Governor Newsom signs into law four bills expanding access to quality behavioral health care at a ceremony in Sacramento on September 25, 2020. Photo: Paula Ginsborg via YouTube
Governor Gavin Newsom has signed into law four bills intended to improve Californians’ access to mental health and substance use disorder services.
“I pledged to put these critical services within reach of more Californians,” Newsom said in a September 25 statement. “The bills I am signing today will help Californians access the behavioral health services they need to recover.”
The coronavirus pandemic and the resulting economic downturn have persuaded Americans of the importance of behavioral health care services. In the last half of August, a National Council for Behavioral Health poll (PDF) found that the gap has widened considerably between demand for mental health and addiction treatment services and the financial viability of organizations that provide them. Over half of NCBH member organizations reported that in the three months before the survey, more Americans sought their services even as these providers lost, on average, 23% of their annual revenue.
A different survey, conducted in the last week of June, showed that one in four people age 18 to 24 seriously considered suicide in the past 30 days. That troubling finding was published in the Morbidity and Mortality Weekly Report of the US Centers for Disease Control and Prevention.
In California, where the wildfire season got off to an early and destructive start, the converging crises are expected to worsen residents’ mental health. “We are very concerned about the layering of multiple stresses on the people of California,” Jim Kooler, DrPH, assistant deputy director of behavioral health in the California Department of Health Care Services, told Jocelyn Wiener in CalMatters.
Here are the four behavioral health bills that the governor approved:
Strengthening California’s Mental Health Parity Law
Gaps in California’s mental health parity law will be bridged under SB 855 by State Senator Scott Wiener (D-San Francisco). “Current state law requires health plans to cover medically necessary treatment of just nine serious mental illnesses,” Jocelyn Wiener reported in an article about SB 855.
Mental health parity laws “have existed in both state and federal law for years, but insurers have used a complex determination of ‘medical necessity’ to deny care” for mental health issues and substance use disorders, Sigrid Bathen wrote in Capitol Weekly. (A recently published CHCF paper by researchers at Georgetown University’s Center on Health Insurance Reforms assessed California’s progress in enforcing the 2008 federal Mental Health Parity and Addiction Equity Act.)
The new state law requires commercial health plans and insurers outside of Medi-Cal (which is regulated by different standards) to provide full coverage for treatment of all mental health conditions and substance use disorders. This includes treatments for post-traumatic stress disorder, generalized anxiety disorder, and opioid use disorder, Sophia Bollag wrote in the Sacramento Bee. The new law also establishes specific standards for what constitutes medically necessary treatment and criteria for the use of clinical guidelines.
Creating a Certification Process for Peer Support Specialists
Under SB 803 by State Senator Jim Beall (D-San Jose), California will create a system to certify peer support specialists, define their roles, and help to scale up the Medi-Cal workforce.
In 2019, CHCF’s Lisa Aliferis visited Washington State to learn about its innovative statewide peer support program. A certified peer support specialist “identifies as having a significant life-altering mental health [or substance use] challenge and has been in recovery for at least a year,” Aliferis was told by Patti Marshall, the peer support program administrator for the Washington Health Care Authority’s behavioral health and recovery division.
Last year, California had not adopted a similar program — even though the US Centers for Medicare & Medicaid Services issued Medicaid reimbursement guidelines for peer providers in 2007. Now, research has shown that peer support for those with co-occurring mental health and substance use diagnoses prevents rehospitalizations and facilitates their ability to live in the community. “When we say [peer support] saves lives, it’s not hyperbole,” Michelle Cabrera, executive director of the County Behavioral Health Directors Association of California, told Jocelyn Wiener in an article about peer support specialists. “It really is a linchpin in moving people [with mental health and substance use disorder issues] into recovery and stabilizing them long-term.”
Expanding Community Paramedicine
Community paramedicine is a locally designed, community-based, collaborative model of care that leverages the skills of paramedics and emergency medical services (EMS) systems to take advantage of collaborations between EMS and other health care and social service providers. Among other expanded roles, community paramedics are trained to handle behavioral health needs and, depending on the locally designed program, can transport intoxicated patients to sobering centers or mental health treatment, and help frequent 911 callers to obtain behavioral health, medical, housing, and social services. All of these protocols take pressure off hospital emergency departments that traditionally have been the only permitted destinations for patients cared for by EMS agencies.
In 2015, California began testing the model of care through 13 community paramedicine pilot projects across the state. An external evaluation conducted by the Healthforce Center at UCSF found that “community paramedics are collaborating successfully with physicians, nurses, behavioral health professionals, social workers, and outreach workers to fill gaps in the health and social services safety net.”
AB 1544 by Assemblymember Mike Gipson (D-Carson) will expand the pilot projects by authorizing local EMS agencies to develop alternative destination programs.
