| Private
health maintenance organizations under contract to the state are
providing far less mental health care to Medicaid recipients than
the the commonwealth pays for, state officials say, with as much as
$18 million a year in public funds unaccounted for.
In a stern letter to 12 HMOs, a copy
of which was obtained by the Globe, officials from the Division of
Medical Assistance said they have "serious concerns"
about the adequacy of mental health and substance abuse services for
Medicaid recipients, noting that the HMOs are falling short of their
contractual obligations to the 90,000 Medicaid enrollees by as much
as $17 per month 3 per patient.
"This is a scandal" said
Dr. Elis Newberger, a pediatrician at Children's Hospital and
president of the Massachusetts Committee for Children and
Youth, an advocacy group. To hear that there have been resources
that in effect have been siphoned away from mental health when we
have such a vast community of need in children and adults is
sickening."
In the letter, Meryl Friedman
director of the HMO program for t the state division, warned the
HMOs that unless they took steps to improve delivery of mental
health and substance abuse care to their Medicaid subscribers, they
would be cut out of any future contracts for such services.
Robert Hughes, president of
Massachusetts Association for HMOs, questioned the accuracy of the
state's figures and said the letter lumps the HMOs together and
"paints with too broad a brush." "This is not
the first time that Medicaid has made serious errors in data and
fact," Hughes said. "I think the plans have worked very
hard to service Medicaid recipients well."
State officials and advocates,
however, say that many troubled children and adults are not getting
the mental health services they need from HMOs. It is not until
these people are in crisis, either suicidal or homicidal, that some
then obtain help from other strapped state agencies, such as the
Department of Mental Health and the Department of Social Services
"We do have the issue of HMOs
treating kids for a short period of time and then recommending that
those families seek DSS contracts for continuing service," said
Linda Carlisle, commissioner of DSS. "And we do know that the
majority of these kids are on Medicaid."
Some social service advocates say
this means that taxpayers may be spending twice over for the same
people, particularly children who have been traumatized by sexual or
physical abuse and need intensive mental health care, such as home based
services or residential care.
"It's double-dipping if these
HMOs are getting blank dollars to provide services to Johnny Jones,
but Johnny Jones is getting those services on a DSS or DMH or
[Department of Youth Services] contract," said Linda Luongo,
former first deputy state auditor and now a management consultant on
human services. Other private insurers are also doing this, she
said, "but the HMOs are the worst offenders."
In her letter, dated April 20,
Friedman said her staff "continued to observe a major gap
between the Division's expectations and the delivery of such
services" by the HMOs. The state reimburses HMOs approximately
$22 per member per month for mental health and substance services,
the letter said, while the contracted HMOs deliver only $! to $5
worth per member per month in mental health and substance services
to their Medicaid enrollees. |
Michael
Bailit, deputy commissioner of the division, said yesterday that $22
per member per month was the average amount spent on the 390,000
Medicaid recipients who receive their mental health and substance
abuse services not from the HMOs but from Mental Health Management
of America, a for-profit company based in Tennessee.
"That is our identification of
the upper payment limit that should be spent on mental health and
substance abuse services," Bailit said. "We are not saying
that that's what these HMOs have to spend, just that ;here is too
big a discrepancy between what they are spending and this upper
limit."
Dr. Dan H. Rome, associate medical
director for mental health services for Tufts Associated Health
Plan, says Tut'ts is spending as much as three times more on
Medicaid patients than the average $4 to $5 per patient per month
cited in the state letter.
"We were surprised and
distressed by the recent somewhat boilerplate letter because at our
review last July we were told we are doing a good job," Rome
said.
Tuft's, with 5,244 Medicaid enrollees,
is the fourth-largest provider. The top three are Neighborhood
Health Plan with 81,271 enrollees, Harvard Community Health Plan,
with 14,901, and HMO Blue, run by Blue Cross/Blue Shield, with
12,280.
Hughes, the HMO association
president, said he thinks the letter that went out last week was motivated
by state officials' desire to bring all mental health and substance
abuse services for Medicaid patients under the jurisdiction of
Mental Health Management of America, the Tennessee-based company, or
whatever managed-care company wins the new contract in July.
State offiicials dispute that
assertion. Bailit said the state has tried for years to get the HMOs
to improve their mental health services and while some strides have
been made, progress has been excruciatingly slow.
Many mental health advocates agreed.
They said that the kind of gatekeeping mechanisms that HMOs put in
place, such as requiring subscribers to see their primary care
physician first and then get a referral for mental health services,
end up being barriers to care for this population. In addition, many
HMOs do not provide the home-based services many of these families
need.
"This is a very highly stressed
and disorganized population, and they are easily discouraged by
barriers," said Hugh Leightman, administrative director of
Wediko Children's Center, a mental health service for high-risk
children. "These people need intensive home-based services and
outreach, and you can't expect them to always come to every
appointment."
"Most at risk of falling
through the cracks," Leightman said, "are poor children
traumatized by physical and sexual abuse." State
officials also raised this concern in their letter, citing a lack of
providers with expertise in sexual abuse and "a lack of
multilingual providers who can treat recipients in their primary language."
"Given the slow rate of
progress of HMOs in this area over the last three to four years, the
division may be forced to carve mental health services out
from the HMOs' juristiction," Friedman's letter concluded
"unless performance dramatically improves before the end of
1995." |