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What’s keeping us up at night? Quality standards for essential benefits

November 30, 2012

Network faithful, we need to have a heart to heart about the essential benefits packages states are required to set up as part of health reform. There is an elephant in the room and it’s a big one, and it goes by the name of “quality.” We are gravely concerned that attention to quality in the provision of mental health services to children and families runs the risk of being stripped to its bare bones as states move forward with designing and implementing their essential benefits packages.

Consider what is taking place with the rules and regulations for health care reform. Most of the action (and decisions for what gets funded in the essential benefits package) will come from the states. Like most things in life, the rule of thirds will probably apply to state benefit packages. Some will be minimal, some will be okay, and some will be stellar. So let’s say that a state like California decides it wants to develop a stellar exchange benefits package. If California decides to cover more intensive services, will they be allowed to draw down additional dollars if they go above and beyond? If we as a nation say we want to strive for the “gold standard” in health care then there needs to be clear guidance and support for doing so. If states are not allowed to draw down federal financial participation dollars for supplemental activities then we are absolutely crippling innovation. States need to be able to support a gold standard should they choose to do so.

States need to be able to supplement essential benefits
If the essential benefits package is the vehicle for ensuring that people with get what they need, such as appropriate mental health services, etc., how can we ensure that what is provided is a quality service? What are needed are clear standards for how states can supplement the essential benefits standards in order to be able to provide quality services that go above and beyond traditional care. Here at the Network we are concerned that what will be covered will be the typical outpatient or inpatient care, which has its place but is not, and should not, be the only “tool in the work shed.” This is a huge problem for families who have children with serious emotional challenges.

Twenty years of research with the Child Mental Health Initiative tells us that if you want to truly effect change for children with serious emotional challenges you need to go beyond traditional inpatient and outpatient services. But here is the kicker – to our knowledge (it would be so exciting to be corrected on this) there are no actual standards for how states can supplement essential benefits standards to be able to pay for services that go beyond the traditional, and our grave concern is that states will end up taking a short-sighted, and what appears at first blush, to be a cost saving approach and provide what is minimally acceptable as defined in the essential benefits package. There is plenty of research that shows the lack of wisdom in providing what is minimally acceptable, folks…

Establish quality standards
We need to raise our voices and encourage HHS to set quality standards for how states can supplement essential benefits to be able to pay for proven successful services and supports that save money in the long run and keep kids in the community. Children with serious emotional challenges and their families deserve nothing less. Here are just a few examples of the types of services we are talking about:

  • Intensive home services
  • Mobile crisis services
  • Respite care
  • Parent Support Provider services
  • Substance abuse treatment – for example, a mother needing services who has young children

Monitor progress
In the essential benefits regulatory language it is clear that states are responsible for monitoring their progress through the creation of an oversight process. But what happens if they don’t do it? Or worse, say they are doing it, but in reality are only going through the motions? How will the federal government make sure that states are doing what they are supposed to do?

What should the federal quality reviews look like? How is the federal government assessing the quality of the benefits packages being set up at the state level?

It is all well and good to say that states should decide, but the decisions made will have a dramatic impact on the quality of care provided to children with serious emotional challenges and their families for the next decade. This absolutely cannot be left up to chance.

So, time to saddle up folks. We are busy crafting language to send to HHS to use as they put together their quality requirements for states. But remember, we are a collective voice, so we want to hear from you. Send your ideas, thoughts, sample language, whatever is raising the hair on the back of your neck as you think about the fact that our nation is oh so close to setting in stone what types of services will be covered and what will not for at least the next decade. Use our contact form and send us your ideas so that we can incorporate them into our message to HHS.

One more thing – CMS has just released a request for information on health plan quality requirements, which we will be responding to. Download the RFI here and study up folks. HHS wants our feedback on a number of quality related products. Let’s ride the elephant instead of being crowded out by the elephant. Wadda ya say?

Scott Bryant-Comstock
President & CEO
Children’s Mental Health Network

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