Making Substance Use Disorder Treatment More Accessible
One-third of adults who receive county services for serious mental illnesses have a co-occurring substance or alcohol use disorder, according to Assemblymember Sharon Quirk-Silva (D-Fullerton). She authored AB 2265, which will authorize counties to use Mental Health Services Act (MHSA) funds — historically limited to mental health services — to treat Californians with co-occurring mental health and substance use disorders.
By removing barriers to using MHSA-funded services for such conditions, AB 2265 will “[increase] access to substance use disorder treatment, [improve] care coordination, and [lead] to a more integrated behavioral health care system,” according to the governor’s office.
Hospital system CommonSpirit Health reported operating revenue losses of $550 million during its fiscal year that ended in June, as the COVID-19 pandemic continues to roil patient volumes.
The 137-hospital system reported its financial earnings Friday for the 2020 fiscal year that ended June 30. CommonSpirit’s expenses also surged during the pandemic as more resources were needed to screen visitors and staff.
“Although it varies significantly by division, beginning the middle of March, the COVID-19 pandemic caused up to a 40% slowdown in volumes,” CommonSpirit’s financial report said. “As communities heeded guidelines to avoid hospitals for non-emergent issues, appointment volume, especially for specialty practices, fell and emergency department volume declined.”
CommonSpirit’s patient volumes did rebound after shelter-in-place orders started to be lifted in April and May, but the volumes are still below pre-pandemic levels.
At the end of the system’s fiscal year on June 30, the volumes on adjusted admissions were down 6.2% compared with the 2019 fiscal year.
Adjusted patient days for the fiscal year were also lower than the same period in 2019 by 5.7%.
At the same time, net patient and premium revenues declined by $239 million, or 0.9% over the same period in 2019.
“The decrease is primarily due to the impact of the COVID-19 pandemic and increased charity care, partially offset by a stable payor mix,” the earnings said.
Overall, CommonSpirit recorded an operating loss of $550 million for the 2020 fiscal year, which was an improvement on the $617 million in losses from 2019.
But those 2020 losses ballooned up to $1.4 billion when not taking into account money the system received from a $175 billion provider relief fund Congress set up as part of the CARES Act to help prop up hospitals and other providers.
The system also reported a $1.3 billion decline in earnings before interest, tax, depreciation and amortization and nonoperating income from March through June.
About 62% of the lost EBITDA has been recouped through the CARES Act funding, and another $500 million remains to be regained, CommonSpirit said.
Overall, CommonSpirit has recorded $826 million in money from the provider relief fund. It also got another $2.6 billion from the Medicare Accelerated and Advance Payment Program, which the system will have to repay.
The system anticipates it will defer $410 million in employer payroll taxes to December 2022, a flexibility also afforded under the CARES Act.
“While the aid received from the programs above provides much needed assistance during this crisis, CommonSpirit is unable to assess the extent to which the amounts and benefits received, or to be received, will offset the long-term changes in volumes, payor mix or service mix,” the report said.
The Department of Health and Human Services has more than $50 billion to still give out to hospitals, but some hospital groups say that more money is needed to combat the financial crisis caused by the pandemic. Talks on a new coronavirus relief deal have stalled in Congress.
While some larger for-profit systems such as HCA and Tenet have posted profits thanks to the provider relief funding, other not-for-profit systems such as Trinity Health and some smaller systems have reported struggles with overcoming the new financial crisis.
A federal appellate court recently ruled that Anthem is required to pay Martin Luther King Jr. Community Hospital in Los Angeles for about 75 emergency room visits from covered patients, according to Bloomberg Law.
The appeal centered on whether Anthem was required to cover services MLK Jr. Community Hospital rendered to employees of Budco Group, an Ohio company, when the hospital was assigned the patients’ benefit payments. Anthem is the administrator of Budco’s Employee Retirement Income Security Act plan, and the employees who received services at the hospital were beneficiaries of the plan.
Between 2015 and 2017, Budco employees visited MLK Jr. Community Hospital’s emergency room at least 75 times and assigned their benefits under the company’s ERISA plan to the hospital as a condition of receiving care. Instead of paying MLK Jr. Community Hospital, which was out of Anthem’s network, the insurance company paid the beneficiaries, forcing the hospital to attempt to recover payment from the beneficiaries. The Budco employees deposited payment into their personal accounts and did not send any of the benefit payments to the hospital.
The hospital sued Anthem and Budco in 2016, seeking benefit payments and declaratory relief. The district court granted summary judgment in favor of the hospitals, and Anthem and Budco appealed.
On appeal, Anthem argued the case was blocked by a provision in its health plan that prevented patients from assigning their rights to third parties such as MLK Jr. Community Hospital, according to Bloomberg Law. The hospital argued that the “anti-assignment” provision did not bar assignments in this case.
