An experimental mental-health and addiction treatment program that has shown early success at combating the opioid crisis at risk of losing its federal funding.
An estimated 9,000 patients could lose access to medication-assisted treatment, and 3,000 clinic jobs could be lost if the funding is not renewed, according to the National Council for Behavioral Health. Some states may feel the impact as early as January, since clinics must give staff 60 to 90 days' termination notice.
Lawmakers in both parties have committed to boosting mental-health and addiction treatment to address the opioid epidemic, but new funding for the behavioral-health clinics initiative was not included in the $8.4 billion package Congress passed in October.
"There was a lot of concern in Congress about the overall cost of the package," said Rebecca Farley David, vice president for policy and advocacy at the National Council for Behavioral Health. Advocates cited an estimate of $520 million to continue the initiative, a cost that bill sponsors and the Congressional Budget Office could not confirm.
David called the program's exclusion from the package "a missed opportunity," pointing out that it is already tested, established and implemented.
Matt Salo, executive director of the National Association of Medicaid Directors, said Medicaid's move toward "value-based payments," which reward providers with incentive payments according to the quality of care delivered, does not align with the clinics' system, in which Medicaid reimburses providers fixed amounts for bundled services.
"It sets payment rates at a higher level than what we would pay anybody else for doing the same thing," he said.
Clinic directors and advocates pointed out that many therapies, including psychiatry, are often reimbursed at rates far below the actual cost to deliver services, and the bundled payments close some of that gap.
The experimental program was set up after legislation in 2014 established standards for a new clinic designation called Certified Community Behavioral Health Clinics and created flexible funding that allowed the clinics to expand patient outreach and services for two years. The program kicked off in eight states in 2017, and during its first, it year served an estimated 381,000 patients, according to a report from the Substance Abuse and Mental Health Services Administration.
Clinics in Oklahoma and Oregon would be the first to lose funding, as their programs expire at the end of March. In Minnesota, Missouri, Nevada, New York, New Jersey and Pennsylvania, the demonstration program runs through the end of May.
Given the looming deadline, states are frantically devising alternative plans. Some are applying for Medicaid waivers, which require periodic renewal and are a larger administrative burden. Others are seeking one-time grants to keep the staff they've hired.
Sen. Debbie Stabenow, D-Mich., co-sponsored both the 2014 legislation and the extension bill now in committee. She cited the need for parity between treatment for mental health and physical health as an inspiration for the initiative.
The clinics are required to provide access to nine services, including emergency crisis intervention, medication-assisted treatment and psychiatric rehabilitation.
“We are making a commitment to comprehensive services and that this is part of the way we look at health care,” Stabenow said in an interview."This is not separate."
At Red Rock Behavioral Health Services in Oklahoma, the multidisciplinary approach has yielded significant results and saved the state nearly half a million dollars by making it possible to treat patients at a lower, less critical level of care, according to CEO Verna Foust.
Before Red Rock joined the program, "there was never enough time for the doctor to really sit down with the therapist or the case manager to really collaborate on what was going on with that patient," she said.
Foust said the reimbursement system gives Red Rock the flexibility to provide care that is not ordinarily billable to Medicaid, such as accompaniment for patients who need extra assistance to get to a primary care doctor, or spending more than five to 10 minutes on medication follow-up appointments.
Cascadia Behavioral Healthcare in Oregon used program funding to build a data analytics platform that showed that people with chronic back pain and mental-health concerns were visiting emergency departments at higher rates than other patients. So Cascadia developed a pain management pilot to cater to that group. Chief Medical Officer Jeffrey Eisen said Cascadia has seen improvements in scores of depression, anxiety and pain, as well as higher quality of life and fewer visits to emergency rooms.
Police departments have been the less obvious beneficiaries of the program. More than half of state prisoners and jail inmates have some mental illness, and of that population, 3 in 4 have a substance-use disorder, according to the National Council for Behavioral Health. When police take an intoxicated person into custody, they generally need to take the person to the emergency room to sober up or receive treatment. That takes time away from public-safety duties, said Rick McCubbin, chief of police in Shepherdsville, Kentucky, which does not have such clinics.
At the Niagara County jail in upstate New York, staffers from the local behavioral-health clinic deliver basic addiction and mental-health care while people are incarcerated, and a mobile unit meets inmates as they are released to take them straight to their first mental-health or addiction consultation. Release is a critical moment, said Deputy Chief Daniel Engert, who is also a jail administrator.
"When people fail to make that first appointment upon release, we've lost them," he said at a panel discussion in Washington this month. "Their condition deteriorates, they reoffend, and then they end up back in jail, or worse, they end up dead."
Recidivism has declined among former inmates who got door-to-door transportation from jail to the clinic, which means the program is working, Engert said.
Eisen said he hopes lawmakers will find a way to preserve the program.
“That would be such an unfortunate consequence,” he said. “It’s too important to change course.”