LOS ANGELES — If you haven’t heard much about the effects of the Excellence in Mental Health Act yet, you’re not alone. However, that’s about to change.
New programs launched this fall will shine what many advocates say is a long-overdue spotlight on the delivery of community behavioral health services in California and 23 other states.
Mental health advocates say “bring it on.”
According to the National Institute of Mental Health, one in four adults experiences mental illness in a given year, while one in 17 lives with a serious mental illness such as bipolar disorder or schizophrenia.
Each year, only 40% of Americans with a mental health condition receive treatment and a mere 10% of those with an addiction receive treatment, according to the National Council for Behavioral Health.
Local jails in the U.S. house an estimated two million people with serious mental illnesses each year, and three out of four incarcerated individuals also suffer from a substance use disorder. Jails in California, specifically Los Angeles County — along with New York and Illinois — are the largest inpatient psychiatric facilities in the nation.
The law of supply and demand appears to be hard at work here. Because of a shortage of treatment options, jails, hospital emergency departments, homeless shelters and nursing homes bear the behavioral health brunt.
The Excellence Act, Section 223 of the Protecting Access to Medicare Act of 2014 (HR 4302) could substantially lighten this load. It was authored by California Rep. Doris Matsui (D-Sacramento) and co-sponsored by Sens. Roy Blunt (R-Mo.) and Debbie Stabenow (D-Mich.) and Rep. Leonard Lance (R-N.J.) and signed into law last year. The act increases access to community mental health and substance use treatment services while improving Medicaid reimbursement for same.
A Call To Expand
In October, the Substance Abuse and Mental Health Services Administration announced that 24 states — including California — would receive a one-year planning grant of just under $1 million from a total $22.9 million allocation. Upon completion of the planning year, states can apply for a two-year pilot demonstration program that will ultimately be offered to only eight of those 24 participants. It’s expected that all the players will opt to stay in the game.
“By incentivizing states to improve the delivery of mental health care at the local level, the demonstration project will help bring mental health up to a level playing field with the rest of our nation’s health care system,” Matsui said. “I look forward to seeing the progress that comes out of the grants in our state.”
That progress could make an even greater impact in the big picture, she said. “As part of our efforts to tackle mental health care reform at the national level, Congress should expand the Excellence demonstration to ensure that more states have an opportunity to benefit from high quality, evidenced-based, and community-driven mental health care that patients and families so desperately need.”
Charles Ingoglia, senior vice president for public policy and practice improvement at the National Council of Behavioral Health, supports the expansion.
“Having a comparable array of comprehensive mental health services available around the country will go a long way to increase access and quality of care,” Ingoglia said. “This will entail a different methodology to pay for care, and hopefully allow for more flexibility, outreach, engagement and better care coordination.”
Focus on Frequent Fliers
As defined in its application, California’s Department of Health Care Services, in partnership with county mental health plans, will use the planning grant for both physical and behavioral health needs of high-cost Medi-Cal users or “superutilizers.” Medi-Cal is California’s Medicaid program.
Almost half of them have a serious and persistent mental illness. They use ED services approximately three times more, and incur inpatient hospitalizations that last longer than the general Medi-Cal population, DHCS officials said.
The act creates criteria for “Certified Community Behavioral Health Clinics” to serve people with serious mental illnesses and substance use disorders and requires participating states to develop a prospective payment system for reimbursing CCBHCs for required services. The department will design CCBHCs as behavioral health homes that also offer culturally competent services that include veterans and their families.
“A lot of people weren’t even aware that this passed in Congress,” said Rusty Selix, executive director of the California Council of Community Mental Health Agencies. “The way California has designed its proposal to focus on ‘frequent fliers’ is really a perfect fit. The state will now dramatically accelerate integration, seeing people in primary care who need behavioral health care and vice versa.”
States now have an opportunity to strengthen and improve service delivery “by exploring or expanding strategies to collaborate on care and integrate care systems,” said Norman Williams, deputy director of public affairs at DHCS.
California plans to use planning grant funds for expert work groups to design the program and funding structures of the CCBHCs, certify local clinics that apply to participate, and develop and submit that demonstration grant application, he said. If California is one of the chosen eight, clinics certified during the grant phase would begin delivering services in January 2017 and would collect and report the required specified evaluation data.
When asked about the proposed 24-state expansion, Williams said that “since the structural and demographic characteristics of the states are quite diverse, it would seem that conducting the CCBHC demonstration in a wide variety of environments would provide useful information about where and with whom the CCBHC model is most effective.”
A Place of Their Own
“L.A. County supports the Excellence Act in enhancing funding for 24/7 crisis services and integrated care services for individuals and families,” said Kathleen Piche, public affairs director for the Los Angeles County Department of Mental Health. “These mental health services are crucial components of a continuum of care that helps stabilize people in the community and provides a pathway to recovery.”
“The people that we service have such a number of co-occurring physical disorders that studies show cause them to die 20 to 25 years earlier than the general population,” said Dave Pilon, president and CEO of Mental Health America of Los Angeles, one of the country’s oldest not-for-profit mental health organizations with sites in Long Beach, Lancaster and Los Angeles.
“One reason that happens is that people with severe and persistent mental illness have trouble — for a variety of reasons — accessing primary care, especially specialty care,” he said. “That’s one of the major benefits of having community behavioral health centers. We make our population feel welcome in ways a typical primary health center does not. Integration will not only improve quality of lives regarding physical health, but it will bring down costs.”
Only 7% of all health care dollars currently go to behavioral health, said Pilon. “The act would confer a certain legitimacy that a behavioral provider like MHALA could act as an individual’s overall health home, allowing us to be their total, holistic health provider. When we focus on people with severe and persistent mental illness, we have to be the dog and primary care becomes the tail. We are the center of the person’s life when they choose us as their health care home.”
“I am so pleased that there’s an emphasis on true care coordination, the hardest thing to do in integration,” said Kita Curry, CEO of Didi Hirsch Mental Health Services in Southern California and a regional director for the National Council. “I like that there’s more funding for people who are uninsurable, and that there’s more funding in general and more flexibility.”
She said, “Everybody has their set of funding and time pressures, so it’s often hard to coordinate,” adding, “Since we can only bill for actually providing services for the client, in many states care coordination isn’t funded. If you don’t talk to each other and get to know each other, the tendency can be to communicate when there’s a crisis instead.”
Paying for Programs
Selix explained the financials in more detail. For outpatient behavioral health, the act increases the federal share of costs from 50% to 65% which thus reduces the state share of costs from 50% to 35%, he said. “That frees up between $300 million and $500 million in state/county costs. These can be reinvested in expanded care, including housing and other costs that federal funds can’t be used for, and thus draw down even more federal funds.”
“The payment model will cover outreach and engagement and other elements of our services that we currently don’t get federal reimbursement for, so there’s even more financial benefit,” Selix said. “State Medicaid directors have said this concept can also be done by CMS waiver if it is shown to pay for itself, which seems likely, so beyond the eight states and two years, it could become nationwide and permanent.”
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