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Two Lee Newspapers' headlines published 11 days apart in March present conflicting views on the effects of changes in Montana’s Medicaid system since the 2017 Legislature adjourned.

"100 protest against Montana health department cuts"

"State’s options for treatment could double"

Which is correct? That state spending reductions will force mental health and chemical dependency treatment providers to cut services? Or that a change in state law may increase the number of Medicaid-eligible addiction treatment programs from 32 to 57 by year’s end?

The Billings Gazette Editorial Board

As with most things in the U.S. health care system, the answer is complicated. To understand this complexity, let’s look at Eastern Montana Community Mental Health Center. With headquarters in Miles City, EMCMHC serves a vast 17-county, 48,000-square-mile region. Last year (before state revenue shortfalls resulted in decreases in Medicaid rates), the center applied to add chemical dependency treatment in five counties where it already provides mental health services.

By using existing staff, telehealth technology and hiring just 1.5 additional full-time-equivalent staff, the center plans to extend addiction treatment to Dawson, Richland, Prairie, McCone and Wibaux counties. Only after the service expansion was ready to start did CEO Brenda Kneeland learn of further proposed changes in Medicaid that will reduce reimbursement to her nonprofit organization and other Montana addiction treatment providers.

The Eastern Montana center is moving forward with addiction treatment expansion while leaving other staff positions vacant, Kneeland told The Gazette.

New service limits

“We are trying to find our footing in regards to the proposed rate cuts (taking effect April 1) and we plan to do our very best to not cut services, but we will not be able to provide what we cannot pay for so time will tell,” Kneeland said. “At this point, we are more concerned with the systemic changes the state is proposing that limit the number of services an individual can receive, require ongoing authorizations and that require precious state dollars being given to a managed care company rather than supporting providers throughout the state who provide direct chemical dependency treatment services to Montanans.”

Like Kneeland, Barbara Mettler, executive director for the Mental Health Center in Billings, sees financial uncertainty for community behavioral health services. Between July and September 2017, the state Medicaid program effectively eliminated mental health case management by reducing the rate below the cost of service. South Central Montana Mental Health Center, which serves Yellowstone and 10 neighboring counties, lost $200,000 in 2016, it eliminated 20 jobs last year, mostly case managers. Revenues and expenses came back into balance for 2017, but after 2.99 percent Medicaid rate cut showed up in February receipts, the center was back the red for the month. In March, DPHHS announced significant changes in addiction treatment payments.

Although the state is processing applications for new addiction treatment programs, some existing services have shut down. For example, in Billings the Center for Children and Families closed last month, shutting down outpatient addiction treatment and safe housing for up to 40 children and mothers in treatment. Western Montana Mental Health Center has closed its offices in Livingston, Libby and Dillon.

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Proposed changes in state Medicaid policy have already prompted change in the Billings center’s intensive outpatient addiction treatment regimen so that clients will have less time in group treatment, even though “best practice for drug and alcohol treatment is group, not individual therapy,” Mettler said. Intensive outpatient treatment will be reduced from four eight-client groups to one.

Most people participating in Billings drug treatment courts need that intensive level of treatment to get off drugs and stay in recovery. With fewer slots available, waiting lists will grow and court cases will be delayed.

Rainbow House 

Mettler is concerned about the future of Rainbow House, a daytime treatment program for seriously mentally ill adults, some of whom live in a Mental Health Center group home. A new state provider manual proposes that only one service per day can be billed to Medicaid. Mettler wonders if that means people who are receiving shelter can’t also be served at Rainbow House.

“No stakeholders were invited to help revise the provider manual,” Mettler said. “We’re still in the dark till we read it in the newspaper.”

Montanans are seeing Medicaid service reductions along with new addiction treatment programs. Health care providers are painfully aware that their reimbursement is less than expected and will stay that way at least through this biennium. They deserve seats at the table to help write the rules they must obey to serve Montana’s most vulnerable citizens.

The state could pay Medicaid providers based on actual, allowable costs as Medicare pays critical access hospitals. The state could transition to a system that pays providers a set fee per patient per month and requires the provider to meet certain outcome measures. Those ideas and others require collaboration. By listening to and working with Montana health care professionals, community clinics and hospitals, Department of Public Health and Human Services leaders would get help with the difficult decisions foisted on them by state revenue shortfalls.

Barbara Mettler, executive director, South Central Montana Mental Health Center

Brenda Kneeland, CEO Eastern Montana Community Mental Health Center

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