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Medicaid: Is it a matter of mission? (Charles Curie)

July 25, 2008
by ccurie
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There are many challenges and obstacles to assuring people have access to quality mental health and substance use treatment. If a vote was taken as to what is the one most constant and difficult challenge that besets the mental health and substance use treatment fields, my vote would be the challenge of adequately funding services. Whether we consider the lack of parity of behavioral health services with health insurance coverage or obtaining the needed public funds to address the ever-increasing demand to treat individuals with mental illnesses and/or addictive disorders, access to quality care is continually jeopardized. In the public arena (federal, state or local governments), there are revenue crises and defending a budget is a major challenge. Gaining new dollars for funding behavioral health services is becoming even more difficult in light of all the competing causes for public dollars.

Medicaid has become a major source of financing behavioral health services (especially mental health care). States and providers have come to depend on Medicaid dollars to fund community-based care. The psych/rehab option has been utilized to fund an array of services that have been essential to people with serious mental illnesses attaining and sustaining a level of successful recovery in the community. More expensive inpatient treatment has been avoided for many individuals in lieu of more cost effective and evidence based services being rendered in the community. Institutional care, once the primary approach to addressing the needs of people with serious mental illnesses, is now viewed as the antithesis of recovery in light of the successes people are experiencing by realizing “a life in the community”. However, Medicaid as a funding source for these important and critical services is perpetually threatened. States and providers find themselves in various positions of losing federal funds and dealing with additional documentation because waivers are being reevaluated and messages come out of CMS and other agencies that rehab and case management services may not be funded in the future. Consumers and families feel vulnerable because, many times, they find themselves living “on the edge” of losing the very services they need to make a life for themselves or their loved ones.

Much of the ongoing debate around Medicaid funding a range of behavioral health services is centered on defining the appropriate “mission” of Medicaid. Some within CMS have taken the position that Medicaid should be viewed as health insurance and only those services deemed “medically necessary” should be funded. This line of thinking then leads to a conclusion that services and programs that are focused on providing psych/rehab or recovery services do not fit in a “medically necessary” model. Interventions that address acute illnesses and short-term medical conditions are much easier to justify within a medically necessary framework. In addition, CMS is under great and constant pressure (OMB, Congress, etc.) to find a way to control expenditures. Clearly and narrowly defining its mission is one approach. As long as CMS presses the issue of medical necessity as a guiding principle for its mission, the mental health and substance use treatment fields are going to be on the defensive in making the argument that rehab and recovery services fit that mission. So, how can we address this issue in a way that overcomes this impasse of “medical necessity”? Here are a couple of thoughts:

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A great point James. Under a medical necessity model approach we must make this case. There are mental illnesses and substance use disorders that fit in a chronic disease model.

There are many illnesses from which there is basically no recovery, diabetes & high blood pressure come immediately to mind, & yet there is no problem with funding the necessary fundamentals to deal with them. Learning the behavioral fundamentals to control a disorder is part of treating any disease from which there is no "cure".

OOI Medicaid Policy

Over 30 years ago it was widely acknowledged that the idea of "cure", when applied to people with severe and persistent mental illness, was inappropriate. Yet in our state proposed changes to the Medicaid Rehab Option Program are now focusing on only funding services that can demonstrate that individuals show constant improvement like the old Byzantine Medicare partial hospitalization benefit.
The notion of maintenance and sustenance and the worthwhile goal of retarding deterioration have been thrown out the window once again. This harkens back to the ridiculous "medical necessity" and "maximum benefit achieved" criteria which were used to rationalize discharging people from protective environments into homelessness or other dangerous placements.
These proposed changes are occurring at the same time that emphasis is being placed on implementing the recovery model, evidence-based practices, and assessing services by looking at comprehensive community linkages. These major disconnects among the needs of the consumers, the process of recovery, evidence-based treatment, and the national Medicaid funding ideology will no doubt result in a dubious system. A system in which both consumers and providers are forced into disingenuous compliance with rules stemming an obsolete acute care medical model designed for infectious diseases.
How long must consumers and their families have their quality of life jeopardized by bureaucrats who fail to see the simple reality of their needs? How long will policy him makers be out of it (OOI)

Mr. Curie is on the right track. A major part of the confusion in Medicaid is between traditional health insurance and long-term care coverage. I have argued in the past (BH June 2007) that a separate funding stream is needed for the latter, perhaps as part of Medicare.

Terry makes the critical point that funding streams must be aligned with the mission of faciltating and sustaining recovery in the lives of people. The life outcomes identified by consumers should be the driver of any "system". We must focus on what works and consumers and families are in a position to define that. Policy makers must realize that recovery is a long term commitment not a short term intervention. At the same time we must demonstrate through outcome measures that people do attain and sustain recovery when there is access to the right supports. The funding mission must be aligned with the recovery mission.

I think the field would have an easier time positioning itself within the chronic disease management model rather than trying to build support for a new funding stream. Redefining the meaning of "medically necessary" will take some time, but perhaps should be a focus of advocates.

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Charles G. Curie is the Principal and founder of The...