State Healthcare Advocate Victoria Veltri describes the latest report on access to mental health and substance abuse treatment as “a call to immediate action.”
The report released Wednesday details what Veltri’s office already knows: Connecticut residents still face significant barriers to preventive and treatment services for mental health and substance use disorders.
In spite of federal and state mental health parity laws, it’s an area of the health care system where having insurance doesn’t necessarily mean access to services.
“Frankly, we have a three tiered system: for the uninsured, one for the publicly insured, and one for the privately insured. The state needs to adopt a vision of healthcare that allows all residents access to high-quality healthcare that takes the best of each system and eliminates the worst,” Veltri said.
However, she cautioned that “the problems with the current system are not solely about insurance.”
Multiple state agencies with varying eligibility requirements provide services or oversight for residents struggling with mental health and substance use disorders, but these efforts are not well understood or coordinated as part of an overall vision for the state, the report explains.
For example, there is plenty of cost shifting that occurs between the state and private insurance companies, especially when it comes to children and young adults.
At an Oct. 17 public hearing, Department of Mental Health and Addiction Services Commissioner Patricia Rehmer testified that her department hears from many parents of adult children with psychiatric disabilities and substance use disorders who have private insurance, but that they cannot access the same services that the state offers.
“We have worked with many families where appropriate to help them access additional levels of care and recovery services, but it is a difficult task, can be resource intensive and not always successful,” Rehmer said.
Some of the parents told heartbreaking stories at the hearing about their attempts to get services for their children. Their testimony showed that the state “has a fractured and fragmented method of delivering care that needs to be coordinated and more data driven in terms of cost effectiveness,” Veltri said.
Veltri emphasized that there are evidenced-based practices used in multiple state agencies, but those practices are not widely utilized beyond the populations that those agencies serve because of restrictions on eligibility and issues with the number of psychiatrists and psychologists in the state.
The report also points out that the state has to do a better job at recovering some of the costs it pays for these types of services.
One witness testified that after repeatedly fighting her insurance company to cover needed hospitalization and outpatient services, she turned to the Department of Children and Families Voluntary Services, and her daughter received intensive in-home behavioral management and therapeutic mentoring, while the family received respite care and parent training.
“All of these services were community-based, evidence-based services that were not covered by her insurance plan and were paid by the state of Connecticut,” the report says.
Dr. Laura Saunders, a child psychologist at the Institute of Living, testified that there are absolutely no private insurance plans in the state that cover in-home psychiatric services. She said the only carrier that covers it is the state’s Medicaid program called HUSKY.
The only thing she can recommend as a provider is a higher level of care than is medically necessary for a child.
“If you have commercial insurance, we have to automatically divert someone to get voluntary services,“ Saunders said. “The lack of access is very, very unfair to these families with commercial insurance.”
In order to access in-home services families have to get a referral from the Department of Children and Families Voluntary Services division.
A year ago, DCF Voluntary Services division spent approximately $16.4 million on necessary mental health and substance use services for children who were also covered by private insurance. Since that time, DCF has partnered with the Office of the Healthcare Advocate to exhaust private healthcare coverage prior to providing state funded services.
“Currently, the state does not appear to have a clear handle of the overall level of cost shifting it is absorbing with respect to mental health and substance use services,” the report concluded. “A detailed study is in order to ensure that the state is not inappropriately incurring costs and that its own resources are used as efficiently as possible.”
And while the private insurance model has not historically integrated mental health and substance use care into overall health, the report found there’s is evidence payment reform models that reward outcomes and care coordination could help.
“Our insurance delivery system is not designed to promote the community based treatment and support services that our public models do,” the report found. “If our goal is to address the needs of ALL residents, whether children, adults or seniors, we must improve access to evidenced based community services and supports. We must recognize that enhancing recovery is not only about healthcare.”
The 60-page report made eight recommendations about how to improve the mental health and substance use system in the state:
1. Connecticut should adopt an overall vision for health that integrates and coordinates access to effective, timely, high quality and affordable mental health and substance use prevention and treatment services into overall healthcare
2. Connecticut’s mental health and substance use delivery system should be synchronized by n coordinating entity
3. Prevention, awareness and screening programs must be enhanced
4. Residents covered by self-funded and fully-insured plans should have access to community-based services
5. Mental Health Parity and Addiction Equity must be enforced
6. The recommendations of the 12/18/12 Program Review and Investigation Committee report should be adopted in full
7. State programs must be evaluated for cost effectiveness, and should be streamlined
8. Cost shifting to the state should be evaluated and minimized .
“Now, more than ever, action is required to address the obstacles to access to treatment for and prevention of mental health and substance use conditions. Connecticut lacks an overall vision of delivery services to all of our residents,” Veltri said.