In an unpublished split decision filed Oct. 2, the U.S. Court of Appeals for the Ninth Circuit ruled in favor of the hospital, holding that the language cited by Anthem allowed assignments to healthcare providers, including those that were out of network.
“The provision lists three entities other than the beneficiary that Anthem may pay directly. Providers are included among those entities,” the court stated. “In the same paragraph, and only two sentences later, the anti-assignment provision forbids beneficiaries from assigning benefits to ‘anyone else.’ This sentence restricting assignment must be read consistently with the entire paragraph, which concerns benefit payments to entities other than the beneficiary. Thus, we interpret the anti-assignment provision’s reference to ‘anyone else’ to permit assignments to those entities, including ‘providers.'”
Alternatively, the appellate court held that the anti-assignment provision is not part of the health plan documents.
“The anti-assignment provision is plainly not a benefit, and therefore the district court correctly determined it should not be incorporated as a description of the plan’s benefits,” the appellate court held.
In his dissenting opinion, Judge Daniel Collins said the anti-assignment provision is an express term of the documents that govern the Budco plan. He also disagreed with the majority’s alternative conclusion that the language of the anti-assignment provision did not bar the assignments that plan beneficiaries made to MLK Jr. Hospital.
Lori Flees, senior vice president and COO of Walmart Health, officially launched Walmart Insurance Services Oct. 6. The insurance agency will “assist people with enrolling in insurance plans and simplify what’s historically been a cumbersome, confusing process,” Ms. Flees said.
Five things to know:
1. Ms. Flees outlined the operations of Walmart Insurance Services in a Oct. 6 blog post. Walmart will begin selling Medicare insurance plans during this year’s open enrollment period, from Oct. 15 through Dec. 7.
2. Walmart Insurance Services will provide Medicare products, including Part D, Medicare Advantage and Medicare Supplement plans. The products will be offered by Humana, UnitedHealthcare, Anthem Blue Cross Blue Shield, Amerigroup, Simply Health, WellCare, Clover Health and Arkansas Blue Cross and Blue Shield. More insurers will be added, Ms. Flees said.
3. In July, the Arkansas Democrat Gazette broke news that Walmart had started seeking Medicare sales managers and insurance agents for a new entity called Walmart Insurance Services.
4. In early October, Walmart announced its partnership with Medicare Advantage insurer Clover Health on its first health insurance plans, which will be open to half a million people in eight counties in Georgia.
5. Walmart’s insurance business is licensed in all 50 states and Washington, D.C. Ms. Flees said the company has hired insurance agents to help people find insurance plans.
NeuroBehavioral Hospital in Crown Point, Ind., terminated the employment of a discharge planner last week after she spoke to the New York Times about nursing homes discharging unprofitable patients, a practice known as “patient dumping,” the NYT reports.
In the Sept. 19 NYT article, Kimberly Jackson said that during the pandemic nursing homes in Illinois and Michigan have repeatedly sent elderly and disabled Medicaid patients to NeuroBehavioral Hospital, a psychiatric facility, even though they were not experiencing psychosis, seemingly in an effort to get rid of patients who are not lucrative for reimbursement or require extra care.
“The homes seem to be purposely taking symptoms of dementia as evidence of psychosis,” Ms. Jackson is quoted in the article.
She was fired from NeuroBehavioral Hospital Sept. 24. Rebecca Holloway, the hospital’s corporate director of human resources, told the NYT that Ms. Jackson violated the hospital’s media policy.
Ms. Jackson told the newspaper she was shocked to be fired for speaking to the media.
“I saw something that was wrong, and I called it out,” she said.
NeuroBehavioral Hospital is part of NeuroPsychiatric Hospitals. The South Bend, Ind.-based network has five facilities in Indiana, two in Texas and one in Arizona.
Fort Myers, Fla.-based Lee Health is freezing salaries for its 13,500 employees next year to help offset financial losses tied to the COVID-19 pandemic, according to the Fort Myers News-Press.
The pay freeze in 2021 will mark the first time in nine years that the publicly operated health system has not given employee raises. Salaries and benefits make up about half of the system’s nearly $2 billion in spending each year, according to the report.
Lee Health is facing a budget deficit for the first time in two decades due to financial strain linked to the pandemic. The salary freeze is one of several steps the system is taking to offset losses and avoid layoffs.
The system has halted most capital projects, and its top executives took pay cuts earlier this year. Lee Health will also reduce the match for employee retirement plans from 5 percent to 4 percent next year, and health plan premiums and copays will also increase, according to the report.
A stop-gap funding bill the president signed into law Thursday will keep the government open until mid-December and includes some provisions that could help providers’ bottom lines. The bill includes relief on advanced and accelerated Medicare loans and a delay of Medicaid payment cuts for disproportionate share hospitals.
