May 23, 2025 • 44 mins
Gerald (Jud) DeLoss, CEO, Illinois Association for Behavioral Health, Tania Archer, Counsel, Moore & Van Allen, Allison Petersen, General Counsel, INTEGRIS Health, and David Shillcutt, Partner, Epstein Becker & Green, discuss hot topics in behavioral health, including trends in managed care behavioral health, federal and state funding for behavioral health, and school-based crisis programs. Jud was Faculty Chair, and Tania, Allison, and David were members of the Faculty, of AHLA’s new course, Behavioral Health Law & Compliance 101. From AHLA’s Behavioral Health Practice Group.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
SPEAKER_03 (00:00):
Thank you.
SPEAKER_00 (00:27):
Welcome to today's podcast, Behavioral Health Hot
Topics.
My name is Jud Delos.
I am the CEO of the IllinoisAssociation for Behavioral
Health.
I'm also on the AHLA Board ofDirectors.
Previously with the BehavioralHealth Task Force, I'd like to
make a quick shout out to agreat resource that AHLA has
(00:47):
recently introduced, BehavioralHealth Law and Compliance 101.
It's an online course.
It's designed for attorneys andother professionals that are new
to behavioral health.
There are 15 modules that youcan review at your leisure, at
your speed, and learn more aboutthe behavioral health field and
the requirements, regulations,nuances of behavioral health as
(01:12):
it relates to the rest of thehealthcare world.
I'd like to turn it over now toTanya to introduce herself.
SPEAKER_02 (01:20):
Thanks, Judd.
Appreciate that.
I am Tanya Archer, counsel withMoore and Ben Allen in
Charlotte, North Carolina.
I'm on our litigation team, butpreviously served as a
compliance director for acommunity health center.
So my practice focuses onfinancial regulatory and
healthcare compliance.
SPEAKER_04 (01:40):
Everyone, my name is Allison Peterson.
I'm general counsel forIntegra's Health, which is a
large charitable health caresystem located in Oklahoma.
SPEAKER_01 (01:50):
And I'm David Shilcott.
I'm a partner at Epson BeckerGreen.
We're a national law firm thatfocuses on health care and labor
and employment.
I do a lot of work in behavioralhealth, managed care, and
regulatory compliance, as wellas being the vice chair of the
behavioral health practice groupfor AHLA.
SPEAKER_00 (02:09):
Very good.
I think we'll kick off our firsttopic of conversation today,
trends for managed carebehavioral health.
David, what trends are youseeing in how managed care
companies are responding tobehavioral health service
demands and delivery changes?
SPEAKER_01 (02:29):
Yeah, you know, one of the first questions or most
common questions that I getthese days is what the impact of
the mental health parity law isboth at the federal and state
level.
And while we see a widevariability among states in
terms of how they are overseeingand enforcing mental health
(02:49):
parity, I'm not seeing a lot ofimpact on patients at this time.
I'm not seeing a lot of impactof parity enforcement per se.
That said, there's a lot ofparity adjacent laws, I would
call them, that are driving morechanges to coverage and service
(03:11):
delivery.
You know, one of the simplesttypes of laws that we're seeing
increasing amount is justprohibitions on things like
prior authorization for mentalhealth and or substance use
disorders.
You know, one thing that I likeabout these kinds of laws is
that everybody knows what theymean.
And so the providers, thepatients, the payers They're
(03:36):
pretty clear about what'srequired, and payers tend to
comply with them.
They tend to increaseutilization.
In many cases, that is a goodthing.
I think not all utilization isequally good, but they are
certainly improving access.
One of the overlooked downsides,I would say, for providers is
(03:59):
that it tends to shift payerbehavior towards retrospective
reviews, recoupments, fraud,waste, and abuse-type
strategies, those can really putmore risk on providers.
And so, you know, you win someon the front end, you lose some
on the back end.
Behavioral health providers inparticular tend to be smaller.
They tend to struggle more withthose types of interactions with
(04:20):
payers.
And so it's an unintendedconsequence, I would say, maybe
not fully unintended, but it isa consequence to watch out for
and that needs to be planned forin states that are passing those
types of laws.
A related requirement withregard to utilization management
that I would also characterizeas still sort of, I think we're
(04:42):
still determining what the realimpact is going to be, is the
trend towards requiring goldcarding for prior authorization
and other forms of utilizationmanagement.
So for providers that meetcertain criteria, then you're
not required to get the priorauthorization or maybe even
concurrent reviews for certaintypes of services.
The impact of those laws onbehavioral health, I think, has
(05:04):
been muted in most cases becausethey tend to come with criteria
like having an approval rateabove a certain threshold, like
you might have to have more thana 95% approval rate for your
authorization requests.
They also might have utilizationvolume minimums.
And so you have to be seeing acertain number of the payer's
(05:25):
patients in order to qualify.
And again, because behavioralhealth providers are often
smaller, as well as the sort ofinherent subjectivity of a lot
of the criteria for manybehavioral health services means
that denial rates are often abit higher.
It can be harder for behavioralhealth providers to meet those
(05:46):
very high thresholds to qualifyfor gold carding programs.
SPEAKER_04 (05:53):
Hey, David, I would just offer that even for
behavioral health providers thataren't smaller, so like within
my health system, behavioralhealth services are often
isolated, unintentionally even,where our billing departments,
our coding departments, themajority of their resources are
focused on our larger servicevolumes.
(06:16):
And so you have to have thosesubspecialists who can really
seek out the opportunities wherewe can be getting a higher
return on our billing or ahigher return on our prior
authorization practices.
And oftentimes it takes work andfocused attention on your
behavioral health departmentalleadership for them to even know
(06:36):
who they raise the flag to orwho they interact with when
there is a problem like whatyou're describing in the rules
changing with how you'reinteracting with payers.
So I think it's a unique problemthat can run the gamut on size
even in a complex health systemenvironment.
SPEAKER_01 (06:55):
Yeah, that's a really great point.
Another sort of gloss on that isthat the gold carding
requirements often apply at thepractitioner level.
And so, again, the volumes maynot be adequate to meet the
thresholds for gold carding.
So interesting concept, but Ithink the impact for behavioral
(07:15):
health has been muted.
Another area that we're seeing alot of interest in among states
is these emerging requirementsfor the payers to use
authorization criteria, medicalnecessity guidelines that align
with or constitute generallyaccepted standards of care.
(07:38):
It's a really interestingconcept.
I think this is, we firststarted seeing this at a
national level with the WIT v.
United decision where theplaintiffs alleged that United's
coverage guidelines did notalign with generally accepted
standards of care.
One of the biggest questions forme is still, what is a generally
(08:01):
accepted standard of care?
The WIT court articulated 12 or13 principles But that decision
is the only place that I've everseen those principles collected
as such.
Many states are simplifying itby specifying specific
guidelines for behavioralhealth, either explicitly saying
(08:23):
something like the AmericanSociety of Addiction Medicines
guidelines, the ASAM criteria.
or the LOCUS or CALLOCUS forbehavioral health, those types
of guidelines.
And in other cases, they'resaying national nonprofit
provider association guidelines.
Some of them, I think, workpretty well, especially where we
(08:46):
see a trend of some of the thirdparty vendors of medical
necessity utilization managementplatforms incorporate those
guidelines.
So like MCG and Interqual arenow incorporating some of those
guidelines into their platformsand where that's getting
integrated.
I think it works prettysmoothly.
(09:08):
But in other cases, it's notclear what the generally
accepted standard of care shouldbe.
And for the purpose, one of theconcerns that I have, a point of
ambiguity that I don't seeanyone really resolving at
present, is that the purpose ofthe provider association
guidelines is generallyoversimplifying somewhat to set
(09:31):
a floor or threshold.
You need to do at least thismuch.
Your services need to be atleast intensive enough to avoid
malpractice because that's whatthis comes out of is
malpractice.
This concept of generallyaccepted standard of care.
It's malpractice if you don't doat least this much, which is
sort of the converse of whatmanaged care is set up to do,
which is to say, you know,Everybody could benefit from
(09:55):
more services to some extent.
How much is too much?
And, you know, given limitedresources.
And so I don't think there's aneasy fit when we talk about
things like urine drug testing.
