Amid the COVID-19 emergency, all eyes have been on skilled nursing facilities (SNFs) and hospitals — and for good reason.
SNFs have accounted for more than 40% of the nation’s COVID-19 deaths, while hospitals have grappled with bed and personal protective equipment (PPE) shortages. As a result, the U.S. Department of Health and Human Services (HHS) has sent billions of dollars in coronavirus relief specifically to those entities.
But now, it’s time for HHS to shift its gaze to behavioral health providers, Chuck Ingoglia, president and CEO of the National Council for Behavioral Providers, stressed during a recent interview with Behavioral Health Business.
The National Council is an advocacy organization with more than 3,300 provider members, most of whom are safety net organizations, meaning they represent the under- and uninsured. Amid the coronavirus, those members are dealing with reduced revenues and increased costs, forcing many of them to cut their services.
At the same time, though, those services have become more important than ever.
In the second quarter of 2020, anxiety symptoms were three times higher than they were a year earlier, according to the Centers for Disease Control and Prevention (CDC). Meanwhile, depression symptoms were about four times as high, and drug overdoses also spiked.
As such, it’s vital for behavioral health providers to get additional, specialized federal support, Ingoglia said.
While payments from the CARES Act Provider Relief Fund can help providers a little bit, the deadline to apply is quickly approaching and that money alone is not enough to keep providers nationwide from cutting vital behavioral health services, he said. Only a dedicated behavioral health funding stream will do the trick.
You can find BHB’s conversation with Ingoglia below, edited for length and clarity.
BHB: First of all, how are behavioral health organizations holding up financially these days in light of the coronavirus?
Ingoglia: According to our June survey, organizations have experienced about a 20% reduction in overall revenue — and that’s an average. You’re going to have organizations that have had much higher loss than that.
As a result, organizations are doing things like having to close programs or furlough staff. That obviously results in them serving fewer people, and when you serve fewer people, your revenue stays low.
So organizations are kind of caught in this self-perpetuating cycle of reduced revenue. At the same time, we were hearing reports of increased rates of overdose deaths in parts of the country.
It’s really troubling seeing these two trends happening side by side.
On top of that, federal funding has been somewhat elusive for behavioral health providers. Medicaid is the nation’s largest payer of mental health services, yet Medicaid providers haven’t exactly been prioritized like Medicare providers have in terms of provider relief funding. What effect has that had on the industry so far?
For the issue related to the Provider Relief Fund and Medicaid providers, part of the confusion has been that HHS has approached decisions related to relief funding in this binary fashion: You’re either a Medicaid provider, or you’re a Medicare provider.
For most behavioral health organizations, they don’t exist in a binary world.
For the average behavioral health organization, especially those that are primarily mental health, 30% of the patient population is dually eligible for Medicare and Medicaid.
The way that HHS implemented the Provider Relief Fund was that organizations automatically got a payment based on their 2018 Medicare fee-for-service billing. Then, they had to go back to a portal that HHS established [to attest to receipt of payment and accept the terms and conditions].
It was very confusing for organizations.
Many organizations also knew that HHS was working on payments to Medicaid providers, so they got this initial Medicare payment and didn’t follow through [with attestation]. They were waiting for their Medicaid payment because Medicaid is a much bigger payor for them.
The Medicare portal closed on June 3, and then this Medicaid portal opened on June 9. When it was opened, it basically said if you got any money based on your Medicare revenue, you are ineligible to participate or to get money from the Medicaid portal.
A lot of organizations got caught in this binary approach, and that was causing a lot of confusion.
What HHS has done is tried to correct this problem by reopening the portal and saying, ‘Any provider is eligible for up to 2% of their net patient revenue.’ So no matter if you [received funds] initially under that Medicare portal, you now have an opportunity to be trued up for up to 2% of their net patient revenue.
HHS’s approach in general through these portals has been to provide organizations or providers with up to 2% of their net patient revenue.
We’re glad that this is finally getting addressed. It’s been very both confusing and frustrating to behavioral health organizations, and we’re glad that HHS is finally correcting that.
