Latest / The Mental Health Evolution / Ep 7: Policy Shifts Reshaping Mental Health Care with Cathy Gilbert

Transcript

Ep 7: Policy Shifts Reshaping Mental Health Care with Cathy Gilbert · The Mental Health Evolution

• 0:00
  (Transcribed by TurboScribe. Go Unlimited to remove this message.) This podcast is part of the Frederick Podcast Network.
• 0:03
  Learn more at listenfrederick.com.
• 0:05
  Welcome to Mental Health Evolution, a podcast about what's changing in mental
• 0:10
  health and why it matters.
• 0:12
  I'm your host, Rachel Harrison, inviting you into honest conversations with
• 0:16
  people from all perspectives in the field, clinicians, tech founders,
• 0:20
  investors, insurance companies, and all the folks in between.
• 0:24
  Let's explore what's working, what's not, and what's next.
• 0:29
  Hello, everyone.
• 0:31
  Welcome back to the Mental Health Evolution podcast, where we are talking
• 0:36
  today about how policy is impacting mental health services, how they're
• 0:41
  provided, as well as system changes and requirements for different care models.
• 0:46
  Our guest today, Kathy Gilbert, currently works as a consultant to providers,
• 0:50
  but she has a history of working in big insurance groups, working
• 0:54
  with provider network development and operations.
• 0:57
  She has done a lot of research into different policies that are
• 1:01
  currently impacting our field, and we are going to dive more into
• 1:05
  that today.
• 1:06
  So I'd like to highlight some information to get us started thinking
• 1:10
  on this.
• 1:10
  One of the big policies that will impact the conversation today is
• 1:14
  the Big Beautiful Bill Act.
• 1:16
  This is known to be making cuts to Medicaid, to SNAP, and
• 1:21
  to Affordability Care Act, offering lower cost healthcare options to many
• 1:25
  Americans.
• 1:26
  And NAMI, the National Alliance for Mental Illness, released this about the
• 1:32
  bill.
• 1:32
  Their statement was that they are cutting Medicaid for millions of Americans,
• 1:37
  and they say they're concerned about the mental health care that will
• 1:40
  not be afforded to millions of people with this bill and will
• 1:44
  have a far-reaching impact.
• 1:45
  But we're going to dig into that a little bit more.
• 1:48
  And before this bill, there were also some other policies, and we
• 1:52
  might dig into these as well, that 2026 would dissolve the Substance
• 1:57
  Abuse and Mental Health Services Administration, also known as SAMHSA, and the
• 2:02
  Health Resources and Service Administration, or HRSA, consolidating them into a
• 2:07
  new administration for a healthy America, as well as additional federal actions
• 2:13
  impacting access to mental health care included reduced funding for LGBTQ+,
• 2:18
  crisis services through 988 Suicide and Crisis Lifeline, halting the $1 billion
• 2:24
  in school mental health professional grants by the Department of Education,
• 2:29
  citing civil rights concerns.
• 2:31
  And all of this was documented from the APA, which is the
• 2:35
  American Psychological Association article titled, New and Proposed Policies
• 2:40
  Affecting Access to Mental Health Care.
• 2:43
  So that's going to be our focus today, is looking at these
• 2:46
  policies, looking at how they are going to specifically impact mental health
• 2:52
  care, and getting some of Kathy's expertise on this.
• 2:56
  So, Kathy, I just want to say thank you so much for
• 2:59
  being here.
• 2:59
  Oh, nice to be here, Rachel.
• 3:01
  Looking forward to the discussion.
• 3:02
  Awesome.
• 3:03
  So let's dig in.
• 3:04
  First, I just want to say all of these changes seem to
• 3:08
  be moving really fast.
• 3:10
  I'm wondering from your perspective, is that just how it feels?
• 3:14
  Or are things actually moving at a faster pace than they have
• 3:18
  previously in terms of policy changes for our industry?
• 3:22
  I think with the big beautiful bill, things are moving really fast.
• 3:27
  So for example, I'll be dating myself, but I did my master's
• 3:31
  thesis on national health care in the U.S. in the 90s
• 3:35
  during the Clinton administration.
• 3:37
  We finally got it in the 2000 teens under the Obama administration.
• 3:43
  So nearly 20 years later.
• 3:45
  So it took 20 years for that change when that discussion started,
• 3:50
  even before that, really.
