State systems to track availability of psychiatric hospital beds vary

Recognizing the critical need for inpatient hospital and residential mental health and substance use disorder treatment settings, the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) has released a report that examines how states make information on open beds available to consumers, the impact of effect that inpatient bed tracking has on patient access, and the challenges that remain with inpatient bed tracking systems. The researchers concluded that among the 17 states that track availability of psychiatric hospital beds, only five states allow for public access. In some states, systems to track the availability of psychiatric hospital beds have been challenged by the reluctance of hospitals to update information on open beds frequently enough to be useful given rapid patient turnover (ASPE Report, August 2019).

Need for inpatient bed tracking

ASPE conducted a study to examine how states make information on open beds available to consumers, the impact of effect that inpatient bed tracking had on patient access, and the challenges that remain with inpatient bed tracking systems. Inpatient hospital and residential mental health and substance use disorder (SUD) treatment settings are a critical component of behavioral health services care. Patients may require an inpatient hospital stay when they experience a psychiatric or SUD emergency, pose a threat to themselves or others, and need 24-hour medical monitoring and treatment. In the absence of a bed registry, emergency room staff, patients, or other providers must call multiple hospitals or residential settings to determine if there is a slot available that would be appropriate given the patient’s needs. This results in long waits in emergency departments.

Systems to track openings

The researchers conducted an environmental scan by identifying states that have systems to track openings in behavioral health treatment settings, such as hospital psychiatric beds and residential treatment beds. The study found among the 17 states that tracked this information, only five states allowed public access. The other 12 states kept the information about bed availability behind a firewall and only available to providers. The researchers found significant variation among states in how the registries were operating, the types of behavioral health providers they included, and perceptions of their usefulness. In some states, systems to track the availability of psychiatric hospital beds have been challenged by the reluctance of hospitals to update information on open beds frequently enough to be useful given rapid patient turnover.

Emergency department staff noted that the system does not negate the need for them to call hospitals to confirm that there is still an open bed that is appropriate for the patient’s needs and that relationships among hospitals and emergency departments and other crisis system staff may be more efficient than using the bed registries. However, some states reported that the registries were very helpful in locating open beds as well as in documenting the need for additional psychiatric beds.

Registries that post available openings in SUD residential, detoxification, and other non-hospital-based systems are less common than hospital bed registries. Connecticut has a publicly-facing registry that indicates openings in SUD treatment settings. Interviewees reported that patients with SUDs and providers like the system and find it useful. However, more effort is needed to make patients and family members aware of the system.

Future research

There have been no formal evaluations of the effect of bed registries on access to care. The report concluded that future research could help improve understanding of the characteristics and processes that make the bed registries most useful. Some avenues to explore include: (1) how financial, regulatory, contractual, and policy levers can be used to encourage participation in bed registry systems; (2) how many consumers are using the public registries and how to increase their usage; (3) whether technology can substitute for human data entry to track available treatment beds; and (4) whether registries reduce the time and effort required to locate an appropriate inpatient or residential bed.

Advocates say Medicaid can shelter the homeless in Pennsylvania

Pennsylvania could use Medicaid to address its homelessness problem, according to advocates that believe the state’s Medicaid program should include additional supportive housing services. Those individuals assert that additional supportive housing services can be included in Medicaid as a “wrap-around support service”—a type of service that CMS endorses and described in a Center for Medicare & CHIP Services Informational Bulletin last year.

Housing services

CMS expressly does not provide Federal Financial Participation (FFP) for room and board as part of additional support services. However, states are permitted to assist individuals through coverage of certain housing-related activities and services. Some of the housing-related services and activities that Medicaid can cover include: (1) services designed to support an individual’s ability to prepare for and transition to housing; (2) services aimed at supporting an individual’s ability to sustain tenancy; and (3) services dedicated to assisting a state in identifying and securing housing options for individuals. Specific examples of each of those services are covered in the Informational Bulletin. The Open Door is an example of an organization that provides housing support services.

Pennsylvania

In Pennsylvania, advocates like The Housing as Health Campaign are asserting that, for many Medicaid enrollees with substance abuse problems, additional support is needed to keep beneficiaries in their homes. Advocates argue that without a consistent funding stream, Medicaid beneficiaries wind up homeless. The Corporation for Supportive Housing (CSH) created a blueprint, or “Crosswalk,” to serve as a map to assist the Pennsylvania Department of Health and Human Services with aligning Medicaid-eligible services with supportive housing services.

Crosswalk

The Crosswalk was designed to guide the state of Pennsylvania, managed care entities, and service providers towards resources that can improve access to substance use treatment and mental health recovery, with a focus on housing. According to the report, individuals with unmet housing needs are often particularly vulnerable due to the high occurrence of low incomes, chronic health conditions, and behavioral health challenges among the population. The report proposes several methods to improve housing and care access for at-risk individuals. CSH started its analysis by considering the services that the state already provides through several Medicaid waivers. While Pennsylvania does have mechanisms to provide some housing support services for elderly individuals, beneficiaries with traumatic brain injuries, and individuals with a physical disability, CSH noted that additional individuals could benefit from supportive housing.

Alignment

The report identified potential opportunities for alignment, where services that are already covered under the state plan could be aligned to better address housing support service needs. For example, the report suggested that, because the Pennsylvania state Medicaid plan covers Individualized Service Plans (ISPs) for the treatment of individuals with severe mental illness, an individual could, possibly, identify housing goals as part of his or her treatment plan, thereby including housing support services through an ISP. The report lists several other types of services with potential for alignment to reduce or eliminate gaps in housing service coverage.

