The Centers for Medicare and Medicaid Services (CMS) will soon release proposed regulations for Medicaid's Rehabilitation Option which, in CMS's own words, will clarify rehabilitation services by “clearly defining allowable services that may be claimed as rehabilitation services, which are optional Medicaid services typically offered to individuals with special needs or disabilities to help improve their health and quality of life.” A full comment period is expected, and behavioral health agencies and associations, such as the United States Psychiatric Rehabilitation Association (USPRA), will have the opportunity to weigh in and help shape the final regulations.
As a newcomer to the mental health field after many years working on Capitol Hill, it has been personally enlightening to see how money flows through states to service providers once it has been appropriated by Congress. As a former staffer on the full House Appropriations Committee for nearly six years, I'm well versed in how federal agencies receive their funding, but I have enjoyed learning the block grant and matching systems available to states and how each is applied. I must confess that it is more complex than I had imagined as a Hill staffer. I suspect this complexity is what makes it difficult for Congress to ensure sufficient funding of effective programs. And even amidst all the media sensationalism about corruption and unethical behavior, the vast majority of members of Congress are good, honest people with high levels of integrity. They, like me, simply lack a solid understanding of how the mental health system works.
And not just elected officials get a bad wrap. CMS is often painted as an evil empire that makes callous decisions about the services individuals can or cannot receive. However, after a two-day road trip with eight CMS staff members directly responsible for oversight of the rehab option, I can assure you that their intentions are good. On February 8 and 22, we visited six model psychiatric rehabilitation programs across Maryland, Virginia, and the District of Columbia, including an Assertive Community Treatment team, clubhouse, day program, peer-operated drop-in center, residential program, and a supported employment program. All are excellent examples of how rehabilitation services delivered in a community setting lead to recovery for individuals with severe mental illnesses.
I commend CMS for its staff's efforts to learn, and in some cases experience, the principles of psychiatric rehabilitation. And while the regulations for rehabilitation services have been drafted, CMS expects, but more importantly welcomes, feedback during the comment period from organizations such as USPRA, rehabilitation providers, and individuals affected by the proposed regulations.
I firmly believe CMS's perspective is not about reducing expenses but about ensuring that effective rehabilitation services are available in every community so that individuals with psychiatric disabilities have the opportunity to begin the recovery process and live up to the Substance Abuse and Mental Health Services Administration's Fundamental Component of Recovery, which states:
There are multiple pathways to recovery based on an individual's unique strengths and resiliencies as well as his or her needs, preferences, experiences, and cultural background. Consumers have the authority to choose from a range of options and to participate in all decisions—including the allocation of resources—that will affect their lives…
Even the states are embracing this philosophy, as they design the best programs of care for their unique and often diverse populations. But why, then, does system transformation begin to disintegrate when the rubber meets the road?
I believe the answer lies in lack of funding. Yes, money is the root of all evil, and when funding doesn't meet demand, difficult and sometimes uneducated decisions are made about which services will be covered. Thus, outcome statistics become vital in determining the effectiveness of one program over another, and evidence-based practices carry even greater weight. When dollars are scarce, documentation of medical necessity comes under scrutiny, and “recovery is difficult to measure” is no longer an acceptable response.
In my travels and communication with programs over the past ten months, I can attest that the members of USPRA practicing the principles of psychiatric rehabilitation bear witness to the power of self-determination and recovery every day. However, each program has a shared responsibility to work collaboratively with the local (state or county) funding authority to ensure adequate reimbursement, particularly in times of scarce funding. Such collaboration and education are keys to transforming the mental health system.
To that end, one of USPRA's goals is to develop strong working relationships with federal agencies and members of Congress to help educate them on the effectiveness of psychiatric rehabilitation and choice in the recovery process. We aim to help them understand that individuals can and do recover from serious mental illnesses and move on to regain a life in the community when given access to appropriate supports. And we hope to show them that increased funding for programs like the Rehabilitation Option is essential in changing how we treat and think about serious mental illness.
Jane M. Porter is Director of Government Affairs and Public Policy for the United States Psychiatric Rehabilitation Association.