• 3:51
  And it felt like ACA wasn't perfect, but it had a lot
• 3:55
  of the elements that helped us get to where we needed to
• 3:58
  be.
• 3:58
  So yes, and now with some of the changes aren't immediate, but
• 4:03
  things seem to be moving extremely fast because, especially in behavioral
• 4:07
  health, change is slow.
• 4:09
  It takes a long time.
• 4:12
  So yeah, this does feel a lot faster, and I don't think
• 4:16
  it's still settled yet on how fast some of these changes are
• 4:19
  going to happen.
• 4:20
  So with that, I would love to hear your perspective.
• 4:23
  How are you looking at these various policies?
• 4:25
  What do you see as the big things that we need to
• 4:28
  be looking at and addressing in the mental health industry?
• 4:32
  Oh, one of it is part of it is more general.
• 4:34
  I see it as just the number of sheer numbers of people
• 4:37
  losing health care coverage over the next 10 years based on the
• 4:41
  bill.
• 4:41
  That's huge.
• 4:42
  A lot of those that lose coverage, I think, will be individuals
• 4:46
  with mental health challenges.
• 4:48
  So because of the work requirement and when you think about this
• 4:52
  in perspective, something else that's happening in the administration is the
• 4:56
  dismantling of the Department of Education, which funds training programs for
• 5:00
  persons with disabilities who now have a work requirement, but the training
• 5:03
  programs may not be there any longer.
• 5:05
  So I think it's even broader than what people are realizing right
• 5:10
  now.
• 5:10
  So that's part of what we have to think about.
• 5:13
  Plus, in the mental health world, for people under ACA coverage or
• 5:18
  Medicare or Medicaid, all three of those are significantly impacted by this
• 5:24
  bill.
• 5:24
  Those are usually our most vulnerable populations, the people that could use
• 5:28
  the additional supports.
• 5:30
  So if they're losing coverage, programs are curtailed, not just in mental
• 5:34
  health, though that population is going to struggle even more.
• 5:38
  So looking for innovative ways to continue to deliver those services, make
• 5:44
  sure people have the right supports and keep it and try to
• 5:47
  keep those support systems, those safety net systems intact.
• 5:52
  I mean, and that's when you think about the whole perspective.
• 5:54
  That's my big concern.
• 5:56
  Well, yeah, but but I think about providers with that, whether it's
• 6:01
  a nonprofit organization, right, that might also be losing grant funding or
• 6:06
  whether it's a practice, a medical practice.
• 6:08
  Those typically aren't people that have the means to pick up the
• 6:13
  slack here, right?
• 6:14
  Or provide services for free or low cost, even, I mean, right.
• 6:19
  Yeah, right.
• 6:20
  Yeah.
• 6:20
  Because the other concern is how are states going to be able
• 6:23
  to manage the cuts in what the federal government portion on the
• 6:26
  Medicaid dollar?
• 6:27
  It's a pretty significant portion for most states of what dollars come
• 6:32
  from the federal versus the state match to fund the Medicaid safety
• 6:36
  net programs.
• 6:37
  I'm concerned that there will be rate reductions and how providers are
• 6:41
  reimbursed, not a total loss, but rate reduction.
• 6:44
  So will they be able to cover costs in mental health?
• 6:47
  The other thing I worry about is, you know, mental health in
• 6:51
  that in the medical world, in the health care world has been
• 6:54
  one of the lowest reimbursed areas historically.
• 6:57
  It has not kept up with other specialties.
• 7:00
  And if those rates are reduced yet again, that's not sustainable.
• 7:04
  Where do you think the rate reduction is going to come from?
• 7:07
  I think it's got to be a combination.
• 7:08
  There's a lot of a combination of public and private dollars, which
• 7:12
  is, you know, kind of where I see I want a combination
• 7:15
  of looking at the legislation and being able to understand it.
• 7:19
  I get really concerned about this.
• 7:22
  It feels like almost a slash and burn mentality instead of really
• 7:25
  looking and evaluating programs specifically and looking how to improve those.
• 7:31
  I mean, honestly, everybody in the health care world has concerns about,
• 7:35
  you know, broad waste and abuse, which is part of what they
• 7:37
  were trying to get at with some of the requirements they put
• 7:39
  in.
• 7:40
  Yeah.
