Behavioral health providers in Oklahoma are concerned about potential cuts to mental health services for some of the state’s most vulnerable residents under a plan to privatize the state’s Medicaid system.  

The company that won the exclusive contract to oversee Oklahoma’s Medicaid program for kids in the child welfare system has said it plans to cut the use of in-patient treatment by offering more preventative care, but won’t release details. 

The Frontier reached out to all four of Oklahoma’s medical managed care companies about the potential for cuts to behavioral health care. None of the companies would agree to an interview.

The Oklahoma Health Care Authority projects up to a 20 percent decline in the use of behavioral health services under a plan to move its Medicaid programs to managed care in October, according to data it submitted to the federal government. 

State health officials say those decreases won’t come from cuts to services. Instead, for-profit insurers tasked with overseeing Oklahoma’s Medicaid spending will focus on providing more preventative care, allowing for less use of more costly services, like inpatient psychiatric treatment. 

“The thing we like to say about managed care is that it’s always about making sure that services are provided at the right time, at the right place and in the right setting,” said Haley Faulkenberry, executive director of the Oklahoma Association of Health Plans, which represents insurers in the state.

Reducing inpatient treatment for children in foster care is part of one insurer’s plan 

The Oklahoma Health Care Authority projects the use of behavioral health services for children in state custody will decline by up to 10 percent under managed care.  

Reducing inpatient behavioral health treatment is part of the strategy for the insurer the state has chosen to manage Medicaid benefits for Oklahoma foster children.

Oklahoma Complete Health, an affiliate of the St. Louis based Fortune 500 insurer Centene, says it will accomplish that goal by providing more preventative programs, but it’s keeping many of the details secret. The Oklahoma Health Care Authority has awarded the company a contract to manage Medicaid benefits for as many as 31,000 Oklahoma kids in the child welfare and juvenile justice systems and other vulnerable youth and families. 

The company wrote in its proposal to the Oklahoma Health Care Authority that it would try to reduce in-patient and residential treatment for children with complex behavioral issues in state custody by strengthening “outpatient services and placement stability in the child’s foster or adoptive home.” The company also said it planned to reduce the use of out-of-state treatment for Oklahoma children in foster care. 

But Oklahoma Complete Health redacted most of its strategy for achieving those goals from the copy of the company’s proposal the Oklahoma Health Care Authority provided to The Frontier. 

Insurers that submitted proposals to the Oklahoma Health Care Authority for managed care contracts were allowed to make their own redactions to copies of the proposals the state released to the public.

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In response to The Frontier’s questions about why the information was exempt from the Oklahoma Open Records Act, the Oklahoma Health Care Authority first cited a state law that allows public bodies to keep companies’ proprietary research confidential as well as another statute that only applies to the state insurance commissioner.

The Frontier consulted with two open records law experts who said there was some question over whether those laws applied in this situation. 

The Oklahoma Health Care Authority then cited another statute that exempts public bodies from  disclosing companies’ information if it would give competitors an unfair advantage in some instances, but did not specify which exemption in the law applied to the Oklahoma Complete Health proposal. 

The Frontier also asked Oklahoma Complete Health for more specifics about the potential for cuts to services for kids in state custody. 

Oklahoma Complete Health would not agree to an interview, but said in a written response that the Oklahoma Health Care Authority requires that any services the company provides “must be no more restrictive than those already taking place under the current system.” 

The company also said it would seek to provide more preventative care in response to The Frontier’s questions about how it would reduce inpatient treatment.

“Centene is a national leader in providing managed care foster services, and provides high-quality care to over 230,000 children in 19 states,” the company said. “We have a proven track record of utilizing innovative services, such as in-home therapy and support systems, where medical data demonstrates measurable improvements in outcomes.”

A representative for managed care companies in Oklahoma pointed to services like those the nonprofit Youth Villages offers for families involved in the child welfare system as examples of preventative programs that more Oklahoma kids will have access to under managed care.

Youth Villages offers a program that provides intensive parenting skills training for families. Another Youth Villages program teaches children aging out of the child welfare system independent living skills. 

Youth Villages now serves about 500 children a year in Oklahoma, but anticipates access to its programs will expand through Oklahoma Complete Care’s contract with the state. The goal is to keep fewer children from entering the child welfare system and needing higher levels of care. 

