Demand for mental health services exceeds expectations

In early December, Virginia significantly expanded mental health coverage under Medicaid. Added 6 new services Increase payments to providers as part of multi-year effort to reduce state’s own dependency Struggling psychiatric hospital.

Six months after deployment, demand for at least one treatment option was already significantly higher than expected, prompting the agency overseeing Medicaid to propose significant policy changes.

Dr. Alyssa Ward, director of behavioral health for the state’s Department of Medical Support Services, announced in June that community stabilization was taking place statewide. It “far exceeded” what the authorities predicted in their budget request to the UN General Assembly.

Long-term care, including therapy and medication management, is usually required to stabilize patients during mental health emergencies and to prevent future accidents after discharge from inpatient care. However, when these services are not readily available, community stabilization is seen as an intermediate option, with crisis providers paying for prevention and intervention, counseling, referrals to more permanent care, etc. can do.

At the 2018 Resource Fair in Richmond, state social services officials enrolled homeless residents on Medicaid. Enrollment in the program has more than doubled since Medicaid expanded, increasing demand for mental health services. (Ned Oliver/Virginia Mercury)

DMAS did not respond to multiple requests for interviews from Mercury and a list of questions asking the agency to quantify how extensively its use was exceeded. agency expectations. but, video presentation Ward announced to mental health providers in Virginia that it is proposing major regulatory changes as part of an effort to make DMAS a “responsible steward” of the state’s Medicaid funding.

“We stick to the predictions made by the General Assembly, and when we see something that exceeds that prediction, we have to account for it,” she said.

As a result, government agencies are proposing to change the approval process for community stabilization services, requiring providers to obtain permission from the government. 6 insurance companies This is the majority of Medicaid participants in Virginia covered before their medical bills are reimbursed.

The shift from near-automatic approval of services to what is known as preapproval is among many supporters and practitioners the future of Virginia’s efforts to overhaul its beleaguered mental health system. has raised concerns about. Dozens of mental health providers have already commented He said the proposed changes would likely delay the delivery of services to some of the state’s most vulnerable patients.

transfer care to the community

To understand why the proposal raises concerns, first: History of Virginia’s Mental Health SystemFor decades, state legislators relied heavily on nine publicly funded mental hospitals to treat patients with severe mental illness. more for bed than for community-based services. These services are still lacking. dangerous levels of overcrowding at many facilities.

Eastern State Hospital in Williamsburg is the largest of nine state mental hospitals. Legislators have increased funding for community mental health services over the past few years to reduce admissions to state hospitals. (Photo credit: DBHDS)

In 2017, Virginia officials launched a concerted effort to reduce mental health hospitalizations by increasing funding for the state’s 40 community service commissions. These local agencies are tasked with providing mental health, substance abuse, and intellectual disability services to low-income Virginians, including: Evaluation of Patients in Crisis Determine if inpatient mental health treatment is needed.

Today, Virginians with serious mental health needs are frequently sent to emergency rooms and, if beds are available, to state hospitals. But the state’s ultimate goal is to prevent hospitalization by increasing the number of health care providers who can treat patients closer to home. Community Service Boards are currently required to provide patients with: A unified set of treatment optionsincluding crisis response, but it is widely acknowledged that they lack the funds and staff to provide assistance to all Virginians who need it (especially the recent mental health hotline Demand for services is expected to increase.)

“We have always emphasized that CSB is a safety net,” says Carlin. “But when we look at state data, it is private providers that provide the majority of behavioral health services to people in Virginia on Medicaid.”

This is where DMAS comes into play. As legislators increased funding for the Community Service Commission, more funds were allocated to reimburse outside agencies that provide Medicaid treatment to Virginians. The initiative, called Project Bravo, is part of the agency’s broader plan to build a suite of services by encouraging more providers to offer a wider range of mental health care.

