PROVIDENCE – When reporting on the huge gaps in mental health and behavioral health care services in Rhode Island, the story often resembles a routine from the Marx Brothers movie, “A Night at the Opera,” in which Chico and Groucho literally tear up a contract on camera, leading to the memorable line: “You can’t fool me. There is no sanity clause.” [See link below to YouTube video.]

The current crazy quilt of Rhode Island’s vershtunk mental health policies, more a tragedy than a comedy, has an equally absurd plot line:

• The R.I. Office of the Health Insurance Commissioner has conducted “market conduct examinations” of the four major commercial health insurers operating in Rhode Island.

• These market conduct examinations identified “violations” committed by all the insurers related to enforcement of federal and state “behavioral health parity” laws, focused on measuring compliance with regulations related to the coverage of mental health and substance use disorder services.

Translated, in the midst of a devastating epidemic of opioid addiction and substance use disorders, which has claimed more than 300 lives a year for the last four years and disrupted thousands of lives and families, Rhode Island’s commercial health insurers have apparently chosen to focus on wringing more money from the system rather than investing in better coverage, according to OHIC’s findings.

“This is not a surprise at all,” said John Tassoni, Jr, the director of operations at the Substance Use and Mental Health Leadership Council of Rhode Island. “We’ve been having discussions about this for a long period of time. There has been a big gap in parity with the mental health and substance use services, compared to any other health care issues.”

• In response to the latest market conduct examination finding, announced by OHIC on Monday, March 30, the UnitedHealthcare Insurance Company and UnitedHealthcare of New England, Inc., agreed “to pay a $350,000 penalty to the state and make a $2.85 million contribution to a community mental-health fund related to several violations that potentially delayed and/or impeded care,” according to the OHIC news release.

UnitedHealthcare has not been alone in its transgressions. Previous OHIC market conduct exams of Blue Cross and Blue Shield of Rhode Island, Neighborhood Health Plan of Rhode Island, and Tufts Health Plan have led to orders to these three insurers to make “contributions” toward a mental health and substance abuse fund.

• On Thursday, April 2, with the ink barely dry on the news release from OHIC announcing the settlement with UnitedHealthcare, Gov. Gina Raimondo announced the creation of a new COVID-19 Behavioral Fund at the Rhode Island Foundation, with more than $5 million designated “to fund nonprofit organizations working to address Rhode Islanders behavioral health needs resulting from the COVID-19 crisis.”

Translated, the money paid in “contributions” for the past sins by the commercial insurers in Rhode Island because of their inequitable coverage of mental health and behavioral health conditions was being “seized” by the Governor to create a new source of funds to pay for the current outbreak of stress and anxiety related to the COVID-19 pandemic, with the Rhode Island Foundation managing the money.

Tassoni said he welcomed the potential influx of new funds to the cash-starved nonprofit agencies providing services. “We are dealing with multiple epidemics now: the opioid epidemic and the coronavirus epidemic,” he said. “This is putting an enormous burden on my member [agencies], on the people that work [on these issues].”

Tassoni also praised Marie Ganim, the R.I. Health Insurance Commissioner, “for doing what she did and calling them on the carpet, because [the insurers] were not treating people fairly, picking and choosing how they wanted to pay claims, and how much they were going to pay.”

Nonprofits have been encouraged to apply for “grants” from the new fund beginning on Monday, April 6. Actual details about how the funds would be dispersed appear to be a work in progress, but according to the news release, funding will be awarded to the following specific programmatic areas:

• To support evidence-informed programs that meet a specific local need related to the COVID-19 pandemic.

• To support operating expenses necessary to continue delivery of behavioral health services.

Further, preference will be given to proposals that serve communities that are disproportionately impacted by behavioral health issues and are underserved by behavioral health supports.

The news release continued: “The new fund will not support research, capital projects, event sponsorships, or individuals. Exceptions for capital expenses may be made if they are related to remote treatment capabilities or filling a gap in residential care.”

In search of a long-term plan
The new “COVID-19 Behavioral Fund” does nothing to correct the cause of the “symptoms” identified by OHIC in its market conduct exams of commercial insurers: how nonprofit providers of behavioral health and mental health services are being financially hamstrung by low rates of insurance reimbursement, with some providers not having seen an increase in rates for more than 20 years. [See link below to ConvergenceRI story, “Show me the money.”]

In addition, the nonprofit agencies have had continued difficulties in getting paid in a timely fashion by managed care organizations under contract with the state, making it difficult to keep their workforce from rapidly turning over because of low pay.

