A year ago, the N.H. Department of Health and Human Services released its 10-year mental health plan, which Gov. Chris Sununu described last February as providing “a road map by which we will finally deliver the system that we need to address our mental health crisis.” Despite its 10-year span, Sununu promised aggressive action, pledging not to “slow roll” it. Indeed, substantial steps were taken in 2019 to implement the plan, and when DHHS issued a status report in late October, the governor said “meaningful progress” on the plan had been achieved.
The vexing problem of the state’s low Medicaid reimbursement rate, however, continues to challenge the system and warns the 10-year plan’s success — as well as the state’s important priority of addressing the opioid and substance abuse issue — is imperiled if the state doesn’t accelerate the reimbursement rate increases faster than currently contemplated.
The reimbursement rate issue is critical because the Medicaid program pays for most treatment for serious medical illness. The funding comes from the federal and state governments, but New Hampshire has lagged woefully behind other states in funding provider reimbursement.
In 2015, an American Academy of Pediatrics survey cited in the 10-year plan showed that New Hampshire reimbursed for psychiatric evaluations at $87.82, compared to the Massachusetts and Vermont rates of $117.42 and $104.13, respectively. Throw in medical services with the evaluations, and New Hampshire was lowest in the nation. Further, the plan reported that New Hampshire reimbursed Medicaid specialty providers, including mental health providers, at 58 percent of the provider cost, compared to a national average of 72 percent.
Exacerbating the problem is that commercial insurance typically reimburses non-mental health providers at well over the estimated provider cost — effectively subsidizing providers for Medicaid reimbursement shortfalls — but doesn’t for mental health services providers. Leaving aside what this says about the nation’s crazy health insurance system generally, this creates far greater financial strain on New Hampshire mental health providers.
This double whammy of lower Medicaid and commercial insurance reimbursements, the 10-year plan reported, seriously impacts access to care by limiting services that can be affordably delivered and by “driving” mental health workers out of New Hampshire. Thus, the very first recommendation of the 10-year plan was to increase funding in the FY 2020-21 biennial budget to continue then-temporary Medicaid rate increases and to strive to get reimbursement rates to the national average, a goal which the plan describes as only “modest.” The governor and the Legislature acted on that recommendation in the budget compromise approved in September by funding the temporary rate increases and providing for 3.1 percent annual increases, the first of which took effect on Jan. 1.
All well and good, but as reported last weekend by Sentinel staff writer Olivia Belanger, those increases may not come fast enough to meaningfully address the workforce shortage problem. Bethann Clauss, the clinical director at Maps Counseling Services in Keene, said that during a recent week the agency had turned away nearly 100 people seeking services because it didn’t have enough clinicians. Statewide, a Henry J. Kaiser Family Foundation study reported that as of December 2018 only 45 percent of mental health needs were being met, a yawning gap unlikely to be significantly closed at the pace at which the state is increasing the Medicaid reimbursement rate, particularly as untreated mental illnesses only add to the eventual burden on the mental health system.
Of further concern is that the workforce shortage caused by the low reimbursement rates has slowed the launch of the Doorway, the state’s regional hub-and-spoke initiative to provide coordinated addiction services. The local center, operated by Cheshire Medical Center, opened last January but has struggled to staff the screening and referral services critical to the initiative. Shawn LaFrance, a Cheshire Medical vice president, says the center has now been able to keep a staff of three, but that’s well short of the eight he envisioned to service the need. Though the Doorway initiative does not depend upon Medicaid funding — it’s supported by a two-year federal grant — the interconnectedness between its workforce needs and those of the general mental health system in New Hampshire is unavoidable.
Right now, there are 270 vacancies across the state’s 10 community mental health centers, according to Phil Wyzik, executive director of Keene’s Monadnock Family Services, the community center in this region. “We don’t have enough applicants for jobs that are vacant,” he said, a problem he notes is compounded by a 16 percent employee turnover rate. As well-intentioned and welcome as the steps taken by the state this year to increase Medicaid reimbursement rates are, the pace of closing the gap must be accelerated to address the current need and to help assure that an effective rollout of the Doorway doesn’t further tax the overall mental health system.