Healthcare Plan Choice Tool: The community feedback period for this idea began on 7/2/2019 and ended on 8/31/2019

What is the problem that needs to be addressed? Please describe how it is related to mental health.
An identified goal of numerous organizations/individuals is getting disabled people or people experiencing mental illness into the workforce. While a noble goal, this goal places the individual in a stressful situation. Measurement by the Homes and Rahe Stress Scale estimates a score of 207 for this life event. Scores between 150-300 are indicated to have a moderate risk of disease in a healthy individual. The Homes and Rahe Stress Scale doesn’t account for the stress associated with mapping current healthcare treatment/expenditures/providers into the new healthcare system/referral network required by being dumped off of Medicaid. There isn’t a tool to easily calculate the costs/benefits of an individual’s current care plan mapped into the healthcare coverage of a new healthcare payer. There isn’t a tool to easily identify the providers that will be taking over care from the Medicaid providers currently providing care. The ACA requirement that health payers cover mental health means that the payer is willing to pay for mental health. It doesn’t mean that there is service capacity with in-network providers to actually perform the care AND keep the same medication regimine. This particular issue will continue to be recycled until a solution is reached agreeable to Orange County Healthcare Agency Innovations team or other entity.

Why is this a concern for Orange County? What can Orange County and other counties learn from this project?
The most obvious reasons. The most likely learning outcome is that there isn’t sufficient capacity in the mental health professional workforce to transfer any significant population from County Behavioral Health systems to proprietary payer in-network providers for mental health (see Out of Network, Out of Pocket, Out of Options in the links below and the doctor shortage documents from the Regional Meeting Resource Staff project comments). The likelihood of keeping the same medication regimine is also placed into peril when a new payer/new provider provides care. Other learning outcomes expected include the difficulty/complexity in transitioning a care plan from Medicaid providers to proprietary in-network providers and the likelihood that an individual will need to re-transition every 12 months as the HR benefits review cycle will likely change healthcare payer options. The orderly succession of healthcare payers/plans is a strategy that keeps people out of the Emergency Room – the setting of troubleshooting where healthcare exceptions are resolved.

What is currently being done to resolve this problem in our county and throughout the United States? If applicable: Is it working; why or why not?
There isn’t a tool provided. Previously, the Orange County Healthcare Agency Innovations Team determined that Mental Healthcare Choice didn’t qualify as a valid choice. With such a decline, this project submission is the next most logical possibility.

What is new or different about this project idea? Please describe how this differs from what is already being done (Question 6). Please list any research that was done on this topic.
Providing such a tool for non-Medicare beneficiaries.

What is the project idea? Please describe how this project will operate.
Creating a tool where a person can take their current healthcare plan and input it into a transformation algorithm that will output the success/failure of such a plan for a given healthcare payer. Such a transformation algorithm will include identification of the specific individual healthcare providers (a person or people licensed under a scope of practice), identification of formulary issues (current drugs are covered, not covered or covered under high tier formulary categories), maximum limits for seeing identified licensed individuals, level of effort in transporation/time/due dilligence to comply with the new plan, any parts of a care plan not covered, the total monthly cost (or benefit) for switching to include premiums, subsidies, copays, drug costs, deductibles, etc. The risk of care plan failure would also be required – for example, the new payer has few providers in stable contracts for care, the new payer is likely to change coverage within 12 months, the new payer is likely to be dropped as a choice within 12 months, the new payer doesn’t have equivalent services (i.e. providers with equivalent quality measures, providers with cultural sensitivity/language requirements, excess capacity of providers to take on new patients, etc), or the likelihood of surprise bills from the new payer. Such a tool would also need to inform the consumer of jurisdictional changes in psych policy. Each city maintains its own 911 response policy for DTS/DTO/GD, each county maintains its own mental health infrastructure, each state maintains its own laws reguarding mental health (i.e. 5150 equivalents, Marchman/Baker Act, forced administration of psych meds, duty to warn, etc). No one bidder/contractor is likely to complete this project. It is anticipated that this project would require a policy change from the state of California to require health insurers/self-insured employers to disclose their mapping of a current care plan on Medicaid into their proprietary system.

