Mental health providers grapple with Medicaid expansion

The House of Representatives passed landmark legislation to overhaul the nation's health-care system, approving a Senate bill and a separate package of amendments.
By Darryl Fears
Washington Post Staff Writer
Tuesday, October 12, 2010; 11:54 AM

For District health officials, it was an easy decision.

The federal government handed them an opportunity to save $56 million over four years by expanding Medicaid this summer and they jumped at it. They switched 35,000 low-income residents from the city -funded D.C. Health Care Alliance insurance plan to a Medicaid plan and reaped the reward.

It looked like a win-win: The city got some financial relief and the new Medicaid beneficiaries got mental health coverage, which was not part of the Alliance plan. But it creates a problem for the city's mental health-care providers, who said this week that they are faced with serving thousands of new clients they are not prepared to manage.

"We support expanding Medicaid eligibility, but you have to have the provider capacity to do it," said Shannon Hall, executive director of the D.C. Behavioral Health Association, an advocate for providers. "If you do one without the other, you're going to have a bad experience for the people who need care."

The complaint by Hall and local mental health providers echoes general concerns about the health-care overhaul raised by hospitals, doctors, nurses and their advocates nationwide who say the mammoth program is being built on a network that cannot support it.

Officials at the D.C. Health Care Finance office, which was in charge of the changeover, said there is no evidence that the local mental health-care network will be overwhelmed.

And Sharon Baskerville, executive director of the D.C. Primary Health Care Association, an advocate for comprehensive insurance coverage, said the complaints are speculative.

"Advocacy is great . . . but it's not to be always about crying," said Baskerville, who noted that children are already being treated for less severe mental health problems under the plan. "It's also about working out solutions."

Mental health screening and treatment as part of primary care is important, experts say, because problems such as depression, anxiety, post-traumatic stress disorder and attention deficit disorders often go undiagnosed until they are severe, and patients show up in hospital emergency rooms, which increases health-care costs.

Between 11 and 36 percent of primary-care patients have a psychiatric problem, according to estimates in studies cited by the American Academy of Family Physicians.

"If you talk to [emergency room] doctors, they'll say they're overflowing with people suffering from a mental health crisis," said Ron Honberg, legal director for the National Alliance on Mental Illness. "They don't have space to put these people."

Federal officials hope to reduce emergency room visits with the overhaul. The Department of Health and Human Services announced last month that it will offer a grant package that includes $20 million to help providers incorporate mental health services into primary care.

Despite arguments for expanding mental health care, and grants to implement it, mental health providers have their share of sympathizers because of the enormous task they face.

According to the Centers for Medicare and Medicaid Services, only Connecticut and the District took advantage of the government's offer to expand Medicaid for Americans who earn 133 percent of the federal poverty level - $14,400 for an individual and $29,300 for a family of four, a category that included more than 13 million uninsured adults in 2008, 17 percent of whom had a fair, poor or chronic mental health condition, according to a report by the Kaiser Family Foundation.

The health-care law requires all states to expand Medicaid when changes are fully implemented in 2014. As states prepare to expand their managed-care programs under Medicaid, many have cut Medicaid fee-for-service reimbursements to doctors who deal primarily with chronic health conditions such as HIV, substance abuse and various mental disorders.

In the District, one clinic, Mary's Center, said it experienced a 70 percent increase in screenings for depression after beneficiaries were switched to Medicaid under the expansion.

The center was already stretched thin to care for patients with severe and chronic forms of mental illness such as schizophrenia, dementia and bipolar disorder under a contract with the Department of Mental Health. Joan Yengo, vice president of programs for the center, which treats 17,000 patients a year, said one solution would be to hire a few managers so that the center can deliver services more efficiently.

"But if they're cutting rates, [care] will be hard to sustain," Yengo said. "We're a federally qualified health center and we can't turn people away. You have this demand on your staff, but you're not getting more resources to increase your staff."

In Southern California, Los Angeles County is bracing for the impact that expanded Medicaid will have on its mental health services. County facilities traditionally have cared for residents with illnesses such as schizophrenia, dementia and bipolar disorder.

"We already have a workforce challenge, a capacity challenge," said William Arroyo, regional medical director of the Los Angeles County Department of Mental Health. "We're going to have to absorb people with less serious conditions. This will force the public mental health system to manage more efficiently than it has."

In the District, city health officials downplayed concerns over the proposed rate cut, saying that it offered doctor reimbursements of only 50 percent of Medicare just two years ago. Health Care Finance raised the rate to 100 percent at that time before proposing to cut it back to 80 percent recently because of budget shortfalls.

"Our proposed changes allow us to not have to cut coverage or benefits for residents who need health insurance, and this puts our rates still ahead of what most other states pay," Julie Hudman, director of the finance office, said in a statement.

Federal and city health officials are not overburdening mental health providers, Honberg said.

"D.C. has spent more for mental health than just about any jurisdiction in the country," Honberg said. "I sympathize with providers who have to worry about rate cuts, but they just might have to absorb some of the impact.

"In the long run, this creates the potential for positive change. In the short run, some significant adjustments have to be made."

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