You know, I don't know what thegenerally accepted standards of
care is for a ceiling.
I know what it is as a floor.
And so, you know, how it's notclear.
I don't think how states areinterpreting that.
SPEAKER_00 (10:18):
David.
Here in Illinois, we've forseveral years, actually prior to
the WIT decision even, utilizedthe ASAM criteria, but it was
more focused on the patientplacement criteria rather than
the generally accepted standardsof care that you mentioned.
So I see...
(10:39):
The kind of the tension betweenthe two and your comment, I
think, rings true about the factthat it does set a floor in
terms of standard of care.
I think there are opportunitiesfor providers to meet those
standards, obviously, to utilizethe patient placement criteria
so that the individual is placedin the correct residential
(11:02):
outpatient detox setting, etc.
I'm just wondering if that mightalso open up an opportunity, as
you mentioned, there's a floor,there isn't a ceiling.
Could that somehow tie into moreof a value-based care
reimbursement model?
Utilize better outcomes, betterquality care, etc.?
UNKNOWN (00:00):
?
SPEAKER_01 (11:22):
Absolutely.
I think everybody hatesutilization management to some
extent.
And value-based paymentmethodologies are certainly one
of the better, it's hard to callanything a best way out right
now, but certainly one of thebetter ways to try to align
incentives between payers andproviders.
(11:42):
We're definitely seeing a growthin interest there.
There's still data issues interms of just having enough
information to design thosevalue-based incentives
appropriately.
There's volume issues forbehavioral health providers
being able to take on sufficientfinancial risk for it to work
appropriately.
(12:02):
But where we can set those up, Idefinitely think that is one of
the better outcomes.
Level of care determinationsare, I think, the area where
this concept works the best.
to the extent that you have adelivery system that has the
appropriate levels of care.
Another challenge there is justthat intake interview is not
(12:26):
always reimbursed appropriatelyor adequately.
And to do the ASAM criteriaappropriately, that is a really
long, intensive interview.
And I think that a lot ofpayment methodologies,
especially in a fee-for-servicetype setting, are not adequately
(12:47):
compensating providers toimplement the criteria with
fidelity.
So that's another area wherevalue-based can really help to
improve implementation.
Shifting finally to out ofnetwork utilization, this is
another network adequacy and outof network utilization.
This is another area I thinkthat we see a lot of frustration
(13:09):
from patients around thecountry.
Probably everybody knowssomebody that has had trouble
getting an appointment for abehavioral health or addiction
treatment service at some point.
And then the question is, youknow, what sorts of policy
solutions should we be followingto address this?
Mental health parity has maybepromise that is yet to be
(13:30):
delivered on, mostly because westill don't have really clear
guidelines about whatconstitutes comparability for
network access.
You know, I really am hopingthat academia and think tanks
are going to help us think aboutbetter network adequacy
standards that could be applied,not just to MAPIA, but also
directly through state law.
(13:51):
Time and distance standards arenot really adequate.
Provider to member ratios arereally inadequate.
They don't really get at theindividual level that the types
of information that we need tomake sure that most members are
getting access, appropriateaccess.
One interesting approach thatI'm seeing in some states is
(14:13):
just a mandate to coverout-of-network services on an
in-network basis if noin-network provider is
available.
That can be labor-intensive toimplement, and a lot of, I
think, is still to be determinedabout the extent to which
providers and members are ableto advocate for themselves
effectively.
effectively to avail themselvesof those requirements.
(14:36):
But I think it's an interestingapproach that intuitively makes
a lot of sense.
somewhat more blunt forceversion that I saw in New Mexico
is that there's a governor orderto just require all
out-of-network substance usedisorder treatment services to
be covered on an in-networkbasis.
Predictably, that drove a prettysignificant spike in
(14:57):
out-of-network utilization.
The question for me that Ihaven't seen fully untangled is
how much of that is justshifting from in-network to
out-of-network.
I think a not in somewhatsignificant proportion of it is,
and I don't know that that makessense in the managed care
delivery context that we have inour country today, but to the
(15:22):
extent that it's allowing forout of network services where
truly there was no in-networkprovider available, I think that
is the issue that we're tryingto address and may be effective.
SPEAKER_00 (15:36):
Similarly, I'm seeing some activity in the
private insurance world withrespect to coverage for
psychiatric or psychiatrists.
The large number ofpsychiatrists that are out of
network in private insurancepanels, et cetera, and the
(15:56):
inability for patients to getin.
So many just go the route ofpaying out of pocket.
I have seen more recentlegislative attempts to tie
reimbursement rates to Medicareor to other formulas to raise
that reimbursement rate to, Iguess, entice psychiatrists to
(16:19):
participate in those insurancepanels.
I'm not sure.
It's not the same process thatyou're talking about in terms of
insuring in-network coverage forout-of-network providers, but
it's kind of a a corollary tothat, I think, providing a
little bit of a push for theprivate insurers to raise
(16:41):
reimbursement, to bring in morepsychiatrists, sort of a carrot
approach.
SPEAKER_01 (16:48):
Yeah, I think that is really the biggest question
that we face right now is how toget more of those psychiatrists
in particular and other mentalhealth providers to participate
in insurance networks.
you know there's a few surveyssuggest that reimbursement rates
(17:08):
are not one of the top, they area reason, but not one of the top
three or four reasons thatproviders cite for participating
in insurance networks.
Where I've looked at data onthis, the comparability, if
you're benchmarking to Medicare,comparability between behavioral
health providers and med-surgproviders actually does work out
pretty well if you're looking,if you're controlling for health
(17:31):
systems versus small providers,if you're controlling for the
types of services that they'reactually billing for.
And so there's There's a lot ofdifferent ways to think about
that, but I would say on thewhole that small increases to
reimbursement may not have atransformative impact.
It's an interesting approach,but I think that most likely
(17:54):
you're gonna need to think morebroadly about ways that payers
can mitigate some of the burdensof participating in network and
beyond just reimbursement ratesin order to really move the
needle.
SPEAKER_04 (18:09):
You mean in the paperwork, David?
SPEAKER_01 (18:12):
Yeah.
Yeah.
Authorizations.
Yeah.
Like the the the investment inbehavioral health and just like
revenue cycle management and,you know, billing and coding and
all that is so much lowercompared to medical surgical
specialties.
I were seeing behavioral healthcatch up.
(18:32):
Certainly, you know, in the pastfew years.
But I would say, you know, ifyou think on like a 30 year
scale, I'm still way behind justin terms of the in the arms race
between between providers andpayers, just not nearly as
mature on the provider side interms of that investment and for
(18:53):
lots of reasons.
But I think that's going todrive it more than anything.
SPEAKER_04 (18:57):
The other aspect that I think is unique about
behavioral health is that peopleare able to successfully run
cash practices.
So they are able to have a moreniche-focused patient population
and run a cash practice.
I think this is kind of a trendthat we're seeing in dermatology
as well, that you get to go dothe patient population that you
(19:18):
enjoy serving and cut out asmuch of the administrative
overhead that you don't want todeal with and that no one thinks
is fun dealing with.
And that's how you can keep yourbusiness a small business.
Because you're right, to scaleall that administrative
overhead, it requires size andsignificance in order to support
the technology and the man hoursto actually make your way
(19:42):
through the paperwork and theback and forth that all those
relationships require.
SPEAKER_01 (19:49):
Well, I could talk all day about this stuff, but
I'm interested in hearing, Judd,I know you've been looking a lot
at federal and state funding forbehavioral health.
Where are you seeing thesetrends?
SPEAKER_00 (20:03):
Well, I think we're really in uncharted territory
right now, David.
I think with the administrationat the federal level, with the
changes that are coming down,sometimes without advance
notice, are having some majorimpacts upon providers and
(20:23):
others.
For example, just this week,while we were preparing for this
podcast, the federal governmentannounced a clawback of about$11
billion in ARPA funding that hadbeen designated for public
health as well as behavioralhealth.
So the announcement here inIllinois, for example, related
(20:47):
to about$28 million inbehavioral health funding that
was dedicated towards our mobilecrisis response teams, our first
episode psychosis response andsome recovery homes, SUD
response.
