A.J. Soto, 7, lies at the threshold of his room and points to a drawing pinned above. An aspiring YouTuber, he enjoys shooting videos that feature his toys and games. [The Providence Journal / Sandor Bodo]

State of Health: Red-Tape Blues

A shift to managed care for mental-health and addiction treatment is fraying the safety net for R.I.’s poor and vulnerable, critics say

WOONSOCKET – “I want to be a YouTuber one day,” 7-year-old A.J. Soto said as he played in the backyard of the modest apartment where he lives with his mother, Erika H. Krueger.

A.J. is bright, creative and irrepressibly energetic. With an old cellphone, he enjoys shooting videos featuring favorite toys and games. On some, he adds a signature touch: a pair of mittens, his personal logo.

Time will tell if illness interferes with his ambitions.

A.J. lives with attention-deficit/hyperactivity disorder, or ADHD, and also a condition that inclines him to temper outbursts: disruptive mood dysregulation disorder, or DMDD. Additional challenges could face A.J. in the future.

“Typically, kids who have DMDD when they grow up have bipolar disorder,” Krueger said when The Journal visited her home. She lives with bipolar disorder, as do her sister and mother, she said.

Krueger and A.J. are clients of Woonsocket-based Community Care Alliance, a nonprofit agency with a staff of more than 500 that provides behavioral health care and related services to some 16,000 children and adults annually. It has the expertise to determine what best suits the mother and son, whose still-developing brain remains receptive to interventions that could improve his life now and into adulthood.

But their ability to deliver that expertise, says the agency’s president and CEO, Ben Lessing, was compromised by the state’s decision to transition Medicaid funding to managed-care organizations, which specialize in physical health but are less knowledgeable regarding people such as A.J and Krueger, whose mental-health needs are complex.

The impact?

A.J. and Krueger now receive a less-than-ideal rotating regimen of care that may save dollars today but cost more tomorrow, according to Lessing and his staff. In human terms, the cost could be incalculable, these professionals say. Krueger agrees.

What has been described by Newport Mental Health president and CEO Jamie Lehane as a “penny-wise, pound-foolish” approach could imperil A.J.’s health long into the future, perhaps irreversibly, Krueger says. Now is the time for best effort; instead, she says, “it’s a mess.”

A.J. and Krueger are far from alone. Thousands of other Rhode Islanders — most of them poor, like Krueger and her son — have been affected by the transition to the managed-care organizations Tufts Health Plan, United HealthCare and Neighborhood Health Plan of RI.

Medicaid.gov defines managed care organizations as groups that by contract to states oversee “delivery of Medicaid health benefits and additional services…” By doing so, the federal government declares, “states can reduce Medicaid program costs and better manage utilization of health services. Improvement in health plan performance, health care quality, and outcomes are key objectives of Medicaid managed care.”

Lessing and officials at a dozen behavioral health-care and substance-abuse treatment centers last month issued a rare public plea for a resolution to problems involving in Medicaid reimbursement for services provided.

The problems have hampered some organizations to such an extent that at least two have been forced to borrow money just to meet already lean payrolls, and one, desperate for revenue, has resorted to selling property. Several have delayed staff paychecks and raises for direct-care workers who earn low wages in the best of times. This has contributed to staff attrition and declining morale, leaders of these agencies say.

In last month’s letter to Gov. Gina Raimondo, Community Care Alliance chairperson Lynda A. Stein, a University of Rhode Island psychology professor, wrote of additional consequences, including jeopardizing “multiple other payment obligations such as healthcare, liability insurance, building maintenance, mortgages, payroll taxes and more.” Most injurious, she wrote, was the effect on lives – the “negative impact” to “the persons we serve who have severe and persistent mental illness” or are battling addiction, or both.

In addition to Community Care Alliance, Thrive Behavioral Health, formerly Warwick’s Kent Center and Warren’s Riverwood Mental Health Services; Discovery House Comprehensive Treatment Center of Providence; Newport Mental Health; and addiction-treatment organization CODAC Behavioral Healthcare are among those who joined last month’s public plea.

