Joint Committee on Financial Services
The Massachusetts Hospital Association (MHA), on behalf of its member hospitals and health systems, appreciates this opportunity to offer testimony in strong support of HB905, “An Act to Expand Coverage and Access to Behavioral Health Services.”
MHA commends the legislature for the many efforts it has undertaken in recent years to strengthen mental health parity protections and enhance access to services (such as Chapter 258 of the Acts of 2014). These have been important steps that have resulted in meaningful benefits for patients. Yet, despite these advances, true “parity” in accessing mental and substance use disorder services remains elusive. This disparity is highlighted by the numerous administrative and regulatory barriers to timely and appropriate services that still exist. These barriers contribute to the daily boarding of patients in hospital emergency departments as they await needed inpatient-level services and care.
The provisions of HB905 address some of the most-pressing administrative barriers and advance reforms that can be taken immediately, with little-to-no financial cost, and that will drastically improve access to services for patients in need of behavioral healthcare. For the past several years, MHA has worked closely with a coalition of behavioral health care providers on identifying and prioritizing these needed fixes. The provisions of HB905 were developed through a coalition effort that includes the Massachusetts Medical Society, the Massachusetts Psychiatric Society, the Massachusetts Association of Behavioral Health Systems, and the Massachusetts College of Emergency Physicians.
HB905 outs forward multiple critical changes to the current system that would advance parity for, and timely access to, appropriate behavioral health services for patients. This essential goal is sought through the following provisions:
Sections 1 and 3 of the bill remove prior authorization requirements for inpatient mental health services for Medicaid and private insurers for the first 14 days, so long as the provider notifies Medicaid or the private insurer within 48 hours of admission. Insurers often use different terms for these barriers such as prior authorization, pre-approval, prior-approval, etc. No matter the terminology used, such insurance barriers to care for mental health patients are discriminatory and reinforce an improper division between mental health services and other medical care. Similar restrictions are not placed on other patients that enter the system through hospital emergency departments (EDs). The language in these sections of HB905 mirror and build upon the similar protections for substance abuse services included Chapter 258 of the Acts of 2014. In that important law, the legislature recognized that penny-focused artificial barriers put in place by the insurance industry were interfering with necessary care and treatment for patients suffering from substance use disorders (SUD). Sections 1 & 3 of this legislation would ensure that similar protections are afforded to all behavioral health patients – whether they are suffering from SUD or any other mental health condition.
Section 2 of the bill would ensure that any qualified clinician is allowed to assess and recommend an order of admission for a patient with a mental health condition. Under current law, only a psychiatrist can make this order of admission - this results numerous delays in getting mental health patients to an appropriate level of care. This standard is in place only for mental health patients – ED physicians are empowered to order an admission for any other patient who suffers from any other medical condition. This is yet another example of a disparity in rules related to treatment for behavioral health rules. This section of HB905 would cure the existing inequity.
Section 4 would expand the number of community-based crisis stabilization services to help care for patients outside of hospital Emergency Departments (EDs), and, if necessary allow such teams, who are directly working with patients, to determine if an admission is necessary to a hospital facility from the community – instead of making the patients go through an ED. This will help speed access to needed services on a timelier basis. Currently, if the community-based screening team under contract with the state determines that an admission is appropriate, they must send the patient to the emergency department which results in duplicative reviews, further delaying care and contributing to ED boarding.
Sections 5 and 6 work in concert with each other to help ensure that insurers are invested in the identification of available services and appropriate placements for patients in need of behavioral health services. Section 5 would require public and private payers to have a live representative available 24/7 to assist healthcare providers in searching for available inpatient or outpatient placement within the payer’s network once the provider determines that further treatment is necessary. The current participation by insurers is disjointed, at best, and more often than not, it is the treating provider that must search for available placements and ensure that any available bed is within the patient’s insurance network and covered. Section 6 of the bill requires insurer to reimbursement providers at the inpatient contracted rate for each 24 hour period that a patient remains boarded in the ED. Currently, insurers have no incentive to assist in the timely identification of available in-patient level treatment. While the patient remains in the ED, the hospital is reimbursed with a minimal per diem payment that falls far below the actual costs of care and services required by patients in that setting. Behavioral health patients regularly wait hours, if not days, in EDs while there is a search for an appropriate and available inpatient bed. During this process, providers must spend multiple hours attempting to obtain appropriate placement and access to care for patients. These two important sections would together require that insurers be directly involved in the process. The outcome would be appropriate access to services and treatment for patients and this would help release crowding pressures on overburdened EDs.