The legislation extending government funding at current levels was passed by the House earlier this month and approved by the Senate on Wednesday. But more sweeping aid many providers wanted, including more grants for hospitals and a higher federal match rate for Medicaid, were left out of the legislation.
Provider groups like the American Hospital Association thanked Congress and the Trump administration for the relief, but AHA noted it would continue lobbying for Medicare loan forgiveness and an extended deadline for the Medicaid DSH cuts.
Dive Insight:
The continuing resolution, and its healthcare provisions within, are pretty much the only direct aid providers can expect from Washington before the looming November presidential election. Congress has largely punted on a fifth round of COVID-19 relief legislation amid partisan deadlock, with Republicans backing a much skinnier package than Democrats.
The CR delays the repayment date for $100 billion in advanced Medicare loans to providers by a year. CMS originally planned to start recouping the loans from providers’ fee-for-service Medicare payments in late July, but unilaterally decided to hold off as lawmakers negotiated the bill.
It also lowers the rate of recoupment to 25% for the first 11 months of repayment, down from the current 100% rate, and 50% for the next six months. Providers have 29 months to pay back the funds in full before interest kicks in, and the interest rate is decreased from 9.6% to 4%.
The original repayment terms and timeline would have been difficult for some cash-strapped doctor’s offices and hospitals to meet, as the burden imposed by COVID-19 hasn’t lifted and is worsening in many areas of the country. Many providers took out the loans earlier this year as a lifeline to stave off insolvency — still a very real threat for many practices.
About 35% of primary care physicians say revenue and income are still significantly lower than pre-pandemic levels, losses that could force them to close, according to a September survey by the Larry A. Green Center and the Primary Care Collaborative.
AHA CEO Rick Pollack said in a Wednesday statement the massive hospital association appreciated the provisions, but would keep pushing for full loan forgiveness, along with extending the delay of DSH cuts for all of the 2021 fiscal year. The CR pushed back the original payment cut start date from Dec. 1 to Dec. 12.
The Association of American Medical Colleges was more worried about the impact on the system.
“We are concerned that health care providers, researchers, students, and public health professionals — who have been our country’s first line of defense against COVID-19 — will remain in limbo despite ongoing challenges that the pandemic presents,” CEO David Skorton said in a statement. “We strongly believe that a larger COVID-19 legislative relief package is essential to our nation’s health.”
However, drastic estimates from providers on financial losses largely haven’t panned out, though public health experts do warn COVID-19 could worsen going into the winter months. AHA estimated U.S. hospitals would see operating profits fall by almost $51 billion in April, the month with the sharpest volume decline because of the pandemic. It’s likelier hospitals lost about half that, according to research from a congressional advisory board, with federal grants covering the worst of short-term losses.
The CR also includes a provision stopping Medicare beneficiaries from seeing a monthly $50 Part B premium hike next year. It will keep the government open until Dec. 11, setting up another funding fight to avoid a shutdown after the election.
Federal agencies have charged 345 people across the country, including more than 100 providers and four telehealth executives, with submitting more than $6 billion in fraudulent claims to payers. Of that, $4.5 billion was connected to telemedicine schemes and about $800 million each to substance abuse treatment and illegal opioid distribution.
More than 250 medical professionals had their federal healthcare billing privileges revoked for being involved in the scams, according to a statement released Wednesday.
The U.S. Department of Justice also said it is creating a new rapid response strike force to investigate fraud cases involving major providers that operate in multiple jurisdictions.
Dive Insight:
Telehealth fraud has increased significantly since 2016, the HHS Office of Inspector General said. As providers have quickly pivoted many services to virtual care during the COVID-19 pandemic, attempts at fraud will likely follow.
One of the cases outlined Wednesday included false claims for COVID-19 testing while another involved a COVID-19 related scheme to defraud insurers out of more than $4 million.
The telehealth fraud allegedly involved a marketing network that lured hundreds of thousands of people into a criminal scheme with phone calls, direct mail, TV ads and online pop-up ads. Telemedicine executives then paid doctors to order unneeded medical equipment, testing or drugs with either no patient interaction or only a brief call.
Those were either not given to the patients or were worthless to them. The proceeds were then laundered through international shell corporations and banks.
The scheme is similar to one DOJ prosecuted in April 2019involving fraudulent telehealth companies that pushed unneeded braces on Medicare beneficiaries in exchange for kickbacks from durable medical equipment companies.
The massive bust included the work of 175 HHS OIG agents and analysts and targeted myriad fraud operations across the U.S. and its territories.
One of the larger scams involved 29 defendants in the Middle District of Florida. A telemedicine company and medical professionals working for it billed Medicare for medical equipment for patients they never spoke to.
In New Jersey, laboratory owners paid marketers to get DNA samples at places like senior health fairs. Doctors on telemedicine platforms then ordered medically unnecessary and not reimbursable genetic testing.
HENRY KOTULA 