And so the question that I thinkis on everyone's mind is, if
(21:11):
this happens, are statesprepared to step in?
And if not, what can be done tomaintain at least a bare minimum
level of funding for providersto ensure that services can
continue?
My thought on that is there'svery little that states could do
to fill that heavy void.
(21:33):
One of the areas that might bepossible is the opioid
settlement funding.
that had been reached by thestate's attorney general that
relates to the settlements withthe opioid manufacturers,
distributors, consultants, etcetera.
That might be an opportunity ora way to fill the gap there.
(21:59):
Currently, I think we're atabout$50 billion overall in
settlement proceeds that werepart of the national settlement.
A variety of statesparticipated, and the vast
majority of states didparticipate in that process.
And I think most have set upwhat were intended to be, and
(22:20):
I'm hopeful, particularly herein Illinois, that the process
will be carried out in a waythat was vastly different than
the tobacco funding litigation.
The settlement of thatlitigation was carried out where
the funds sort of disappearedand there wasn't a lot of
accountability, so to speak,with respect to how those funds
(22:41):
tied back to the damages, thenegative impact of tobacco.
So I don't know if there areother ways or other concerns.
Obviously, each day is a new daywhen it comes to the federal
decision Alison, I know thatthere were some changes with
(23:02):
SAMHSA recently announced aswell.
SPEAKER_04 (23:03):
Right.
So what also occurred this weekis that there was recognition
that there's going to be someconsolidation happening from
agencies that previously havebeen recognized as distinct
entities It appears that they'regoing to be consolidated into a
new administration for healthyAmerica.
(23:24):
And so SAMHSA, the SubstanceAbuse Mental Health Services
Association is going to beconsolidated.
And that's not a guarantee thatthere will be cuts to funding or
cuts to even positions.
No SAMHSA positions haveofficially been listed as in the
(23:45):
news articles right now as thosethat are being cut, but I think
it's to be expected that it'slikely to occur.
What's interesting in my realm,in the broader healthcare
delivery realm is that Medicaidis the single largest payer of
behavioral health services foradults in America.
(24:06):
And Medicaid is also becomingmore and more of a prominent
payer for substance use disorderservices as well.
So with the cuts that Doge hassaid that it's going to
implement in our federalgovernment.
Of course, there's been a lot ofspeculation for a long time
about what that means forMedicaid and Medicare.
(24:29):
There's been a lot of assurancesthat Medicaid won't be cut or
that Medicare won't be touched,but it still seems really hard
to believe that you can't touchthose entities or those delivery
mechanisms just given the sheersize and scale that they
represent in our federal budget.
So I think that's another areafor us to just continually watch
(24:50):
as to how do you cut Medicaid?
How do you consolidate SAMHSA?
And what are those impacts ondelivering behavioral health and
substance use disorder servicesin states, particularly with
those who have federal matchingprograms?
You know, I think that'ssomething that Oklahoma
especially is keeping an eye onof when those federal dollars go
(25:16):
away.
It's not as if Oklahoma has adesignated rainy day fund ready
to swoop in and say, okay, we'vegot the rest.
We're fully expecting that we'regoing to be seeing a reduction
in overall spend that we'regoing to have to accommodate.
Do any of you have any otherthoughts on how you know, the
(25:37):
potential cuts.
We don't know of any certain,but any potential cuts that
could be coming our way thatcould be impacting the delivery
of behavioral health
SPEAKER_02 (25:46):
Yeah, Alison, I'll say I think I've shared your
skepticism in watching the news,not just this week, but maybe
even since the newadministration came in, that
there's all these assurancesthat there's going to be more
efficiency but less spending,that programs will remain intact
despite all of therestructuring.
And so I think it is a littledifficult to believe.
(26:07):
I think a healthy amount ofskepticism in this area is
healthy to kind of repeat that.
But, you know, speaking from, Iguess, from my background with
community health centers, theyrely on federal grants and
monies for a lot of theirfunding in order to provide
medical care, dental care,behavioral health services, and
(26:28):
substance use services,especially.
And so I think they have verylittle wiggle room for revoking
or rescinding funding or grantsupport and expecting for their
programming to be able tosurvive.
I think we saw there wasactually a little bit of
whiplash.
There was some more kind ofquick decision of funding.
(26:50):
Don't know exactly what theoutcome of that's going to be
yet.
But the programs are having to,I think, quickly figure out how
to still provide services andprovide for the need because the
need doesn't go away justbecause the funding does.
And so I think you and I at somepoint within this group have
(27:10):
talked about how if you removeone set of resources, it means
that there is weight on someother portion of the system.
And so where is that support andservice going to come from?
Who's going to have to kind ofthin out or spread their
resources more thinly to figureout how to still provide and
(27:32):
meet those needs.
SPEAKER_04 (27:34):
Definitely.
And, you know, as far as ahealth system like mine, what
we're doing to prepare forpotential cuts is really
recognizing that we could havehigher ER volumes of patients
who are otherwise currentlyprovided for the FQHCs or in
community behavioral healthcenters and We're really being
intentional about where we haveinvestments in our community and
(27:57):
where we have, let's say, freehealth fairs, recognizing that
in the future, we're going toneed to be intentional to find
places where there are pullbackor drawdowns of care, of that
preventative care or of thatearly intervention care that
right now is keeping people outof that crisis and emergency
(28:17):
situation, necessitating them tovisit our ERs.
We don't have a shortage ofvolume in our ERs in Oklahoma.
So this is not a situation wherewe're excited about having more
patients coming to our ERs.
We wanna be sure that thepatients that are coming to our
ERs are the ones that need to bethere and that we are able to
(28:37):
treat those lower acuityconditions or non-emergent
conditions at the right levelsetting.
And so really partnering withFQHD's Community Behavioral
Health Centers and identifyingwhere they are experiencing cuts
or delineation and, sorry, wherethose community behavioral
(28:58):
health centers may beexperiencing reductions in their
abilities to meet the communityneed.
How's the health system like usable to step in and partner with
them, perhaps formally orinformally, or how are we able
to infuse another element ofpreventative or non-emergent
care alongside them?
Ideas that we have that we'reexploring is partnerships with
(29:20):
behavioral health telehealthcompanies, is looking at how we
are already able to access someof those services, but in our
rural communities where they arenot due to a lack of broadband.
So we're really looking at howwe're drawing attention to what
that means for their ability toaccess care at home.
(29:41):
different levels of our stategovernment to ensure that they
see those deserts and what thatcould mean in terms of if you've
got an overrun ER with someonewho didn't need to be there, had
they had access to a differentpoint of care, then when you are
an emergency or your loved oneis in an emergency, it could be
that much harder to reach us.
(30:02):
So really personalizing theimpact that some of this could
have in terms of escalating theneed and creating emergencies,
whereas today those emergenciesare being avoided by preventable
or community intervention.
Tanya, you and I had also hadsome conversations about some
school-based crisis programsthat you have familiarity with.
(30:25):
What are the benefits andchallenges of those school-based
crisis programs?
SPEAKER_02 (30:30):
Yeah, so, I mean, obviously, I think school-based
programming is crucial.
The school has kind of presenteda foundation to address things
like anxiety, ADHD, ADD.
We've seen, you know, over,unfortunately, over the last
decade or so, increases in gunviolence in our school systems.
(30:54):
And that, I think, is directlyrelated to behavioral health
issues that haven't beenaddressed or maybe were not
previously identified.
So I think some of the benefitsdefinitely include being able to
address those things early onhaving some early intervention
with students to prevent healthproblems from escalating having
(31:15):
Reduction in barriers to mentalhealth services will make it
more accessible for thosestudents, especially in
underserved communities.
And sometimes that includesthose rural communities that you
just mentioned where access maybe difficult, transportation
issues may exist.
To the point about guns, gunviolence in our schools, just
(31:36):
hopefully reducing providing asafer school environment.
If students have their needsmet, if they're getting support
for mental health issues or evenfor substance abuse issues, then
hopefully we're seeing saferschool environments and then
reduced behavioral issuesbecause they're being addressed
at the school system.
(31:56):
And we've said, you know, foryears, the school is where a
student spends most of theirday.
Most of their interactions aregoing to be in the school
environment.
