I am concerned with the ethical, legal, and even fiscal consequences of the emergency regulations that impacted MHSS effective 12/1/13. Ethically, these regulation changes will harm community members with severe mental illness. Restrictive eligibility criteria will prevent those with severe mental illness from receiving vital community based support. Beyond that simple fact, the manner and timing of this transition have been extremely poor. These regulation changes were officially announced 10/31/13 through a Medicaid Memo, leaving providers 30 days to implement the changes, which at that point included transitioning to the latest Diagnostic Statistical Manual (DSM 5). In the 30 days leading up to the changes going into effect, it was determined that providers were not prepared to transition to the DSM 5 and that this transition would have to occur at a later date. It is laughable to me that DMAS and Magellan, who began as the behavioral health services administrator on 12/1/13, would take into account providers’ difficulty transitioning to using a manual for accurate diagnoses, but will not consider the difficulty for the clients who will be losing such an important service, especially at a time of year that statistically is very difficult for the mentally ill and has increased risk of suicidality associated with the Holidays. Conflicting reports of how this will impact clients only led to the confusion and difficulty in preparing clients effectively for possibly losing their services. Even clients who meet all eligibility are now being denied, because the service appears to be going “too in-depth” into their mental health needs.  It is contradictory for DMAS to report only those with the most severe mental illness will be allowed to receive MHSS, but providers will not be allowed to work therapeutically with these individuals and must limit their interventions to basic skills training, as this does not allow providers to address the “mental health” portion of Mental Health Skill-Building Services. Research in mental health and helping relationships consistently points to the therapeutic relationship as the most important aspect of facilitating change with clients. Attempting to pigeonhole providers into just doing surface skills training will not allow for stabilization of clients in the community and appears to be a very poor attempt at justifying DMAS’s recent encouragement for providers to hire less qualified mental health paraprofessionals to do this important work.

Ethically and legally, there are serious issues with the regulations within the emergency guidelines including violations of HIPAA and Human Rights. The emergency regulations note that providers may document past treatment through phone calls to outside providers. Releasing information such as this over the phone violates HIPAA. The regulations also state that providers must coordinate with the PCP regarding any medication non-compliance. However, this is a violation of Human Rights, as it is the client’s choice what to communicate with their providers. As a mental health provider, I have focused on educating clients about accurately reporting medication compliance and discussing any issues with their provider, as well as addressing any barriers to them communicating openly, but I have not violated their confidentiality by reporting to their provider regarding their medication compliance. Requiring this will create additional barriers to individuals receiving services, especially those who may suffer from paranoia and/or delusions that may impact their trust in providers. These portions of the regulations place providers at risk of either failing to meet regulatory requirements set forth by DMAS, or violating regulatory requirements established through Licensing and dictated by sound therapeutic guidelines for treatment.

As a tax payer, I appreciate fiscal responsibility, but I feel strongly that these regulations are fiscally irresponsible. Prevention and less restrictive community based services are fiscally responsible responses to the mental health needs of the Commonwealth. Limiting community based services to individuals will only increase the recidivism of psychiatric hospitalization and incarceration, which are far more costly to the State than preventive services. If the State is interested in reducing abuse of the system, enforcing the current regulations is the key, rather than implementing more restrictive regulations that will negatively impact our communities and lead to greater strain on our medical system and legal system. 

I urge lawmakers and community members to consider the impacts of these emergency regulations and if this type of detrimental regulation change is worth false promises of reducing costs for the State.