CODAC president and CEO Linda Hurley told The Journal that “in the midst of our opioid overdose crisis,” her organization “is beginning to eliminate vital programming. At this time of historic need, CODAC is faced with rates below the cost of service, and with inconsistent and delayed payments from Medicaid and the managed-care organizations, respectively.  

“We have never before provided care to this number of individuals and their families. For over two years, CODAC has in good faith continued to provide services for Rhode Island’s most vulnerable. Like any business, CODAC, along with our community behavioral health providers, cannot continue without cost-of-living increases and timely payment. The state’s safety net is in jeopardy of collapsing.”

“In the midst of a suicide and opioid overdose crisis, this administration has allowed the  managed-care insurers to make it virtually impossible for the providers like Newport Mental Health to meet the needs of the most vulnerable and fragile group of citizens,” said Lehane, the agency’s president and CEO. “The MCOs’ failure to pay us for the services we are providing now puts us at the brink of having to reduce lifesaving services. The pattern appears clear that the healthcare of low-income people is not the priority of this administration and their managed-care corporations.”

Along with Community Care Alliance, Newport Mental Health has borrowed money and sold property to meet payroll. Lehane and his senior managers have taken a 20-percent salary cut and 12 members of his administrative staff have agreed to a one-day-a-week furlough for three months. “Staff have stepped up in the face of this crisis,” Lehane said. “They have not let it interfere with services to our clients.”

Looming over all, many say, is the state’s long-standing neglect of a community system that in the 1990s was a national model.

“At one time, Rhode Island was a leader in the country in creating a system that provided integrated treatment of mental-health and substance-use disorders,” Substance Use and Mental Health Leadership Council president CEO Susan A. Storti told The Journal. “Over time, this eroded due to the lack of adequate federal and state funding and insufficient reimbursement rates. This resulted in a downward spiral of the behavioral-healthcare service-delivery system.”

Said Lessing: “Over the past 10-plus years, the state of Rhode Island has abdicated its responsibility for assuring and continuing to evolve a network of community mental health organizations that can effectively and comprehensively serve children and families and adults.”

Particularly hard-hit, Lessing asserts, are “people living with serious or severe and persistent mental illness, children with severe emotional disturbance and their families, and persons that have experienced severe trauma and are challenged with other psychosocial challenges, including poverty, substance use and domestic violence.”

The impact, Lessing asserts, extends beyond individual cases.

“We are failing to connect the dots if we don’t think that a lack of accessible community-based behavioral health services is not relevant to children and families involved with the Department of Children, Youth and Families, adult incarceration and reentry to local communities, veterans, their families and other persons living with trauma histories.”

These, in essence, were also the findings of a multi-part Journal investigation published in 2014, and a related Journal investigation of children’s mental health services a year later. The managed-care difficulties, advocates say, have only exacerbated the situation.

Where once governors and legislators made behavioral health care a priority, advocates say, support has waned. Today, they assert, only Senators Joshua Miller and Louis DiPalma and a few others in the General Assembly serve as champions.

“There is no simple solution to this complex set of problems, and as such, this requires continued, extensive intervention and I believe policy changes,” DiPalma told The Journal. When payment processing was transferred to managed-care organizations three years ago, he said, the state gave insufficient support to organizations for the shift.

In summer 2016, DiPalma said, he asked for and participated in weekly calls with the state Medicaid office, the managed-care organizations and community organizations “to begin a targeted effort to address the multitude of issues, including the inadequate reimbursement for outpatient services while required to foot the bill for outpatient services. While the state has delegated the responsibility and authority for claims processing, they cannot delegate the accountability.”

Miller told The Journal: “People are attracted to the simple and to simple solutions, and this has neither. This is one of the most broken parts of the system. But there are ways to fix this, legislatively and comprehensively.”

