ProPublica: Insurers deny mental health care using illegal guidelines
The main point: A ProPublica investigation found that insurers frequently review patients’ progress in higher-level mental health treatment (e.g., intensive outpatient, residential) to see if they can be moved down to a lower — and cheaper — level of care.
The investigation found that insurers cite both progress made by the patient and lack of progress in the patient’s condition to deny ongoing care.
Why it’s important:
Doctors are left trying to convince insurers that patients are making enough progress to stay in treatment, but not so much that the companies cut them off from care. When insurers demand that providers spend time justifying care, it takes them away from patients.
Mental health care can be particularly prone to these progress-based denials because mental illness can be fluid and lack objective improvement standards (e.g., X-rays show when bones have healed).
Treatment is expensive. Without coverage from insurance, many patients stop treatment, which can lead to worsening conditions, relapse and even death.
The details: ProPublica found scores of lawsuits over the past decade in which judges have criticized insurance companies for citing a patient’s improvement to deny mental health coverage.
In a number of those cases, federal courts ruled that the insurance companies had broken federal law (ERISA).
To justify denials, insurers cite utilization management guidelines they use to determine how well a patient is doing and whether to continue paying for care. Companies say the guidelines are independent, widely accepted and evidence-based, but insurers have also used guidelines they developed themselves.
Several insurance employees said they were required to prioritize the proprietary guidelines their company used, even if against their clinical judgment. Federal judges have criticized insurance company doctors for using such guidelines.
In Wit v. United Behavioral Health, a federal judge concluded that United Healthcare’s guidelines did not adhere to generally accepted standards of care and allowed the company to wrongly deny coverage for mental health and substance use disorder services. He ruled that the insurer would need to change its practices. But United appealed the ruling, and the case has been sent back to a lower court. Largely in response to Wit, nine states have passed laws requiring insurers to use guidelines that align with leading standards of care, like those developed by nonprofit professional organizations (e.g., the ASAM Criteria).
Alcohol consumption is the third leading preventable cause of cancer in the U.S., after tobacco and obesity, increasing risk for at least seven types of cancer.
In the U.S., there are about 100,000 alcohol-related cancer cases and about 20,000 alcohol-related cancer deaths annually.
Less than half of Americans recognize alcohol consumption as a risk factor for cancer.
The details: The advisory includes a series of recommendations to increase awareness to help minimize alcohol-related cancer cases and deaths, including:
Updating the existing Surgeon General’s health warning label on alcohol-containing beverages to include cancer risk
Reassessing the guideline limits for alcohol consumption to account for cancer risk
Advising individuals to be aware of the relationship between alcohol consumption and increased cancer risk when considering whether or how much to drink
Highlighting by public health professionals and community groups of alcohol consumption as a leading modifiable cancer risk factor
Strengthening and expanding education efforts to increase general awareness
Informing patients in clinical settings about this link, and promoting the use of alcohol screening and treatment referrals as needed
Next steps: Only Congress can mandate new warning labels, and the call for the new mandate will likely face strong resistance in Congress.
NYT/Banner: Deadly treatment and housing practices in Baltimore
A New York Times/Baltimore Banner investigation found that PHA Healthcare in Baltimore provides inadequate care using potentially illegal practices, leading patients to relapse, fall deeper into addiction and/or die.
The business model:
The company rents apartment buildings, then offers free rooms to people, many of them homeless, if they attend group counseling sessions. By taking no government money for housing, the business avoids the state’s strict rules for regulated recovery facilities.
Medicaid pays more than $3,000 per patient for counseling each month, amounting to $15 million since the company opened in 2020.
But: Federal kickback laws make it illegal for Medicaid providers to offer free housing to patients in exchange for enrolling in their treatment. The operators of PHA Healthcare had no experience providing drug treatment.
The treatment:
The counseling sessions are offered only online and often involve watching irrelevant videos and answering repetitive questions for hours. Many sessions are led by unlicensed counselors with no prior experience in addiction treatment.
Residents are often overseen by untrained house managers, who have regularly ignored positive drug tests and overdoses and have even sold drugs to patients.
Patients are not consistently connected to mental health professionals and prescribers or regularly checked on. Naloxone is not consistently available.
The conditions: Many of the apartment complexes are poorly maintained and ridden with drugs and crime.
The outcome: Reporters traced the deaths of at least 13 people to PHA Healthcare since 2022, more than other treatment programs.
How this happened:
Trying to entice more providers into the field, state health authorities poured money into recovery programs, barely vetted new operators and halted most in-person inspections.
In January 2020, Optum rolled out broken technology that left the state unable to process Medicaid claims for addiction services. Maryland was forced to pay providers based on educated guesses for nearly a year. Optum could not monitor or properly audit spending, and the Health Department stopped referring fraud cases to prosecutors. Auditors stopped visiting programs in person during COVID.
State regulators at one point learned that PHA Healthcare had been operating with an expired license for almost two years. It told the company to stop treating patients but then allowed it to obtain a new license.
What’s coming:
The state expects to impose regulations next year to strengthen oversight and potentially require providers to obtain state approval for any recovery homes they operate.
In September 2023, a Medicaid notice warned providers to stop “offering housing as an incentive” to draw patients into treatment. This October, Medicaid warned providers for a third time about illegal housing, now threatening to refer them for prosecution.
The Food and Drug Administration (FDA) issued a Federal Register notice recommending modifications to the labeling statements for buprenorphine-containing transmucosal products for the treatment of opioid dependence (i.e., Suboxone, Zubsolv, other generic versions).
The details:
The FDA is recommending revisions to the labeling to avoid a reported misperception that labeling for these products includes a maximum daily dose (16-24 mg).
The recommended changes seek to clarify that daily maintenance dosages can be incrementally adjusted for each patient based on their individual therapeutic need and that daily dosages higher than 24 mg per day may be appropriate for some patients.
Why it’s important: Such changes may help patients receive treatment more targeted to their individual needs. Particularly in the age of increased fentanyl prevalence and potency, higher dosages of buprenorphine may sometimes be needed to adequately treat patients with opioid use disorder.