[T]he Department of Vermont Health Access will cut in half the amount that Medicaid pays for group therapy sessions starting next year. Many of the state’s most vulnerable patients will be negatively impacted, according to clinicians and advocates.
Group therapy is a less expensive and clinically effective treatment option for people dealing with substance abuse problems, mental or behavioral health problems. It is also used to help abuse or trauma victims, sex offenders and troubled youths, experts say.
In addition to the payments being halved in January, the length of therapy sessions that can be billed to Medicaid was shortened in July. That could lead social service agencies and private practices to reduce or eliminate group therapy programs.
“Clinically, (cutting group programs) is a terrible idea. Financially, it might be our only option,” said Margaret Joyal, director of outpatient services for Washington County Mental Health Services.
State officials say the decision was necessary to comply with federal regulations and intense pressures on Vermont’s Medicaid budget.
Gov. Peter Shumlin has directed all state agencies and departments to level-fund their budgets and look for savings where they can. At the same time, Vermont’s Medicaid program is facing an estimated $40 million budget shortfall.
“The cut was based on money,” DVHA Commissioner Steven Costantino said in an interview Thursday. The greatest pressure on Medicaid’s budget is increased caseload, he said. Eligibility for the program was expanded as part of the Affordable Care Act, and now roughly one-third of low-income Vermonters receive some form of Medicaid.
Medicaid’s payment rates for group therapy dropped from $61 per patient for a 90-minute session to $41 for a one-hour session in July. Starting in January, the rate will be $20.50 for one-hour sessions. The cut will save the Medicaid program an estimated $1 million next year.
Costantino said the reduced rate puts Vermont more in line with other New England states, citing Connecticut’s $21 rate as an example. He was not aware if group therapy programs in Connecticut have more patients than those in Vermont, and whether that impacts the need for higher payments.
The state and health care providers face tremendous challenges in ensuring the sustainability of Medicaid, he said.
Costantino said DVHA is working to ensure that changes are based on sound clinical choices.
The cost of cuts
Washington County Mental Health offers several group therapy programs that meet weekly and typically draw four to 10 participants. There are two trauma treatment groups; a men’s group for newly released inmates; a recovery group for women with co-occurring trauma and substance abuse issues; and general wellness programs focused on cooking, yoga and mindfulness activities that support recovery.
“I don’t know what we’re going to do,” Joyal said. Many group programs are drop-in sessions, and they’re frequently the quickest way to get people who are struggling into therapy. That’s especially true in rural areas where there is a lack of therapists, experts say.
Rick Barnett, a private practice psychologist in Stowe and past president of the Vermont Psychological Association, said he has already heard from independent psychologists who won’t offer group therapy once the rates are reduced in January.
Barnett, who has run group therapy sessions for people with drug and alcohol problems, said the reduced rates are absurd given the state’s focus on addiction treatment.
Sex offenders are required to enter group therapy upon release from corrections, Barnett said, and he wonders what will happen to those clients once the cuts have gone into effect.
“That Medicaid would decimate this primary treatment modality seems unconscionable,” he said.
DVHA will monitor the impact of the rate change, and the cut could be revisited if it reduces access to group therapy, he said.
Hour-and-a-half sessions that were previously billed to Medicaid in 15 minute blocks must now be billed in one-hour segments. That was required to comply with federal regulations that date back to 2013, according to Aaron French, DVHA deputy commissioner for Health Services and Managed Care.
Joyal, of WCMH, says there’s no clinical basis for the change, and that it actually goes against established best practices, especially for trauma survivors.
French said he reviewed the medical literature with DVHA’s chief medical officer.
“It can still be done in an hour,” French said. “There’s nothing that indicates that a group (session) has to be an hour-and-a-half to be effective.”
If therapists holding group sessions feel that an hour-and-a-half is important to clients, they should continue to offer that service on their own time. Medicaid, however, will only pay for an hour, he said.
Medicaid payments are set using a “mathematical formula” based on “utilization, physician effort,” and the “direct and indirect cost” of each service, according to a recent memo from DVHA to Medicaid providers. Payments also take into account “the amount of legislatively allocated, aggregate dollars available to reimburse for professional services.”
Erasing the Medicaid rate increase
Ken Libertoff, a 30-year veteran of mental health advocacy, wrote a letter to the Green Mountain Care Board, urging the members of the quasi-judicial body to maintain group therapy rates at the current level.
Libertoff wrote that DVHA will rely on “the general theme that they are trying to ‘update’ group psychotherapy codes” to be in compliance, and while he’s not an expert on medical coding, he can say with conviction that Medicaid beneficiaries will lose access to group therapy because of the cut.
“It will cause practitioners to reduce or abandon this treatment modality, not because it is ineffective or costly but because the state (DVHA) is nearsighted and looking little beyond an end line,” he writes.
Julie Tessler, executive director of Vermont Care Partners, said a 0.2 percent aggregate increase in Medicaid rates for designated agencies and other community health providers approved by the Legislature this year will be all but wiped out by the reduction to group therapy rates. Vermont Care Partners is a trade group that represents Vermont’s 11 designated agencies, which are social service nonprofits with exclusive state contracts to provide care for a region.
The 0.2 percent increase amounted to $970,000, while the group therapy rate cut is expected to cost providers a combined $1 million (some providers affected by the cut weren’t receiving the 0.2 percent increase).
The irony, according to Washington County’s Joyal, is that the Department of Mental Health, which works closely with the designated agencies, spent years encouraging organizations like hers to increase their group therapy offerings — because of their low cost and excellent results.
From her office, a stone’s throw from the emergency department at Central Vermont Medical Center, Joyal said underfunding group therapy will put even more pressure on hospitals and inpatient psychiatric facilities.
Many patients already spent protracted stays in hospital emergency departments waiting for inpatient placements. The nearby Vermont Psychiatric Care Hospital is not running at capacity.
Without the programs to keep people from going into crisis, Joyal said, the hospital and inpatient mental health system is likely to see even greater demand.
