Morgan T. Sammons, PhD, ABPP
Middlemen in mental health care have a deservedly unsavory reputation. Any practicing clinician is too painfully aware of the arduous necessity of qualifying patients for treatment, and the seemingly endless cycle of denials and appeals orchestrated by low-level employees of major HMOs. All too often, clinicians and patients gave up out of sheer exhaustion if nothing else, which in effect makes a mockery of state and national parity legislation. As we are all aware, even though national parity legislation exists, (the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008; MHPAEA), this is quite variably applied and enforced. Even with partial implementation of the Affordable Care Act (ACA), patients with otherwise good health insurance may find it difficult to locate reimbursable services, and this difficulty grows according to the cost and complexity of a disorder (inpatient substance abuse, long term mental health care, etc.). Lower income patients with less comprehensive health care plans face access hurdles unimaginable in other developed nations, this, among other lagging indicators, has caused the U.S. to be named the world leader in health care inequities (Hero, et al., Health Affairs, June, 2017).
Although the word “capitation” is often anathema to psychologists, redolent as it is with connotations of restricted panels and low reimbursement rates, well-devised capitation models may actually be good for psychologists and their patients. Capitation, as a refresher, refers to an alternative to fee-for-service reimbursement schemes wherein providers or systems are reimbursed not for patient visits, but are given a flat annual fee for every patient enrolled in that system, regardless of the services provided. For example, with a $5,000 per patient annual cap, a psychologist with 400 covered patients would make $200,000 annually, whether or not they saw any patient, but would have to absorb any individual patient billing in excess of $5,000.
Obviously, it would be in the psychologist’s best interest to keep individual patients healthy. And this is where earlier capitation models met their downfall. Insurors and HMOs were under tremendous pressure to keep their costs under the cap, and this led to many maneuvers, painful to both individual patients and individual providers alike, to restrict access, limit care, cut provider reimbursement, and otherwise keep costs to a minimum. Unregulated capitation was both heartless and headless, and in the end did little to improve healthcare outcomes, though it did make many HMO investors quite wealthy.
By including quality metrics, the Affordable Care Act altered capitated models in a way that was focused on more than cost control, but such protections are not contained in current versions of the American Health Care Act, at least those versions under present Senate consideration. David Feinberg, the CEO of Geisinger Health Systems, described for Adam Davidson in the 29 May 2017 issue of the New Yorker (“A bipartisan way of improving health care”) how capitated systems led Geisinger to invest in the health of its beneficiaries, improving both enrollee health and the system’s bottom line. As a part of their capitated model, Geisinger offered quality groceries in hospital pharmacies, so that enrollees could pick up their medications and healthy groceries at the same time, a major benefit for enrollees who lived in lower-income, “food desert” neighborhoods.
Our colleague Ben Miller, a psychologist leader in integrated healthcare at the University of Colorado, has echoed the virtues of capitation in an article in the January 2017 American Psychologist. Ben and his colleagues argued that of the extant available payment models, a modified capitation model stood the best chance of providing a sound financial basis for Integrated Behavioral Health Homes, inasmuch as such payment models would have the effect of forcing mental health treatment into an overall service delivery scheme. Ben’s article is a superb synopsis of the pros and cons of various payment strategies, for those of you seeking a primer on behavioral healthcare reimbursement, it is highly recommended (Miller, B. F., et al., Jan, 2017; Payment reform in the patient-centered medical home...American Psychologist, 72, 55-68).
A less convincing payment scheme is now being promoted as a component of the AHCA (American Health Care Act). High risk pools are being incorporated into the current version of the ACHA as a mechanism of providing coverage for individuals with pre-existing conditions, such as cancer, complicated pregnancy, and persistent mental illness. By separating these patients into different actuarial pools, the thinking is that risk can be adjusted to manage the higher costs that such patients incur. But Jean Hall, professor of medicine at University of Kansas, has argued that before the ACA, high risk pools were inadequately funded and did not significantly reduce costs (Hall, J. P., "Why and How to Avoid High-Risk Pools for Americans with Preexisting Conditions," To the Point, The Commonwealth Fund, June 5, 2017). Particularly if the Medicaid cuts proposed under the ACHA go into effect, high risk pools are likely to be an even less adequate means of accommodating the needs of patients with costly, pre-existing conditions. Hall noted that reinsurance programs under the ACA were effective in controlling costs for high risk conditions, and recommends this be continued as an alternative.