What is lacking is a coordinated, integrated system of care, according to Susan Storti, Ph.D., RN, the president and CEO of The Substance Use and Mental Health Leadership Council of Rhode Island.

“To me, the only way that gets addressed is that you have to look at the system as a whole, you need to identify where the gaps are, and you need to identify where are the success stories, and you need to start to move forward with creating a system of care that looks at those gaps, and looks at those success stories, to see if there is some way those two things can be merged to be able to truly address what is happening in the field,” Storti said. “To be able to support that type of infrastructure, there needs to be a better reimbursement rate, because it’s not going to happen without that.”

The new “COVID-19 Behavioral Fund” will serve as an emergency financial lifeline for many agencies that are swimming as fast as they can to keep afloat with increasing demands placed upon them by the coronavirus epidemic, but some agencies have expressed worry that it will prove to be a short-term fix, without any plans for a long-solution.

Advocating for the need to increase rate reimbursements by Medicaid and by the commercial insurers can be frustrating. “It is like proving gravity at this point; there is nothing left to prove,” said Linda Hurley, president and CEO of CODAC, Inc., describing the frustration she feels when arguing about the need to increase reimbursement rates. Hurley is a member of the Senate study commission on insurance rate reimbursements chaired by Sen. Joshua Miller, where she gave a presentation that detailed the ongoing disparities in insurance rates and the detrimental impacts on clients and being able to recruit and maintain staff. [See link below to the presentation.]

The view from OHIC
In between the announcement of the settlement with UnitedHealthcare and the news release about the formation of the new “COVID-19 Behavioral Fund,” ConvergenceRI had reached out to OHIC to get the agency’s responses to a number of questions. Cory King, OHIC’s director of policy, responded promptly.

ConvergenceRI: The latest news release detailing the settlement with UnitedHealthcare appears to document that all the major health insurers in Rhode Island – UnitedHealthcare, Blue Cross and Blue Shield of Rhode Island, Tufts, and Neighborhood Health Plan – have all been found to have major problems with how their reimbursements for mental health and behavioral health services have been applied. Is that an accurate statement?
KING: The market conduct examinations did not review the level or methodology employed to calculate provider reimbursements but did concentrate on the decisions that influenced payment for certain covered services during the years that were sampled and reviewed. OHIC’s focus was on the application of insurer benefit determination policies and processes, specifically prior authorization and utilization review as applied to behavioral health care.

ConvergenceRI: Based on OHIC’s actions, what recommendations will you be making to the Commission on Insurance Rates led by Sen. Josh Miller, of which Marie Ganim is a member?
KING: We have not completed the Market Conduct Exam of the four insurers that is looking at “network adequacy.” That review will offer more information that is directly germane to the question of access to needed care and should be helpful to the work of that Commission.

ConvergenceRI: Last year, the chief medical officer at the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals did an analysis that found only 6 percent of patients who had been diagnosed with a substance use disorder or a mental health condition received holistic treatment for both, identifying a huge gap in the alleged system of care. Is that something that OHIC can address in its affordability standards?
KING: Yes, OHIC’s focus over the short and long term is to make policies that will facilitate the creation of a system of care for patients with physical and behavioral health issues.

The current proposed Affordability Standards begin with behavioral health integration into primary care to promote universal screening for depression, anxiety and substance use disorders and to support warm handoffs to behavioral health clinicians.

OHIC will continue to work with payers, providers and other state agencies to address the full continuum of behavioral health services.

ConvergenceRI: Has OHIC done any analysis of the research from the pilot HealthPath program launched in 2014 to provide wrap-around services for mental health and behavioral health care for one bundled fee, involving Blue Cross, Care New England and the for-profit arm of the Providence Center?
KING: No. However, OHIC does encourage payers to develop innovative approaches to health care payments to support better delivery of care.

BCBSRI has been a good partner in doing so. OHIC has requested a new position in the Governor’s proposed FY 21 budget to work with consumers, providers, state agencies and multiple payers on behavioral health system development. The innovative payment and care delivery program mentioned would be a logical model to review in that context.

The view from the Rhode Island Foundation
ConvergenceRI also reached out to the Rhode Island Foundation and to its president and CEO, Neil Steinberg, asking: While the new fund will certainly address critical needs and gaps caused by the pandemic, is there a longer-term need to look at the systemic issue of low and disparate reimbursement rates by insurers? And if that is so, what kinds of solutions and recommendations do you see becoming part of the long-term health plan for Rhode Island?