Section 7 of the bill would require insurance coverage for mental health and substance abuse services provided to a patient, regardless of the location of the service. Psychiatrists and other behavioral health professionals continue to be severely limited in the number of behavioral health diagnosis codes that they are capable of applying when submitting claims for reimbursement from certain payers. And even those codes can only be used sparingly. HB905 will require insurers to recognize the evaluation and management services related to behavioral health conditions provided in hospital emergency departments and other outpatient settings, something that current codes do not allow for now. It is important to note that the language included in HB905 (section 7) is based on similar language that the legislature adopted as part of section 32 of Chapter 118 of the acts of 2013, where the legislature required that the MassHealth PCC program provide such coverage. Essentially, the language would ensure that all patients suffering from a mental health or substance abuse condition would be able to have their treatment covered, regardless of the location of the service or the severity of their illness. The goal of this provision is to eliminate the disparity currently faced by patients seeking to access routine behavioral health services. The language adopted by the legislature only impacted the MassHealth PCC population for the 2013 state fiscal year. This provision, however, would apply to all insurers. To better help explain why this language is necessary, we provide the following first-hand example:
“Insurers routinely do not cover certain services if the patient shows up for an evaluation in a non-behavioral health setting. For example, a patient may come to a hospital or health center for medical service following a drug overdose. The treating healthcare provider may find that, in addition to medical issues, the patient suffers from major depression. The provider will then have a behavioral health provider evaluate the patient and determine a course of treatment (inpatient or outpatient) for the behavioral health diagnosis. However, since the patient was evaluated by a behavioral health clinician in a non-psychiatric setting, many insurers will not recognize the behavioral health services provided because they refuse to cover a behavioral health diagnosis and treatment in that setting.”
Section 8 of the bill would develop a supplemental payment for MassHealth mental health & substance abuse services to address the gap between the programs standard reimbursement from its and 95% of the cost of care provided for mental health & substance abuse services. The MassHealth program is the single biggest payer of behavioral health services, yet the rates it pays to healthcare providers are woefully inadequate. Growing Medicaid underpayments have affected all health care providers. Medicaid behavioral health reimbursement, in particular, has long been neglected. A review by the state’s own behavioral health managed care contractor shows that acute care hospitals with psychiatric units are paid approximately 70% of the costs of care. The state must renew its commitment to these needed services if we have any chance of gaining the investments necessary for the system.
Section 9 would help address the critical shortage of care available for children and adolescents who also have an intellectual disability. It requires the Department of Mental Health to develop a “difficult to manage unit” of at least 15 beds by October of 2016 either within an existing DMH facility or at a facility contracted by the department. Such services are sorely lacking in the commonwealth. The establishment of this needed unit should be a top priority.
Section 10 would establish a task force co-chaired by the EOHHS Secretary and the Trial Court Administrator, to develop legislative recommendations to streamline judicial reviews to expedite the delivery of care for inpatient hospital commitments and Rogers’s guardianship hearings. Speedy judicial reviews of these cases are essential to the provision needed services. Yet, the judicial process can often be stagnant, which potentially places patients in jeopardy by preventing their placement in an appropriate level of care. While the commonwealth is likely reluctant to commission yet another behavioral health-related task force, the complexity and sensitivity of this issue requires a team approach in order identify efficient procedures for these critical proceedings.
Section 11 of HB905 would expand private insurer coverage for community-based behavioral health services for children and adolescents. Currently, these services are only covered by Medicaid through the Children’s Behavioral Health Initiative. This provision mirrors language encompassed by HB789, which is also under consideration by the committee. The children of families with commercial insurance now either go without these services, or use “secondary MassHealth” to obtain these services. One in five children and adolescents experiences symptoms of a diagnosable mental health disorder each year. Half of all lifetime mental illnesses begin by age 14 (with 75% beginning by age 24). Among children ages 9 to 17, 11% experience significant impairment from mental illnesses and 5% experience extreme functional impairment. In 2008, the state implemented the Children’s Behavioral Health Initiative (also known as the Rosie D. remediation), which reflected the recognition that children and adolescents in Massachusetts who suffer from mental illness needed access to community-based services in order to minimize the need for inpatient services. Yet families who have commercial insurance should not be required to rely upon MassHealth in order to access services for their children. Right now, families pay MassHealth premiums to access wraparound care through the CBHI. Yet the community- based care that wraparound services provide (including therapy in community settings, specialist consults, ongoing staff support and psychological evaluations) can prevent costly hospitalization of these children. The state shouldn’t have to pay for services that should be covered by commercial insurance plans.
Each of these HB905 proposals would result in meaningful change for the challenges plaguing the state’s behavioral health system MHA looks forward to working with the committee to advance these important fixes in an expedient manner. We respectfully urge the committee to issue HB905 a favorable report.
Thank you for the opportunity to offer testimony on this important matter. If you have any questions or require further information, please contact Michael Sroczynski, MHA’s Vice President of Government Advocacy, at (781) 262-6055 or msroczynski@mhalink.org.