Two Sides of the Same Health Care Coin

Fred Goldstein
Recently two articles were sent to me by Cliff Frank, a colleague and friend. If you know anything about Cliff, you’ll know that 1) if he’s sending something, it’s worth reading, and 2) he doesn’t mince words. In this case, with regard to the first article, it was one short line:
“Fascinating article about crap in our own state (Florida).”
After reading it and sending an email in which I discussed the historical basis of this behavior, my response became three short lines:

• “Just more recycling of S.O.S.”
• “How much good care could be provided if we got rid of this garbage.”
• “Shaking my head.”

The Mother Jones article – “Mom, When They Look at Me, They See Dollar Signs” – was an unbelievable read about the abuses being done by substance abuse treatment centers in Florida and around the country. Well, I really shouldn’t have considered it unbelievable. In the early 90’s I got out of that industry quickly after arriving at one of a two psychiatric/substance abuse hospital system whose owners were doing some things that just weren’t ethical or possibly legal, although not to the extent of this article. The examples cited in this article were way beyond the pale:

• Putting the people up in hotels after being discharged from the treatment center and providing them with drugs so they can then test positive and be readmitted,
• Paying the patient for coming to the facility and while they are there, paying huge bonuses to patient recruiters, and
• Charging exorbitant fees.

This and much more was done in an effort to continue to get more admissions and re-admissions and to make money. I would expect that most if not all of these patients had some form of commercial insurance, which paid the $3,000 lab fee or $22,000 per day rates that were discussed in the article.
I wondered how many of the insurers or TPAs picked up on the issue or sought to intervene and get the person help at an alternative, better facility. Uncovering things like this or monitoring multiple admissions would be something one would expect from an administrator providing admission reviews, pre-certifications and claims audits. Unfortunately, none of that was discussed in the article.
*********
Cliff’s second article discussed the recent California Federal Court ruling against United Health Care’s Optum Behavioral Health (See Brian Klepper’s commentary in this edition). In the case, Wit v. United Behavioral Health and Alexander v. United Behavioral Health, the plaintiffs alleged “that they were improperly denied benefits for treatment of mental health and substance use disorders because UBH’s Guidelines do not comply with the terms of their insurance plans and/or state law.”
The Plaintiffs “asserted “two claims: 1) breach of fiduciary duty and 2) arbitrary and capricious denial of benefits.” Specifically, the plaintiffs claimed that UBH breached these duties by:

1. Developing guidelines for making coverage determinations that are far more restrictive than those that are generally accepted even though Plaintiffs’ health insurance plans provide for coverage of treatment that is consistent with generally accepted standards of care; and
2. Prioritizing cost savings over members’ interests.

There were all sorts of interesting findings throughout the ruling including that the court found one witness for the Plaintiff to be “…particularly persuasive” and the other “generally credible.” That said, with regard to the UBH witnesses, “The Court found that with respect to a significant portion of their testimony each of them was evasive – and even deceptive – in their answers when confronted with contrary evidence. Therefore, the Court discounts the testimony of UBH’s expert witnesses …”
The Court also found numerous issues in UBH’s claims review and its denial process. Most important, they documented how UBH focused on the acute portion of the incident and not the broader psychiatric or substance abuse issues, as an evidence based approach would have been expected to do.
The court also found that United had a structural conflict of interest in applying its own restrictive coverage rules because it felt pressure to keep benefit expenses down so it could offer competitive rates to employers.
The Full Court Findings are here.
*******
Mental health and substance abuse care are important components of our healthcare system, with diseases and conditions that impact millions of Americans to varying degrees. Behavioral health has tremendous stigma which causes individuals to not access care, to wait to access care, and to sometimes even deny a condition. At the same time, the impact of untreated or poorly managed mental illness has a profound effect on employers. Numerous studies document the powerful impact of mental health on presenteeism, absenteeism and increased medical costs. To get a sense of the magnitude of the problem, check out the costs of substance abuse for your company at the National Safety Council’s Substance Use Cost Calculator for Employers.
*********
The linkages between these two stories extend beyond the fact that they both have to do with mental health; they are examples of why our healthcare system struggles so. On the one hand, the rehab centers sensed an opportunity, based upon expanded coverage in the Mental Health Parity Act and the Affordable Care Act. This was amplified immensely by the opioid epidemic, also created by our health care system, to take advantage of a vulnerable population and to maximize the revenues that could be extracted from it.
On the other side a large payer, per the court’s findings, takes advantage of a population, denying services and again maximizing the population’s revenue,
I couldn’t help wonder about the health plans’ and TPAs’ roles in all this. Shouldn’t they be on the lookout for just these abusive cases and doing everything possible to get rid of the vendor behaviors? Shouldn’t they find high quality mental health providers and help their members? Do they not also have some culpability there?
So, if you’re an employer, as a practical matter consider asking your health plan or TPA the following questions. Be sure to maintain appropriate confidentiality, which may require third party review.

1. How do you view the vendor managing mental health and substance abuse benefits for your company? Get a feel for who they have working on these issues, their expertise, compassion, empathy; but you’ll need to do more than ask or review their language, you’ll need to dig deeper. As you can see UBH claimed they had a good process and that it was evidence based etc.
2. How do they handle denials?
3. How many denials have they made? For what services?
4. How many readmissions have there been? How many people were admitted 2, 3, 4, 5 or more times for the same issue? To the same facility? A facility owned by the same owners.
5. Do they monitor facilities?
6. How do they contract their network? Have they sub-capitated or carved out their mental and substance abuse to a 3rd party?
7. What are the requirements for mental health and substance abuse facilities to be in the network?
8. How do they ensure quality? What reports do they generate? Who looks at them? What are their responses to these reports? Have they ever dropped a facility from their network and if so, why? (I recall, when I was operating a health plan, our subcontracted mental health provider sending us monthly reports with a “goose egg” in the patient complaints line. They were sending us these even as our Director of Quality was submitting patient complaint reports to them. We quickly called them in after bringing this up multiple times and told them we’d found a new vendor.)
9. How do they identify fraud, and how much fraud have they uncovered?
10. Hire a third party to survey your employees, and seek to find out if any are experiencing issues like these.
11. Perhaps send out a notice to employees and ask them to call the Employee Assistance Program (EAP) if they are experiencing anything like these two stories so they can feel safe reporting it. And ask your EAP to be on the lookout for this.
12. And if you’re really concerned, bring in a third party with expertise in this area to review just what you are getting for your employees.

Fred Goldstein is Founder & CEO of Accountable Health, LLC, which helps organizations develop better plans to improve the health of individuals, populations and the organization’s bottom line.