[M]ental health advocates want state regulators to reverse a decision from this summer that will cut in half how much clinicians make for group therapy sessions.
Advocates and mental health providers have sent letters to the Green Mountain Care Board, which regulates health care reform in Vermont, and the Department of Vermont Health Access, which regulates the state’s Medicaid program.
At issue is a July decision the department made to cut the Medicaid reimbursement rate for group psychotherapy from $41 per 50-minute session to $20.50. The cut is scheduled to take effect Jan. 1.
The cut that looms in the next few weeks is on top of a cut in July, when the department also lowered the Medicaid reimbursements. Previously, therapists could charge in 15-minute units for up to two hours of care—which meant a standard 90-minute session reimbursed $61 per patient.
The Department of Vermont Health Access estimates that the 2015 cut reduced payments to providers by about $118,000 over the last six months of 2015. The state says the Jan. 1 cut, which is more severe, will help save the state $1.05 million for all of 2016. The earlier cut did not provide as much savings because many providers were already doing hour-long sessions, so fewer were affected.
Steven Costantino, the commissioner of the Department of Vermont Health Access, which oversees the state’s Medicaid program, said the state made the billing changes to comply with federal regulators. Additionally, he cited states such as New York, New Hampshire, and Massachusetts that reimburse in the $14 to $22 range.
The cut also comes at a time when the Medicaid program is costing Vermont a lot of money. As of last month, the state was facing a $36.7 million Medicaid shortfall in the current fiscal year’s budget and $54.1 million shortfall in next year’s budget. Costantino said rate cuts can generally save money, but insists this decision was about compliance.
“You’re always facing the potential of disallowances, meaning the feds can recoup the federal match, which basically means you’d have to replace the federal money with state money,” Costantino said.
“We want to really combine the fact that we want to stay competitive within the region in terms of rates, but we also want to do what’s clinically and appropriate within best practice,” he said.
But psychologists and social workers across the state say the cut will discourage providers from offering group therapy, which they say is a good way to treat poor Vermonters, people recently released from prison, sex offenders, and domestic violence victims.
“Group therapy is one of the most effective and cost-effective treatments out there, and so I worry that it’s going to reduce access,” said Eilis O’Herlihy, the executive director of the Vermont chapter of the National Association of Social Workers.
“I’ve done (group therapy) in the past in a past job, but in my current life I help people find access to it and it’s hard,” O’Herlihy said. “One-on-one therapy is really hard work. Couples therapy is really hard work. Family therapy is really hard work. But group is the hardest work I’ve ever done.”
Questions of parity
Ken Libertoff, an advocate, said mental health has been “singled out” for a drastic cut in reimbursement, and predicted the cut would have a “chilling impact” on access to the service throughout Vermont.
“I would submit that there is no other area of health care where providers are facing 50-percent reductions in reimbursement,” he said. “I don’t think specialists—I don’t think cardiac surgeons or internists—are threatened with 50-percent reductions.”
Rick Barnett, a psychologist with a private practice in Stowe, said about half of his patients use Medicaid. He offers group therapy to people in diversion programs that require psychotherapy after people get DUIs and for substance abuse treatment programs that require a provider to check in periodically with a patient.
Six people in a group is the ideal number, Barnett said, so Medicaid currently reimburses him $246 for a group session, usually 50 minutes long, and the cut that takes effect Jan. 1 would reduce that to $123 for a full group. Two years ago, he would have made $366 for a 90-minute session with six people.
He said the reduction is substantial because of the administrative aspects of scheduling six people to come in at the same time, filling out documents to bill the insurers, taking on the liability of having six patients in one office, and paying the overhead to have an office that can accommodate six patients.
If the rates get cut, Barnett predicted that people who used to see six people in one hour for $41 each may schedule 20-minute check-in sessions and bill for $40 per session. Providers would make roughly the same amount of money—and Medicaid could spend roughly the same amount of money—but the patients wouldn’t experience the “extremely powerful” peer support that comes during a group session, he said.
“It totally violates parity, and it violates the governor’s own mission that he’s been on since 2013 to provide the best addiction treatment services we can,” Barnett said. “He’s contradicting himself. If he’s not preventing these cuts, then he’s basically showing that he’s completely duplicitous.”
Tom Powell is a psychologist with a practice that specializes in patients who interact with Vermont’s legal system. He is the former clinical director for the Department of Corrections, where he used group therapy as a go-to tool for treating sex offenders, but he doesn’t offer group therapy at his private practice.
When sex offenders get out of prison, some offenders may be in denial of the abuse they perpetrated, he said, but they often admit their crimes once they see another offender in a group therapy session who owns up to what he did, Powell said. Without group therapy, he said recidivism could go up.
“What we see is just the collapse of a system in front of us,” Powell said. “It’s a fragile system, and I’m afraid we’re taking the legs out from a system that’s only got three legs in it. If it had four it’d still stand up, but it doesn’t.”
“It was a Fifth Floor decision that I think said, ‘We’re just not gonna allow Medicaid money to go out for this stuff,’” Powell said. “When you take a bunch of hardcore addicts and preferential pedophiles and say, ‘You can do this in 50 minutes. You don’t need 90 minutes,’ they just don’t know what they’re talking about.”
Questions of politics
In November, Libertoff was one of several mental health advocates who attended a Green Mountain Care Board meeting to discuss mental health care and substance abuse treatment. The looming cut to group therapy rates was the topic of the day.
Con Hogan, a member of the Green Mountain Care Board, was receptive. He wrote in an email this week that he is “deeply concerned” about the group therapy cuts, but he is withholding final judgment until the board holds a public hearing on the group therapy rates.
The board will have a meeting as part of the series on mental health integration into health care reform on Dec. 10. Al Gobeille, the chair of the Green Mountain Care Board, said members of the Shumlin administration may attend and may talk about the cuts. Costantino said Friday morning he hadn’t yet been invited.
“We actually don’t have the ability to do anything, other than to bring (the group therapy issue) into the public eye or to somehow make a comment on it,” Gobeille said. “I think that DVHA should make the case to the public of why they’re doing this, and I think transparency is our friend.”
During the 2015 legislative session, Gov. Peter Shumlin proposed creating a .7-percent payroll tax on employers to raise Medicaid reimbursement rates and expand the Green Mountain Care Board. Since that proposal failed, reimbursement rates haven’t been in the public eye, Gobeille said.
“Medicaid should actually probably have its rates reviewed by the Green Mountain Care Board,” he said. “There should be some independent body that has a say in Medicaid rate that’s a public, transparent agency.”
Currently, the Department of Vermont Health Access works with the Clinical Utilization Review Board to set Medicaid rates. The board is made up of doctors throughout the state and meets roughly every month.
Costantino said he agrees with providers that group therapy is an important treatment option. He called the new rate a “very, very difficult change and transition” and said he is open to any meeting on the issue.
