By Dave Ranney
KHI News Service
TOPEKA, Aug. 31
It”s been two months since the Kansas Department of Social and Rehabilitation Services launched a major initiative aimed at bringing the state”s mental health system into compliance with federal standards.
So far, the changes have prompted few complaints.
“Have our phones been ringing off the hook over this? No, they have not,” said Rick Cagan, executive director at the National Alliance on Mental Illness-Kansas office in Topeka. “But the jury is still out. There”s a lot that remains to be seen.”
Driven by warnings the system had fallen out of compliance with federal standards requiring that consumers have adequate choice among providers and would soon face millions of dollars in fines, SRS dropped its fee-for-service payment system, contracting instead with Kansas Health Solutions, a managed care company with ties to the state”s 27 community mental health centers.
Billing under the new system is reportedly going reasonably well.
“Claims are being paid in a timely manner,” said Kansas Health Solutions CEO Michael Goldberg. “We”ve had some issues to work through, and there”s been the frustration that comes with new billing rules. But there”s not been a big blowup or what I”d call a big stumble. It”s been fairly smooth, actually.”
Each month, the state”s community mental health centers see almost 39,000 patients
including 17,000 children
whose visits are covered by Medicaid. In July and August, Kansas Health Solutions processed more than 13,460 claims for mental health services.
“One of the things CMS (Centers for Medicare and Medicaid Services) said Kansas needed to do was to open up the network and create more choice for consumers,” Goldberg said.
SRS opened the Medicaid-funded system to private providers, giving patients the option of receiving services outside their community mental health centers.
So far, 617 private practitioners
psychiatrists, psychologists, counselors, social workers, and marriage and family therapists
have agreed to see Medicaid patients.
The state”s foster-care contractors
KVC Behavioral Health, United Methodist Youthville, The Farm, and St. Francis Academy
have signed on as well, adding more than 250 practitioners to the mix.
“Those are wonderful numbers,” said Steve Erikson, director of mental health at SRS. “Consumers will have a choice, which is what this is about.”
Before July 1, someone on Medicaid had to use their community mental health center for mental health services. Private practitioners were not eligible for Medicaid reimbursements.
Now, Erikson said, patients will be able to choose from a list of providers who”ve agreed to see Medicaid patients.
“What the numbers show, I think, is that people are interested and want to be part of the system,” he said. “We”re excited about that.”
Sky Westerlund, executive director at the Kansas Chapter of the National Association of Social Workers, isn”t so sure.
“I wouldn”t say this is what you”d call an opening of the flood gates,” she said. “A few people have signed up, but we”ll have to see how long they stay. The pay is below market rate and the paperwork is more than what people can manage without getting paid more.”
Targeted case management
SRS also adjusted its interpretation of targeted case management
arranging services for people
and what”s eligible for Medicaid reimbursement.
“It used to be one person could do targeted case management, now there have to be two,” said Ron Denny, executive director at the Four County Mental Health Center in Independence.
One of the case managers will be tasked with arranging the services; a second case manager has the job of seeing that the patient actually receives the services.
“We”ve always thought it was more efficient to have the person who hooked you up with services be the same person who made sure you got them,” he said.
But the federal government wanted two people involved to assure that too much decision making was not vested in one person, creating a system of checks and balances.
Denny is a former deputy secretary of health care policy at SRS.
“It”s not that it”s a worse model, it”s that it”s a more complicated model,” he said. “And it”s a dramatic change. I mean, this is the first time targeted case management has changed since the 1980s.”
It means new staff must be hired or caseloads readjusted.
But Denny and other center directors say there”s a bigger financial issue on the horizon.
CMS has told SRS that Medicaid will only pay for services deemed medically necessary. But center directors say the criteria for knowing which services will be deemed “medically necessary” and covered for reimbursement by the program are unclear.
“It”s an area that”s somewhat fuzzy.” said Dwight Young, executive director at the Center for Counseling and Consultation in Great Bend.
For example, for services that teach socialization to be considered medically necessary, community mental health centers must be able to show that without it a patient”s condition would worsen.
“The expectation is that we”ll have to prove a negative,” Young said. “First of all, that”s a difficult thing to do and, second, we don”t want to put in a position of stopping something to see if a person slides backward just to prove a point.”
Some mental health advocates aren”t pleased by the development.
“What”s lacking here is an understanding that for some, mental illness is a chronic disease, not unlike diabetes, that requires ongoing maintenance,” said Roy Menninger, a former president and CEO of the famous Menninger psychiatric clinic. “You wouldn”t cut off a diabetic person”s access to insulin once their condition stabilized. So why would we cut off a mentally ill person”s access to the services once they”ve stabilized?”
So far, neither SRS nor Kansas Health Solutions has denied payment for a service not considered medically necessary.
SRS Secretary Don Jordan made clear that he wanted Kansas Health Solutions and the community mental health centers to spend the first 90 days after the changes making sure services were accessible, provided and paid for. The process for sorting out which services are medically necessary is expected to begin this fall.
“There”s some nervousness out there,” said Goldberg at Kansas Health Solutions.
Goldberg insisted that community mental health centers will be paid for services that are truly needed.
“We need to encourage improvement, certainly, but we can”t withdraw services if somebody going to end up back in the hospital,” he said. “That doesn”t make sense.”
Still, he said, some services may not pass the medically necessary test.
SRS” Erickson said community mental health centers will need to “look at other funding sources” for some services. “I believe the financial resources are there for them to do so.”
That remains to be seen. Community mental health center directors have long argued that Medicaid doesn”t cover their costs and that they often have to use the non-Medicaid portion of their budgets to offset the shortfalls.
“It”s too early to know whether the resources are adequate, based on the system”s new design,” said Mike Hammond, executive director at the Association of Community Mental Health Centers of Kansas. “It appears there are adequate resources for meeting the needs of our Medicaid population. Our fear now is that with all the changes
changes that we”ve never dealt with before
we may not have the resources for meeting the needs of our non-Medicaid population.”
Legislators set aside an additional $17 million for community mental health centers this year. Hammond said the centers will ask for an additional $8.8 million next year.
-Dave Ranney is a staff writer for KHI News Service, which specializes in coverage of health issues facing Kansans. He can be reached at
dranney@khi.org
or at 785-233-5443, ext. 128.