A physician’s job is to heal the sick, help the wounded and lately protect their rights to quality physical and mental healthcare. As a practicing physician for 30 years, I can tell you integrating healthcare does not take place at the payer level, it takes place at the provider/patient level. Some of the most vulnerable citizens in this state are persons with serious mental illness, intellectual and developmental disabilities and substance use disorders.
Michigan is trying to decide how to best deliver and coordinate Medicaid physical and behavioral healthcare and services. A public firestorm was started when Governor Snyder proposed Executive Order 298 in his fiscal 2017 budget to simply turn over the $2.6 billion behavioral health system to the 11 largely private for-profit $8 billion Medicaid HMOs. Transferring funding does not “integrate care,” it integrates taxpayer resources targeted to serve vulnerable people under private, often publicly-traded, stockholder or private family owned business control. This business model puts profits over people and is not based on care or service.
The 298 Workgroup established by Lt. Governor Brian Calley and Nick Lyon, Director of the Michigan Department of Health and Human Services, met for over a year, to explore ways to best integrate physical and behavioral health care in our State and recently submitted their 298 report/recommendations to the Legislative leadership. The Medicaid HMOs were active members of the workgroup along with the input of countless citizens. The citizens who participated in this process decided they want both public oversight and public control over public dollars meant to serve and support the most vulnerable citizens of this state. They don’t want their healthcare turned over to private insurance companies. Medicaid HMOs now want to toss a yearlong report that impacts the most vulnerable citizens in the State and just transfer $2.6 billion of public money to private insurance companies. It’s called a money grab and has nothing to do with optimizing care or the best interest of Michigan citizens.
There have been inflammatory articles from Medicaid HMO Association leadership, particularly by Meridian President and COO Jon Cotton asserting, “Their [MI public behavioral health system] time has passed. Medicaid health plans should take over that role,” he said. “It’s like comparing a bicycle to a Ferrari. You both go from A to B, but the ride is different.” We can cut $200 million out of the behavioral health system & health plans have the experience to manage both systems. “They say they can help the state save money, improve quality and care coordination and extend more services to patients.”
Let’s look at the facts:
- Michigan’s Public $2.6 billion behavioral health system provides care with a 7% admin costs/overhead rate. The for-profit $8 billion Medicaid physical health HMO system provides care with a 17% admin costs/overhead rate. Simply “taking over” the behavioral health system would result in roughly $260 million being taken away from direct care services and transitioned to HMO overhead (President, CEO, executive salaries). Since 100% of the clients in the behavioral health system use services as opposed to 20% in the HMO physical health system, this amounts to a $260 million removal of care and services to our most vulnerable population. The public says it doesn’t want the bloated costs of a “Ferrari”.
- Quality of care. A review using 2016 HEDIS quality scores for Michigan Health Plans (MHP) indicate less than “Ferrari” like performance at just slightly above average compared to national results. Of note almost 35% of indicators fall below the 50th percentile nationwide. Another 44% were below the 75th percentile.
- For nearly 20 years private health plans have poorly demonstrated their ability to manage the behavioral health and intellectual/developmental disability supports and services benefit. The psychiatric and psychotherapy benefit for the state’s Medicaid enrollees who have ‘mild-to-moderate’ mental health conditions in communities across the state have pointed to long waiting times and the inability to gain access to this benefit due to the fact that the health plans have few, if any, psychiatrists and psychotherapists taking new Medicaid patients. If you can’t manage the “’mild-to-moderate” you can’t be trusted to manage the “severely ill” behavioral health client. This is not the track record of a group that can adequately manage the care of some of the most vulnerable members of our communities. This “Ferrari” has mostly been in the shop.
The track record of the health plans relative to behavioral health care in Michigan is historically poor, they see an opportunity to enrich themselves at the expense of Michigan’s citizens by “integrating” billions of tax dollars under their private/profit control. This is bad public policy and as physicians we owe it to our patients and the communities we serve to speak up for those who often cannot speak for themselves.
Herbert C. Smitherman Jr, MD, MPH, FACP is Vice Dean, Diversity and Community Affairs, Associate Professor, Department of Medicine and Karmanos Cancer Institute, Wayne State University School of Medicine/ Detroit Medical Center, President and CEO, Health Centers Detroit Foundation, Inc. and Board Chairman, Detroit Wayne Mental Health Authority.