“One of the things that we are excited about with managed care is that we’ll be able to deliver services preemptively to kids before they actually enter the foster care system,” said Natalie Jones, regional advisor for Youth Villages in Oklahoma.

Study found worse outcomes for children in Missouri after managed care 

Managed care has led to worse outcomes for children with mental illness in Missouri, according to one study. 

Children in Missouri were nearly twice as likely to experience suicidal thoughts or attempts after a hospitalization when the state transitioned most of its Medicaid programs to managed care, according to a 2019 report by the Missouri Hospital Association. 

After the transition, the companies that manage the state’s Medicaid programs frequently rejected longer psychiatric hospital stays for children, leading to medication as the primary treatment option, said Chuck Hollister, executive director for the Missouri Psychological Association.

“Not only was it harder to admit a kid, but the length of stays have become so short under managed care, that really all you can do is just hand a kid a pile of medication and let him go,” Hollister said.

Missouri’s switch to statewide managed care in 2017 resulted in nearly 200 additional hospital visits for suicidal children and adolescents within 90 days of discharge from a psychiatric hospital, the Missouri Hospital Association report found. 

The average stay at a psychiatric hospital for children and adolescents was cut by more than five days for kids covered by Medicaid managed care plans, the report found. Those additional days in a hospital can be critical to stabilize a child’s mental health, Hollister said. 

Oklahoma’s managed care contracts come with provisions that require discharge plans for patients leaving inpatient care, Faulkenberry said. Insurers will also track hospital readmissions as a measure of success. 

The Oklahoma Health Care Authority also said that Oklahoma’s four medical managed care insurers will use national standards for approving psychiatric hospitalizations and will pay for medically necessary treatment. 

“Our goal is to better health for Oklahomans, which means higher value care and better health outcomes,” the Health Care Authority said in a statement.

Oklahoma’s poor mental health rankings exacerbated by pandemic

Oklahoma behavioral health providers say they’re concerned about potential cuts to mental health services in the wake of the coronavirus pandemic, which has exacerbated the state’s need for mental health and addiction treatment as well as a rushed transition to managed care as the state also expands Medicaid. 

The Mental Health Association Oklahoma and the Alliance of Mental Health Providers of Oklahoma have submitted letters to the Centers for Medicare and Medicaid in opposition to the state’s shift to managed care, citing the potential for insurance companies to cut services to maximize profits. 

“In a state where only one in every three citizens with a mental illness receives adequate care, we cannot afford to place more restrictions on essential care,” Terri White, CEO of Mental Health Association Oklahoma wrote. 

The nonprofit Mental Health America ranks Oklahoma No. 38 among states for the prevalence of mental illness and low access to care and No. 40 for mental illness and lack of care for youth. 

While Medicaid expansion will give more Oklahomans access to care, Verna Foust, CEO of Red Rock Behavioral Health Services, one of Oklahoma’s largest community mental health centers, said potential cuts to services under managed care won’t help the state’s growing mental health crisis. 

“The amount of services people are needing has just increased tremendously,” Foust said.

The number of crisis calls Red Rock handles each month has grown by 60 percent during the pandemic, she said.

Jennifer McCollum, executive director of the Alliance of Mental Health Providers of Oklahoma said she doesn’t think privatizing Medicaid will help health outcomes in the state. Factors like reducing poverty and improving education play more important roles, she said. 

“Managed care is not going to move the needle,” McCollum said. “If I live long enough, and you’re still around in 30 years, you and I are going to have a conversation about how this didn’t work.” 

Three of Oklahoma’s four medical managed care companies, Humana Healthy Horizons, Blue Cross Blue Shield of Oklahoma and Oklahoma Complete Health would not agree to interviews with The Frontier, but provided statements saying they would continue to cover medically necessary behavioral health services, as well as provide more preventative care. The fourth company, United HealthCare, did not respond to The Frontier’s questions, but helped arrange an interview with a representative from the trade group Oklahoma Association of Health Plans. 

Blue Cross Blue Shield of Oklahoma said it would offer peer support specialists for people struggling with mental illness and substance abuse as well as cover necessary behavioral health services under its managed care contract with the state. 

The insurer Humana Healthy Horizons said it would improve access to mental health services in Oklahoma through its network of more than 3,300 behavioral health providers in the state.
“Our approach to care focuses on critical social determinants of health issues that may impact members, which should reduce their need for behavioral health services,” the company said in a statement.