STATE HOUSE — Addiction treatment industry officials skewered proposed reimbursement rates from the Patrick administration as “completely inadequate” and “capricious” during a hearing Tuesday before lawmakers who are reviewing the rate-setting process.
Leaders of residential substance abuse recovery homes blamed the state Center for Health Information and Analysis for relying on flawed data to draft the new rates, which they said
would fall far short of covering the actual cost of delivering care.
At a time when Gov. Deval Patrick has declared the opioid addiction crisis an emergency, providers said the failure to adequately compensate providers could jeopardize the community-based network of recovery homes and force patients into costlier hospital settings.
“If nothing changes, we will not exist in another five years. In fact, I think five years is optimistic,” said Daniel Mumbauer, president of the Plymouth-based High Point Treatment Center.
Members of two legislative committees – Public Health and Substance Abuse and Mental Health – convened the hearing to solicit testimony from behavioral health and addiction treatment providers on the implementation of Chapter 257, a 2008 law designed to update payment rates for providers of rehabilitation, education, and workforce training services.
A coalition of provider organizations this summer sued the Patrick administration for failing to fully implement the rate increases according to the timeline outlined in the law. Administration officials told the committees that 95 percent of the new rates have been set or are under development.
Health and Human Services Secretary John Polanowicz and Administration and Finance Secretary Glen Shor submitted a letter to the committees explaining that new rates totaling $342 million in additional reimbursements for providers have been funded since 2008.
The secretaries cited the pending litigation as the reason they did not appear at the hearing to testify.
With recovery home directors estimating it would cost roughly $52 million extra to raise rates to an acceptable level, Rep. Elizabeth Malia warned it could take a focused effort and commitment by lawmakers to new sources of revenue.
Malia, co-chair of the Mental Health and Substance Abuse Committee, recalled campaigning against a ballot repeal of a state sales tax on alcohol that would have provided funding for substance abuse treatment.
“That still really sticks in my craw,” Malia said of voters’ rejection of the alcohol tax.
Malia pledged to work with her House colleagues on funding during the next session, but cautioned, “We cannot have what we won’t pay for.”
“I can guarantee you when we get back into session in January with all the good intentions in this room, unless every one of your legislators is willing to support specific increases, sometimes in taxes or whatever revenue sources there is, we will be back here next year and the year after,” Malia said.
The proposed rates would provide state reimbursement of $82 per day for each residential bed, though providers estimate their actual costs are closer to $120. The directors of the recovery homes said the rates would provide insufficient funding for salaries, employee benefits, professional training and food for clients.
“Recovery homes would be at a competitive disadvantage in the marketplace,” said John McGahan, president of the Gavin Foundation. “This salary package will not attract seasoned experienced clinicians.”
Rep. Jim Lyons, an Andover Republican, questioned why community providers would be getting squeezed if what they are requesting amounts to less than 1 percent of the state budget.
“I urge that we take a good hard look at this and make sure these organizations get the funding they need to provide the services to the folks who really, really need it,” Lyons said.
The community-based provider organizations said they supported the new standards for care developed by the Bureau of Substance Abuse Services, but said CHIA refused their requests to base the rate adjustments on model budgets to implement the new standards. Instead, according to the providers, CHIA used data reported by the recovery homes detailing how they spend state funds that does not take into account the actual cost of delivery treatment.
“The goal was to avoid the situation that you’re describing today,” said Rep. Ruth Balser, a Newton Democrat. “The intent was to pay human service workers a salary reflective of the importance of the work that you do.”
CHIA officials did not respond to a request for comment.
Jonathan Scott, president of Victory Programs, said employees in his organization struggle to be able to save for retirement, and pointed to examples of rates paid for other residential services through the Department of Public Health that far exceed the rates proposed for recovery homes.
He said recovery homes like Victory Programs struggle to make ends meet by fundraising and tapping resources like food banks.
“We’ve been left to fend for ourselves,” Scott said, calling the rate setting process used by CHIA “illogical” and “lazy.”
“You don’t have to have an MBA to see the egregious and unjustifiable examples after examples of the lowest possible costs applied,” Scott said.
Rep. Denise Provost, a Somerville Democrat, shared a story with the committees about a group home resident in her district last month raping and beating a woman on the street in broad daylight.
“I am profoundly concerned that folks who are paid less than $30,000 a year to care for a very challenging population of patients do not have the education, the training, by and large, or the motivation to deliver the kind of care that is necessary for the recovery of the patients themselves,” she said.
Rep. Nick Collins, a South Boston Democrat, acknowledged the pressures on the state budget, but called the rates “inadequate” to meet the needs of residents.
“If these programs fail, we fail as a Commonwealth,” Collins said.
By Matt Murphy
A new study by the Harvard Medical School revealed that even in Boston — a city that is often celebrated as a healthcare hub — access to mental health care remains limited.
Among the other cities featured in this investigation (Houston and Chicago), Boston stood out as the most difficult to get an appointment with a psychiatrist.
This report brings much needed-attention to one insurance insurance companies role in this limited access. Among its findings was a call for insurance companies to offer better access to mental health care by providing more accurate information about local clinicians, specifically in regards to whether they are accepting new patients.
Another day, another story about how the system that provides access to mental health care services is in need of major reform.
Dr. Murray Feingold brought some much-needed attention to one of the biggest medical crises we face today — the inaccessibility of mental health care for people who need it most.
The causes of this crisis include the extreme lack of psychiatrists and other mental health care professionals and the dearth of facilities where care can be provided to these patients.
The basic cause is insufficient funding to the mental health care field.
The article — featured in The Dedham Transcript and other publications across the state this week — goes on to illustrate the complexity of the situation and the necessity of a top-down overhaul of how we, as a country, tackle inadequate access to mental health care.
