Governor Snyder’s Proposal to Privatize Taxpayer-Funded Mental Health Service
In his FY-17 executive budget, Governor Snyder proposed that, by Sept. 2017, all Medicaid CMH clients and money be transferred to the state’s 11 Medicaid HMOs, which would assume responsibility for managing beneficiary needs regarding mental illness, emotional disorder, developmental or intellectual disability, and substance use disorder.
Legislators were swamped with complaints over this proposal. Lt. Governor Calley stepped in and formed a 120-person workgroup to examine the matter. This workgroup met five times (through June ’16) and issued a report with suggested values for publicly funded health care, as well as multiple recommendations for structural and operating changes in our health care systems. The latter recommendations were called “Design Elements.” Among them was a rejection of the Governor’s proposal. The Calley Workgroup (which required a two-thirds super-majority for any actions) said money for management of person with both behavioral and other medical needs would be better given to CMH programs than Medicaid HMOs.
The state’s Department of Health & Human Services (DHHS) is now holding respectively separate “affinity group” sessions in various locations for “eligible populations” (service recipients and their families), service providers and service managers/payers. Participants are being asked a series of questions connected to Design Element recommendations coming from the Calley Workgroup.
When these “affinity groups” are over in early November, DHHS intends to develop a draft plan of next steps in Michigan and distribute the draft for public comment in late November. The Department will then develop a final plan for delivery to the Legislature in mid-January of 2017. For these tasks, DHHS has available assistance from a new workgroup of about 20 people, split roughly evenly between advocacy groups and providers/payers.
Why the Governor’s Proposal is Not a Good Idea
*Medicaid HMOs have a profit motive and incentive that does not exist in the same way for CMH programs. HMOs often ration service access and provision in order to achieve profits.
*Medicaid HMOs are connected to government primarily through contracts. CMH programs are connected to government via law. CMH programs have much greater transparency and accountability responsibilities as governmental entities than do HMOs as governmental contractors. These include consumer/family representation on governing boards and compliance with FOIA and Open Meetings regulations.
*Medicaid HMOs have little experience with severe behavioral disorders. Our CMH programs have over 40 years experience with them.
*Much of the services available through CMH programs today recognize and rely on the great importance of social supports to foster recovery and the capacity to deal with one’s symptoms and life situations. The Medicaid HMOs rely on the old-style “medical model” where a physician makes a diagnosis and then says, “This is the medical treatment you need for that diagnosis.”
*CMH programs are legally required to give service beneficiaries the opportunity to engage in person-centered planning and self-determination choices regarding their desires and needs. Medicaid HMOs do not use these tools.
*The Governor’s proposal could require tens of thousands of state residents to leave their current doctors and providers for new ones that are imposed on them. This violates all modern thinking on consumer choices in behavioral health care.
*Simply turning all Medicaid health care money and management responsibility over to Medicaid HMOs does not guarantee better coordination and integration of health care for persons with both behavioral and other medical conditions. Coordination/integration is best achieved at the points where people directly receive services, and there will still in most cases be the need for respectively different and separate service providers. That is where the key to improved integration/coordination lies. The key does not rest with simply putting all Medicaid health care money in a single pot and saying to the HMOs, “Go run with it.”
Other Key Matters on the Table
The Calley Workgroup’s Design Element recommendations covered some critical points for improved behavioral health service in Michigan. These points cannot be eliminated from or watered down in the DHHS report to the Legislature next January.
Below are five of the most important Design Element recommendations:
*There must be open access to mental health and epilepsy medications in Michigan Medicaid. This has been the practice in Michigan for the past 12 years, through a combination of state law and policy. DHHS is now threatening to give the Medicaid HMOs control of access to these drugs, which means they would all be subject to prior authorization or other bureaucratic procedures that delay receipt of the drug prescribed by a beneficiary’s doctor. The open access protections currently existing for Medicaid mental health and epilepsy medications must be made permanent.
*A state-level entity with sufficient authority and freedom should be established to handle complaints about publicly funded health care services. In most cases today, grievances, appeals and rights complaints are judged by those who provide and/or pay for services. That is a conflict of interest which stacks the deck against consumers and families. It’s also too confounding for consumers and families because there are far too many complaint mechanisms to select from. The concept here is that the state either: (1) contracts with an independent entity to play this role; or (2) gives an existing unit in a state department special authority, policy freedom and funding to do it. The new state-level entity would be the responsible party for judging whether complaints about publicly funded health care services are valid. Mediation could be included among the services of the new entity, and there could still be one time-limited opportunity to resolve the complaint locally before it moves to the state entity.
*Person-centered planning must be available to all recipients of publicly funded health care and must be done with integrity. CMH programs utilize person-centered planning, but must get better at it. Medicaid HMOs don’t utilize this tool and must be legally required to do so (as is the case with CMH programs). Among other things, “integrity” means that person-centered planning is independently facilitated if the service recipient so desires.
*CMH programs statewide must be more uniform in their policies, procedures, capacities and operating definitions. There is wide variability among these programs, in areas such as person-centered planning & self-determination; criteria for priority client status; eligibility assessment; CMH pre-admission screening; available service array; utilization of peer supports and services; and financial obligations for service. This raises legitimate questions about unequal responses to different individuals in different parts of the state.
*The effect of multiple layers of bureaucracy in the public mental health system must be evaluated. We have a state department (DHHS), regional Prepaid Inpatient Health Plans (PIHPs), local CMH programs and providers contracted by CMH programs. Additionally, some PIHPs/CMH programs contract with “middle managers” who oversee contract providers instead of the PIHPs/CMH programs doing it themselves. Do we have too many of these layers? Do they interfere with effective service availability, access and delivery? What is their impact on system costs?