A planning document from the Virginia Department of Medical Support Services outlines a proposed suite of mental health services, including community stabilization in support of patients at risk. (Provided by DMAS)

Community stabilization, once called crisis stabilization, is seen as an important part of the state continuum. planning documentIn a June presentation, Ward said the service’s goal is to remedy longstanding gaps in access to care.

“It’s the people who are being released into the community from higher levels of care, and the community service is not there,” Ward said. Did.”

What’s not clear is why so many providers charge for this service. Karlin believes part of the reason is simply high need across the state, but there are also concerns that fraud plays a role. reported cases of unscrupulous health care providers waiting outside hospitals and offering hotel rooms to homeless patients discharged from mental health visits.

“They’ll say, ‘Oh, I see you’re out. We can place you in a hotel room. Your insurance will pay for that,'” Carlin said. “So they don’t really provide community stabilization, but they charge for it.”

In a presentation to health care providers, Ward also said the service’s “misuse” influenced the proposed regulatory change, which banned the federal government from paying for housing with Medicaid funds. The agency did not respond to questions about whether efforts were made to reprimand or revoke the license.Virginia Provider Improperly Billing Medicaid for Community Stabilization Treatment.

“DMAS does not seem to want us to take advantage of community stabilization at all.”

Despite concerns about the bad guys, many health care providers say that requiring insurers to pre-approve stabilization services is a big move, similar to Virginia’s efforts to build a broader network of mental health services. I am afraid that I will end up hurting the patient.

When the state first expanded community stabilization services under Medicaid, providers could request a refund through a simple registration form. This essentially enrolled the patient in the service for a period of time. However, under the preapproval process, state contract insurance companies, known as managed care organizations, have the power to approve or deny requests and dictate how long individuals receive care.

In theory, this process is designed to help prevent improper billing and control state spending on Medicaid services. However, many providers say pre-approval imposes a significant administrative burden, especially for smaller institutions.

Katie Francis, Program Manager for Mental Health Services at Childsavers, a Richmond-based nonprofit, said: The agency is still providing treatment for children and families, but stopped offering crisis intervention services in December due to changes in the state’s Medicaid program.

One of ChildSavers’ biggest challenges was with a new manual that sets more specific requirements on how many mental health services they can provide and what services they can provide in order to be reimbursed. But Francis said the proposal to require pre-approval for community stabilization, in addition to other regulatory changes, would make it even more difficult for childsavers to re-implement crisis services given their experience with the process. He said he would.

We continue to rely on the wishes of the insurance companies.

– Katie Francis, Mental Health Services Program Manager at ChildSavers in Richmond

Like other health care providers, she said one of the major issues is that each of the state’s six managed care organizations has its own certification system. Some included multiple plans, depending on the type of insurance plan. According to Francis, getting pre-approved for services often required dozens of pages of paperwork and hours of phone calls just to get the forms to the right people.

“We have a one-person billing team managing 30 different clinicians, so providers ended up doing a lot on their own just because it takes time,” she said. said.

The same concerns were shared in written public comments on the proposed regulatory changes. Multiple practitioners noted that DMAS requires the mental health agency to submit a pre-approval request within one business day of him, but that there is no required response time for insurance companies. Francis says in her experience approvals can be unpredictable and in some cases she can arrive within a day and in other cases it can take up to a month.

“This could put providers in scenarios where they are unable to initiate emergency services for clients in urgent need due to delays in receiving approvals,” read one anonymous comment. , noted that managed care organizations did not appear to be required to approve legitimate requests for community stabilization, and wrote that the new policy appeared to be designed to render services unusable.

“DMAS does not seem to want to take advantage of community stabilization at all with these recent changes,” another provider wrote. Remove/replace the service entirely instead of slowly deteriorating it.”

The agency did not respond to questions about whether the insurer plans to establish a timeline for responding to requests. However, Carlin predicts that some providers will simply stop providing services if the process is delayed or rejected significantly.

“This is already treatment day treatment — there are large agencies that no longer offer services because they are not approved and cannot afford to pay for it,” she said. “So if this is a situation where our concerns are materialized to a large extent, I think it will be a deterrent.”

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