Under Steinberg’s leadership, the Rhode Island Foundation convened a group of stakeholders and produced a draft of a 10-year, statewide health plan for Rhode Island, and then held a meeting with stakeholders in February to discuss what was in the plan. [See link to ConvergenceRI story below, “Will the health care industry willingly relinquish its economic power?”]

Chris Barnett, the senior communications and marketing officer at the Foundation, referred ConvergenceRI to the outline on Pages 12 and 13 of the vision articulated in the Health in Rhode Island plan, under the heading: “Improve behavioral outcomes by focusing on access to care, coordination of care, and prevention.”

Here are the bullet points:

• Create a continuum of care and identify gaps.

• Address gaps in alternative levels of care, including where to send someone after facility-based care and ensuring sufficient step-down facility capacity.

• Conduct data analysis to support implementation strategies.

• Coordinate with Rhode Island Health Care Cost Trends Steering Committee to look at behavioral health care cost data from the All Payers Claims Database.

• Conduct a “lean manufacturing review” to assess and improve the system, with a eye toward missed connections where the ball is dropped in patients’ care, and ensuring that high-quality, cost-efficient existing efforts are sustained.

• Use community capacity more effectively, and support it appropriately.

• Improve dialogue between inpatient and outpatient systems.

• Address capacity challenges for youth [7-12 years] and adolescents [13-18 years]. Sustain and scale efforts in infant behavioral health.

• Reform the ways we finance behavioral health care. Address the financial frailty of the mental health provider network.

• Support integration of behavioral health care and primary care.

• Address disparities in treatment, including through a continued focus on ensuring equitable coverage, e.g., application of existing parity laws.

As a management plan, it sounds comprehensive. But, nowhere in the bullet points discussing the framework for the long-term plan for behavioral health does there appear to be an explicit strategy focused on the need to raise the reimbursement rates or to ensure that providers get paid on time by managed care organizations under contract with the state. The bullet point to “address the financial frailty of the mental health provider network” could be translated into any number of policy interventions unrelated to increasing low reimbursement fees.

Translated, there appears to be “no sanity clause” within the long-term plan’s framework.

Lost in translation
A study by Milliman, an actuarial firm, looking at the rates of reimbursement around behavioral health care and mental health care in Rhode Island, has been completed and has now been shared with stakeholders.

In a letter dated Feb. 28, Ben Shaffer, the Acting Medicaid Director and Deputy Secretary at the R.I. Executive Office of Health and Human Services, addressed what he described as the limitations of the study.

Shaffer wrote: “This study should be viewed as the first step in exploring behavioral health rates and services. We recognize that this was not an exhaustive review of all behavioral health services and is not meant to be representative of all services.”

Shaffer continued: “Additionally, as all of these services are included in managed care, but not analyzed here, the capitation rates should be considered in any future study or discussions.”

Finally, Shaffer wrote: “We note that because of time limitation of federal funding, Milliman was not able to engage any stakeholders regarding the final rate models, comparison rates, or the final report, which is a standard and critical step for all of our payment system and rate-setting design and evaluation projects for Medicaid and other public agencies.”

Translated, the study appears to been conducted in a half-assed manner, in ConvergenceRI’s opinion, in its attempt to analyze the disparities of Medicaid rates for mental health and behavioral health services.

To sum up, the statewide long-term plan for behavioral health care in Rhode Island apparently failed to address the two of the biggest concerns: the need to increase reimbursement rates and the need to ensure payments are made on time by managed care organizations. Even worse, the potential documentation to support the need to raise Medicaid reimbursements appears to be lost in translation because of a flawed study. You can’t fool me. There is no sanity clause.

Nuance and context
Jonathan Goyer, who heads the state’s efforts to develop a recovery friendly workplace initiative in Rhode Island, recently shared some new data on the latest research calculating how much substance use in the workforce is costing employers annually.

Twelve employers have submitted letters of interest in participating in the Recovery Friendly Workplace initiative, representing a total of 3,428 employees, within the industry sectors of health, public administration, social services, education and nonprofits, according to Goyer.

Goyer provided a snapshot of the costs, based on those 12 employers. Cumulatively, the costs of substance misuse in the workforce for those specific employers alone totaled $996,016 per year, with lost time accounting for $294,943 in costs, and job turnover and re-training costing approximately $352,947. Health care costs were $348,126.

Of 3,428 employees across all 12 employers, Goyer continued, it was determined that 264 were suffering in active addiction, as were 700 of their dependents and/or direct family members.

An equally fascinating data point according to the data snapshot provided by Goyer: alcohol was the number-one substance being misused.