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.
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