October 10 is World Mental Health Day, a day initiated by the World Health Organization to raise awareness of mental health issues and work to ensure access to mental health care for all. This year, stressors of the COVID-19 pandemic, including social isolation and economic destabilization, have caused a mental health crises in which one in four young adults have considered suicide.
Today, we interview IMPAQ Principal Research Associate Rekha Varghese, PhD, MPP to learn more about the work IMPAQ is doing to support an innovative new program from the Centers for Medicare & Medicaid Services (CMS) aimed at increasing access to mental health care. Dr. Varghese is a health economist with more than twenty years of experience with policy analysis and program evaluation, including leading roles on mental health and substance use disorder projects for CMS and the Medicaid and CHIP Payment and Access Commission (MACPAC).
How are you and your team working to address issues related to mental health care access?
Rekha: In November 2019, CMS announced its approval of a groundbreaking demonstration to expand access to behavioral health treatment. Implemented by the Washington, DC Medicaid Agency, this five-year demonstration project broadens treatment services available to both adult and child Medicaid beneficiaries diagnosed with serious mental illness (SMI) and/or serious emotional disturbance (SED), while also providing additional services for individuals with substance use disorder (SUD).
My team and I are currently working to help the DC Government evaluate the effectiveness of this new Medicaid 1115 Waiver Demonstration, called the Behavioral Health Transformation Demonstration. We designed a mixed methods evaluation to assess whether the demonstration is successfully increasing access to SMI/SED and SUD treatment and improving health outcomes for DC Medicaid beneficiaries with mental health and/or substance use disorder.
On the quantitative side, we will analyze Medicaid claims data using regression modeling to estimate the effects of the Demonstration. On the qualitative side, we will interview stakeholders such as provider and plan representatives as well as the implementing agencies, Department of Healthcare Finance and Department of Behavioral Health. We will also survey Medicaid beneficiaries to hear the direct perspectives of those using the program.
Analyzing both the quantitative and qualitative data, we aim to understand whether the demonstration worked in achieving its objectives and how. These insights will help both CMS and the Washington, DC Medicaid Agency refine and continue to improve their approaches to ensuring broad access to vital mental health care services.
What are some of the greatest challenges in ensuring adequate access to mental health services, and how is your work at IMPAQ helping to address those challenges?
Rekha: One particularly vexing challenge is the high rate of comorbidity between mental illness and substance use disorders. Studies have shown that about half the people who experience a mental illness will also experience a substance use disorder at some point in their lives and vice versa. Co-occurring SMI and SUD is associated with difficulties engaging in and adhering to treatment. The high incidence of unemployment, lack of health insurance, and experiences of homelessness and incarceration among this population exacerbate the challenges.
We hope that our evaluation of the DC 1115 Waiver Demonstration will contribute to the evidence-base of effective interventions to increase access to and treatment of individuals experiencing both SMI and SUD. This is because the DC Demonstration is the first combined SMI/SED and SUD Medicaid 1115 Waiver demonstration.
Another challenge is that physical and mental health care is often disjointed, with a lack of communication between the various providers treating a patient. To address this, we need to focus on the provision of person-centered, integrated and coordinated care that allows for a team-based approach in a single care setting when possible. This is an overarching objective of the DC 1115 Waiver Demonstration. In another project with a similar goal, IMPAQ supported the Pennsylvania Department of Human Services to identify best practices for a fully integrated primary and behavioral health care system and develop tools for health partners in the state to assess their current level of integration.
DC’s 1115 Waiver began in January of 2020, shortly before the pandemic escalated in the United States. How has COVID-19 affected this project?
Rekha: The COVID-19 public health emergency coinciding with the demonstration launch has definitely made our evaluation trickier. Because of the economic downturn, Medicaid enrollment may increase, placing greater demands on system. The pandemic stressors will likely increase the number of people needing mental health care; there could be more overdose deaths. There could be less utilization of some of the community-based demonstration services with more restrictions and more people staying home. All of these factors could confound our estimates of the effects of the demonstration.
To disentangle the effects of the demonstration from that of the pandemic, we will follow evaluation best practices. For example, we will include COVID-prevalence measures in our regression models. We will ask participants in the interviews and surveys to help us understand their perspectives on how COVID-19 has changed policy, provider, and beneficiary behavior, as well as health outcomes.
Social justice, including health equity, has been in the spotlight in recent months. In what ways might the 1115 Waiver, if successful, contribute to creating more equitable access to mental health services?
Rekha: The DC 1115 Waiver Demonstration goes beyond improving access to mental health care and substance use disorder treatment—it directly addresses issues related to health equity and social determinants of health.
The demonstration provides community-based services such as employment support and psychosocial rehabilitation. Employment support services include vocational and therapeutic supports to help people prepare for, obtain, and maintain a part-time or full-time job in a competitive employment setting, earning at least minimum wage. Psychosocial rehabilitative services use behavioral, cognitive, or supportive interventions to assist individuals with SMI to develop social networking, independent living, budgeting, self-care, and other skills that will enable them to live in the community and to prepare for securing and retaining employment.
These social support services are expected to enhance the ability of patients to follow through on their treatment plans as well as make lifestyle changes, which can result in an overall improvement in their quality of life. These customized services focus on (or pay attention to) the additional challenges these Medicaid beneficiaries with mental health needs face coming from disadvantaged or marginalized backgrounds.
What do you most enjoy about your work to address mental health?
Rekha: I love working on a diverse portfolio of projects that provide the opportunity to address issues of mental health from various angles, including both program implementation and evaluation.
Recently, I directed a project for MACPAC that assessed the effect of expanding Buprenorphine prescribing authority to Nurse Practitioners (NPs) and Physician Assistants (PAs). In the study, we found that providing NPs and PAs the ability to prescribe Buprenorphine, a treatment for opioid use disorder, increased the rate of access to and use of this treatment. It felt great to be part of a study advancing the evidence for what works in ensuring more people gain access to a proven treatment.
A few years ago, I supported CMS in testing a new model under the ACA that waived Medicaid’s Institutions for Mental Diseases (IMD) exclusion, allowing Medicaid reimbursement for certain services provided in private psychiatric hospitals. Interestingly, DC was one of the 12 states and regions participating in that demonstration, called the Medicaid Emergency Psychiatric Demonstration. Today, this waiver of the IMD exclusion is a major component of the demonstration we are currently evaluating in DC.
It is gratifying to see how my efforts through program implementation and evaluation support have a direct impact on improving the lives of thousands of people who are grappling with mental health issues.