MT overlooks family doctors role in mental health
Rural Mental Health
Primary care providers in rural state get more time for credentialing
After four months of operating a statewide managed behavioral health program in Montana, Maryland-based CMG Health has learned an important lesson about behavioral health in rural areas—many people still go to their family doctor or other primary care providers for these services.
This fact of rural life was overlooked when Montana Community Partners (MCP), the non-profit/for-profit partnership operating the program, first assembled its network. The result was widespread confusion among patients and primary care providers, who continued to bill for services even though they were not credentialed under the new program.
Primary care physicians recently were given another extension to the deadline to get credentialed. They now have now until Sept. 30, according to Jani McCall, executive director of MCP. Physicians associated with HMOs will not be required to submit an application.
No psychiatrists in area
"There are huge areas of the state where there is no psychiatrist in shouting distance," says Randy Poulsen, managed care bureau chief for the state’s Addictive and Mental Disorders Division. "We didn’t emphasize strongly enough, and Montana Community Partners didn’t understand well enough the role primary care providers play in furnishing mental health services," he says.
After Sept. 30, MCP will continue to reimburse uncredentialed providers in areas where no credentialed providers are available. MCP also will be holding quarterly training sessions for primary care providers as part of its contract with the state.
In other states, CMG Health is "used to being able to send a patient to another provider across town, but (in Montana) the next hospital may be 250 miles away," says Mr. Poulsen.
The joint venture between CMG and the non-profit Care Coalition of Montana, comprising 20 human service organizations and community mental health centers, was designed to avoid such basic misunderstandings of the local system.
A year before the state’s Mental Health Access Plan (MHAP) was implemented, Medicaid paid claims for behavioral health services to a wide assortment of providers, including federally qualified health centers, certified rural health clinics and mid-level practitioners such as registered nurses.
Despite this record, almost everyone associated with MHAP agrees that not enough attention was paid to primary care providers in the first months of the new program.
The large number of elderly covered under the contract also was not fully appreciated, according to Alan Strange, executive director of the Montana Primary Care Association. "If they are on medication management, it is impossible for a psychiatrist to look at all of these patients. (MCP) has to make arrangements with local physicians." He also notes that in rural areas using local providers can make the difference between keeping people at home with their support network of family and friends or hospitalizing them.
Kathy McGowan, executive director of the Montana Council of Mental Health Centers, says the partnership so far hasn’t worked as well as she had hoped. In hindsight, she says, the partnership "wasn’t well spelled out in terms of what it would look like operationally. They were sitting over there doing what they do and we were waiting for them to make overtures." Some of the problems are now being ironed out, she says, adding that she is "guardedly optimistic" for the future.
Critics of the program worry, however, that the planned acquisition of CMG by a competitor, Merit Behavioral Care of Park Ridge, NJ, could add another layer of bureaucracy to management of the program.
Authorization of treatment
Among the other issues being addressed in MHAP are timely determinations of eligibility and timely authorizations for treatment. The Western Montana Mental Health Center in Kalispell, MT submitted written testimony to a MHAP governing board detailing a number of cases in which clients ran out of medication and could not obtain services because of delays in getting clients cleared for "financial" or "clinical" eligibility for services. The testimony called the authorization process "cumbersome, disorganized, even chaotic.
"All of these distractions mean staff are not present in the program for the consumers," the testimony said.
Ms. McCall, who previously served as the head of a Montana organization providing therapeutic foster care and family services, acknowledges the authorizations problem. She notes that MCP is now moving away from the rigid utilization management system, which works better for commercial business than for the public market.
Too harsh a start
According to Mr. Poulsen, "the mistake CMG made is that they should have erred on the side of laxity to begin with. They started out too harshly."
MCP is now being much more flexible in extending authorizations for all outpatient and community services, Ms. McCall says. "Instead of authorizing only four outpatient visits, we might now authorize eight or 12. For case management, we might authorize three months instead of one month." MCP also is "simplifying and shortening paperwork" and "moving all authorizations for therapeutic foster care and youth care to regional offices. The partnership is sending mobile teams to mental health centers to help clear up questions about authorizations and teach providers how to process claims, she says. This change should speed up the review process considerably, she says, noting that some of their reviewers for outpatient services have had has as many as 1,000 cases on their desks.
Finally, Ms. McCall notes that MCP is renegotiating part of its contract with the state to provide for "constructive eligibility." Under this approach, MCP "will provide case management and emergency services for 90 days to people who choose not to or can’t make an application" for the program. A case manager will then work with them to make them eligible for the program, she says.
Contact Mr. Poulsen at 406-444-5622; Ms. McGowan at 406-443-1570; Mr. Strange at 406-442-2750; and Ms. McCall at 888-599-2233.
MT overlooks family doctors role in mental health
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