I think we’d make the further point, however, that when, on average, organizations are experiencing a 20% reduction in revenue, a 2% payment is not going to be sufficient to keep our system whole.
Another area I assume that’s confusing when it comes to provider relief funding: HHS sent out Medicare payments automatically, but providers seeking Medicaid money have to apply.
That’s absolutely true. And for many behavioral health organizations, Medicare is a very small payor.
I was talking to one of our member organizations that has a $95 million a year annual budget, and the automatic Medicare payment that they got from HHS was $68,000.
For each organization that got a Medicare payment, HHS sent this email to whoever is the billing contact person instructing organizations to go to this portal to attest and do all these other things.
But if you didn’t take those actions, you weren’t eligible to receive more money. And if you received that initial automatic payment and didn’t follow through, you were then ineligible for participating in the Medicaid tranche.
I thought that this confusion was this particular to behavioral health, but what I’ve heard from many other Medicaid providers is that their members were in the same position: They don’t think of themselves as Medicare providers, so they didn’t follow through on that first automatic payment, and then found themselves frozen out of the Medicaid tranche.
HHS has rectified at least part of that problem by reopening the portal for all providers who have received less than 2% of their net patient revenue in provider relief funding. Providers now have until August 28 to apply for funding. What should behavioral health providers know heading into that deadline?
We would encourage any organization that bills Medicare and/or Medicaid to make sure that they go to the portal.
The question will be making sure you’ve gotten the 2% that’s due to you. What I have found is that this whole process is really complicated.
What has been the biggest driver behind the financial struggles providers have had amid COVID-19? Is it that 20% revenue drop, the costs associated with personal protective equipment or something else?
There are unanticipated expenses on top of the reduction in revenue.
The reduction in revenue, I would attribute to multiple things. For one, not every patient and not every service works well from a telehealth perspective.
Organizations have done a yeoman’s job of trying to make that shift to telehealth, but what they have found is that there are certain patients that this doesn’t work for. There’s a variety of reasons: They don’t have the right technology. They don’t have hotspots. They don’t have enough data. Or it’s just a manifestation of their illness, and they can’t get it together to participate via telehealth.
Certain kinds of modalities are more difficult. Some organizations have really struggled with some of the more intensive interventions like intensive outpatient, which is several times a week and group driven for several hours.
Then, if you’re operating residential programming, the other reason you might have reductions in revenue is that you’re having to follow social distancing protocols. You might not be able to have as many people in congregate settings as you ordinarily would.
At the same time, you’re having increased expenses.
Most behavioral health organizations historically haven’t had to purchase PPE. Then early on in the pandemic, organizations had to buy equipment for their staff and sometimes clients in order for them to conduct services via telehealth.
As the virus has flared up in different parts of the country, sometimes some staff are out sick. So you have to pay overtime to have other staff cover shifts. Some organizations have had to do things like home food delivery … to stay connected and support their clients, which they’re not getting paid for.
There are all these factors coming together to increase costs for organizations.
It sounds like any little thing will help at this point. Have a lot of organizations taken advantage of PPP loans?
Lots of organizations have applied for PPP loans.
In the first round of the program, there was lots of confusion on the part of lenders as well as on the part of organizations around eligibility. Eventually that got worked out, but there are also a lot of behavioral health organizations that have more than 500 staff and therefore they were not allowed to apply for PPP loans.
That’s also been very uneven across the industry.
What else needs to happen at the federal level to help behavioral health providers?
What we want from HHS is a dedicated funding stream for behavioral health organizations.
HHS has had dedicated funding streams for critical access hospitals, for nursing homes, for federally qualified health centers, ect. We want something comparable for behavioral health organizations.
My enduring concern is that organizations are experiencing tremendous financial stress and reducing their capacity at the same time that we’re experiencing an increased need for care.
According to our last survey, 71% of organizations have had to cancel, reschedule or turn away patients over the last three months.
I worry about the overall capacity of our public mental health system. The next crisis we’re going to confront is that if Congress does not appropriate more financial support for states and municipalities, budget cuts that are going to happen at the state level are going to further compromise our ability to provide behavioral health care.
That’s going to be the next axe to drop.
Companies featured in this article:
