by Feggy Art
Many mental health advocates are cheering healthcare reform. Although there was a separate bill requiring mental health parity in insurance coverage–meaning that it should be treated equally to physical conditions when it comes to benefits–passed in 2008, this legislation goes farther. Here are five facts about the health insurance reform bill and its impact on the treatment of mental health conditions.
With the eventual ban from denying people with pre-existing conditions, those with mental health conditions will have easier access to affordable health insurance. Many times, health insurers refuse to underwrite someone with a diagnosis of depression, anxiety disorder, bipolar disorder, or schizophrenia. That is regardless of how well-controlled the condition may be, and regardless of their physical health. The newly passed bill changes that. Insurers will also no longer be allowed to exclude that particular condition from any coverage they extend.
Small businesses with under 50 employees are now subject to the mental health parity laws, while they were not under the previous bill. Their previous exclusion was due to the increased cost of coverage, but Democrats and other supporters of reform believe that the upcoming exchange markets (run by the states) will assist small employers. The plans sold in the exchanges will meet the parity standards.
The bill doesn’t necessarily mean that people will receive gold-plated mental health coverage. Instead, it states that the coverage should be equal to physical health coverage. If someone picks a bare-bones, high-deductible health insurance plan, their coverage will be limited all-around. What is outlawed is inequality; for example, an insurer cannot charge a higher co-payment for a psychiatrist visit than they would for any other medical specialist. Neither can they deny a patient the opportunity to receive out-of-network mental health treatment, if patients are allowed to seek medical care out-of-network. Also, they cannot limit the number of visits or days of inpatient treatment for substance abuse or mental illness any more strictly than they would for surgery or physical illnesses.
The elimination of lifetime and annual caps on benefits will also be helpful. Mental health treatment can be very costly. Inpatient rehabilitation for substance abuse or eating disorders can cost tens of thousands of dollars per month, which can quickly eat up the limits of most health insurance plans. Fewer patients will suffer from incomplete treatment due to their inability to afford continued help.
The bill’s expansion of Medicaid eligibility will help the mentally ill, whom many experts believe are more likely to be uninsured. Moreover, all Medicaid coverage (not just managed care programs) will now offer equal coverage for mental health conditions.
Mental health change ahead
BEN HOGWOOD MOREHEAD CITY — The entity that oversees behavioral health in the county will have to merge with another larger entity to meet state requirements.
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In 2007, the governor of Minnesota proposed a mental health initiative and the legislature passed it. One of the more important components of the initiative was legislation amending Minnesota’s two programs for the uninsured – General Assistance Medical Care and Minnesota Care – to add to the comprehensive mental health and addictions benefit.
Who Is Covered?
General Assistance Medical Care covers those with income at or below 75% of the federal poverty level who meet one or more of additional criteria known as General Assistance Medical Care qualifiers. Qualifiers include waiting or appealing disability determination by Social Security Administration or state medical review team; or being in a homeless or live in shelter, hotel, or other place of public accommodation.
Minnesota Care covers children and pregnant women, parents, and caretakers up to 275% of the federal poverty level, except that parents and caretakers gross income cannot exceed ,000. Single adults without children increased to 200% of federal poverty level by January 1, 2008 and will rise to 215% of federal poverty level by January 1, 2009.
What Services Are Covered?
For Minnesota Care, there are limits of ,000 on inpatient care for any condition (physical, mental health, or addictions) for parents over 175% of federal poverty level and childless adults. For General Assistance Medical Care, inpatient benefits are fully covered. Both programs cover chemical dependency outpatient services. An intensive array of outpatient and residential mental health services are available.
What Is The Cost?
In Minnesota, the Medicaid Temporary Assistance for Needy Families population, General Assistance Medical Care and Minnesota Care are enrolled in comprehensive nonprofit health plans that are responsible to deliver and are at risk for the entire health benefit, including behavioral health. Adding mental health rehabilitative services (including adult rehabilitative mental health services individual and group rehabilitation services, assertive community treatment, intensive residential treatment and mobile and residential crisis services) to Minnesota Care was projected to cost .40 per person per month. For General Assistance Medical Care, which includes a homeless population, the cost was .01 per person per month. The additional targeted case management service was projected to cost .22 per person per month for Minnesota Care and .66 for General Assistance Medical Care.
The legislature appropriated a total of million in additional state dollars in fiscal year 2008 and $ 3.5 million in fiscal year 2009 to add the adult rehabilitative services and case management in Minnesota Care. State funds previously targeted for case management were moved from the counties to the state in an amount of .4 million in fiscal year 2009.
What Led To Comprehensive Coverage?
The state collected data on the residents served by Minnesota Care, General Assistance Medical Care, and Medicaid managed care plans serving non-disabled populations, and discovered that an increasing number of individuals with serious mental illnesses were in these plans. Several insurance reforms – similar to those included in the national healthcare reform bill – modified the private market, including guaranteed issue in small and large group plans, broader rate bands, parity for mental health and chemical dependency services, medical loss ratios, high risk insurance pool, and others. A lawsuit by the attorney general called attention to health plan denials of payment for court-ordered treatment, for example for civil commitment or out of home placement for adolescents.
Health plans settled with an agreement that behavioral and mental health benefits would be covered by a health plan if the court based its decision on a diagnostic evaluation and plan of care developed by a qualified professional. In addition to the court-ordered services provision, the state contracts and capitation with prepaid health programs (Minnesota Care and General Assistance Medical Care) were amended to align risk and responsibility for services in institutions for mental illnesses, 180 days of nursing home or home health, and court-ordered treatment. There were also highly successful experiments reducing costs and improving outcomes for commercial and non-disabled Medicaid clients who were offered a more intensive community based mental health service that improved coordination with and linkages to behavioral healthcare, primary care, and other needed services.
These demonstrations produced a positive return on investment – .38/person/month – and gave the health plans tools to manage the increased risk that resulted from several insurance reforms, including parity, a statutory definition of medical necessity, and the court-ordered treatment provision.
The state supported comprehensive coverage because it sought to provide mental health and addiction services in Minnesota as part of mainstream healthcare. Minnesota’s mental health agency and other stakeholders desired to move mental illness from its historical treatment as a social disease requiring social services to an illness like any other. They wanted to foster earlier interventions and avoid shifting enrollees among different programs in order to access specific services. Operationalizing this change required rethinking medical necessity determinations, provider credentialing, contracting, procedure codes and other processes common to private insurance plans.
How Did It Get Through The Political Process?
Three factors significantly contributed to the political viability of a benefit expansion in the Minnesota Care and General Assistance Medical Care programs:
>> The governor of Minnesota and the administration provided strong leadership. The provisions to expand the mental health benefits in these plans were part of the governor’s mental health initiative, set forth in advance of the 2007 legislative session.
>> An extremely strong coalition of stakeholders formed a mental health action group. This group is co-chaired by a representative from the department of human services and included representation from the private insurance industry and organized and knowledgeable advocacy and provider communities.
>> There was strong support in the legislature for the expansion of benefits in Minnesota Care and General Assistance Medical Care, including from a member of the finance committee in the house, who has a son with schizophrenia. The creation of a mental health division in the health and human services policy committee also helped move the policy discussion forward.
Why Does This Approach to Healthcare Reform Work?
A recent survey of community behavioral health organizations found that on average, 42% of reimbursement for services came from private insurers. While this represents the average, the survey found that there was quite a range in reimbursement sources. For community behavioral health organizations that specialize in services such as Assertive Community Treatment or case management, Medicaid is the predominant reimbursement source, either through fee-for-service or managed care.
Reimbursement from private insurance and Medicaid managed care is uniformly better than Medicaid fee-for-service. In addition to higher rates, the private insurers and Medicaid managed care organizations have been willing to offer special contracts for packages of services for crisis care and hospital discharge plus aftercare.
Mental health employment program set to close
A program that helps people with mental health disabilities land jobs has lost its federal funding and will have to close down by the end of March. The national BUILT Network program — administered by a St.[...]
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Due to greater understanding of how many Americans live with mental illnesses and addiction disorders and how expensive the total healthcare expenditures are for this group, we have reached a critical tipping point when it comes to healthcare reform. We understand the importance of treating the healthcare needs of individuals with serious mental illnesses and responding to the behavioral healthcare needs of all Americans. This is creating a series of exciting opportunities for the behavioral health community and a series of unprecedented challenges Mental health organizations across the U.S. are determined to provide expertise and leadership that supports member organizations, federal agencies, states, health plans, and consumer groups in ensuring that the key issues facing persons with mental health and substance use disorders are properly addressed and integrated into healthcare reform.
In anticipation of parity and mental healthcare reform legislation, the many national and community mental health organizations have been thinking, meeting and writing for well over a year. Their work continues and their outputs guide those organizations lobbying for government healthcare reform. .
MENTAL HEALTH SERVICE DELIVERY
1. Mental Health/Substance Use Health Provider Capacity Building: Community mental health and substance use treatment organizations, group practices, and individual clinicians will need to improve their ability to provide measurable, high-performing, prevention, early intervention, recovery and wellness oriented services and supports.
2. Person-Centered Healthcare Homes: There will be much greater demand for integrating mental health and substance use clinicians into primary care practices and primary care providers into mental health and substance use treatment organizations, using emerging and best practice clinical models and robust linkages between primary care and specialty behavioral healthcare.
3. Peer Counselors and Consumer Operated Services: We will see expansion of consumer-operated services and integration of peers into the mental health and substance use workforce and service array, underscoring the critical role these efforts play in supporting the recovery and wellness of persons with mental health and substance use disorders.
4. Mental Health Clinic Guidelines: The pace of development and dissemination of mental health and substance use clinical guidelines and clinical tools will increase with support from the new Patient-Centered Outcomes Research Institute and other research and implementation efforts. Of course, part of this initiative includes helping mental illness patients find a mental health clinic nearby.
