State continues process for behavioral health Medicaid waiver
About three years after starting the process, the state is finally moving forward with a plan to try something different with behavioral health patients on Medicaid in an effort to reduce costs.
The Alaska Department of Health and Social Services has been in the process of applying for a Section 1115 waiver through the federal Center for Medicare and Medicaid Services since 2017 under former Gov. Bill Walker, which would allow the state to use Medicaid funding on non-traditional services for patients with behavioral health and substance use disorders.
The waivers, which target innovative practices not usually authorized by Medicaid, are intended to help states demonstrate a way to reduce health care costs while still providing care.
The origin of the program goes back to 2016, when the Legislature passed a Medicaid reform bill and directed the DHSS to apply for the waiver, said Gennifer Moreau-Johnson, the director of the DHSS Division of Behavioral Health.
Behavioral health is the lynchpin to Medicaid reform, she said; without an effective behavioral health system, underlying problems driving costs will remain. But it may not necessarily fit into the same screening tools as other medical procedures like measuring height and weight. Without an effective continuum of care that emphasizes intervention, behavioral health issues escalate into crises.
“If you think of Medicaid as a health care model, behavioral health doesn’t fit really neatly into the model,” she said.
The federal government fast-tracked the portion of the application related to substance use disorders, approving it in November 2018 with an effective date of Jan. 1, which allowed the state to get the ball rolling on providing those services. The state is expecting approval for the behavioral health section any day, Moreau-Johnson said.
Behavioral health services in the state suffer from both a lack of availability in all communities and overuse at the acute end of the care spectrum. By the time patients access services, they are typically at a critical stage, and families may be broken up as children are put into the care of the Office of Children’s Services.
Inpatient services are limited in Alaska, with only a set number of beds available at Alaska Psychiatric Institute in Anchorage.
The waiver targets three specific populations: children, adolescents and their parents or caretakers with or at risk of mental health and substance use disorders; transitional age youth and adults with acute mental health needs; and adolescents and adults with substance use disorders.
In addition to the difficulty for patients, delivering acute care for behavioral health disorders is often the most expensive. That is a key opportunity to reduce costs, said Farina Brown, the deputy director of the Division of Behavioral Health.
The waiver program helps expand the number of services that are eligible to bill Medicaid, such as the standardized screening for mental health and substance use disorders, and community-based outpatient services and mental health day treatment.
That draws down federal funds to help support services that are needed or are already being provided rather than relying on state funds. In some cases, what the division has done has been to align service codes to make services clearer to bill, Brown said.
The waiver is authorized for five years. However, the state has to complete a number of evaluations along the way, Moreau-Johnson said. The program has to show budget neutrality to the federal government and, in the case of the cash-strapped state government, show savings, she said.
“Section 1115 waivers get evaluated to a degree that no other waiver does,” she said. “We are, for example, required to hire an outside evaluator. We also have a contract with an outside actuarial firm.”
Originally, the state applied for both the behavioral health and substance use disorder components. Because the federal government fast-tracked the substance abuse portion, the state was able to get some of the components in place earlier, Moreau-Johnson said.
Currently, 96 sites are operating around the state, with the majority clustered in urban areas but nine “early adopters” operating in more rural areas, she said.
Capacity is a major concern. The workforce and facility availability in Alaska is already limited, and Moreau-Johnson said providers and organizations in behavioral health identified workforce as a top concern for behavioral health service expansion.
The state has contracted with Optum, an outside organization that provides various services for health plans and population health management, as an administrative services organization to help offset the capacity issue. One of the key goals of the program is to help keep individuals from having to leave their communities to obtain quality mental health services, she said.
“We want to reduce the number of people being treated out of state but also the people going to Anchorage for treatment,” she said.
Brown noted that a recent bill passed by the Legislature also expands provider eligibility to licensed medical family therapists and licensed clinical social workers, who can provide family therapy as an early intervention.
Though the cost savings are a major driver for implementing the program, Brown added that providing behavioral health care for individuals who need it should still be the purpose.
“This is really about providing services to those in need, to meet folks where they’re at, helping providers serve people,” she said. “At the end of the day, this is about changing people’s lives.”
Elizabeth Earl can be reached at [email protected].