Implementation of Idaho’s Medicaid Managed Mental Health Contract with Optum Health, Inc. has had a rocky start and has resulted in some major changes in the delivery of Medicaid covered mental health services in Idaho. There have been problems encountered by mental health service providers in processing and obtaining authorizations for services, but this article will not address those issues. I intend to focus on the problems being experienced by Idahoans with serious mental illness (SMI) and children with serious emotional disturbance (SED), in obtaining community based mental health services and supports. Most of the controversy revolves around authorization of Community Based Rehabilitation Services (CBRS).
For many years, Idaho Medicaid provided a service called Psychosocial Rehabilitation (PSR). This service consisted of a mental health worker meeting with a person with SPMI, or SED and teaching them skills related to surviving in the real world while coping with a serious mental illness. PSR workers helped their clients recognize recurring symptoms of their illness, stick to their treatment plans, evaluate the effectiveness of their medications and their side effects, cope with stressors in their lives (family crises, evictions, expulsions, deaths of loved ones, encounters with the police, etc.), and build independent living skills (budgeting, shopping, getting or keeping a job, dealing with chronic health conditions, etc.). The strict rule definition of PSR limits it to skill building activities, but when a PSR worker found a client without food, behind in their rent, out of medications, afraid to leave the house to go to the doctor appointment (or whatever), they often just helped the person deal with the crisis. They might take them to the grocery store to get some staples, coach them through a call to the landlord about the rent, drive them to the doctor appointment, or help them understand their diabetes diet restrictions. If they find them in a crisis, they might take them to the emergency department of the hospital. Bureaucrats may argue about whether all of these activities fall under the definition of PSR, but they are all needed if we hope for people with SPMI/SED to survive in the community and stay out of hospitals, jails, prison, juvenile justice system, or homeless shelters.
Optum doesn’t use the term Psychosocial Rehabilitation. They offer an identical service called Community Based Rehabilitation Services (CBRS). The Psychiatric Rehabilitation Association (PRA) uses the term Psychiatric Rehabilitation to cover this type of service. The American Psychiatric Association includes Psychosocial services in a larger category of "Psychotherapeutic Interventions" which include Psychosocial rehabilitation, and in-home and community based services such as "Psychoeducational services" and others not named in the treatment guidelines (see e.g., APA Treatment Guide –Bipolar Disorder p. 52).
Services for children are equally confusing. In addition to the terms used above, there are a host of packaged services and approaches which may include some or all of the services described as PSR, or CBRS. "Wrap Around Services" and "Intensive In-home services" are two phrases used by the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U. S. Department of Health and Human Services, to describe evidence based approaches which include services that Optum calls CBRS, along with other services. In addition, there is great overlap between other services such as Assertive Community Treatment teams (ACT teams) and CBRS even though it also includes some things that a CBRS client would not receive. While these words and phrases do not always describe exactly the same things, they have many common features and they significantly overlap each other. A person receiving any one of these services might not be able to tell the difference between one and another. In this article, I will use Optum’s term, Community Based Rehabilitation Services (CBRS), unless the context requires something else.
What is Optum doing?
Since the implementation of Optum’s contract some patterns have emerged.
- CBRS services to children have been significantly reduced.
- CBRS Services to people with both a mental illness and an intellectual disability have been significantly reduced.
- CBRS services have been reduced for people with diagnoses other than Schizophrenia (although Dr. Berlant has acknowledged that there is evidence that CBRS is effective for a range of diagnoses).
- CBRS services have been reduced in frequency and duration for many recipients and authorizations for CBRS are very short term.
In general the reason for reducing or denying CBRS is that it is not "medically necessary" according to the Optum care levels which are said to be based on the treatment guidelines of the American Psychiatric Association (APA) or the practice parameters of the American Academy of Child and Adolescent Psychiatry(AACAP), or SAMHSA. You will not find "CBRS" in these guides because CBRS is a term invented by Optum to describe psychosocial rehabilitation services (PSR). Due to the confusion over terminology described above, it is more difficult to nail down the evidence for the service.
Optum medical directors have declared publicly that CBRS is not an evidence based practice for children. The American Academy of Child and Adolescent Psychiatry would seem to disagree.