Additional Information:
https://www.nami.org/About-NAMI/Publications-Reports/Public-Policy-Reports/Mental-Health-Parity-Network-Adequacy-Findings-/Mental_Health_Parity2016.pdf https://nami.org/About-NAMI/Publications-Reports/Public-Policy-Reports/The-Doctor-is-Out/DoctorIsOut.pdf https://www.forbes.com/sites/peterubel/2018/02/28/bait-and-switch-the-sneaky-way-your-employer-just-passed-healthcare-costs-onto-you/#ccb47f37fbed https://www.shrm.org/resourcesandtools/hr-topics/benefits/pages/employers-hold-down-health-plan-costs-for-2019.aspx https://www.mercer.us/what-we-do/health-and-benefits/strategy-and-transformation/mercer-national-survey-benefit-trends.html https://www.kff.org/health-costs/report/2017-employer-health-benefits-survey/view/print/ https://www.healthaffairs.org/doi/full/10.1377/hlthaff.25.6.1538 https://www.cms.gov/newsroom/press-releases/enhanced-tools-available-help-people-medicare-improve-their-health-care https://www.nami.org/About-NAMI/Publications-Reports/Public-Policy-Reports/State-Mental-Health-Legislation-2015/NAMI-StateMentalHealthLegislation2015.pdf

 

June 18, 2019

6 comments

Innovations Team

Thank you for your submission. The innovation team needs additional information to explore this proposed idea. Please elaborate on your responses as best as possible so that we may work through our review process.

•To develop this type of tool would involve the inclusion of a large number of variables and the collaboration of health care plan providers and the State of California. This collaboration and development would likely take longer than the five years allotted to an Innovation project. Would there be a way to modify the idea in order to create learning objectives that could be measured within Innovation timelines?

The underlying pain associated with this project submission and the Mental Health Care Choice submission is living in an economy that isn’t designed for people with mental illness. Both submissions describe an intervention intended to enable participation in the workforce by allowing an individual with mental illness to at least understand what to expect in healthcare when starting a job. Previously, the Innovations team decided that Mental Health Care Choice wasn’t appropriate for Innovations. So, this is the next, most easiest, intervention to describe.

The Innovation Team’s response to this submission is analogous to the response of a person experiencing mental illness when looking for a job. This submitter wishes the Innovation Team’s response could be copied to the Social Security Administration’s SSI/SSDI decision makers and be used as a valid justification for receiving disability. So many variables, so much collaboration, so complex, arrrrgh…so please just grant the disability claim.

Unfortunately, that is not the reality we live in. Other submitters have tried employment or supportive employment project proposals, but the issues surrounding change of payer, change of provider, change of formulary, etc are not addressed.

Keep in mind, this submission is from a person on Medicaid whose mental health and medical health providers accept Medicaid. Medicare and Medi-Medi have their own separate issues that aren’t well understood by this submitter and can make life more difficult for Medicare / Medi-Medi beneficiaries before employment comes into the picture.

There are other alternatives that could work on a more limited or easier basis as follows:

1) Contact Mercer with this exact underlying issue and see what their response is. If Mercer is to be paid anything it is for outcomes performance – so many jobs enabled by fixing this particular healthcare issue – and not for delivery of a report nor billing of time. Better yet, if an Orange County Employer or Employers that already use Mercer could get them thinking about it and pay for it in funds already being spent.

2) Contact Society for Human Resources Management in the same way. Either Mercer or SHRM probably has contact with a jurisdiction that might do it better than Orange County. What other jurisdictions do probably doesn’t fit here, but its sometimes its just nice to see how something works when it works well.

3) Attempt a 1332 Waiver (https://www.govinfo.gov/content/pkg/FR-2018-10-24/pdf/2018-23182.pdf) – an intervention at the state level. It would be something wild like classifing all mental health insurance as public insurance. This is essentially what already exists according to NAMI – mental health is either cash pay or public insurance pay. There isn’t much private insurance pay. Or, people with serious mental illness/mental illness associated with medical disease get to stay on Medicaid reguardless of income and the employer/employee pays some predictable monthly cost to the risk pool while retaining access to their current care team. Someone who understands the 1332 process would be much better than I to describe how it works or doesn’t work. There is always the moral hazard involved with a choice like this.