So it just kind of provides anopportunity if they do need
intervention, whether that'searlier or they've already had
some intervention and they needsome pickup of those services to
have that at the school level.
(32:18):
But as for challenges, I thinkwe've already started talking
about funding.
Funding is always going to be,always has been, and always
likely will be a hurdle.
It impacts the ability to hireand retain qualified staff.
I do know that it is moredifficult to recruit and retain
staff in those harder accessareas or in rural areas, which
(32:40):
are actually at higher risk ormay have higher incidence of
need for behavioral healthservices.
So provider shortages, I thinkthat happens across the
behavioral health kind of realm,but specifically in the school
system and in the school-basedenvironment, that has a
different impact.
There's still a stigma, I think,about accessing behavioral
(33:05):
health issues.
And in the school system, you'rein that kind of adolescent age
where you're experiencing a bitof anxiety anyway, it might add
some extra angst if you feellike you may be exposed or
someone may see you accessingthose services.
And then I think kind of goingback to recruitment issues,
(33:28):
there may also be like trainingand capacity give good training
to the staff so that they areequipped for the issues that are
going to come up at a schoollevel.
I think adolescent behavioralhealth services are by
definition going to be differentand distinct than adult school,
adult behavioral healthservices.
(33:48):
So making sure that you've gotstaff that are adequately
trained, not just present andnot just willing to be there,
but also able to actually givetargeted and intentional
behavioral health services tothose students.
SPEAKER_04 (34:03):
Yeah, Tanya, our interaction with schools has
been along those lines ofsupporting community programs.
I think it's rare thatcharitable health systems don't
have some form of a communitygiving program and health
insurers, you know, for-profitcompanies do this as well.
Major companies in communitiesare always giving back to the
(34:24):
community in a variety of ways.
But I think healthcarefacilities or healthcare systems
specifically recognize theimportance of investing in that
early preventative interaction,particularly in adolescents.
So Integris Health partners witha group called the Hope Squad.
The Hope Squad is a school-basedprogram that supports schools in
(34:46):
identifying students to helpraise the need, to recognize the
need in their, I was about tosay colleagues, but in their
fellow students.
So the Hope Squad is trainingstudents and administration to
recognize crises building beforeit becomes to a crisis point.
so that those students can gethelp before they're in an
(35:08):
emergency situation.
And that's such an obvious smartinvestment from a health system
like Integris Health whereyou're just trying to identify
where someone needs help beforethey're at that crisis point
where they have to come to theER and come to the most
expensive cost setting.
That's also something that youcan see where managed care
companies would be supportive offrom an access point as well.
(35:29):
So I think the school-basedprograms, there's a plethora of
options and with the fundingchallenges that we discussed
before that might be coming ourway, that I think that's where
you're going to see some smarterinvestments being shifted from
those community giving programs,focusing on preventative care,
access to care in order to fillthe void that may be created
(35:53):
with funding challenges.
One other comment I just feelthe need to make which is the
cuts that could be coming fromthe federal level and then the
state's inability to fill thematch or to fill the void that
could be created.
Sometimes those arecharacterized as malicious or
mal-intent.
(36:13):
And I just wanna draw attentionto oftentimes the legislators
that are involved in thosedecisions are put in really
difficult positions.
And this isn't a situation inwhich anyone is wanting to hurt
someone or wanting to causeharm.
I think it's important toremember that these are big
numbers And then a lot of bigimpacts can boil down to some
(36:38):
small decisions that could justbe, you know, a shift here that
then has dominoes that cause,you know, that clinic that was
in that one rural community toclose.
And that couldn't really beentirely foreseen by the
decision that was made thousandsof miles away.
So, you know, I'm not trying todefend all of the changes that
are happening, but just toacknowledge that at least as
(36:59):
we're interacting with our statelegislators and our federal
delegation Our whole goal isensuring that they just
understand the importance of thefunds or how the funds are used
now and what possible impactscould be as they're wrestling
with really tough decisions withsome big goals.
Those goals also have anobjective to do good for America
(37:23):
or to do good for the nation inways that that are different
than what our current funding orstructure is set up for.
So that's just something that Ialways try to step back and
remind myself of whenever we'reconfronted with some of those
big changes and unknowns thatcould be coming our way.
SPEAKER_02 (37:42):
Yeah, I agree with that, Allison.
I think, you know, as we moveforward and, you know, we're
kind of in this resourcequestion mark area that it's
going to be important to have.
Number one, those partnershipsthat you talked about, like with
your health system and thecommunity health service.
systems, but also to make surethat everyone realizes we're all
(38:04):
kind of trying to figure it outas we go along.
It's a bit of an unpredictablearena that we're in right now,
and everyone's trying to makesure that they're not just being
compliant, but that they're alsoservicing the needs.
And so that does lend itself tokind of a difficult, challenging
area where sometimes difficultand challenging decisions have
to be made.
(38:25):
So completely agree with that.
SPEAKER_01 (38:28):
Yeah, if there's a call to action here, in my
opinion, it's that where we havemajor budget cuts potentially
and concurrent to majorreorganization and staffing
cuts, especially at the federallevel, those regulators often
(38:50):
create that sort of connectivetissue between those very hard
funding challenges that get madeat the legislative level and the
on the ground impact of thefunding.
And so, Alison, the types ofcommunity investments and
support services that you talkabout that we help to render
(39:12):
care cost-effective, keepingpeople out of the ER, making
sure that we're spending themoney in the right place.
So often those are, I thinkthere's a risk of those, they're
often funded through sort ofsupplemental ancillary types of
programs, special authoritiesand Medicaid, things like that.
Things that are going to beappear to be on the chopping
(39:34):
block often and are going to beeasy to get lost in the shuffle,
especially where the regulatorsand policymakers that were
responsible for creating themand understand their value and
how they fit with the system maybe getting reshuffled or getting
no longer in their roles.
(39:55):
And so I think there's a realneed for providers and advocates
to come together and understandthat the policymakers that have
traditionally been in thatintermediary role may no longer
be in place and that we need tobe able to talk with funders
about the need for these EDdiversion, crisis stabilization
(40:21):
programs, school-based servicethat are cost effective and are
as well as being integral toquality outcomes.
SPEAKER_00 (40:36):
This is a fascinating discussion and to
piggyback on some of thecomments made as well as add to
some of the excellent thoughts.
In addition, as David mentioned,I think there is a need for the
mobile crisis, the communityintervention programs that do
(40:58):
divert folks in crisis from theERs and the EDs, which are less
effective in treating thesituation.
Those in mental health crisisalso cause disruption within the
emergency departments withrespect to those needing more of
a medical surgical intervention.
(41:18):
And it's more cost effective toutilize a less intensive, more
mental health-focusedintervention.
So the rollout of the 988 crisisline, the use of mobile crisis
teams, the introduction ofcommunity-based living room
(41:40):
programs and other crisisstabilization type facilities
are less expensive if you'relooking at it from a
cost-effective standpoint, lessintrusive or less invasive, less
of a disruption for those thatare in need of a physical
medical type of intervention inan emergency department, et
(42:00):
cetera.
So all of that kind of comestogether in addition to keeping
in mind, I think all of ustouched on this a little bit
today, the idea that if we'renot able to treat patients those
with a behavioral health need ora crisis, then it's going to
have to be addressed in someother way.
And that might fall uponAllison's system in their
(42:23):
emergency department.
It might fall on a school-basedcrisis program that has to
intervene in a more seriousmatter and working with the
managed care organizations andhow they seek to provide the
best care and obviously managecosts.
So I don't know if If any of youhave any final thoughts for
today to sum up, I sort of doneso right now, and I'd like to
(42:47):
turn it back over to each ofyou.
SPEAKER_04 (42:48):
Hey, Jed, I would just comment that the Behavioral
Health 101 program that youmentioned at the top of the hour
covers a lot of those differentintervention points and gives a
definition of what they are andhow they interact with the
behavioral health care servicescontinuum.
And it's been great talking toyou guys.
(43:08):
I've loved learning from each ofyour perspectives.
So thanks so much for having me.