• 7:41
  But 99.9% of people that go into behavioral health in
• 7:46
  the health care world aren't going into it for the money.
• 7:49
  No, they're going into it because they care.
• 7:52
  And so when they talk about all the slash and burn because
• 7:55
  they're going to save because people are abusing the system, I'm like,
• 7:58
  where are you seeing that?
• 7:59
  It's so small comparatively.
• 8:01
  So, yeah, I'm not sure.
• 8:03
  There's so much that remains to be seen on these on all
• 8:07
  the pieces of this bill.
• 8:09
  It's like they cancel, like I said, they canceled, you know, they're
• 8:13
  cutting this and required work.
• 8:14
  They're also cutting the training programs.
• 8:17
  OK, does that work when you have individuals who need support?
• 8:20
  And that's a large group of the mental health.
• 8:23
  My husband actually was a vocational rehab counselor.
• 8:25
  He's since retired and he worked with that population, helping them get
• 8:30
  jobs.
• 8:30
  That program that he worked in was funded through the Department of
• 8:33
  Education.
• 8:34
  And he worked with individuals with disabilities to help them get jobs,
• 8:38
  many of them with mental health challenges.
• 8:41
  Yeah, I hear you that it's going to have a bigger impact
• 8:43
  than just what we see.
• 8:45
  Yes, people are using losing medical coverage.
• 8:48
  And what else does that impact?
• 8:51
  I even think about, you know, society impact, right?
• 8:54
  If people are getting support with mental health concerns and able to
• 8:58
  walk into a clinic or whatnot, that that prevents a lot of
• 9:03
  maybe maladaptive behaviors or other places where that's going to come out
• 9:08
  and affect our communities.
• 9:10
  So I'd like to talk about your consulting work.
• 9:14
  What types of clients do you work with?
• 9:16
  And I'm curious what you're seeing with them with this policy.
• 9:20
  Like what kind of conversations are you having?
• 9:23
  What are you telling people that they should be thinking about?
• 9:26
  What does that look like?
• 9:28
  Well, I work with a lot of clients in the digital health
• 9:31
  space.
• 9:32
  So either virtual care or hybrid, which they also may offer in
• 9:36
  -person care in some markets.
• 9:39
  So a combination of those and plus a couple more traditional behavioral
• 9:43
  health settings.
• 9:44
  Most of my clients are in some way tied to behavioral health.
• 9:47
  So I have a few that are, you know, more in the
• 9:50
  allied therapies, though occasionally something different, but for the most
• 9:56
  part in behavioral health, which is where my career has been is
• 10:00
  primarily behavioral health.
• 10:01
  I started out as a social worker.
• 10:03
  So I had that going all the way back to early career.
• 10:06
  I didn't know that.
• 10:07
  Yeah, that's cool.
• 10:09
  So and what I'm telling them, one of the things there is
• 10:12
  a piece of the legislation that actually is good for virtual care
• 10:17
  providers.
• 10:18
  And it could be good because that may be where some things
• 10:21
  move so that people can have affordable and health insurance coverage is
• 10:25
  there was a provision during COVID that waived allowed health plans or
• 10:31
  employ self-employed employ self-insured employer groups to allow virtual care
• 10:38
  or telehealth to be covered without having to meet the deductible and
• 10:42
  or pay the co-insurance co-pay could be waived for telehealth
• 10:47
  visits.
• 10:48
  They love to deal with preventative care and they waive that.
• 10:50
  There is a provision in the Big Bad and Beautiful Bill that
• 10:55
  does make that permanent that allows benefits to not require deductible to
• 11:02
  be met to pay for virtual care visits.
• 11:06
  So in all of that, there's a positive.
• 11:08
  Yeah.
• 11:09
  I was trying to find some.
• 11:10
  So that's good.
• 11:12
  But there's another issue that's not addressed in that bill or that
• 11:17
  act now that there's a requirement in mental health and substance use
• 11:22
  for an in-person visit every six months or a year when
• 11:26
  implementing telehealth that expires September 30th.
• 11:29
  Congress has not acted to change that yet.
• 11:32
  So that come but you need you kind of need both.
• 11:35
  You kind of do.
• 11:36
  So we're waiting to hear on that other piece, but it is
• 11:40
  good, especially for individuals that have those high deductible plans, which a
• 11:44
  lot of companies have gone to to make at some insurance affordable
• 11:48
  to members.
