NMHA Calls on HCFA to Establish Medicaid Standards In Separate Letters to States, NMHA Offers to Help Close Contract Loopholes
Alexandria, VA (May 8, 1998) The National Mental Health Association (NMHA) is ratcheting up pressure on the Health Care Financing Administration (HCFA) and the states to heed warnings on managed behavioral healthcare contracting.
In separate letters, NMHA calls on HCFA to establish specific regulations and guidance to protect people with mental illnesses from tightly managed care in the Medicaid program, and offers to help Medicaid and mental health directors in the 50 states draft better contracts with managed care organizations (MCOs).
As the states accelerate efforts to contract with MCOs to lower mental health treatment costs, mental health advocates worry that a combination of financial incentives and loopholes in contracts prompt MCOs to deny care to those who arguably need it most: people with severe mental illnesses who receive their care through the Medicaid program. Recent studies suggest advocates have good reasons to be concerned -- and to demand remedy.
"Studies by the George Washington University Center for Health Policy Research continue to raise red flags about laxness and vagueness of state contracts with MCOs, allowing the MCOs to practice as they see fit," said Robert Gabriele, NMHA Senior Vice President. "Meanwhile, the lives of people with severe mental illnesses hang in the balance."
The latest study was released last month. In response, Gabriele has written HCFA Administrator Nancy-Ann Min DeParle: "To our grave dismay, though not to our surprise, the study shows only minimal improvement in the quality of managed care contracting in the states over the first study in 1997."
Last year, NMHA called on HCFA to develop regulations to solve problems highlighted in the studies, conducted by Sara Rosenbaum. At the time, HCFA assured NMHA that Quality Improvement System for Managed Care (QISMC) guidelines would address the problems. HCFA (Cont.)
Gabriele wrote DeParle, "Unfortunately, the draft QISMC guidelines are so generic and demand so little of MCOs, especially in mental health and substance abuse, that they do virtually nothing to raise the bar in managed care contracting and "protect people with mental health and substance abuse disorders in the ill-planned and too-rapid march to managed care."
Gabriele asks DeParle to:
-- Establish a national standard that would prevent MCOs from disenrolling Medicaid clients for disruptive or non-compliant behavior (which may be a symptom of their disorder).
-- Require states to establish special enrollment procedures for adults with severe mental illnesses and children with serious emotional disorders.
-- Establish regulations -- or at least provide strong guidance to states -- on minimally acceptable definitions of medical necessity.
-- Require states to open their medication formularies to new atypical anti-psychotic medications and newer anti-depressants as first line treatment options in all cases.
In separate letters to the 50 state Medicaid and 50 mental health program directors, Cynthia Folcarelli, NMHA Director of State Healthcare Reform, says when states give too much discretion to MCOs, they put mental health consumers at risk of being denied care, but also put the state at risk of liability for Medicaid services the MCOs do not provide. Folcarelli writes:
"We would like to work with you to close the dangerous loopholes in these contracts Ö The NMHA network of consumers, family members and advocates has both the technical expertise and the 'real life' experience to help you craft provisions in Request for Proposals and contracts that will protect consumers and ensure that public dollars are properly spent."
The new study, Negotiating the New Health System: A Nationwide Study of Medicaid Managed Care Contracts, found contract ambiguities in areas critical to a mental health consumer: enrollment and disenrollment procedures; competency requirements for network service providers; relationships between MCOs and state agencies; Access-time standards; service definitions; medical necessity criteria; and, specifications for drug formularies. The report was prepared for and released by the federal Center for Mental Health Services.
Reporters seeking more information may call Patrick Cody at NMHA: (703) 838-7528.
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