SPEAKER_02 (43:13):
Yeah, I think my final thought would just be that
in addition to being compliantas we move forward, we'll, as
usual, have to also beintentional and creative and,
you know, create partnershipsand find resources maybe to make
sure that we're still servicingthose behavioral health care
needs.
SPEAKER_01 (43:32):
Very well said.
I really appreciate thediscussion today and I
SPEAKER_03 (43:36):
hope we can do it again soon.
Thank you.
SPEAKER_00 (00:27):
Welcome to today's podcast, Behavioral Health Hot
Topics.
My name is Jud Delos.
I am the CEO of the IllinoisAssociation for Behavioral
Health.
I'm also on the AHLA Board ofDirectors.
Previously with the BehavioralHealth Task Force, I'd like to
make a quick shout out to agreat resource that AHLA has
(00:47):
recently introduced, BehavioralHealth Law and Compliance 101.
It's an online course.
It's designed for attorneys andother professionals that are new
to behavioral health.
There are 15 modules that youcan review at your leisure, at
your speed, and learn more aboutthe behavioral health field and
the requirements, regulations,nuances of behavioral health as
(01:12):
it relates to the rest of thehealthcare world.
I'd like to turn it over now toTanya to introduce herself.
SPEAKER_02 (01:20):
Thanks, Judd.
Appreciate that.
I am Tanya Archer, counsel withMoore and Ben Allen in
Charlotte, North Carolina.
I'm on our litigation team, butpreviously served as a
compliance director for acommunity health center.
So my practice focuses onfinancial regulatory and
healthcare compliance.
SPEAKER_04 (01:40):
Everyone, my name is Allison Peterson.
I'm general counsel forIntegra's Health, which is a
large charitable health caresystem located in Oklahoma.
SPEAKER_01 (01:50):
And I'm David Shilcott.
I'm a partner at Epson BeckerGreen.
We're a national law firm thatfocuses on health care and labor
and employment.
I do a lot of work in behavioralhealth, managed care, and
regulatory compliance, as wellas being the vice chair of the
behavioral health practice groupfor AHLA.
SPEAKER_00 (02:09):
Very good.
I think we'll kick off our firsttopic of conversation today,
trends for managed carebehavioral health.
David, what trends are youseeing in how managed care
companies are responding tobehavioral health service
demands and delivery changes?
SPEAKER_01 (02:29):
Yeah, you know, one of the first questions or most
common questions that I getthese days is what the impact of
the mental health parity law isboth at the federal and state
level.
And while we see a widevariability among states in
terms of how they are overseeingand enforcing mental health
(02:49):
parity, I'm not seeing a lot ofimpact on patients at this time.
I'm not seeing a lot of impactof parity enforcement per se.
That said, there's a lot ofparity adjacent laws, I would
call them, that are driving morechanges to coverage and service
(03:11):
delivery.
You know, one of the simplesttypes of laws that we're seeing
increasing amount is justprohibitions on things like
prior authorization for mentalhealth and or substance use
disorders.
You know, one thing that I likeabout these kinds of laws is
that everybody knows what theymean.
And so the providers, thepatients, the payers They're
(03:36):
pretty clear about what'srequired, and payers tend to
comply with them.
They tend to increaseutilization.
In many cases, that is a goodthing.
I think not all utilization isequally good, but they are
certainly improving access.
One of the overlooked downsides,I would say, for providers is
(03:59):
that it tends to shift payerbehavior towards retrospective
reviews, recoupments, fraud,waste, and abuse-type
strategies, those can really putmore risk on providers.
And so, you know, you win someon the front end, you lose some
on the back end.
Behavioral health providers inparticular tend to be smaller.
They tend to struggle more withthose types of interactions with
(04:20):
payers.
And so it's an unintendedconsequence, I would say, maybe
not fully unintended, but it isa consequence to watch out for
and that needs to be planned forin states that are passing those
types of laws.
A related requirement withregard to utilization management
that I would also characterizeas still sort of, I think we're
(04:42):
still determining what the realimpact is going to be, is the
trend towards requiring goldcarding for prior authorization
and other forms of utilizationmanagement.
So for providers that meetcertain criteria, then you're
not required to get the priorauthorization or maybe even
concurrent reviews for certaintypes of services.
The impact of those laws onbehavioral health, I think, has
(05:04):
been muted in most cases becausethey tend to come with criteria
like having an approval rateabove a certain threshold, like
you might have to have more thana 95% approval rate for your
authorization requests.
They also might have utilizationvolume minimums.
And so you have to be seeing acertain number of the payer's
(05:25):
patients in order to qualify.
And again, because behavioralhealth providers are often
smaller, as well as the sort ofinherent subjectivity of a lot
of the criteria for manybehavioral health services means
that denial rates are often abit higher.
It can be harder for behavioralhealth providers to meet those
(05:46):
very high thresholds to qualifyfor gold carding programs.
SPEAKER_04 (05:53):
Hey, David, I would just offer that even for
behavioral health providers thataren't smaller, so like within
my health system, behavioralhealth services are often
isolated, unintentionally even,where our billing departments,
our coding departments, themajority of their resources are
focused on our larger servicevolumes.
(06:16):
And so you have to have thosesubspecialists who can really
seek out the opportunities wherewe can be getting a higher
return on our billing or ahigher return on our prior
authorization practices.
And oftentimes it takes work andfocused attention on your
behavioral health departmentalleadership for them to even know
(06:36):
who they raise the flag to orwho they interact with when
there is a problem like whatyou're describing in the rules
changing with how you'reinteracting with payers.
So I think it's a unique problemthat can run the gamut on size
even in a complex health systemenvironment.
SPEAKER_01 (06:55):
Yeah, that's a really great point.
Another sort of gloss on that isthat the gold carding
requirements often apply at thepractitioner level.
And so, again, the volumes maynot be adequate to meet the
thresholds for gold carding.
So interesting concept, but Ithink the impact for behavioral
(07:15):
health has been muted.
Another area that we're seeing alot of interest in among states
is these emerging requirementsfor the payers to use
authorization criteria, medicalnecessity guidelines that align
with or constitute generallyaccepted standards of care.
(07:38):
It's a really interestingconcept.
I think this is, we firststarted seeing this at a
national level with the WIT v.
United decision where theplaintiffs alleged that United's
coverage guidelines did notalign with generally accepted
standards of care.
One of the biggest questions forme is still, what is a generally
(08:01):
accepted standard of care?
The WIT court articulated 12 or13 principles But that decision
is the only place that I've everseen those principles collected
as such.
Many states are simplifying itby specifying specific
guidelines for behavioralhealth, either explicitly saying
(08:23):
something like the AmericanSociety of Addiction Medicines
guidelines, the ASAM criteria.
or the LOCUS or CALLOCUS forbehavioral health, those types
of guidelines.
And in other cases, they'resaying national nonprofit
provider association guidelines.
Some of them, I think, workpretty well, especially where we
(08:46):
see a trend of some of the thirdparty vendors of medical
necessity utilization managementplatforms incorporate those
guidelines.
So like MCG and Interqual arenow incorporating some of those
guidelines into their platformsand where that's getting
integrated.
I think it works prettysmoothly.
(09:08):
But in other cases, it's notclear what the generally
accepted standard of care shouldbe.
And for the purpose, one of theconcerns that I have, a point of
ambiguity that I don't seeanyone really resolving at
present, is that the purpose ofthe provider association
guidelines is generallyoversimplifying somewhat to set
(09:31):
a floor or threshold.
You need to do at least thismuch.
Your services need to be atleast intensive enough to avoid
malpractice because that's whatthis comes out of is
malpractice.
This concept of generallyaccepted standard of care.
It's malpractice if you don't doat least this much, which is
sort of the converse of whatmanaged care is set up to do,
which is to say, you know,Everybody could benefit from
(09:55):
more services to some extent.
How much is too much?
And, you know, given limitedresources.
And so I don't think there's aneasy fit when we talk about
things like urine drug testing.
You know, I don't know what thegenerally accepted standards of
care is for a ceiling.
I know what it is as a floor.
And so, you know, how it's notclear.
I don't think how states areinterpreting that.
SPEAKER_00 (10:18):
David.
