Nine-year-old Kendra sits in one of the private rooms on the second floor of Boise’s Downtown public library with her community-based rehabilitation services worker, Jennifer Beason.
Beason slides a workbook to Kendra. It is what she calls her feelings journal. “Do you know what relieved is?” she asked.
Without missing a beat, Kendra rattles off examples of feeling relieved.
“Like you forgot to bring home a paper, a really, really important paper, and then you brought it home, but you left it in your backpack and you thought you left it at school,” she said. “And then you’re relieved you still have it.”
For a year and a half, Kendra and Beason have spent about four hours each week developing social and personal skills Kendra falls short on because of a tumultuous start to her life.
By the time she was 3, Kendra was in a foster home, removed from her biological parents because of severe abuse and neglect.
“No child should go through what she went through,” said Kendra’s adoptive mother, Ginger Kreiter. “Because of what she went through, it put her in severe trauma. She had no coping skills with your ordinary life.”
That’s why Kendra has been receiving community based rehabilitation, individual counseling and occupational therapy. She’s been receiving similar services, off-and-on, since she was 3. They have all been paid for through Medicaid, the shared federal-state health insurance program for poor and disabled people.
But since behavioral health services offered through Idaho’s Medicaid program were privatized through a managed-care contractor in September 2013, some recipients of services have seen their approved hours cut back or eliminated.
Kendra’s final Medicaid-provided community based rehabilitation appointment was earlier this month. Kendra has been diagnosed with attention deficit hyperactive disorder, and reactive attachment disorder. Her mother says she’s also been diagnosed with post-traumatic stress disorder, although that diagnosis isn’t part of her file with Optum Idaho, a division of UnitedHealth Group, the state’s managed-care contractor.
Community-based rehabilitation, formerly known as psychosocial rehabilitation, is meant to help someone with a mental illness function within the community. It teaches people coping skills and real-life skills, from hygiene and home management to financial management and social skills.
Optum is deliberately curbing those services, saying community based rehabilitation isn’t always the best treatment or medically necessary.
“It’s important to re-emphasize the transformation the state is doing to focus care on the use of more evidence-based practices,” Optum Idaho’s Executive Director Becky DiVittorio said.
A NEW MANAGER FOR MEDICAID’S BEHAVIORAL HEALTH
That’s been a familiar line from Optum Idaho as the company has faced criticism from service providers and lawmakers during the bumpy first year of Optum’s three-year contract.
During the first 12 months of Optum’s contract, the state — with a mix of state and federal dollars — has paid the company $126 million. *That cost only includes outpatient care. Idaho still manages its inpatient care, along with several other services. In fiscal year 2014, Idaho Medicaid mental health expenses totaled $157 million, an increase from $148 million in fiscal year 2013, before the start of the Optum contract.
Idaho’s mental health Medicaid costs have increased each fiscal year since 2006, while the state’s funding of its behavioral health division has fluctuated.
Overall, the state’s support of mental health programs has become a smaller share of the total $2.5 billion Department of Health and Welfare budget, from a 2006 peak of 11.2 percent to *8.8 percent in fiscal year 2014.
Service providers — the mostly-small businesses and nonprofits whose claims for payment for Medicaid patients Optum must approve — have submitted formal complaints with the company and the federal government. They report long wait times for service authorizations and claims reimbursements measured in cents instead of dollars. Some providers have even closed their doors permanently blaming the instability of Optum’s operation.
The state and Optum contend that overhauling the behavioral health portion of Idaho’s Medicaid program won’t be smooth and seamless. But say it will be worth it. The company, and some lawmakers, anticipate better care through evidence-based treatment.
For Kreiter, that answer isn’t acceptable. Her adoptive daughter “lacks huge social skills, even now,” she said. “That [community based rehabilitation] has helped her a lot with the social skills. They’re getting her out there. They tackle every life event you think of to prepare her for when she gets older. If we don’t take care of the kids now, then it’s going to cost a lot more to rehabilitate them as adults.”
Since Optum began overseeing Idaho Medicaid’s behavioral health payments, it has cut community-based rehabilitation services by 10 percent.
It has added alternative services. Optum says it has approved a 25 percent increase in the number of children getting individual therapy, a 34 percent increase in adults accessing individual therapy, and a tripling in children receiving family therapy.
In Kendra’s case, Optum Chief Medical Director Dr. Jeffrey Berlant says community based rehabilitation could actually hurt her development.
“The treatment for reactive attachment disorder, according to the American Academy of Child and Adolescent Psychiatry, is to avoid service people getting in the way of a bond being formed between the new caregiver and the child,” Berlant said. “Having something like CBRS get in the middle is actually contra-indicated by those guidelines.”
Instead, Optum has recommended that Kreiter and her husband enroll in family therapy and extended parenting-skills training.
“Kendra needs to address the trauma that she’s been through and that makes her feel embarrassed and ashamed, even though we’re constantly telling her it wasn’t her fault,” Kreiter said. “She needs that privacy.”