Robin Williams’s passing has reminded the public how mental health problems manifest themselves in real, consequential ways. Fans, family and friends seemed to be devastated by his loss, not only because we will miss his future great contributions to our society, but because the impending question of whether there was something that we could have done to stop this.
MGH psychiatrist John Herman reminds us of this sentiment in Kevin Cullen’s Boston Globe piece:
When, in my shop, there’s a suicide, everybody feels terrible. There is a universal sense of guilt. Everyone wonders if there is something we could have done or could have done better. Any physician who loses a patient wonders that.
Advancing the public dialogue on the important work to be done to help those who are still suffering is one way we can still help; and it is quite an apt legacy for Williams, who not only gave us the medicine of laughter but also used his remarkable career to often highlight the stories of people affected by depression and suicide (with movies like What Dreams May Come, Good Will Hunting and World’s Greatest Dad, to name a few).
But we need to make sure that this conversation isn’t just talk. We need take action to ensure that those who need mental health care, have access to it. Because something that this Boston Globe article highlighted that we as clinicians have come to know all too well is that “reimbursement rates have dropped even further in the last couple of years.” In turn, many of us have been caught between a rock and a hard place, “financially survive by taking only out-of-pocket patients… [or] leave the business entirely.”
The sad truth is that Williams was one of the lucky ones. He could easily afford out-of-pocket access, and he probably fought and won more of his previous mental health battles because of it.
For the vast majority of people, who have neither the money nor the clout of a Hollywood star, the prospects are even more daunting in a country where insurance companies, not doctors, decide who gets taken care of and who gets substandard care and who gets financially ruined trying to keep a loved one alive.
As clinicians we didn’t need Robin Williams’ passing to remind us what is at stake, but it should inspire us. We have a responsibility to use the tools at our disposal to turn this upswing in awareness into expanded access to mental health care.
Amazon’s price control fight in the ebook publishing world has brought some recent attention to the dangers of a “monopsony.” This recent New York Time article sheds light on what kind of market this power dynamic creates:
The Supreme Court justice Sonia Sotomayor, when sitting on a lower court, once described monopsony as the “mirror image” of monopoly. Unlike a monopoly, which occurs when a seller of goods has the power to unlawfully raise prices of what it sells, a monopsony occurs when a buyer of goods has the power to unlawfully lower the prices of what it buys. Each violates antitrust laws: As the Supreme Court has long recognized, they both result in a misallocation of resources that harms consumers and distorts markets.
In this case, Amazon gained control over the ebook market by first engaging in predatory pricing (selling ebooks at prices below what it was purchasing them for). Then Apple began selling ebooks through their “app store model,” where book publishers (just like app developers) could name their own price and Apple would simply get a percentage cut. For a moment, ebook publishers and authors were given back some power to set the own pricers for their goods.
Soon after, Amazon helped spur a misguided lawsuit that would charge ebook publishers with antitrust violations for “price fixing” through this new app store model. The result? Both parties settled out of court. But now the story becomes relevant again as the terms of the settlement expire and we get to see what Amazon will do with its monopsonistic power — and what the publishers and authors will do to fight back.
If the search for a stable job was not daunting enough for young adults, concurrently finding an affordable and accessible psychologist or psychiatrist can seem near impossible. As NPR reports, the obstacles are many:
Some felt they couldn’t take time off from new jobs and internships to regularly see a therapist or psychiatrist, and several said they had trouble finding someone who had experience working with young patients.
Recent graduate Rebecca Greenlee’s story paints a picture of the rough terrain that these young adults navigate.
As a college student, Greenlee was able to see a mental health provider through an on-campus service. Finding care off campus was much harder.
She got a temporary job working for the local government, but the position didn’t come with any benefits. Taking time off for weekly visits was difficult, too. Eventually, she went to a public clinic where she had to wait over eight hours for a preliminary appointment.
“It’s enough to make people just give up,” Greenlee says. Without support from friends, she says she wouldn’t have gotten through the transition.
For these vulnerable young adults in need of mental health care, the only help seems to come in the form of advice: plan ahead, rely on your friends and keep persevering.
Elisabeth Rosenthal’s series on health care cost drivers finally shines a spotlight on the elephant in the room: the money’s not going to the delivery of care.
In what is perhaps the least shocking revelation to those engaged in the actual delivery of health care, a New York Times analysis shows compensation for hospital and insurance executives far outpaces that of physicians, nurses and other health professionals. In fact, hospital administrators brought in more than double the typical provider. Insurance CEOs hauled in nearly triple, despite being even further removed from the clinician-patient relationship.
From the New York Times story:
The proliferation of high earners in the medical business and administration ranks adds to the United States’ $2.7 trillion health care bill and stands in stark contrast with other developed countries, where top-ranked hospitals have only skeleton administrative staffs and where health care workers are generally paid less. And many experts say it’s bad value for health care dollars.
“At large hospitals there are senior V.P.s, V.P.s of this, that and the other,” said Cathy Schoen, senior vice president for policy, research and evaluation at the Commonwealth Fund, a New York-based foundation that focuses on health care. “Each one of them is paid more than before, and more than in any other country.”
She added, “The pay for the top five or 10 executives at insurers is pretty astounding — way more than a highly trained surgeon.”
Rosenthal quotes studies that show administrative costs in the United States are significantly higher than any other country — making up 20 to 30% of our health care costs. That’s twice as much as other developed countries. The disproportionate overhead has been a major driver of ever-increasing health care costs for both businesses and consumers.
Dr. Abeel Mangi, a cardiothoracic surgeon at the Yale School of Medicine, summed the situation up well:
“Most doctors want to do well by their patients…Other constituents, such as device manufacturers, pharmaceutical companies and even hospital administrators, may not necessarily have that perspective.”
Read the full article from the New York Times.