Here in Illinois, we've forseveral years, actually prior to
the WIT decision even, utilizedthe ASAM criteria, but it was
more focused on the patientplacement criteria rather than
the generally accepted standardsof care that you mentioned.
So I see...
(10:39):
The kind of the tension betweenthe two and your comment, I
think, rings true about the factthat it does set a floor in
terms of standard of care.
I think there are opportunitiesfor providers to meet those
standards, obviously, to utilizethe patient placement criteria
so that the individual is placedin the correct residential
(11:02):
outpatient detox setting, etc.
I'm just wondering if that mightalso open up an opportunity, as
you mentioned, there's a floor,there isn't a ceiling.
Could that somehow tie into moreof a value-based care
reimbursement model?
Utilize better outcomes, betterquality care, etc.?
UNKNOWN (00:00):
?
SPEAKER_01 (11:22):
Absolutely.
I think everybody hatesutilization management to some
extent.
And value-based paymentmethodologies are certainly one
of the better, it's hard to callanything a best way out right
now, but certainly one of thebetter ways to try to align
incentives between payers andproviders.
(11:42):
We're definitely seeing a growthin interest there.
There's still data issues interms of just having enough
information to design thosevalue-based incentives
appropriately.
There's volume issues forbehavioral health providers
being able to take on sufficientfinancial risk for it to work
appropriately.
(12:02):
But where we can set those up, Idefinitely think that is one of
the better outcomes.
Level of care determinationsare, I think, the area where
this concept works the best.
to the extent that you have adelivery system that has the
appropriate levels of care.
Another challenge there is justthat intake interview is not
(12:26):
always reimbursed appropriatelyor adequately.
And to do the ASAM criteriaappropriately, that is a really
long, intensive interview.
And I think that a lot ofpayment methodologies,
especially in a fee-for-servicetype setting, are not adequately
(12:47):
compensating providers toimplement the criteria with
fidelity.
So that's another area wherevalue-based can really help to
improve implementation.
Shifting finally to out ofnetwork utilization, this is
another network adequacy and outof network utilization.
This is another area I thinkthat we see a lot of frustration
(13:09):
from patients around thecountry.
Probably everybody knowssomebody that has had trouble
getting an appointment for abehavioral health or addiction
treatment service at some point.
And then the question is, youknow, what sorts of policy
solutions should we be followingto address this?
Mental health parity has maybepromise that is yet to be
(13:30):
delivered on, mostly because westill don't have really clear
guidelines about whatconstitutes comparability for
network access.
You know, I really am hopingthat academia and think tanks
are going to help us think aboutbetter network adequacy
standards that could be applied,not just to MAPIA, but also
directly through state law.
(13:51):
Time and distance standards arenot really adequate.
Provider to member ratios arereally inadequate.
They don't really get at theindividual level that the types
of information that we need tomake sure that most members are
getting access, appropriateaccess.
One interesting approach thatI'm seeing in some states is
(14:13):
just a mandate to coverout-of-network services on an
in-network basis if noin-network provider is
available.
That can be labor-intensive toimplement, and a lot of, I
think, is still to be determinedabout the extent to which
providers and members are ableto advocate for themselves
effectively.
effectively to avail themselvesof those requirements.
(14:36):
But I think it's an interestingapproach that intuitively makes
a lot of sense.
somewhat more blunt forceversion that I saw in New Mexico
is that there's a governor orderto just require all
out-of-network substance usedisorder treatment services to
be covered on an in-networkbasis.
Predictably, that drove a prettysignificant spike in
(14:57):
out-of-network utilization.
The question for me that Ihaven't seen fully untangled is
how much of that is justshifting from in-network to
out-of-network.
I think a not in somewhatsignificant proportion of it is,
and I don't know that that makessense in the managed care
delivery context that we have inour country today, but to the
(15:22):
extent that it's allowing forout of network services where
truly there was no in-networkprovider available, I think that
is the issue that we're tryingto address and may be effective.
SPEAKER_00 (15:36):
Similarly, I'm seeing some activity in the
private insurance world withrespect to coverage for
psychiatric or psychiatrists.
The large number ofpsychiatrists that are out of
network in private insurancepanels, et cetera, and the
(15:56):
inability for patients to getin.
So many just go the route ofpaying out of pocket.
I have seen more recentlegislative attempts to tie
reimbursement rates to Medicareor to other formulas to raise
that reimbursement rate to, Iguess, entice psychiatrists to
(16:19):
participate in those insurancepanels.
I'm not sure.
It's not the same process thatyou're talking about in terms of
insuring in-network coverage forout-of-network providers, but
it's kind of a a corollary tothat, I think, providing a
little bit of a push for theprivate insurers to raise
(16:41):
reimbursement, to bring in morepsychiatrists, sort of a carrot
approach.
SPEAKER_01 (16:48):
Yeah, I think that is really the biggest question
that we face right now is how toget more of those psychiatrists
in particular and other mentalhealth providers to participate
in insurance networks.
you know there's a few surveyssuggest that reimbursement rates
(17:08):
are not one of the top, they area reason, but not one of the top
three or four reasons thatproviders cite for participating
in insurance networks.
Where I've looked at data onthis, the comparability, if
you're benchmarking to Medicare,comparability between behavioral
health providers and med-surgproviders actually does work out
pretty well if you're looking,if you're controlling for health
(17:31):
systems versus small providers,if you're controlling for the
types of services that they'reactually billing for.
And so there's There's a lot ofdifferent ways to think about
that, but I would say on thewhole that small increases to
reimbursement may not have atransformative impact.
It's an interesting approach,but I think that most likely
(17:54):
you're gonna need to think morebroadly about ways that payers
can mitigate some of the burdensof participating in network and
beyond just reimbursement ratesin order to really move the
needle.
SPEAKER_04 (18:09):
You mean in the paperwork, David?
SPEAKER_01 (18:12):
Yeah.
Yeah.
Authorizations.
Yeah.
Like the the the investment inbehavioral health and just like
revenue cycle management and,you know, billing and coding and
all that is so much lowercompared to medical surgical
specialties.
I were seeing behavioral healthcatch up.
(18:32):
Certainly, you know, in the pastfew years.
But I would say, you know, ifyou think on like a 30 year
scale, I'm still way behind justin terms of the in the arms race
between between providers andpayers, just not nearly as
mature on the provider side interms of that investment and for
(18:53):
lots of reasons.
But I think that's going todrive it more than anything.
SPEAKER_04 (18:57):
The other aspect that I think is unique about
behavioral health is that peopleare able to successfully run
cash practices.
So they are able to have a moreniche-focused patient population
and run a cash practice.
I think this is kind of a trendthat we're seeing in dermatology
as well, that you get to go dothe patient population that you
(19:18):
enjoy serving and cut out asmuch of the administrative
overhead that you don't want todeal with and that no one thinks
is fun dealing with.
And that's how you can keep yourbusiness a small business.
Because you're right, to scaleall that administrative
overhead, it requires size andsignificance in order to support
the technology and the man hoursto actually make your way
(19:42):
through the paperwork and theback and forth that all those
relationships require.
SPEAKER_01 (19:49):
Well, I could talk all day about this stuff, but
I'm interested in hearing, Judd,I know you've been looking a lot
at federal and state funding forbehavioral health.
Where are you seeing thesetrends?
SPEAKER_00 (20:03):
Well, I think we're really in uncharted territory
right now, David.
I think with the administrationat the federal level, with the
changes that are coming down,sometimes without advance
notice, are having some majorimpacts upon providers and
(20:23):
others.
For example, just this week,while we were preparing for this
podcast, the federal governmentannounced a clawback of about$11
billion in ARPA funding that hadbeen designated for public
health as well as behavioralhealth.
So the announcement here inIllinois, for example, related
(20:47):
to about$28 million inbehavioral health funding that
was dedicated towards our mobilecrisis response teams, our first
episode psychosis response andsome recovery homes, SUD
response.
And so the question that I thinkis on everyone's mind is, if
(21:11):
this happens, are statesprepared to step in?
And if not, what can be done tomaintain at least a bare minimum
level of funding for providersto ensure that services can
continue?
My thought on that is there'svery little that states could do
to fill that heavy void.