LOCAL PROVIDERS TOLD TO ADAPT
For Idaho Medicaid’s mental health service providers, the switch to Optum has meant reimbursement rates have changed, clients’ services have changed, and providers are being asked to adapt to a new system that doesn’t yet have all the tools needed to run smoothly.
One of the state’s largest providers, Boise-based Idaho Behavioral Health, has seen a 28 percent decline in the number of community based rehabilitation hours approved for its clients. The company says its services are more cost-effective than individual therapy or hospitalizations.
“You're getting more bang for your buck, you're getting a more efficient way of spending your budget,” says Idaho Behavioral Health President and CEO Tami Jones, “and it should always be a part of an effective community based mental health treatment program.”
As Kendra’s case highlights, Optum — and the state — believe there are Idahoans who’ve been getting the wrong treatment based on their diagnosis.
Even the businesses who provide them acknowledge that community-based rehabilitation services have been used as a sort of one-size-fits-all solution to a range of mental-health problems. A big reason, they say, is that Medicaid in Idaho hasn’t been willing to pay for alternatives, forcing them to do what they can for patients within the authorized list of reimbursable services.
That’s a criticism state Rep. Fred Wood understands. Wood, himself a doctor, is a Republican from Burley who chairs the Idaho House Health and Welfare Committee.
“A lot of the treatment programs, the up-to-date programs just weren’t brought in [to Idaho],” Wood says. “So that is a valid criticism, I think. But that was the past. And just because that was the way we used to do it – and it was wrong – doesn’t mean that’s the way we ought to do it in the future.”
FIGURING FINANCES IN A PARK
Community-based rehabilitation is the appropriate treatment for people who’ve been diagnosed with various forms of schizophrenia, according to the American Psychological Association. So it was a shock to Teresa Koscierzynski and her providers when she was told earlier this year that Medicaid would no longer pay for her six weekly hours of CBRS.
Teresa, 28, has been diagnosed with schizoaffective disorder, a mix of bipolar disorder and schizophrenia.
Since she was 15 years old, Teresa has been in and out of Idaho’s state mental hospitals. Her most recent stay at State Hospital South in Blackfoot was in 2012. She was there for six months.
Teresa’s CBRS worker Kristin Cordero helps manage her monthly finances. They sat at a picnic table at a Boise park one recent day, working through Teresa’s Social Security disability income checks for October.
“I just got a raise, right?” Teresa asked.
Cordero’s employer, Access Behavioral Health, is Teresa’s payee. The Boise company collects her monthly disability income and cuts her weekly checks so she can better manage the money.
“You’re going to get five checks in October, OK?” Cordero said.
Teresa can’t work. She has a hard time being around other people because of the near-constant noise of voices in her head.
“My purpose is to help her function in the community with her mental illness,” Cordero explained. “If she didn’t see me, she’d never leave her apartment. She would isolate to her apartment, and that would make it worse.”
Teresa doesn’t have family in Idaho, so Cordero and four other service providers have become her support system. Teresa lives with a new cat in her small apartment in west Boise. She knows she has certain struggles that most people don’t, but she is in denial about her diagnosis.
“I’m trying to get her to accept it so that I can help her more with it,” Cordero said. “She can’t live in group homes, because she’s been kicked out of them, because (of) what happens when she hears the voices. She thinks it’s me, or you, or them or anyone else, so then she gets really aggressive.”
Cordero’s goal is to show Teresa she can go to the store, or be outside of her home, without getting angry at the people around her.
Access Behavioral Health was able to stop Teresa’s CBRS cuts from taking effect, preventing a gap in services. But every three months, Teresa’s file is sent to Optum for re-authorization. Every three months, Teresa and Cordero worry a change in services could have a big effect on her fragile situation.
“On paper, maybe it doesn’t look bad,” Cordero said. “But I have no idea what they’re thinking. They don’t know the kind of clients that we’re working with every day that need this help.”
Asked why she needs to see Cordero three times a week, Teresa answered, “My sanity. I think my sense of security would go down, because if something bad happened, who would I go to? And, it would go downhill probably pretty fast.”
Teresa’s goal is to stay out of the state hospital and continue learning how to live on her own.
“There’s times when I think I can do it, and times when I think I should check myself in, I’m not doing too great,” she said. “But then I say ‘No, I gotta pull through – I gotta.”
Teresa’s case is atypical. Cordero said when they first started working together two years ago, she felt there should have been a better option for someone like Teresa with a chronic mental illness that prevents her from fully participating in the life most people know.
For now, a cobbled-together plan of community based rehabilitation, individual therapy, medication management and in-home personal care workers are the best option they can come up with. It’s a life wholly reliant on a state system in flux.
Optum’s Dr. Berlant says CBRS, like other kinds of rehabilitation, doesn’t go on forever. It stops when skills are learned, although Berlant acknowledges some people may never have the capacity to learn the skills they need to survive.
“With [CBRS] training, they don’t have fewer symptoms, they don’t have fewer relapses, they don’t have fewer hospitalizations, they don’t necessarily function better,” he said. “But they may function in ways that may improve the quality of their life.”
“In Crisis” is a collaboration between the Idaho Statesman and Boise State Public Radio.
*This correction/clarification was added after the story was originally published.