From Bad to Worse:

Editor’s Note: This is an Opinion by Medical Directors from the Community-Based Mental Health Centers in Montana.

Montana Substance Use Statistics: Since the year 2000, more than 700 Montanans have died from opioid overdose. Forty-four percent of all drug overdose deaths are attributable to opioids. One in seven high school students has taken prescription drugs without a doctor’s prescription. Ninety percent of Montanans with a Substance Use Disorder are not receiving treatment. There are 300 deaths attributed to alcohol in Montana annually. Eighty-three percent of all traffic fatalities are attributable to alcohol. There was a 427 percent increase in meth violations from 2010-2015.

Comprehensive Community Mental Health Centers were created in 1963 by President John F. Kennedy when he signed into law the Community Mental Health Act. This Act drastically altered the delivery of mental health services. The law led to the establishment of comprehensive community mental health centers throughout the country, and it helped people with mental illnesses that were “warehoused” in hospitals and institutions move back into their communities.

In Montana, the law led to the creation of four community-based comprehensive mental health centers: Western Montana Mental Health Center, Center for Mental Health, South Central Montana Regional Mental Health Center, and Eastern Montana Community Mental Health Center. We write today as the medical directors for these four centers.

Montana’s revenue shortfall recently has caused drastic cuts to our budgets, as well as many other social service agencies that serve some of Montana’s most vulnerable people. To date, cuts have been implemented that have severely reduced our budgets, caused the closing of treatment programs, impacted therapeutic group homes, required dozens of staff to be laid off, and put in jeopardy our ability to continue to treat our clients with community-based programs. These cuts are reminiscent of the managed care debacle when the State partnered with an out-of-state company, Magellan, in the mid-1990s.

Now, the state is proposing additional cuts to treatment for our Behavioral Health clients. Substance Use Disorders and Mental Health Conditions overlap 80 percent of the time. These are people living with a substance use disorder from alcohol, prescription drugs, or substance use. We find ourselves on the frontline of a national epidemic. According to Montana’s Attorney General, Tim Fox, one in 10 Montanans is dependent on or abusing drugs or alcohol. In Montana’s Department of Public Health and Human Services (DPHHS) Substance Abuse Prevention and Treatment Services State Plan 2015-2018, the State lists as its first goal, “To provide evidence-based program supports and services that improves and sustains the recovery of individuals with substance abuse disorders to provide needed services to a minimum of 10,000 people per year.”

However, the new rule proposed by DPHHS actually suggests cutting the rate paid for SUD assessments, shortening the number of hours for group treatment sessions, reducing the number of group sessions available to those needing treatment support for recovery, increasing the staffing requirements for recovery homes, and reducing the rates of reimbursement for all services which ultimately will grossly reduce the availability of services in Montana communities. These reductions in reimbursement further cripple the ability to pay a fair wage to the clinicians who serve these clients.

This is ineffective for obvious reasons, and even more so in that that the Attorney General recently held a summit to support Montana in this time of substance use disorder crisis, specifically with opioid and methamphetamine use disorders. In addition, the State wisely expanded SUD service options through Medicaid Expansion so that more treatment could be provided, which was an excellent move. However, with the severe reduction of reimbursement rates and the time restrictions for groups, as well as the reduction of the assessment rate, the State is now, wittingly or unwittingly, forcing a reduction in access to available treatment.

For over 10 years, the Substance Abuse and Mental Health Services Administration (SAMHSA) and the State of Montana have actually promoted the development of Integrated Behavioral Health Care which is currently reflected in the award of a SAMHSA grant to fund treatment statewide to address the current opioid epidemic in Montana. This requires the ability to provide appropriate levels of care and wrap-around services based on an integrated care model. The State’s proposed action to decrease treatment availability and reimbursement rates raises serious questions regarding our collective ability as providers to service the grant. These actions potentially will deny access to our citizens not only for the grant project, but across all levels of treatment services state-wide.

It is important to note that the standards for treating SUDs were not devised by the Montana providers, but by the American Society of Addiction Medicine (ASAM). Forcing providers to offer less treatment than what is required by ASAMs evidence-based standards is detrimental to the citizens of Montana.

These proposed changes appear arbitrary and not well thought out. In any medical treatment system, one seemingly small or relatively insignificant change causes a domino effect on the entire treatment delivery system which results in devastating reductions in the treatment efficacy. These changes are neither based on best practices nor do they align with the national standards of care. If the proposed rules are brought into being, Montana will experience a collapse of treatment for substance use disorders, simply because we cannot afford to sustain our services.

These short-sighted measures only result in a shifting of costs to the criminal justice system, our hospitals, emergency rooms, social services, foster care, and Montana State Hospital. Let alone the guaranteed increase in deaths from overdoses that accompany a lack of available resources.

If the State decides to re-engage with Magellan for managed care, Montanans will find themselves reliving the not-so-distant history of Magellan gutting behavioral health care in Montana. The State’s decision to partner with Magellan in the mid-1990s eventually led to the closing of several psychiatric and substance abuse programs across the state and led to the demise of a continuum of care for all services. Do we want to be there again?

Signed:

Medical Directors from Montana’s four Comprehensive Community-Based Mental Health Centers.

Daniel Nauts, M.D. and Edward Erbe, M.D., Western Montana Mental Health Center, Missoula

Eva LaRocque, M.D., Center for Mental Health, Great Falls

Bruce Whitworth, M.D., South Central Montana Regional Mental Health Center, Billings

Joan “Mutt” Dickson, M.D., Eastern Montana Community Mental Health Center, Miles City