4) Conduct an equivalent of the DARPA Challenges (https://www.darpa.mil/work-with-us/public/prizes) or Millenium Math Prize (https://www.claymath.org/millennium-problems) to design parts of an economy that would work for people with mental illness. This could be more interesting because more than just the healthcare component could be addressed.

5) Get a(an) Orange County employer(s) (Goodwill doesn’t count for this purpose) to attempt sustainable employment at market rates (i.e. above the Medicaid FPL) while addressing the transition in health care required.

6) Change insurance/reinsurance regulation, rules or incentives. Offer reinsurance for mental health expenses at affordable rates in exhange for portability of care plans between insurance products.

Keep in mind this issue exists because there isn’t agreement on what constitutes quality mental healthcare. If there was agreement then everyone would be doing the same thing.

My hypothesis that attempting to find a job isn’t a good use of time is affirmed by the Innovation Team’s response. There is not easy access to valid information to make informed economic choices – prerequisites for a market to exist.

If none of the market level interventions listed previously are options then recognizing the consequences of such a decision is important. In economics, every purchase is a sale and every sale is a purchase. So, without market level interventions, the consequence is that the labor market isn’t competing nor providing symmetrical information for labor experiencing mental illness. This shouldn’t surprise anyone. Also, there isn’t much to be gained by attaching morals or ethics to economic realities.

Keeping someone in sustainable employment compatible with Medicare/Medicaid or both is easier in a down economy with a low-minimum wage (less labor demand and lower wage means a person can work longer prior to hitting the FPL threshold for loss of healthcare). In this context sustainable employment means keeping a job for a long period of time. Sustainable employment does not mean that that income associated with that employment is sufficient to pay for food, water, sanitation, trash, housing, clothes, etc. This submitter has modeled personal income over three years to meet a contractual goal similar to the Medicare/Medicaid FPL threshold and it isn’t easy nor straightforward. It did require the flexibility to start/stop income at a moment’s notice and did create issues for long term investments associated with that income source.

The Orange County Healthcare Agency OCMHSA Plan Update FY2019-2020 doesn’t see much success in employment, except for the Military/Veteran demographic. Understanding the underlying healthcare differences between Military/Veteran (i.e. Veterans Administration) and non-military (i.e. Medicare/Medicaid) coverage could be interesting. The Veterans Administration doesn’t have an income limit (at least not known to this submitter) while Medicare/Medicaid does. Creating metrics that measure employment to the FPL threshold for non-military could probably be very interesting and provide insight into why FSPs and others aren’t able to show impact in Employment.

Previously, employment INN suggestions were submitted. The main challenge with these is that without a market with predictable healthcare choices/costs there isn’t likely to be a flow of people from the INN intervention to the next step. Thus any INN/MHSA intervention would likely need to create enough labor demand to match the labor supply to show impact for an Employment goal. Government subsidizing production/sales in any particular industry isn’t fair to the people who made long term investments prior to the subsidy. Subsidizing the person is kinder to those operating in a free and fair market with predictability.

Revisiting market or management level interventions would be a great research topic for someone. Having open-access to de-identified raw data used to create the OCMHSA Plan Update FY2019-2020 (and previous years) would enable others to answer these open questions. As previously noted in other INN suggestions, sharing/access to information is restricted by various Federal, State and local laws/policies/procedures.

This submitter is neutral regarding the value of employment for people experiencing serious mental illness. It is unclear if the drama associated with getting a job/keeping a job is worth the little income expected from the jobs readily available for people with serious mental illness.

Research shows that an 8 hour work week has mental health benefits and any extra hours beyond 8 have diminished/no additional benefit. (https://www.sciencedirect.com/science/article/abs/pii/S0277953619303284). However, people experiencing mental illness tend to be placed in exploitative situations that may include 1) Reduced income compared to employees without mental illness in positions with the same job description; 2) Unpaid internships/volunteering; 3) Higher work demands compared to employees without mental illness; 4) Possibly other situations that may be identified by other submitters.