American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters – Schizophrenia:
Although further studies are needed, youth with EOS (Early Onset Schizophrenia) should benefit from adjunctive psychotherapies designed to remediate morbidity and promote treatment adherence. Strategies for the patient include psychoeducation regarding the illness and treatment options, social skills training, relapse prevention, basic life skills training, and problem solving skills or strategies. Psychoeducation for the family is also indicated to increase their understanding of the illness, treatment options, and prognosis and to develop strategies to cope with the patient’s symptoms.( Journal of the American Academy of Child & Adolescent Psychiatry, Volume 52, Number 9- September 2013. p. 986, note: this parameter is being revised)
AACAP – Treatment Guidelines – Bipolar
Bipolar disorder significantly affects social, family, academic, and developmental functioning. Therefore, in addition to efforts directed at reducing further episodes, psychosocial interventions are needed to address the myriad of disruptions that emerge in the wake of the disorder. Efforts to enhance family and social relationships, including therapies directed at communication and problem-solving skills, are likely to be helpful.(p.120)
Therefore, a comprehensive, multimodal treatment approach that combines psychopharmacology with adjunctive psychosocial therapies is almost always indicated for early onset bipolar disorder. Although medications help with the core symptoms of the illness, they do not necessarily address the associated functional and developmental impairments and the frequent need for support and skills building.(p.120)
The Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for Medicaid Services (CMS) in the U.S. Department of Health and Human Services have issued a joint information bulletin with a list of evidence based psychosocial service models for children with SED. The bulletin concludes:
While the core benefit package for children and youth with significant mental health conditions offered by these two programs included traditional services, such as individual therapy, family therapy, and medication management, the experience of the CMHI and the PRTF demonstration showed that including a number of other home and community-based services significantly enhanced the positive outcomes for children and youth. These services include intensive care coordination (often called wraparound service planning/facilitation), family and youth peer support services, intensive in-home services, respite care, mobile crisis response and stabilization.
The only service in the Optum array which approaches or incorporates elements of these SAMHSA/CMS recommended services is CBRS.
The Psychiatric Rehabilitation Association (PRA) is the national group which Optum and Idaho Medicaid use to certify CBRS providers in Idaho. PRA offers a specialized certificate in Psychiatric Rehabilitation for Children (http://www.psychrehabassociation.org/practitioner-training-continuing-education/children%E2%80%99s-certificate-psychiatric-rehabilitation-courses ). It would seem clear that these recognized experts consider CBRS for children to be evidence based practice also. And if there is any lingering doubt that Children’s Psychosocial Rehabilitation as practiced under Idaho Medicaid is evidence based and provides an objective and measurable benefit, it has been dispelled by the research published in the peer reviewed journal article "Preliminary Evaluation of Children’s Psychosocial Rehabilitation for Youth With Serious Emotional Disturbance" Research on Social Work Practice, Vol. 19 No. 1, January 2009 p.5-18. A study conducted in Idaho by Nathaniel J. Williams. The study showed "Participants improved significantly in psychosocial functioning and psychological symptoms, with effect sizes ranging from large to small. Improvements were clinically significant for 78% of participants" (p.1) and "Of the participants, 78% exhibited clinically significant improvement in their overall functioning across an average treatment time of 13 months. Participants’ improvement on the CAFAS/PECFAS was statistically significant and reflected a large effect size. Reductions in the number of severe subscales were similarly robust. Finer grained analyses of the CAFAS/PECFAS subscales revealed that participants experienced statistically significant improvements in functioning and psychological symptoms."
Mental Illness and Intellectual Disability
Mental Health diagnoses are often ignored in people who have an intellectual disability (ID, formerly called mental retardation, MR) and as a result they do not receive appropriate mental health services. Nevertheless, studies show that mental illness is very common in people with ID. This applies to both children and adults. The AACAP practice parameters say:
Mental disorders occur more commonly in persons with MR than in the general population. However, the disorders themselves are essentially the same. Clinical presentations can be modified by poor language skills and by life circumstances, so a diagnosis might hinge more heavily on observable behavioral symptoms. (p.1)… The principles of psychiatric treatment are the same as for persons without MR, but modification of techniques may be necessary according to the individual patient's developmental level, especially communication skills. Medical, habilitative, and educational interventions should be coordinated within an overall treatment program.(p.8S)
Robert Lieberman in "Recovery from Disability: the Manual for Psychiatric Rehabilitation" explicitly includes Intellectual disabilities among those who will benefit from PSR/CBRS. (p.12). I have found nothing in the literature which says that CBRS is ineffective with people who have an intellectual disability. Many dually diagnosed Idahoans can attest to the benefits they received from PSR/CBRS and to the harm suffered when it was withdrawn too early. I have found many sources which say that PSR/CBRS providers need additional training and expertise to properly provide mental health services to people with ID, and sources which say that mental health systems improperly exclude people with ID from mental health services. However, such exclusion would be impermissible under the Americans with Disabilities Act and other anti-discrimination laws.
Diagnoses Other Than Schizophrenia
The APA guidelines for Bipolar Disorder say:
"When the functional impairments of bipolar disorder are severe and persistent, other services may be necessary, such as case management, assertive community treatment, psychosocial rehabilitation, and supported employment. These approaches, which have traditionally been studied in patients with schizophrenia, also show effectiveness for certain individuals with bipolar disorder…Nevertheless, the weight of the evidence suggests that patients with bipolar disorder are likely to gain some additional benefit during the maintenance phase from a concomitant psychosocial intervention",(APA Treatment Guidelines, p.52)"
It is important to note that the APA does not have guidelines for all major mental illness diagnoses. Therefore, it would be wrong to assume that the APA has any position on the appropriateness of CBRS for other diagnostic categories. Indeed, the guidelines themselves state:
These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome for every individual, nor should they be interpreted as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate recommendation regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data, the psychiatric evaluation, and the diagnostic and treatment options available. (emphasis added, p.iv).
