As providers, consumers and administrators scramble to salvage FamilyCare as a viable CCO, an equally significant issue critical to those orphaned by their closure has garnered less public attention. What subscribers will be going toward, rather than leaving behind, has not fully been illuminated.
The healthcare community is experiencing an increasing rift between medical providers and mental health providers in relation to the two CCOs and their respective approaches to care. Health Share, the remaining CCO if FamilyCare closes, is more liberal with medical care than mental health, which isn’t true of FamilyCare. Health Share functionally limits mental health visits to an average of 1-2 per month based on what they call a “level of care” assignment – a formula of symptom criteria that corresponds to medically necessary services (i.e. type, frequency and duration of care). FamilyCare, on the other hand, allows mental health providers the power and freedom to determine best treatment for their clients and asserts that this model has resulted in lower healthcare costs overall.
When displaced FamilyCare subscribers land in the Health Share system, not only will they lose many of their medical and mental health providers, but they will also be subject to these limits. Where they benefitted from deeper psychotherapy to address trauma that underlies some of what makes them OHP-eligible, they now can expect to be disrupted by Health Share’s limiting and micromanaging approach to mental health. While Health Share’s public face speaks to no limits in mental health care, their practices make access to it impossible for many, particularly those harmed by institutions with little tenacity to fight barriers.
The Mental Health Parity Act was made law in 1996. It’s a fairly complicated law that asserts (in short) that mental health and substance use disorders must be covered at the same benefit level and with the same restrictions as medical and surgical coverage. Oregon Expanded Medicaid is not exempt from this law, but the question remains whether they apply these same functional limitations and medical necessity formulae to medical providers treating Health Share subscribers. Given the enthusiasm of some of the medical community related to Health Share monopolizing OHP’s CCO options, it appears unlikely.
Despite FamilyCare mental providers’ desperation to not abandon their clients, they find Health Share’s disregard for their skill, expertise and education, deplorable and are themselves despairing at the thought of working within their system. The few mental health providers that are currently contracted with Health Share are burdened with waitlists months long, and full-time (non-billable) staff just to manage those lists and respond to inquiries from subscribers desperate to initiate care. The costs, therefore, associated with attending to Health Share’s subscribers are far greater than those of FamilyCare. For many clinics and private practitioners, that is the difference between remaining viable and not serving OHP clients at all.
As we all approach answers to the question of FamilyCare’s longevity, we must not omit examination of the future of services, should they shut their doors. These questions (and more) should be answered by our legislators and OHA before they stubbornly walk away from the bargaining table, leaving our most vulnerable community members without care:
Is Health Share’s parity structure legal or ethical?
How will OHP subscribers fair without access to regular care or the power to collaborate with providers who actually know their specific needs?
Is it ethical (or legal) to apply a formula for care to a population with a diverse set of health concerns?
Is it cost-effective for subscribers to access ER services more often because they cannot access care when they need it?
How will a rift between subscribers’ medical and mental health subscribers impact coordination of their care and overall health?
How will the quality of care of in-network, and taxed, mental health providers impact subscriber care (and subsequent costs to the state)?
How do we, as a community, want to prioritize health…from a short-term financial balance perspective or a long-term overall cost approach?
Cures Act doesn't add parity requirements -- it seeks clarity and enforcement of existing rules. See more at: htps://www.healthcaretownhall.com/?p=8340#sthash.9I4tCd7U.dpbs