In interviews and email exchanges with The Journal since early March, Lessing, Lehane, Storti and members of their staffs listed more specific issues, some related to the transition from direct payment to payment now funneled through managed-care organizations, and others of longer standing. Managed-care organizations took over services to children a decade ago; three years ago, adult services were transitioned to them.

Among the issues:

— Overutilization of emergency departments and a growing habit of “boarding” patients in those departments until proper beds can be found. These practices are considerably more costly than community-based services that might prevent hospitalization in the first place.

— A system of submitting claims that is unreasonably complex and that often results in denials, which require resubmittal, adding to delays in payment for services already provided.

— Substantial incompatibilities in billing software and coding used by the health-care providers and managed-care organizations, and inadequate financial and training support to organizations to bridge this gap.

— Residential treatment program rates that have not increased in a quarter-century.

— Staff vacancies in safety-net programs that have increased caseloads for remaining case managers, clinicians, psychiatrists and nurses.

— The state’s slow response in addressing cash-flow problems experienced by the organizations.

— Managed-care protocols that favor less expensive in-office services at the expense of intensive, home-based services, which are more costly but save in the long term by preventing hospitalizations.

“These and other problems were avoidable or could have been addressed and resolved quickly had the Executive Office of Health and Human Services over the last three years not been vehement in its use of managed care,” Lessing said. “There has been an unwillingness to acknowledge that in its current iteration, managed care simply has not worked.”

Said Storti: “While there were meetings held between the MCOs, the community providers, EOHHS, the Office of Medicaid, and the state department of Behavioral Healthcare, Developmental Disabilities and Hospitals in an effort to rectify these issues, the issues continued.”

David Levesque, director of public relations for the Executive Office of Health and Human Services, responded point-by-point in an email to The Journal.

— Regarding claims, he wrote, in part:

“The state is committed to helping every Rhode Islander in need of mental health or substance abuse disorder treatment. That goal is simply not attainable without our behavioral health providers. … Since implementing managed care for behavioral health services, Medicaid has worked tirelessly to ensure providers’ needs — and, ultimately, the needs of our citizens — are met by the state’s managed care organizations.”

— On software:

“The software systems used by the MCOs and providers are compatible. As with any software system, glitches do exist. That is why the recent launch of Neighborhood Health’s new behavioral health vendor, Optum, was watched closely by Medicaid staff, who have worked with Neighborhood, Optum and the provider community prior to and beyond launch …”

— Financial and training support:

“The state not only helped bridge the transition but continues to work with our providers and other stakeholders. That includes almost daily conversations with providers as well as with their Leadership Council. … We continue to provide one-on-one training and technical assistance on the phone and in person …”

— Cash-flow problems:

“Medicaid has been extremely accommodating to behavioral health providers seeking interim payments when a provider requests them. Medicaid has often processed payments within 24 hours. Rarely has it taken longer than 72 hours to have a check available to a provider. Our Medicaid team cannot recall not being able to meet a provider’s timetable for an interim payment when a provider expresses a payroll concern.”

— In-office service versus home-based:

“MCOs are required to provide Medicaid members with the services that will meet their clinical needs — they may not favor a less-expensive service if a higher-cost service is clinically necessary. When deemed appropriate, eligible beneficiaries can be enrolled in the state’s Medicaid-funded Assertive Community Treatment (ACT) program, which offers home-based services including respite, personal assistance services and supports (PASS), and home and community-based services (HCBS). Community mental health centers can also provide at-home assessments as needed for Medicaid beneficiaries …”

The Journal reached out to individual managed-care organizations.

In an email response, Neighborhood Health Plan of Rhode Island Chief Medical Officer Dr. Marylou Buyse spoke of the organization’s 25 years of experience with people served by Medicaid and of the “strong partnership among the community health centers, community mental health centers, and the State of Rhode Island to serve individuals and families” and Neighborhoods commitment to “work together to address the overall health care system transition into new models of care and payment.”