The Performance Standards for Psychiatric Rehabilitation of the Community Care Behavioral Health Organization , (2008 revision) use this standard:
General Description of Psychiatric Rehabilitation
Psychiatric Rehabilitation services are designed to address the needs of individuals with a history of severe mental illness as evidenced by a diagnosis of schizophrenia, major mood disorder, psychotic disorder not otherwise specified, schizoaffective disorder or borderline personality disorder of the DSM IV classification. The person receiving services must also have a moderate to severe functional impairment as a result of mental illness.(p.2)
Robert Paul Lieberman, M.D., Professor of Psychiatry UCLA Medical School (the founder of the field of evidence based psychiatric rehabilitation and the author of Recovery from Disability: the Manual for Psychiatric Rehabilitation) says:
The term "mental disability" is preferentially used to delineate the disorders afflicting patients who are appropriate recipients of rehabilitation… Psychiatric rehabilitation can benefit all those whose psychiatric disabilities endure beyond a relatively brief treatment of symptoms…Several terms have been used in the literature to delimit the population of the mentally disabled. The most frequent are terms such as "severely mentally ill", "chronic mental patients", and "seriously and persistently mentally ill"… A large number of individuals with disparate mental disorders listed here are often deemed disabled by the various criteria delineated above:
- Bipolar disorder
- Major Depression and disthymia
- Obsessive-compulsive disorder
- Social phobia
- Panic and agoraphobia
- Posttraumatic stress disorder
- Some personality disorders such as borderline, schizotypal and schizoid
- Developmental disorders such as pervasive developmental disorder or Down Syndrome (Recovery from Disability, p.9-11)
In my own search, I did not find any source which suggested that PSR/CBRS is only effective for people with schizophrenia. Dr. Berlant has acknowledged that CBRS may be appropriate for many people with Intellectual Disabilities depending on the nature and extent of the functional limitations involved. Optum spokespersons have publicly stated that there is no I.Q. cutoff for CBRS. In any case, the broad consensus is that psychiatric rehabilitation by whatever name, is generally indicated for anyone with a severe and persistent mental illness resulting in disability which persists beyond the period of acute treatment. CBRS is the only service in the Optum plan which can provide "psychosocial rehabilitation" or other ongoing psychosocial services. In fact, Optum does not offer any other psychosocial services which are evidence based such as, assertive community treatment, psycho-educational services, "wrap around" services or intensive in-home services. With the exception of case management, there is nothing to fill the gap between clinic services and hospitalization. For people who have severe and persistent mental illness, this is a serious shortcoming.
Proper use of Treatment Guides and Evidence Based practices
It is important to note that the APA practice guidelines do not cover all evidence based practices and are not properly used to refuse coverage for a treatment or service which is recommended by a treatment team for a particular person. The APA only has practice guidelines for 12 mental health diagnoses. They don’t include Shizoaffective, or Schizotypal disorders, for example. It would be wrong to assume that the lack of an APA guideline constitutes a basis for finding that CBRS is not evidence based for diagnoses which do not have guidelines. The APA says of the guidelines:
The guidelines linked on this page, excluding Major Depressive Disorder, are more than 5 years old and have not yet been updated to ensure that they reflect current knowledge and practice. In accordance with national standards, including those of the Agency for Healthcare Research and Quality's National Guideline Clearinghouse, these guidelines can no longer be assumed to be current.
Since only one guideline is current, the failure of the guidelines to take PSR/CBRS into account should not be determinative of whether it is medically necessary or evidence based. Perhaps more importantly the APA says of each guideline:
The American Psychiatric Association (APA) Practice Guidelines are not intended to be construed or to serve as a standard of medical care. Standards of medical care are determined on the basis of all clinical data available for an individual patient and are subject to change as scientific knowledge and technology advance and practice patterns evolve. These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome for every individual, nor should they be interpreted as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available.
Similarly the AACAP declares:"These parameters are not intended to define the standard of care, nor should they be deemed inclusive of all proper methods of care or exclusive of other methods of care directed at obtaining the desired results."
It is simply improper to use the guidelines as a basis to deny a treatment when the treatment is benefitting a patient based on the assessment of the treating psychiatrist and other treating clinicians.
Idaho has a long history of providing psychiatric rehabilitation services to children, people with intellectual disabilities, and people with a variety of psychiatric diagnoses. Although these services have occasionally been of poor quality, overall Idahoans have benefitted greatly from them and many have suffered from their loss. Close individual review of the actual benefits of CBRS to any individual and professional scrutiny of the value of the service are desirable and responsible. Categorical denial of services to individuals who benefit from the service and who will be harmed by the loss of the service, serves no purpose and can cause great harm.