Could Blue Cross & Blue Shield of Rhode Island transform the state’s mental-health landscape by changing how it pays providers – not just by raising pay rates, but by expanding what it’s willing to pay for?
What if patients having a crisis could get a specialized team to visit them at home, or spend days in a clinic, rather than check themselves into Butler Hospital?
Rhode Island's Market Has Changed. Developers, Builders, Investors and Sellers Must Change With It.
By Emilio DiSpirito IV License Partner | Engel & Völkers Oceanside Leader | The DiSpirito…
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What if primary-care doctors were encouraged to screen patients for everything from depression to alcoholism, and were able to refer patients with both mental-health and substance-abuse problems to a single, Blue Cross-paid clinic for comprehensive treatment?
What if UnitedHealthcare of New England did the same, and RIte Care and the rest of the public health care system made a corresponding effort?
Just a handful of changes, says a new study by the Rhode Island SHAPE Foundation, could make an impact “across the entire behavioral health system,” dramatically improving Rhode Island’s access to care and, potentially, reducing the need for the costliest services.
The study, titled “Difficult Seas: Navigating Behavioral Healthcare in Rhode Island,” was paid for by Blue Cross, and conducted by Booz Allen Hamilton and the RAND Corporation and a local team of experts and mental-health leaders. It is the third of four follow-ups to Blue Cross’ 2002 SHAPE study.
The original study had found a rising demand for inpatient psychiatric services that could push local hospitals beyond their capacity by next year. It also raised concern about the availability of behavioral health services, especially for children and adolescents.
Using 2002 Blue Cross claims data, state data, interviews with over 70 stakeholders (payers, providers, legislators, etc.) and consumers, and a review of national research and “promising practices,” the new study doesn’t report anything ground-breaking, but rather documents known problems and suggest ways in which they could be addressed.
It identifies two root causes: stigma – which keeps people from acknowledging their problems, seeking help and advocating for themselves – and “chronic under-funding,” which drives poorly paid providers out of the system and makes important services scarce.
The result is that patients aren’t getting the care they need, the study says, and that leads to lost productivity, disability, school problems, and even suicide.
About 1 in 5 Rhode Islanders used mental-health services in 2002, the study says, though researchers could only estimate how many didn’t go through an insurer (only 57 percent of adult psychiatrists take private insurance, and 26 percent take RIte Care).
Mental-health and substance-abuse specialists only served 9.4 and 1.5 percent of the population, respectively; the rest of patients got treated by medical doctors. Primary-care providers, the study found, are handling many “straightforward” cases – prescribing drugs for depression, for example – and some manage more complex cases for lack of alternatives. That’s even more common among pediatricians, who often report being unable to get children to a psychiatrist when they need to, but are also reluctant to prescribe drugs for anxiety or depression given the recent controversies over their safety.
Payers could change this landscape, the SHAPE study suggests, by paying behavioral-health providers better, so more will want to see patients and accept insurance. To help the many primary-care providers treating behavioral disorders, the study also urges payers to reimburse doctors and mental-health specialists for consulting with one another, so, say, a pediatrician can call a psychiatrist for advice on how to treat a troubled child.
At a roundtable last Monday, Robin Meili, of RAND, said United, through a pilot program, is now paying for such consultations in California, a model that could be replicated here.
The study also cites several examples of integrated medical and behavioral care programs, including recent efforts by Thundermist Health Centers and Hillside Avenue Family and Community Medicine, and a partnership between Memorial Hospital of Rhode Island and Community Counseling Center.
For patients who need more intensive help, the study urges private insurers to better fund “intermediate services” such as intensive outpatient treatment, day programs, residential treatment and community-based support. In 2002, only 1.6 percent of Blue Cross subscribers who got mental-health treatment used such services, while 42 percent of patients in the public system did. Intermediate services are crucial to preventing the crises that land people in emergency rooms and at mental hospitals, the study notes, and they provide a safe and less costly alternative to keeping patients hospitalized for prolonged periods.
For patients who need more intensive help, the study urges private insurers to better fund “intermediate services” such as intensive outpatient treatment, day programs, residential treatment, and community-based support. In 2002, only 1.6 percent of Blue Cross subscribers who got mental-health treatment used such services, while 42 percent of patients in the public system did. Intermediate services are crucial to preventing the crises that land people in emergency rooms and at mental hospitals, the study notes, and they provide a safe and less costly alternative to keeping patients hospitalized for prolonged periods.
On the substance-abuse front, the study makes two main recommendations: expand the availability of services, especially in the private sector, where many patients now have to go out of state for treatment, and encourage, through financial and other incentives, an “integrated” approach that allows, say, a depressive who’s also drinking too much to get treatment for both conditions together.
At Monday’s event, response to the study was generally positive, but two key legislators who could influence state funding for behavioral care, state Rep. Steven M. Constantino (D-Providence), the House Finance Committee chairman, and state Sen. Elizabeth H. Roberts (D-Cranston), chair of the Senate Health and Human Services Committee, expressed a reluctance to just throw more money at the system.
“We need to not just focus on funding,” Roberts said. Costantino said he hoped Christopher F. Koller, the governor’s nominee for health insurance commissioner, would address some of the problems identified by the study, with an emphasis on attaining true parity between behavioral and physical health care.
Koller, who is still serving as CEO of Neighborhood Health Plan of Rhode Island, said on issues such as intermediate care, “it seems to me that the state has to be a leader,” but he also said market demand could change insurers’ policies. “None of us do this out of some great altruism on our part,” he said. “We do it because people put pressure on us.”
William A. Hancur, associate director for behavioral health at Blue Cross, said his company has already taken several steps to improve coverage, including an average 30-percent hike in provider reimbursement rates last August (plus a 2-percent hike Jan. 1), and better coverage for intermediate services.
Blue Cross is also now reimbursing primary-care doctors for behavioral-health screenings, stressing that diabetes, obesity, heart disease and other major physical problems have strong ties to people’s behavior.
But those changes don’t come cheap, Hancur noted: The higher provider pay alone is expected to cost an extra $8– to $9 million.
“We’re real proud that over the last couple of years, we’ve implemented several changes recommended in this study,” Hancur said. “But it did put us at a tremendous financial disadvantage. That is a dilemma. It’s a problem, because we want to move forward, but we always have to balance that with the cost of premiums.”
The full study is available at www.rishape.org.