Buyse acknowledged some continuing problems with some providers, writing that “while Neighborhood is meeting our contractual requirements, we know a few behavioral health providers are experiencing delay in payment for a variety of reasons. Therefore, we have offered extra assistance and training to billing staff to address any specific claims and payment concerns to help solve their issues and expedite payment…

“We are aware the community mental health centers are seeking a new structure to the Medicaid program for behavioral health services from EOHHS. We remain committed to our partnership with the State and the community mental health centers as we work together to address the behavioral health needs of those who benefit from the State’s Medicaid program.”

Minnesota-based United HealthCare also responded by email, writing: “We work closely with our state partners and providers to help our members get the services they need, and are committed to ensuring claims are paid promptly and accurately. We ask any provider with a specific concern to contact us directly so we can work together to ensure timely payment.”

Sonya Hagopian, Vice President, Corporate Communications and Public Relations at Tufts Health Plan, told The Journal: “We are working proactively with the affected providers and the state to resolve any outstanding issues.”

Patrick Kennedy is no stranger to plights such as A.J.’s and his mother’s, or to the larger issue of how people living with disorders of the brain fare in the American health-care system. A co-sponsor while representing Rhode Island in Congress of the Mental Health Parity and Addiction Equity Act of 2008, which requires insurers to provide coverage for mental-health and addiction treatment, Kennedy today heads The Kennedy Forum, a leading national organization on these issues.

In a recent interview, Kennedy said that with no national or state comprehensive “strategy” to achieve parity, care of people with mental-health and addiction issues becomes a game of “Whac-a-Mole”: address one need only to have another pop up again and again.

“Until we fix the separate and unequal system of care those with mental-health and substance-use disorders face on a daily basis,” Kennedy said, “nothing will truly change. We have to move to a health-care system that treats the whole person — one set up to address mental-health and substance-use disorders before stage four, just like we do with cancer.

“But to build the foundation of that system, everyone, not just insurers, must walk the walk for parity. Health plans, regulators, payers, and state and federal policymakers are all culpable. They all have a responsibility to make sure people have access to the care they need. Sometimes that means asking tough questions and demanding transparency and accountability. We know what needs to be done to make a difference. We are just lacking the political will to get it done. It’s time for people to stand up and say enough is enough.”

Since control of payment for services that Community Care Alliance provides to A.J. Soto and Erika Krueger has gone to managed care, the son and mother have been in a cycle that she and the agency’s staff say is counterproductive.

First, intensive community-based care is authorized. The cost is $88 per contact; there may be multiple contacts in a week.

“We work with Mom, we work on parenting skills, we work with A.J.,” said Daniel Barbosa, licensed mental-health counselor and team manager of children’s behavioral health at Community Care Alliance. “We try to create a schedule, more structure in the home. We work with the school.”

With this, A.J. is stabilized — and then is switched to office-only care, less intense and cheaper, $68 to $72 for a visit. Community services having been withdrawn, A.J. falls back into disruptive behaviors. Home services must then be reauthorized, and when A.J. improves, they are ended and office-based services resume. Several times this cycle has repeated, Barbosa and Krueger told The Journal.

The situation is further complicated by logistics: Krueger owns no car, so she must walk with her son some 20 minutes to the nearest bus stop and then ride to the office, where the professionals who see her son might be strangers from the last visit.

“Because of his behaviors, it's difficult to even get him to come along,” said Krueger.

And she must deal with disruptions from school: When A.J. acts out, she sometimes is called to take him home. That interrupts her son’s education, and also her own, the computer-literacy classes she is attending as she works toward finding employment.

“It’s kind of rough,” Krueger says.

“Home-based care is, hands-down, more effective,” Barbosa said.

“They get to see better how he really is,” said Krueger.

Said Lessing: “The social-justice considerations where low-income people are concerned is glaring. Who speaks for them? Have we reached a point where payment and procedural issues that the administration should be able to manage need to be legislated?”