Historically, behavioral health treatment has been viewed more so a social service than specialty healthcare. There were limited agencies across the state that provided access, funding was limited, and somewhere between the cloak of 42 CFR Part 2 and the rooms steeped in anonymity we didn’t have a ton of good outcomes data to back us up. As a field, we were just doing what we felt was the right thing; you know “keeping what we had, by giving it away” – sometimes literally.
In 2018 the field saw the single largest change it had ever undergone, the behavioral health redesign. The traditional healthcare and behavioral healthcare budgets were merged at the state Medicaid level. Clinicians were tasked with demonstrating medical necessity to justify client placement in certain programs. We were all introduced to managed care organizations (MCO’s) presenting multiple different processes and preferences for prior authorizations, standards of care, and reimbursement for services rendered. In short, one day we woke up and went to work in a totally different environment – and we weren’t playing on Rookie mode anymore – this was ALL MADDEN level stuff.
Collectively, the field was shaken. Reimbursement rates were down. Denials were up. The CEO of one MCO went as far to say that he was having daily conversations with providers to discuss strategies to keep their doors open. Numerous high level professionals in the field thought that this would be the end of the small behavioral health agency.
However, some changes happened. Medicaid stepped in. Some money shook loose. We learned what the new MCO’s wanted to see. We got better at demonstrating the need for treatment for the individuals in our programs. And – the problem kept going. 2018 saw a record number of overdose deaths in Ohio. Only to be topped in 2019. Only to be topped in 2020. Only to be topped in 2021.
You can’t have the helpers shutting up shop in the middle of the largest, most invasive, deadliest behavioral health crisis in the nation’s history. But not only did no one close; the opposite happened – there was a boom.
In 2020, the city of Portsmouth put a moratorium in effect that halted the establishment of any additional treatment centers within the corporation limits due to the oversaturation of substance use treatment facilities in the area. While the city may be attempting to standardize and streamline the process for founding and operating a substance use disorder (SUD) treatment facility in Portsmouth, the current moratorium is short sighted. What if the Betty Ford Clinic wanted to come to town? What about the treatment centers that are already here and not operating under the highest level of accrediting supervision? And other than waiting for feedback about zoning updates – what is really being done to create a standard for what high quality behavioral health treatment we expect from local providers?
Below is a list of some things that can be helpful in making your own informed decision about the quality, efficacy, and sustainability of a behavioral health treatment provider.
NON PROFIT v. FOR PROFIT
While it is not the tale tell sign of a reputable agency, a good place to start is identifying the nature of a treatment agency and its profit status. Is the agency mission driven or monetarily focused? While a non-profit business is still a business, it isn’t focused in maximizing profit for personal gain. With that being said, not all non-profits are good, and not all for profits are bad.
Some good differentiation questions to discern war profiteers from individuals who wanted to lend a helping hand to their local and regional fellows, and found that starting an LLC was the quickest way to get in the game:
Who is the owner, and where do they live? Columbus? New York? If the owner is not a local person that has a vested interest in the community, what is their interest here? Does the for-profit agency only offer services with high return and profit margin?
In the field, we know that a large portion of the services, clinical and otherwise, that clients need to be successful in recovery are not fiscally advantageous – some examples: providing child care, transportation services, employment tracks, transitional living programs, and primary healthcare.
On the flip side, what are some questions that can be posed to identify a non-profit agency that is truly dedicated to fulfilling their mission? Some thoughts below:
Who is on the board of directors? What is the incentive for individuals to join said board? When profits are realized, what happens to that money? What are the objective differences between a non-profit CEO and a for-profit owner?
While the market might be flooded with agencies, the workforce is in staunch competition for high level licensed staff – that can be few and far between in a rural area.
Clinical supervisors are responsible for making sure licensed and credentialed staff are operating within their scope of practice, meeting documentation requirements regarding content and timeframe, and are there to offer guidance in navigating difficult client situations and circumstances.
Clinical supervision is the foundation of a solid treatment program, and describing it as a “full time job” would be an understatement. With that being said, not all clinical supervision situations are created equally. Some clinical supervisors send very little time with their agency; perhaps as a contractor, or a contractor for multiple agencies.
What are the implications on the quality of care and outcomes for clients being served by treatment providers who do not have full time access to full-time clinical supervision by an appropriately licensed staff?
CONTINUUM OF CARE
We briefly touched on some service offerings in the for-profit v. non-profit section. As mentioned, some behavioral health services have a high reimbursement rate, low overhead cost, or are cost effective when operated in a certain manner. On the other side of that coin, there are some services and program offerings that are break even at best. Unfortunately for the bottom line, operating a comprehensive
continuum of care doesn’t bode well to financial success. BUT – for the client population to come in and have successful outcomes, offering appropriate services across all levels of care is of the utmost importance.
What if you walked into an oncologist, in need of a surgery, radiation and chemotherapy protocol, and all-inclusive follow up care… to be told that you are in – they’re going to take care of you, BUT all they do is radiation?
You’d leave. You wouldn’t enroll as a patient there. You’d find another provider.
In behavioral health treatment, we see this anomaly. Programs that offer a single level of care, with no internal resource or plan for aftercare. Residential treatment with no transitional living opportunities or developments, no outpatient aftercare, and no integrated primary health follow ups.
A quality treatment provider is going to be able to offer multiple parts of the continuum to support client success. A quality treatment provider is going to offer some level of residential treatment, partial hospitalization and/or intensive outpatient programming, and the option for long term, individualized aftercare.
Shouldn’t there be someone keeping an eye on all this anyway? You wouldn’t go to an oncologist that only offered radiation, just like you wouldn’t go to a hospital that wasn’t accredited by the joint commission.
In the heart of it all (O-H…), the Department of Mental Health and Addictions Services (OMHAS) is responsible for accrediting and overseeing all behavioral health treatment providers in the state. For them, there are two initiatives: access and quality. At this point, with an issue as pervasive as the opioid epidemic and subsequent overdose crisis – access reigns supreme. Though, OMHAS isn’t the only accrediting body that has jurisdictions to add oversight and validity.
The Commission on Accreditation of Rehabilitation Facilities (CARF) is an international, non-profit entity focused on quality metrics in behavioral health. CARF is the gold standard in behavioral health treatment endorsement. While there is a costly application process and extensive investigations to certify and recertify, agencies invested in holding their quality to the highest standard will invest in that mission. Locally, CARF certifications are limited: Ascend, Shawnee Family Health Care, and The Counseling Center – ironically, all non-profit agencies.
While state and international certifications are cool – it also may be important to look a little closer to home for a nod of approval. Across the state, Alcohol Drug Addiction and Mental Health Services boards (ADAMHS) operate, procuring funds and stewarding them to local, reputable agencies. In addition to large scale OMHAS and CARF accreditations, another attribute of a quality treatment provider is their contract status and relationship with their local ADAMHS board.
The opioid epidemic has been raging in our area for over two decades at this point. As if it wasn’t bad enough, the isolation that kept us sheltered from larger COVID outbreaks negatively impacted
individuals with substance use and mental health disorders. Anxiety, depression, and overdose deaths are on the rise.
Rather than wishing away the problem, or that things were different in regards to the methodology or presence of treatment facilities in our area – I encourage you to continue to do you research, have conversations about your expectations of treatment facilities, and working with local stakeholders to maintain the highest quality of care possible for our region.
This writer’s opinion is their own and not the opinion of this newspaper
Max Liles is the Senior Director of The Counseling Center, INC. He can be reached at 740-357-7693 or visit www.thecounselingcenter.org.