The top roadblock to recruiting providers remains Medicaid's low rates, although many also complain about restrictive rules imposed by state agencies. “We work primarily with a population that has the resources to seek private treatment for their mental health,” said Douglas Bodin, CEO of a Los Altos, Calif.-based therapeutic consulting firm. “The public sector is riddled with waste, fraud and bureaucratic inertia that render appropriate interventions specifically tailored to each individual nearly impossible.”
Low-income patients often take longer to treat because they have other issues that must be addressed, including poor housing, transportation and nutrition. It often falls to mental health professionals to deal with these issues.
For mental health providers who have decided to treat Medicaid beneficiaries, the decision can be rewarding. In the small city of Chehalis, Wash., about 45 minutes south of Olympia, hopelessness tied to unemployment is high, said Tre Normoyle, behavioral health director at Valley View Health Center. “I see what I call chronic despair, where nothing is going right, and they don't see a way out of their circumstances,” Normoyle said. “Seeing people get mental health treatment, and finding mental illness that was previously undiagnosed and see them finally start to feel better is pretty meaningful.”
A number of states still have administrative roadblocks that block access to mental health services for Medicaid beneficiaries. The American Psychological Association is working with several states whose rules prevent Medicaid reimbursement for psychologists and other mental health providers in private practice settings. The trade group is unclear about the limitations' origins, but surmise they were meant to save money.
“There are providers that want to participate,” said Shirley Ann Higuchi, the APA's associate executive director of legal and regulatory affairs.
Many mental health practices are willing to take on interns or postdoctoral fellows to serve Medicaid beneficiaries, but many states decline to reimburse them. That means financing internships is difficult, making it harder to recruit and train the next generation of psychologists willing to work with low-income populations, said Stacey Larson, director, legal and regulatory affairs at the APA.
Some plans use community-based peer counseling as an alternative to specialty practices. A licensed professional such as a psychiatrist may consult on a case or see the beneficiary a few times a year while the plan lines up a person with personal experience of a specific behavioral condition to be a peer counselor on a regular basis.
“There's a friendship bond that forms, where there's a feeling that they've been in your shoes and know what you're going through,” said Tom Lutzow, CEO of iCare, a Milwaukee-based health plan co-owned by Humana. “There's a real trust there.”
Besides reducing ER visits for beneficiaries, peer counselors are also much less costly than a psychiatrist. A peer counselor may earn $22 an hour, much less than a psychiatrist, Lutzow said.
In the long run, however, the key to guaranteeing access to mental health services is providing higher reimbursement for the entire package of Medicaid services, which will require the states and the federal government to spend more to ensure access, providers and plan officials say.
“The reality is that provider reimbursement rates are a function of what state governments budget for Medicaid,” said Pamela Greenberg, CEO of the Association for Behavioral Health and Wellness, a trade group for behavioral health and wellness companies.