MENTAL HEALTH SYSTEM MANAGEMENT
5. Medicaid Expansion and Health Insurance Exchanges: States will need to undertake major change processes to improve the quality and value of mental health and substance use services at parity as they redesign their Medicaid systems to prepare for expansion and design Health Insurance Exchanges. Provider organizations will need to be able to work with new Medicaid designs and contract with and bill services through the Exchanges.
6. Employer-Sponsored Health Plans and Parity: Employers and benefits managers will need to redefine how to use behavioral health services to address absenteeism and presenteeism and develop a more resilient and productive workforce. Provider organizations will need to tailor their service offerings to meet employer needs and work with their contracting and billing systems.
7. Accountable Care Organizations and Health Plan Redesign: Payers will encourage and in some cases mandate the development of new management structures that support healthcare reform including Accountable Care Organizations and health plan redesign, providing guidance on how mental health and substance use should be included to improve quality and better manage total healthcare expenditures. Provider organizations should take part in and become owners of ACOs that develop in their communities.
MENTAL HEALTHCARE INFRASTRUCTURE
8. Quality Improvement for Mental Healthcare: Organizations including the National Quality Forum will accelerate the development of a national quality improvement strategy that contains mental health and substance use performance measures that will be used to improve delivery of mental health and substance use services, patient health outcomes, and population health and manage costs. Provider organizations will need to develop the infrastructure to operate within this framework.
9. Health Information Technology: Federal and state HIT initiatives need to reflect the importance of mental health and substance use services and include mental health and substance use providers and data requirements in funding, design work, and infrastructure development. Provider organizations will need to be able to implement electronic health records and patient registries and connect these systems to community health information networks and health information exchanges.
10. Healthcare Payment Reform: Payers and health plans will need to design and implement new payment mechanisms including case rates and capitation that contain value-based purchasing and value-based insurance design strategies that are appropriate for persons with mental health and substance use disorders. Providers will need to adapt their practice management and billing systems and work processes in order to work with these new mechanisms.
11. Workforce Development: Major efforts including work of the new Workforce Advisory Committee will be needed to develop a national workforce strategy to meet the needs of persons with mental health and substance use disorder including expansion of peer counselors. Provider organizations will need to participate in these efforts and be ready to ramp up their workforce to meet unfolding demand.
Mental Health Patient Relates To Loughner
The mass shooting in Tucson and the mental history of suspect Jared Loughner has sparked debate about whether the state’s mental health services are adequate.
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2009 is a critical year. Promised economic recovery and healthcare reform legislation are opportunities for meaningful financial commitments to mental health and addictions services and mental healthcare organizations are offering a practical actionable agenda:
- The integration of primary care services in behavioral health settings: The Healthcare Collaborative Project brings together behavioral health and primary care organizations offering a bi-directional approach for care. The need for behavioral health services in primary care is widely accepted. But the integration of primary care services in behavioral health settings remains controversial despite the fact that individuals with serious mental illness appear to have the worst mortality rates in the public health system. Therefore, mental healthcare organizations are actively pursuing single points of accountability to enhance continuity of care for this underserved population.
- Cost-based-plus financing that supports service excellence: People want and deserve quality services but quality services depend on skilled staff. Low salaries have created – and are perpetuating – a recruitment, retention, and quality crisis for behavioral healthcare. We need a workforce of skilled staff delivering nationally recognized practices within organizations that live by the rule “If you don?t measure it, you can?t improve it.”For mental healthcare organizations, healthcare reform is an opportunity to bring “parity” to public mental health services by ending the second class status of community mental health and addiction providers in America?s safety net.
- Federal mental health funding stream dedicated to mental health and integrated treatment services for the uninsured: The uninsured have exceptionally high rates of untreated mental illnesses with co-occurring addiction disorders and there is no safety net. State plans to cover the uninsured have all but disappeared and federal universal coverage plans may well be incremental. We have large numbers of individuals with treatable mental illnesses and addictions in our overburdened emergency rooms, in jails, and on the streets with no access to services that can engage them, treat them and return them to work. We must stop denying our economy productive taxpayers and wasting human lives.
- Eligibility for social security disability for people with addiction disorders: Addiction has come a long way from the days when it was perceived as merely a failure of will. Today, there is growing public awareness and acceptance of addiction as a chronic, relapsing condition that requires continual monitoring and management, as do other chronic illnesses like diabetes, asthma, and hypertension and yes, mental illness. If we accept addiction as a chronic illness then we must advocate that people with addiction disorders be eligible for disability support.
- Funds to support investments by behavioral healthcare organizations in information technology: We talk about information technology and service transparency, but behavioral healthcare organizations that move forward to automate their clinical systems get no support, funding, or technical assistance. We and those we serve cannot continue to be marginalized. Healthcare reform and economic recovery will depend upon the expansion of information technologies and behavioral health providers must be included.
- Expansion of research-based education and prevention practices: There are mental health and addiction prevention and education programs that work. These include research-based prevention initiatives that reduce the risk of childhood serious emotional disturbance by treating maternal depression, the Nurse-Family Partnership Program that has an array of consistent positive effects across multiple trials, and Mental Health First Aid – an evidence-based mental health literacy program. Now we must adequately fund and support the spread of these interventions to communities across the country.