(21:33):
One of the areas that might bepossible is the opioid
settlement funding.
that had been reached by thestate's attorney general that
relates to the settlements withthe opioid manufacturers,
distributors, consultants, etcetera.
That might be an opportunity ora way to fill the gap there.
(21:59):
Currently, I think we're atabout$50 billion overall in
settlement proceeds that werepart of the national settlement.
A variety of statesparticipated, and the vast
majority of states didparticipate in that process.
And I think most have set upwhat were intended to be, and
(22:20):
I'm hopeful, particularly herein Illinois, that the process
will be carried out in a waythat was vastly different than
the tobacco funding litigation.
The settlement of thatlitigation was carried out where
the funds sort of disappearedand there wasn't a lot of
accountability, so to speak,with respect to how those funds
(22:41):
tied back to the damages, thenegative impact of tobacco.
So I don't know if there areother ways or other concerns.
Obviously, each day is a new daywhen it comes to the federal
decision Alison, I know thatthere were some changes with
(23:02):
SAMHSA recently announced aswell.
SPEAKER_04 (23:03):
Right.
So what also occurred this weekis that there was recognition
that there's going to be someconsolidation happening from
agencies that previously havebeen recognized as distinct
entities It appears that they'regoing to be consolidated into a
new administration for healthyAmerica.
(23:24):
And so SAMHSA, the SubstanceAbuse Mental Health Services
Association is going to beconsolidated.
And that's not a guarantee thatthere will be cuts to funding or
cuts to even positions.
No SAMHSA positions haveofficially been listed as in the
(23:45):
news articles right now as thosethat are being cut, but I think
it's to be expected that it'slikely to occur.
What's interesting in my realm,in the broader healthcare
delivery realm is that Medicaidis the single largest payer of
behavioral health services foradults in America.
(24:06):
And Medicaid is also becomingmore and more of a prominent
payer for substance use disorderservices as well.
So with the cuts that Doge hassaid that it's going to
implement in our federalgovernment.
Of course, there's been a lot ofspeculation for a long time
about what that means forMedicaid and Medicare.
(24:29):
There's been a lot of assurancesthat Medicaid won't be cut or
that Medicare won't be touched,but it still seems really hard
to believe that you can't touchthose entities or those delivery
mechanisms just given the sheersize and scale that they
represent in our federal budget.
So I think that's another areafor us to just continually watch
(24:50):
as to how do you cut Medicaid?
How do you consolidate SAMHSA?
And what are those impacts ondelivering behavioral health and
substance use disorder servicesin states, particularly with
those who have federal matchingprograms?
You know, I think that'ssomething that Oklahoma
especially is keeping an eye onof when those federal dollars go
(25:16):
away.
It's not as if Oklahoma has adesignated rainy day fund ready
to swoop in and say, okay, we'vegot the rest.
We're fully expecting that we'regoing to be seeing a reduction
in overall spend that we'regoing to have to accommodate.
Do any of you have any otherthoughts on how you know, the
(25:37):
potential cuts.
We don't know of any certain,but any potential cuts that
could be coming our way thatcould be impacting the delivery
of behavioral health
SPEAKER_02 (25:46):
Yeah, Alison, I'll say I think I've shared your
skepticism in watching the news,not just this week, but maybe
even since the newadministration came in, that
there's all these assurancesthat there's going to be more
efficiency but less spending,that programs will remain intact
despite all of therestructuring.
And so I think it is a littledifficult to believe.
(26:07):
I think a healthy amount ofskepticism in this area is
healthy to kind of repeat that.
But, you know, speaking from, Iguess, from my background with
community health centers, theyrely on federal grants and
monies for a lot of theirfunding in order to provide
medical care, dental care,behavioral health services, and
(26:28):
substance use services,especially.
And so I think they have verylittle wiggle room for revoking
or rescinding funding or grantsupport and expecting for their
programming to be able tosurvive.
I think we saw there wasactually a little bit of
whiplash.
There was some more kind ofquick decision of funding.
(26:50):
Don't know exactly what theoutcome of that's going to be
yet.
But the programs are having to,I think, quickly figure out how
to still provide services andprovide for the need because the
need doesn't go away justbecause the funding does.
And so I think you and I at somepoint within this group have
(27:10):
talked about how if you removeone set of resources, it means
that there is weight on someother portion of the system.
And so where is that support andservice going to come from?
Who's going to have to kind ofthin out or spread their
resources more thinly to figureout how to still provide and
(27:32):
meet those needs.
SPEAKER_04 (27:34):
Definitely.
And, you know, as far as ahealth system like mine, what
we're doing to prepare forpotential cuts is really
recognizing that we could havehigher ER volumes of patients
who are otherwise currentlyprovided for the FQHCs or in
community behavioral healthcenters and We're really being
intentional about where we haveinvestments in our community and
(27:57):
where we have, let's say, freehealth fairs, recognizing that
in the future, we're going toneed to be intentional to find
places where there are pullbackor drawdowns of care, of that
preventative care or of thatearly intervention care that
right now is keeping people outof that crisis and emergency
(28:17):
situation, necessitating them tovisit our ERs.
We don't have a shortage ofvolume in our ERs in Oklahoma.
So this is not a situation wherewe're excited about having more
patients coming to our ERs.
We wanna be sure that thepatients that are coming to our
ERs are the ones that need to bethere and that we are able to
(28:37):
treat those lower acuityconditions or non-emergent
conditions at the right levelsetting.
And so really partnering withFQHD's Community Behavioral
Health Centers and identifyingwhere they are experiencing cuts
or delineation and, sorry, wherethose community behavioral
(28:58):
health centers may beexperiencing reductions in their
abilities to meet the communityneed.
How's the health system like usable to step in and partner with
them, perhaps formally orinformally, or how are we able
to infuse another element ofpreventative or non-emergent
care alongside them?
Ideas that we have that we'reexploring is partnerships with
(29:20):
behavioral health telehealthcompanies, is looking at how we
are already able to access someof those services, but in our
rural communities where they arenot due to a lack of broadband.
So we're really looking at howwe're drawing attention to what
that means for their ability toaccess care at home.
(29:41):
different levels of our stategovernment to ensure that they
see those deserts and what thatcould mean in terms of if you've
got an overrun ER with someonewho didn't need to be there, had
they had access to a differentpoint of care, then when you are
an emergency or your loved oneis in an emergency, it could be
that much harder to reach us.
(30:02):
So really personalizing theimpact that some of this could
have in terms of escalating theneed and creating emergencies,
whereas today those emergenciesare being avoided by preventable
or community intervention.
Tanya, you and I had also hadsome conversations about some
school-based crisis programsthat you have familiarity with.
(30:25):
What are the benefits andchallenges of those school-based
crisis programs?
SPEAKER_02 (30:30):
Yeah, so, I mean, obviously, I think school-based
programming is crucial.
The school has kind of presenteda foundation to address things
like anxiety, ADHD, ADD.
We've seen, you know, over,unfortunately, over the last
decade or so, increases in gunviolence in our school systems.
(30:54):
And that, I think, is directlyrelated to behavioral health
issues that haven't beenaddressed or maybe were not
previously identified.
So I think some of the benefitsdefinitely include being able to
address those things early onhaving some early intervention
with students to prevent healthproblems from escalating having
(31:15):
Reduction in barriers to mentalhealth services will make it
more accessible for thosestudents, especially in
underserved communities.
And sometimes that includesthose rural communities that you
just mentioned where access maybe difficult, transportation
issues may exist.
To the point about guns, gunviolence in our schools, just
(31:36):
hopefully reducing providing asafer school environment.
If students have their needsmet, if they're getting support
for mental health issues or evenfor substance abuse issues, then
hopefully we're seeing saferschool environments and then
reduced behavioral issuesbecause they're being addressed
at the school system.
(31:56):
And we've said, you know, foryears, the school is where a
student spends most of theirday.
Most of their interactions aregoing to be in the school
environment.
So it just kind of provides anopportunity if they do need
intervention, whether that'searlier or they've already had
some intervention and they needsome pickup of those services to
have that at the school level.
(32:18):
But as for challenges, I thinkwe've already started talking
about funding.
Funding is always going to be,always has been, and always
likely will be a hurdle.