So maybe it would be smart to apply the clinical wisdom that many of us have acquired from our patients with unstable personality disorders. Restricting access to care for such patients in many instances leads to higher costs and worse outcome. We know that lack of access in primary care leads to higher incidence of chronic, preventable illnesses and is in general far more costly than preventive interventions. In psychology those of us who have experienced patients with so-called Axis 2 problems (I avoid the use of “borderline personality disorder”, as I’m convinced that the difficulties most such patients display result from trauma rather than an inherently disordered personality structure) understand that restricting access is a surefire way of prompting escalation, disordered behavior and heightened demands for care. Conversely, establishing well-structured access mechanisms assures patients in crisis of their ability to communicate with a provider, which in turns tends to lead to de-escalation, reduction in self-injurious behaviors, and cost-avoidance. This clinical wisdom can, I think, be applied to broader models of health care delivery. Devising payment mechanisms that restrict access is likely to take us back to short term, emergent treatment schemes for mental health problems, akin to the “revolving door” phenomenon associated with poorly designed programs for the persistently mentally ill. In other words, restricting access results in fragmentation, poorer outcome, and higher and generally avoidable costs.
We must consider population health as an investment. If we are to succeed in the goal of improved population health, investments in health education, health related spending programs, health education and access are all necessary. The good news is that the available data clearly demonstrate a very positive return on investment for such expenditures. In the U.S., indirect health care spending (including social service, education, and related support programs) results in a decline in mental health morbidity and mortality. European data indicate an even more convincing association between health care expenditures and a reduction in mortality from common medical conditions (Mackenbach, et al., June 2017 Health Affairs).
As I have argued in previous columns, the moral hazard argument in mental health care access is specious. Asserting that the individual “purchase” of health care follows market driven laws of supply and demand is quite bluntly a diversionary argument that has no grounding in reality. It may be politically smart to argue that lower taxes represent a greater good than access to health care, but deferring spending on access and prevention is anything but wise, as it unavoidably results in much higher costs, greater health care inequities, and an inexorable decline in population health that is wholly predictable and sadly, wholly avoidable. If we continue to treat the health care of American citizens as a political commodity and not as an investment in our future, we will get exactly what we deserve.
As this column goes to press, the US Senate is poised to vote on their version of the American Health Care Act. The Senate has recently made a draft discussion substitute bill available (https://www.budget.senate.gov/imo/media/doc/SENATEHEALTHCARE.pdf). It is in many ways quite similar to the version passed by the House. It proposes immediate elimination of ACA imposed taxes on capital gains and other high value incomes, and it keeps the ACA provision to allow dependents up to age 26 to remain on their parents’ plans. It eliminates ACA imposed mandates for individuals and many corporations to enroll in or offer healthcare insurance. It also dramatically curtails Medicaid funding to an even greater degree than the current House proposal. In general would make it more difficult or expensive for low or middle income families to afford health insurance. While the Senate draft does include language for pre-existing conditions, it makes it easier for states to get waivers for what are termed essential health benefits, including children’s health, maternity benefits, and mental health benefits. Most analysts see the proposal as disadvantageous to persons with mental illness or substance abuse problems.
Although it does not yet have CBO scoring, it seems Senate leaders are eager to vote on the bill before the July recess so that other items on their legislative agenda can be addressed. It seems most likely that the Senate will call a vote on the bill on or before 29 June. Dr. Tony Puente, the current President of the American Psychological Association, noted that cuts to Medicaid, while being implemented more slowly than in the House bill, would be even more draconian, and has urged the Congress to reject the Senate Draft bill. APA likewise strongly opposed the House version (the House bill may be found at https://www.congress.gov/bill/115th-congress/house-bill/1628. I urge Registrants to become familiar with the House legislation and to keep track of the arguments surrounding the Senate bill, and to provide individual input to their elected representatives.
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