Rethinking Medicaid

Advocates are not directly asking for a change as to the kind of services covered by the Pennsylvania Medicaid program. Instead, the CSH report and other efforts are asserting that housing problems can be best improved through a better application of existing services under the Medicaid state plan. Advocates hope that such a rethinking of Medicaid will improve health by putting a roof over the head of more individuals.

States’ failure to include substance abuse benefits goes untreated

Over two-thirds of state benchmark health plans violate requirements to cover treatment for addiction disorders put into place by the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). The National Center on Addiction and Substance Abuse (the Center) surveyed addiction treatment benefits offered among 2017 Essential Health Benefits (EHB) benchmark plans and found none offered what it considers to be “adequate” addiction treatment benefits. The main problem, the Center believes, is that although the ACA requires coverage of substance use disorder (SUD) services as an EHB and requires that the SUD benefits be provided at parity with comparable medical/surgical benefits, the ACA does not specifically define what those benefits should be. It leaves that up to the states, and that is where they fall short.

Analysis

The Center analyzed those benefits offered within each of the 50 states to determine the minimum level of benefits available to those covered in state exchange plans. Each state’s 2017 EHB-benchmark plan was then reviewed to determine whether it: (1) satisfies the ACA’s requirements regarding coverage of addiction benefits; (2) complies with parity requirements; (3) provides adequate care for addiction by covering the full range of critical benefits without imposing harmful treatment limitations; and (4) provides enough information to fully evaluate compliance and adequacy of benefits. Clouding the review, the Center noted, is the problem that plan documents for 88 percent of state plans lacked sufficient detail for it to fully evaluate parity, compliance, and the adequacy of addiction benefits.

Most commonly missing

Many plans either frequently exclude or do not explicitly cover benefits related to residential treatment and the use of methadone maintenance therapy. The Center found that 18 percent of the plans lacked compliance with parity requirements, while 31 percent of the plans contained possible parity violations. Over half of plans violate the EHB requirement for tobacco cessation coverage and nearly half violate the ACA’s requirement for coverage of prescription drugs to treat addiction. Although the ACA specifically prohibits the use of per-beneficiary annual or lifetime dollar limits for EHB, Texas and Michigan are in violation of this requirement. Further, Alaska’s plan does not even cover services and supplies relating to diagnosis and treatment of addiction.

“Addiction is a chronic disease that often goes untreated, and when patients can’t access addiction treatment it can lead to disability and premature death,” said the report. “In order to fulfill the ACA’s intent of dramatically expanding access to addiction treatment, states should revise their EHB benchmark plans to comply with the law … This will help to close the addiction treatment gap, improve the health of patients seeking addiction treatment, and decrease costs for the health plans in the long-term.”

The importance of parity and the problem of unenforcement

Federal law requires that mental health benefits are equivalent—in terms of restrictions and limitations—with medical health benefits. However, the specific provisions of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) that mandate the parity are, in many cases, going unenforced. The result is that individuals are having trouble accessing care—the very problem the parity was designed to remedy.

Why?

Although there many potential reasons why the parity rules aren’t being followed, one report suggests the failures are caused by the difficulty of implementing the ACA and the slow regulatory processes of the federal government. For example, the rules that govern parity for private insurers were not put into effect until 2014 and some rules—those pertaining to parity for Medicaid plans—have yet to take effect.

High stakes

The importance of parity is illustrated by the number of individuals with mental health and substance use disorders. According to the most recent survey by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), almost 44 million adults experienced some form of a mental illness. According to SAMHSA, fewer than half of those individuals receive mental health care. Additionally, 20.2 million adults had a substance abuse disorder in the past year. Also at issue is the nation’s heroin and painkiller epidemic, which claims 78 lives each day.

Task Force

Acknowledging that something is wrong with the state of parity enforcement, the White House issued a presidential memorandum creating an interagency Mental Health and Substance Use Disorder Parity Task Force designed to ensure better compliance with the parity rules.  Specifically, the task force was designed to:

  • identify and promote best practices for compliance and implementation;
  • identify and address gaps in guidance, particularly with regard to substance use disorder parity; and
  • implement actions during its tenure and at its conclusion to advance parity in mental health and substance use disorder treatment.

The memorandum also directs the task force to conduct outreach efforts to patients, consumer advocates, health care providers, specialists in mental health care and substance use disorder treatment, employers, insurers, state regulators, and other stakeholders.

Enforcement

Not all states have dropped the enforcement ball. For example, the California Department of Managed Health Care imposed a $4,000,000 administrative penalty on the Kaiser Foundation Health Plan, Inc. in 2013 for parity violations that resulted from mental health service wait times. However, continuing access problems and the creation of the task force suggest that enforcement is the exception rather than the rule.

Beyond parity

Part of the problem is that to meet behavioral health demands, stakeholders need to do more than obtain parity. Based upon that understanding, some lawmakers are pushing for more systemic changes with legislation like The Mental Health Reform Act of 2016, which would assist with enforcement of current requirements (including parity), ensure federal funding to help states provide mental health care services, promote best practices, and increase access. Whichever way is the next step forward, there is little doubt that some action is necessary to improve access to and the provision of behavioral health care.