CLEVELAND, Ohio – Northeast Ohio Behavioral Health, a mental health center for children and families, closed its doors Oct. 18 after serving the community for 28 years.
The center, which had offices in Cuyahoga Falls and North Canton and specialized in treating children who experienced sexual abuse, is one of a handful of facilities like it that have fallen victim to state changes in behavioral health treatment of its Medicaid patients, a move affecting roughly 700,000 Ohioans.
A difference in how services are coded for billing and how providers are paid left Northeast Ohio Behavioral Health fighting to stay open throughout 2018. By mid-October, executive director Dr. Robin Tener knew the battle had been lost.
“I did not go down without a fight. I feel like I have been fighting Goliath here,” Tener said, a day after officially closing the center. “I love this work, and I love the people we worked with. It’s hard for me to imagine not doing that,” she said. “This should never ever, ever have happened to us.”
As part of a multi-year effort to modernize behavioral health in Ohio’s Medicaid system, the Kasich administration in January expanded the way services could be coded, adding more than 100 new codes to the system. Then, in July, the state transitioned from a fee-for-service model in which providers billed the state directly to managed care, requiring providers submit claims to insurance plans. The goal, the state said, was to align Ohio’s Medicaid system with federal codes and to expand services.
But providers, like the center, say the transition is full of processing and reimbursement delays and is putting a financial strain on a field already overwhelmed by the opioid epidemic.
Conversely, the state and representatives of insurance plans say issues with the new system are more the exception than the rule.
“The data to date suggests that behavioral health integration is going well and continues to improve,” said Miranda Motter, president and CEO of the Ohio Association of Health Plans, a state trade association for the health insurance industry.
“It’s just a lot of change in a pretty short period of time in the middle of an opioid crisis,” said Geoff Collver, associate director of The Ohio Council of Behavioral Health & Family Services Providers, a state trade association that represents mental health providers.
Overloading a system
When Tener closed her center, she was still waiting for nearly $40,000 in Medicaid claims to be paid by managed care plans. She didn’t want to take a proffered loan from the state and instead, for months, pulled money from her personal savings to prop up her business. She laid off 30 employees.
“I didn’t want to dump 400 clients into our mental health system; I wanted to continue to see them,” said Tener, a clinical psychologist. “It wasn’t enough.”
Two other Canton facilities said the government’s changes to behavioral health contributed to either their closing or sale. And centers around the state are laying off employees and cutting services, according to Lori Criss, CEO of The Ohio Council of Behavioral Health & Family Services Providers.
“The last thing we wanted was for it to disrupt care for patients across the state. That’s where we are now,” she said. “There’s a high potential for people to get hurt. This will not be painless for communities.”
Criss expects the situation to get worse. From July through October, the Ohio Department of Medicaid provided cash advance payments to providers to help with the transition. Those payments end Oct. 31.
“We’re going to see more layoffs of staff. We’re going to see programs restricting,” Criss said. “We’re going to see some organizations close.”
Making tough decisions
A patient, Sharon M., who asked to withhold her last name for privacy, has been sober for 11 years. She relies on The Centers for Families and Children in Cleveland to manage her bipolar disorder and to help her maintain sobriety.
“The people here help me stay on the right track. If I start having any of those feelings to use again, I always have someone to talk to, to help me stay in the right direction,” said Sharon, who used to be addicted to crack cocaine.
Her life now is much different than it was when she was using. She takes care of herself. She’s no longer being taken to the hospital for treatment. She spends more time with her daughters and grandchildren.
“It’s just changed my life completely since I’ve been off drugs,” Sharon said. “My life is 100 percent better. It’s wonderful now. That’s a life I would never ever want to live again.”
But The Centers is facing some “tough decisions,” according to Elizabeth Newman, president and CEO of The Centers and Circle Health Services, a community health center.
“Obviously, we’re not getting close to what we were pre-July 1 in terms of the revenue coming in,” Newman said, noting that the organizations are receiving incomplete and delayed payments. “We’re trying to figure out: Is there a way to do this moving forward or do we have to reduce capacity?”
Jessica Fisher, a counselor for Alcohol and Other Drugs, listens to a client during group at The Centers. (Gus Chan / The Plain Dealer) The Plain Dealer
She said the billing system is a lot more complex now and requires additional infrastructure to deal with the multiple managed care organizations.
“If we have to fight for every dollar here, what does that mean for us long term?” Newman asked. “We certainly don’t want to have to reduce capacity, but at the end of the day we have to figure out how we make it through this.”
A learning curve
The state and those representing insurance plans are encouraged by the transition process and say that options for extended repayment of the loans should help providers.
“We understand the significant learning curve with the new system; however, data suggests that month over month significant improvement is being made in the area of claims payment,” said Tom Betti, press secretary for the Ohio Department of Medicaid. “Issues have been minimal and quickly resolved through the collaboration of the plans and other providers.”
In a September presentation to the Joint Medicaid Oversight Committee, a body of state legislators that oversees Medicaid’s operations in Ohio, Barbara Sears, director of the Ohio Department of Medicaid, said progress is being made.
“While room for improvement exists, we are confident that [behavioral health] integration is stable and improving month over month,” her report said.
In July, plans denied 19 percent of claims and paid $23 million in reimbursements. By August, denials decreased to 16 percent and payments climbed to $59 million, according to Sears’ report.
Criss, for her part, said that progress has been too slow.
On Oct. 17, the National Alliance on Mental Illness of Ohio, an organization for individuals and families with mental illness that has supported the redesign, sent a letter to state leaders requesting that cash advances continue through the end of the year and that something be done to ensure providers are receiving payments in a timely fashion.
“Colleagues report that payment delays were a major contributing factor resulting in layoffs and the termination of needed programs. This is unacceptable,” writes Terry Russell, executive director of NAMI Ohio. “Although there may be plenty of blame to spread around and reasons that this delay is occurring, the persons who ultimately suffer are our loved ones with mental illness. The system must find a remedy to this problem.”
Both NAMI Ohio and The Ohio Council are part of a task force that regularly meets with the state over the behavioral health transition.
“…It is clear that the decision to provide advance payments over the last few months has lessened the chance that fewer services would be available due to redesign,” Russell writes, requesting that cash advances continue through January.
He characterized the holidays as “the most difficult time of the year for people living with mental illness, as well as those serving in our provider agencies.”
The state has not agreed to provide additional advance payments.
In the meantime, Tener hopes other centers don’t experience the same fate she did.