• 11:49
  So that's one piece of maybe good in the legislation.
• 11:53
  And since I work with a lot of digital providers, that's we're
• 11:57
  excited about that piece.
• 11:58
  That's good news because some of those are programs and programmatic where
• 12:04
  their payment structure is for a program and somebody with a high
• 12:07
  deductible health plan, those high deductible health plans have deductibles of
• 12:11
  $2,500 to $5,000.
• 12:13
  So if you're going for care, it's a lot unless you have
• 12:17
  something nature.
• 12:18
  It's a long time to your health plan kicks in.
• 12:20
  That is a long time.
• 12:22
  So, yeah, when you think about in perspective, I mean, it's across
• 12:26
  all health services that you see, but still that's that's a big
• 12:31
  deductible.
• 12:32
  And it allows for more services to be paid out of health
• 12:35
  savings accounts.
• 12:36
  So without impacting health savings accounts.
• 12:39
  So seems like a positive for employers and employees with with coverage
• 12:43
  and having that covered basically from day one.
• 12:47
  Anything that you think is important for solo and group practice owners
• 12:52
  to be aware of?
• 12:53
  Maybe, you know, you're talking about working with a lot of virtual
• 12:57
  folks, but even folks that are seeing clients day to day, what
• 13:01
  are your thoughts for them?
• 13:03
  You know, they need to just be aware of monitoring coverage, especially
• 13:08
  if they participate with Medicaid and ACA plans that to be aware
• 13:14
  and maybe support their their patients in that recertification and reminding
• 13:20
  them and helping them to maintain their coverage.
• 13:23
  I mean, that's one piece.
• 13:24
  Also to monitor for watch for changes and how coverage changes, because
• 13:30
  I think benefit plans are going to change a little bit.
• 13:32
  So monitoring for what services are covered.
• 13:36
  I think basic mental health services and the standard codes are going
• 13:39
  to continue to be covered.
• 13:41
  But one of the things I noticed is there's a mandate under
• 13:45
  a number of the ACA plans for a minimum level of copayment
• 13:50
  elections.
• 13:51
  I think it was something like thirty five dollars.
• 13:53
  So copayments may change.
• 13:55
  There may actually be times when you were used to there being
• 13:57
  no copayment.
• 13:58
  Now there's a copayment.
• 13:59
  So really being aware, continuing your eligibility checks and benefit
• 14:04
  verifications, most of those are electronic and sometimes it's hard to keep
• 14:08
  track of.
• 14:08
  But just keep re verifying that I think is going to be
• 14:11
  really important.
• 14:12
  The other thing I noticed, which I think is critical, especially if
• 14:17
  they participate with some of the Medicaid plans, they used to be
• 14:21
  that for Medicaid in most states, when people were getting enrolled, they
• 14:25
  they could retroactive up to three months.
• 14:29
  Coverage.
• 14:29
  They've reduced that to one month in that bill.
• 14:32
  So when you're used to as people are in, you know, getting
• 14:36
  enrolled in Medicaid, especially if that's a population that you see, you
• 14:40
  know, if somebody is applied, they would retroactive it and it takes
• 14:43
  them time to process.
• 14:44
  So sometimes that three months gave them time to get it processed
• 14:47
  and they retroactive it back to the application date.
• 14:50
  Now they're only going to be able to go back a month.
• 14:51
  Yeah.
• 14:52
  Which can make a difference, a significant difference.
• 14:55
  Because I'm concerned about application processing taking longer with the and
• 15:00
  that would also impact those redeterminations of eligibility every six months.
• 15:06
  Those get delayed.
• 15:07
  Somebody could lose coverage.
• 15:08
  It could take a while.
• 15:09
  Then they they would only be able to retroactive it back a
• 15:12
  month to be in state coverage.
• 15:13
  Yeah.
• 15:14
  Potentially.
• 15:14
  What is your recommendation for how often to check for eligibility?
• 15:19
  And if there are changes?
• 15:21
  I mean, you should ask the patient at every visit.
• 15:24
  And I think that's pretty standard.
• 15:25
  But I would almost check monthly just to, you know, make sure
• 15:29
  nothing changes.
• 15:30
  And that's about how often things kind of change on a Medicaid
• 15:32
  roll.
