessions yearly since 2019.
• Nurse practitioners increased their provision of psychotherapy by nearly 14% from 2020 to 2021. Other non-mental health-specific specialties increase psychotherapy services as well. These may also reflect responsiveness to increased needs in the Medicare population. Whether these changes were sustained in 2022 or will be in the future remains unkown, and worth monitoring.