The non-negotiable needs of a person experiencing Serious Mental Illness as related to employment include:

1) Compliance with at least Minimally Adequate Treatment (at least 4 visits to a Psychiatrist/Doctor every 12 months in combination with pharmacotherapy OR at least 8 visits to a Psychiatrist/mental health specialist). These visits are typically available during business hours only and thus equate to at least 4 OR 8 half-days off per year. Thus, the personal time off (PTO) provided by most employers would be mostly consumed by compliance with Minimally Adequate Treatment. Any additional healthcare requirements, such as routine medical screenings, vaccinations, lab tests, imaging, etc are not included in this accounting.
2) Predictable healthcare expenses that includes: premiums, professional visit co-pays, co-insurance, pharmaceutical co-pays
3) Tolerance of previous issues involving employment stability, legal issues, credit issues, etc.
4) A work schedule, including transportation time, that is compatible with activities of daily living and sleep. Currently, sleep is not traditionally classified as an activity of daily living, but should be.
5) Sustainable expectations that don’t have frequent surprises like dramatic changes in schedule, overtime leading to decreased sleep, changes to healthcare benefits that require redesign of a care plan.

Based upon anecdotal experience, SSI/SSDI is available for people with serious mental illness if applied for during the window of crisis. If application is postponed then various consequences occur that may include extensive time (5+ years)/effort (reapplication, hiring a lawyer, numerous appeals) to obtain SSI/SSDI. If a person with serious mental illness chooses to obtain further education instead of applying for SSDI then it is likely that the work credits earned for Social Security are lost and the person will only qualify for SSI, experiencing a lifetime of reduced income. It is expected that many people in Orange County have serious mental illness, but do not have SSI/SSDI due to the navigation/timing problems.

Retirement is the final issue associated with work/income/labor. As previously mentioned, people who lost their work credits due to untimely application for SSI/SSDI will not qualify for Social Security. The likelihood that retirement savings is quite low is quite high (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3114713/ https://www.ncbi.nlm.nih.gov/pubmed/21461932 https://www.ncbi.nlm.nih.gov/pubmed/21282782 https://www.ncbi.nlm.nih.gov/pubmed/17882460 https://www.ncbi.nlm.nih.gov/pubmed/11159617 https://www.ncbi.nlm.nih.gov/pubmed/18801222). Conspicuously missing from these studies is any study from the United States. Please see Inclusive Data Gathering (Vital Development Statistics).

The Kaiser Family Foundation recently published research about the individuals that incur high healthcare spending who are on Employer Health Plans (https://www.healthsystemtracker.org/brief/a-look-at-people-who-have-persistently-high-spending-on-health-care/).

Despite the 30 Day readmission data from First Aid for USMLE Step 1 and AHRQ, people experiencing mental illness didn’t even make the list. Sepsis did make the list (#2 for Medicare payer). Heart Failure didn’t make the list explicitly, but various Heart Failure/Fluid Overload associated diagnoses did (Renal Failure, Multiple Myeloma, Respiratory Failure) (#1 for Medicare Payer).

There isn’t enough data to support any conclusions, but this does suggest that mental health diagnoses aren’t well represented on Employer Health Plans. Not even Depression made it onto a list with many serious chronic diseases. This selection pressure is interesting from a research perspective.

Associated with the employer healthcare issues are other parts of an employment benefits package.

Read through the fine print of most employer benefits and mental illness can be a disqualifying condition for life, short term disability, long term disability, long term care, accidental death and other insurance products offered by employers. Anecdotal evidence supports the hypothesis that litigation would be required to receive any of these benefits when a person experiencing mental illness needs them. Litigation is another of the many scavenger hunts that degrade mental health and are not well tolerated.

If this is the case then having the ability to opt-out of the benefits that are not benefits for a person experiencing mental illness would be beneficial. The per-capita cost of these benefits would be redirected from the benefit vendor to the employee as direct earned income cash in salary or time-period based compensation. At a minimum, having an employer edit out the many contracts that are of no value to a person experiencing mental illness would be of great value. It is quite dehumanizing to sit through an employee on-boarding only to realize that most of the benefits offered don’t apply to a person experiencing mental illness. Such a reality isn’t usually disclosed during the interview process.

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