It impacts the ability to hireand retain qualified staff.
I do know that it is moredifficult to recruit and retain
staff in those harder accessareas or in rural areas, which
(32:40):
are actually at higher risk ormay have higher incidence of
need for behavioral healthservices.
So provider shortages, I thinkthat happens across the
behavioral health kind of realm,but specifically in the school
system and in the school-basedenvironment, that has a
different impact.
There's still a stigma, I think,about accessing behavioral
(33:05):
health issues.
And in the school system, you'rein that kind of adolescent age
where you're experiencing a bitof anxiety anyway, it might add
some extra angst if you feellike you may be exposed or
someone may see you accessingthose services.
And then I think kind of goingback to recruitment issues,
(33:28):
there may also be like trainingand capacity give good training
to the staff so that they areequipped for the issues that are
going to come up at a schoollevel.
I think adolescent behavioralhealth services are by
definition going to be differentand distinct than adult school,
adult behavioral healthservices.
(33:48):
So making sure that you've gotstaff that are adequately
trained, not just present andnot just willing to be there,
but also able to actually givetargeted and intentional
behavioral health services tothose students.
SPEAKER_04 (34:03):
Yeah, Tanya, our interaction with schools has
been along those lines ofsupporting community programs.
I think it's rare thatcharitable health systems don't
have some form of a communitygiving program and health
insurers, you know, for-profitcompanies do this as well.
Major companies in communitiesare always giving back to the
(34:24):
community in a variety of ways.
But I think healthcarefacilities or healthcare systems
specifically recognize theimportance of investing in that
early preventative interaction,particularly in adolescents.
So Integris Health partners witha group called the Hope Squad.
The Hope Squad is a school-basedprogram that supports schools in
(34:46):
identifying students to helpraise the need, to recognize the
need in their, I was about tosay colleagues, but in their
fellow students.
So the Hope Squad is trainingstudents and administration to
recognize crises building beforeit becomes to a crisis point.
so that those students can gethelp before they're in an
(35:08):
emergency situation.
And that's such an obvious smartinvestment from a health system
like Integris Health whereyou're just trying to identify
where someone needs help beforethey're at that crisis point
where they have to come to theER and come to the most
expensive cost setting.
That's also something that youcan see where managed care
companies would be supportive offrom an access point as well.
(35:29):
So I think the school-basedprograms, there's a plethora of
options and with the fundingchallenges that we discussed
before that might be coming ourway, that I think that's where
you're going to see some smarterinvestments being shifted from
those community giving programs,focusing on preventative care,
access to care in order to fillthe void that may be created
(35:53):
with funding challenges.
One other comment I just feelthe need to make which is the
cuts that could be coming fromthe federal level and then the
state's inability to fill thematch or to fill the void that
could be created.
Sometimes those arecharacterized as malicious or
mal-intent.
(36:13):
And I just wanna draw attentionto oftentimes the legislators
that are involved in thosedecisions are put in really
difficult positions.
And this isn't a situation inwhich anyone is wanting to hurt
someone or wanting to causeharm.
I think it's important toremember that these are big
numbers And then a lot of bigimpacts can boil down to some
(36:38):
small decisions that could justbe, you know, a shift here that
then has dominoes that cause,you know, that clinic that was
in that one rural community toclose.
And that couldn't really beentirely foreseen by the
decision that was made thousandsof miles away.
So, you know, I'm not trying todefend all of the changes that
are happening, but just toacknowledge that at least as
(36:59):
we're interacting with our statelegislators and our federal
delegation Our whole goal isensuring that they just
understand the importance of thefunds or how the funds are used
now and what possible impactscould be as they're wrestling
with really tough decisions withsome big goals.
Those goals also have anobjective to do good for America
(37:23):
or to do good for the nation inways that that are different
than what our current funding orstructure is set up for.
So that's just something that Ialways try to step back and
remind myself of whenever we'reconfronted with some of those
big changes and unknowns thatcould be coming our way.
SPEAKER_02 (37:42):
Yeah, I agree with that, Allison.
I think, you know, as we moveforward and, you know, we're
kind of in this resourcequestion mark area that it's
going to be important to have.
Number one, those partnershipsthat you talked about, like with
your health system and thecommunity health service.
systems, but also to make surethat everyone realizes we're all
(38:04):
kind of trying to figure it outas we go along.
It's a bit of an unpredictablearena that we're in right now,
and everyone's trying to makesure that they're not just being
compliant, but that they're alsoservicing the needs.
And so that does lend itself tokind of a difficult, challenging
area where sometimes difficultand challenging decisions have
to be made.
(38:25):
So completely agree with that.
SPEAKER_01 (38:28):
Yeah, if there's a call to action here, in my
opinion, it's that where we havemajor budget cuts potentially
and concurrent to majorreorganization and staffing
cuts, especially at the federallevel, those regulators often
(38:50):
create that sort of connectivetissue between those very hard
funding challenges that get madeat the legislative level and the
on the ground impact of thefunding.
And so, Alison, the types ofcommunity investments and
support services that you talkabout that we help to render
(39:12):
care cost-effective, keepingpeople out of the ER, making
sure that we're spending themoney in the right place.
So often those are, I thinkthere's a risk of those, they're
often funded through sort ofsupplemental ancillary types of
programs, special authoritiesand Medicaid, things like that.
Things that are going to beappear to be on the chopping
(39:34):
block often and are going to beeasy to get lost in the shuffle,
especially where the regulatorsand policymakers that were
responsible for creating themand understand their value and
how they fit with the system maybe getting reshuffled or getting
no longer in their roles.
(39:55):
And so I think there's a realneed for providers and advocates
to come together and understandthat the policymakers that have
traditionally been in thatintermediary role may no longer
be in place and that we need tobe able to talk with funders
about the need for these EDdiversion, crisis stabilization
(40:21):
programs, school-based servicethat are cost effective and are
as well as being integral toquality outcomes.
SPEAKER_00 (40:36):
This is a fascinating discussion and to
piggyback on some of thecomments made as well as add to
some of the excellent thoughts.
In addition, as David mentioned,I think there is a need for the
mobile crisis, the communityintervention programs that do
(40:58):
divert folks in crisis from theERs and the EDs, which are less
effective in treating thesituation.
Those in mental health crisisalso cause disruption within the
emergency departments withrespect to those needing more of
a medical surgical intervention.
(41:18):
And it's more cost effective toutilize a less intensive, more
mental health-focusedintervention.
So the rollout of the 988 crisisline, the use of mobile crisis
teams, the introduction ofcommunity-based living room
(41:40):
programs and other crisisstabilization type facilities
are less expensive if you'relooking at it from a
cost-effective standpoint, lessintrusive or less invasive, less
of a disruption for those thatare in need of a physical
medical type of intervention inan emergency department, et
(42:00):
cetera.
So all of that kind of comestogether in addition to keeping
in mind, I think all of ustouched on this a little bit
today, the idea that if we'renot able to treat patients those
with a behavioral health need ora crisis, then it's going to
have to be addressed in someother way.
And that might fall uponAllison's system in their
(42:23):
emergency department.
It might fall on a school-basedcrisis program that has to
intervene in a more seriousmatter and working with the
managed care organizations andhow they seek to provide the
best care and obviously managecosts.
So I don't know if If any of youhave any final thoughts for
today to sum up, I sort of doneso right now, and I'd like to
(42:47):
turn it back over to each ofyou.
SPEAKER_04 (42:48):
Hey, Jed, I would just comment that the Behavioral
Health 101 program that youmentioned at the top of the hour
covers a lot of those differentintervention points and gives a
definition of what they are andhow they interact with the
behavioral health care servicescontinuum.
And it's been great talking toyou guys.
(43:08):
I've loved learning from each ofyour perspectives.
So thanks so much for having me.
SPEAKER_02 (43:13):
Yeah, I think my final thought would just be that
in addition to being compliantas we move forward, we'll, as
usual, have to also beintentional and creative and,
you know, create partnershipsand find resources maybe to make
sure that we're still servicingthose behavioral health care
needs.
SPEAKER_01 (43:32):
Very well said.
I really appreciate thediscussion today and I
SPEAKER_03 (43:36):
hope we can do it again soon.
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