NAMI Texas Policy Position on the PCG/Rider 71 Study Recommendations and the Texas Council’s Proposal to Revamp the Mental Health System in Texas

NAMI Texas Policy Position on the PCG/Rider 71 Study Recommendations and the Texas Council’s Proposal to Revamp the Mental Health System in Texas

The NAMI Texas Public Policy Committee reviewed the PCG/Rider 71 study report and recommendations and the Texas Council’s proposal to revamp the Texas mental health system and made the following observations/recommendations to the NAMI Texas Board.  The Board adopted the recommended positions on November 4, 2012.

  • NAMI Texas supports the PCG recommendations for the state to initiate a 1915i waiver request to provide a range of alternatives to institutional care for persons with mental illness, similar to the HCS provisions for persons with developmental delays.
  • NAMI Texas supports the need for increased funding for community services for persons with mental illness.
  • NAMI Texas supports the restoration of funding of residency programs for behavioral health professionals and for funding programs to provide for student loan forgiveness for professionals who practice in underserved areas.
  • NAMI Texas supports the expansion of the YES waiver, which provides for intense community services for children and adolescents who would not otherwise qualify for Medicaid who have high needs and risk incarceration and/or hospitalization. The services are aimed at ensuring family preservation in cases where children or adolescents might be relinquished by parents to the care of the state in order to achieve needed services if the waiver services are not available.
  • NAMI Texas supports the need for data transparency but does not agree that the only way to achieve consistent comparisons of programs across the state is to have one model for the entire state.  The diverse needs and resources across our large state call for local solutions that meet local needs rather than for a one-size-fits-all solution.  If various models are evaluated by measuring outcomes, it would be possible to compare results across diverse programs to determine efficacy and quality.
  • NAMI Texas does not support the recommendation for the state to devise a specialty program for integration of mental health services and other medical services as the members believe that the 1115 waiver offers opportunities for communities to integrate services in ways that address local needs and incorporate local resources, which is already happening in both the NorthSTAR program and in many other Local Mental Health Authority (LMHA) regions in the First Pass of the 1115 waiver, and more are planned for the Second Pass.
  • NAMI Texas supports the expansion of the BHO model to urban and surrounding areas because it has a thirteen year record of reducing costs, serving greater numbers without waiting lists, separating the provider and authority roles, providing consumer choice through multiple providers, which, in addition to consumer choice, produces both greater efficiencies and better quality services through competition, and,  despite lower per-member-served costs, achieves outcomes in the top quadrant among LMHA regions as measured by DSHS.  NAMI Texas does not feel that this model would achieve these successes in rural areas and small cities that are not adjacent to or near larger markets so does not support the recommendation for state-wide expansion.
  •  NAMI Texas has a number of serious concerns about the 1b recommendation of a carve-in model to the existing Medicaid Managed Care HMOs.
    • Mental Health and Substance Abuse services would be a small percentage of the services offered by the HMOs and would likely receive far less attention than they do in either the current model in the majority of the state or the BHO model. One limited study by the Lewin Group, albeit with incomplete data, indicated the STAR model in Texas did not serve the MH and SA population as well as the NorthSTAR model, which is a BHO carve-out model. The study cited other studies with similar findings in other states when carve-ins and carve-outs were compared for persons with serious and persistent mental illness.
    • The carve-in model as presented in the PCG report does not detail whether or not there would be a Local Mental Health Authority or what the mechanism, if any, for local control would be.
    • The carve-in model as presented by the PCG report leaves open the question about what would happen to the non-Medicaid (indigent) population, which might be left out of the model or might be carved in with the Medicaid population, which would require an at-risk model of contracting with the HMOs to ensure that all who needed services received them.
    • NAMI Texas has concerns about HHSC’s oversight of the current managed care programs for STAR, STAR-plus, and CHIP, which has not been very rigorous and would likely not provide the oversight needed to ensure that persons with serious and persistent mental illness and/or substance abuse disorders received the care needed.
    • NAMI Texas  does not agree that if 1b is adopted the state should evaluate the continuation of the NorthSTAR model which is preferred by the NAMI affiliates in the NorthSTAR area and widely supported by the stakeholders in that community.  The only reasons given for the possible discontinuation of this model are to make the system uniform across the state, which NAMI Texas does not support due to the diverse needs and resources in different areas of the state, and to make data collection and comparison simpler.  NAMI Texas believes that comparison of outcome measures, which would give a clearer picture of efficacy and quality than some measures currently employed, would be possible across multiple systems.

In addition to the concerns about the carve-in model as detailed by the PCG report, NAMI Texas has additional concerns about a carve-in model as presented in the Texas Council Proposal.

The Texas Council’s carve-in model includes the LMHA’s retaining both the authority and provider roles, which presents an inherent conflict of interest that would not be workable in an HMO carve-in model with multiple providers.  There would not be a level playing field among competing providers if one of them was also the LMHA.  The HMO would be put in the position of contracting with a provider that also served as the authority that had the role of oversight of its activities. 

At the Texas Council’s presentation on its model hosted by the Hogg Foundation on 10-30-12, the Council indicated that the LMHAs would only retain what are essentially the administrative functions of the authorities: 

  • Local planning
  • Manage and provide services for people who are medically indigent
  • Secure local funds
  • Manage crisis response
  • Linkage and provision of supportive housing
  • Interface with criminal justice
  • Facilitate benefit eligibility
  • Assist with access to covered services
  • Coordinate essential services across systems
  • Educate the public
  • Disaster response

(List of responsibilities the LMHAs would maintain is taken from slides presented by the Texas Council 10-30-12 at the meeting at the Hogg Foundation)

This would leave local areas with no real authority over the HMOs in planning program changes or overseeing contracts with providers, which would all rest at the state level through either HHSC or DSHS. 

If the LMHAs remain the authorities, they should not be the entities to assess members for eligibility for the Special Category to receive the full array of mental health services.  Either all contracted full service providers should be able to assess or there should be an independent assessment entity to ensure fair distribution of patients by patient choice or some other mechanism if the patient did not have a preference.

The Texas Council proposal suggests that any eligible provider would need to go through the onerous DSHS certification process before being eligible to be contracted with by the HMO to provide psychosocial rehabilitation or case management services.  Only one independent (non community center) provider has managed to achieve that certification, and that certification was frozen so that HHSC could pursue a 1915b waiver to restrict contracting for rehab and case management to the LMHAs.  Maintaining the need for providers to achieve that certification would needlessly restrict competition and consumer choice.  HMOs follow nationally accepted credentialing practices that adequately vet providers to ensure their ability to provide the services for which they are contracted.  DSHS and the Texas Council indicated at the meeting at the Hogg Foundation that a new certification process would be put in place.  It is not possible to judge before that process is in place whether or not it would prove a barrier to competition among providers.

NAMI Texas agrees with the Texas Council proposal that SPMI members have a medical home, but believes that the medical home for persons with serious and persistent mental illness should be the mental health provider rather than allowing for a choice of FQHCs, medical clinics, or primary care settings.  Providing other medical care at the mental health care setting is preferable for persons with SPMI.

NAMI Texas agrees with the Texas Council’s proposal that DSHS have a role in oversight of the carve-in mental health portion of the program if this model is implemented

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