• 15:33
  And even if somebody is employed and changes jobs, usually it's covered
• 15:37
  till the end of the month.
• 15:39
  Oh, that's true.
• 15:40
  That's true.
• 15:41
  So figuring out a way to kind of do some re-verification,
• 15:45
  you know, on a regular basis.
• 15:46
  That's good.
• 15:47
  That's good, concrete advice.
• 15:49
  I like that.
• 15:50
  So you're not backpedaling or caught unaware or those kinds of things.
• 15:56
  Right.
• 15:56
  Because, you know, those individuals may be individuals that aren't going to
• 15:59
  be able to pay that bill.
• 16:01
  Right.
• 16:02
  So, I mean, that's, you know, that that would be one of
• 16:06
  the things I would really look at.
• 16:07
  And, you know, I'm also concerned about from the health plan perspective,
• 16:11
  them being able to maintain networks because if you're in a month
• 16:14
  where you can stay with just commercial and private insurance or private
• 16:18
  pay, it's going to even make access more challenging for those individuals
• 16:21
  that don't have that available to them.
• 16:23
  Yeah, I see that too.
• 16:25
  Definitely makes all of that challenging.
• 16:28
  We are about out of time for this episode.
• 16:31
  And I'm wondering if you could highlight one critical piece of information
• 16:36
  for people to know.
• 16:38
  What would be your top line policy takeaway that folks should know
• 16:43
  about?
• 16:44
  Oh, there's so many points.
• 16:45
  No, I'm asking a hard question.
• 16:49
  Yeah, it's really to pay attention to what the changes are.
• 16:54
  Watch those communications from the health plans you participate with.
• 16:58
  So because they're going to be telling you how they are implementing
• 17:01
  the requirements of the changes.
• 17:04
  So my takeaway from all of it, as things settle out and
• 17:07
  health plans figure out what's going on and even the state Medicaid
• 17:12
  associations really watch for those notices.
• 17:17
  Not just what's in the news, but watching for those direct notices
• 17:20
  that plans do send out.
• 17:21
  And I know it's easy to ignore those because you can get
• 17:24
  bombarded.
• 17:25
  But I think in this time of fast change, especially for small
• 17:30
  individual and group practices, really pay attention to those notices as things
• 17:34
  are settling and they'll tell you what's changes are coming and coverage
• 17:38
  and how they're because it could change some processes.
• 17:41
  It could change, could mean rate changes, could mean a whole variety
• 17:46
  of things.
• 17:46
  So I think when things are moving this fast, it's really critical
• 17:50
  to watch for those notices or try to monitor the payer websites
• 17:54
  because that's where they're going to put stuff.
• 17:56
  I love that.
• 17:57
  That would be my...
• 17:58
  I do.
• 17:59
  Yeah, because with information, we can make better decisions.
• 18:04
  So that's great.
• 18:06
  Right.
• 18:06
  Because you don't know exactly.
• 18:08
  It's going to be...
• 18:09
  Medicaid is going to be slightly different in each state.
• 18:11
  Each state's impacted differently and health plan changes.
• 18:15
  Each plan is going to have to figure out how they're going
• 18:17
  to account for the changes.
• 18:20
  I mean, Elevance and Centene in the last week have come out
• 18:23
  with the restatement of earnings.
• 18:25
  I'm sure it's coming from United.
• 18:26
  It's going to be coming from all the major players who are
• 18:29
  involved in ACA, Medicare and Medicaid, which all of the major players
• 18:34
  are.
• 18:34
  Yeah.
• 18:35
  Yeah.
• 18:36
  Well, Kathy, thank you so much for being here and sharing in
• 18:39
  this conversation about policy changes for the mental health industry.
• 18:43
  Your perspective has been awesome.
• 18:45
  And thanks for the concrete takeaways, too.
• 18:48
  So we will wrap up this episode and we'll hope to hear
• 18:52
  you back next time.
• 18:56
  Thanks for listening to the Mental Health Evolution podcast.
• 19:00
  Join the conversation.
• 19:01
  Find us on socials, send us your thoughts and tell us what
• 19:04
  you're seeing in your corner of the mental health world.
• 19:07
  Until next time, stay curious and keep evolving.
• 19:15
  Live radio, local podcasts, the Frederick Podcast Network and listenfrederick
• 19:19
  .com.