Cape Cod Times (Mass.), June 2:
The Affordable Care and Patient Protection Act (aka Obamacare) requires behavioral health be addressed by the legal, medical and insurance communities on par with physical health. There has been progress, at least in Massachusetts, but work remains in order to overcome the weaknesses in various systems and the stubborn barriers raised by stigma.
Post-ACA legislation in the commonwealth began to address the lack of parity lingering after decades of deinstitutionalization of mental health patients and the long-term shift to community-based services. Minimum stays for behavioral and substance abuse services were increased recently, the opioid crisis has raised almost everyone’s awareness, and innovative, grassroots community services sprout up all around.
One continued weak point in the continuum of service for behavioral health is the insufficient reimbursement of outpatient services. We see barriers to maximizing the skills of devoted clinicians, and difficulty in retaining them in the face of limited financial resources.
According to Vic DiGravio, president and CEO of the Massachusetts-based Association for Behavioral Healthcare, outpatient care is the cheapest and most effective care that can be provided: It diverts patients from hospital emergency departments and reduces re-admissions, both of which are much more expensive than outpatient care. DiGravio recently noted that the cost of treatment for a physical condition such as asthma or chronic obstructive pulmonary disease is two to three times higher for a patient who also lives with behavioral health issues.
A study on outpatient services by the Massachusetts Behavioral Health Partnership, which offers integrated medical and behavioral health care to more than 360,000 MassHealth (Medicaid) members, showed that stagnation in rates since 2007 fails to provide coverage for five of six critical services.
Comprising diagnostic services, individual and family therapy, group therapy, medication management, family consultation and case consultation, reimbursement rates are sufficient only for case consultation. It happens to be the one service of the six with more of a focus on planning and strategy than on the complicated social interactions tackled by the other five. Dealing with humans is expensive.
Medication management, for example, is dependent upon patients keeping their appointments, which is connected to diagnostic and therapy services, but also depends on highly skilled clinicians, such as psychiatrists and advanced practice registered nurses. The outdated, inadequate reimbursement system constrains the capacity of all outpatient clinicians, and works against an organization’s ability to retain workers enticed by higher salaries at hospitals, colleges, and other better funded institutions. And services curtailed by limited funds (another significant problem among many of the 85 members of the Association for Behavioral Healthcare) make it more likely that patients will need inpatient services instead of making progress toward healing.
Complicating the impacts of inadequate reimbursements is consideration of the financial status of the patients served by the myriad community-based organizations. It is the low-income client whose options are limited, and who tends to forgo services as they become harder to access.
Those in need of behavioral health services commonly face stigma, whether it be institutionalized discrimination that erects barriers to opportunity; public opinion that worries more about the common stresses of daily life than of citizens suffering from schizophrenia or depression; or self-loathing conceived by systemic marginalization.
The Baker administration has not ignored the reimbursement issue, and we look for more leadership from both the governor, the Legislature, and insurers as awareness grows of the value to society and our fellow citizens of supporting adequate outpatient care.
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