Beginning April 1, Montana is set to start dismantling the addiction treatment system that is serving most drug court participants, addicted parents of children in foster care and addicted criminal offenders who were sentenced to probation on condition that they stay off drugs.
This sure isn’t what the 2017 Legislature talked about last winter and spring. Readers may recall that the Commission on Sentencing recommended boosting availability and access to effective substance use treatment to reduce recidivism. Montana’s prisons are at capacity and most of the inmates are addicted to alcohol or other drugs.
Parental drug addiction, particularly meth use, is the No. 1 factor in the explosion of child abuse and neglect cases statewide. In Yellowstone County, parental drug addiction is a factor in two-thirds of child abuse and neglect filings.
The Montana Department of Public Health and Human Services has scheduled a public hearing for March 1 on payment and service cuts for addiction treatment. The department already sent notices to Medicaid patients that the cuts will happen on April 1.
The rule notice contains boiler plate language that DPHHS considered these factors as required by Montana law:
- Protecting those persons who are most vulnerable and most in need, as defined by a combination of economic, social and medical circumstances.
- Giving preference to the elimination or restoration of an entire Medicaid program or service, rather than sacrifice or augment the quality of care for several programs or services through dilution of funding.
- Giving priority to services that employ the science of prevention to reduce disability and illness, services that treat life-threatening conditions, and services that support independent or assisted living, including pain management, to reduce the need for acute inpatient or residential care.
None of those claims is true. The exact opposite is happening: Cuts fall hardest on the most vulnerable; reimbursements are reduced below the cost of providing service; and community care is slashed, leaving nothing but the most expensive and limited inpatient treatment in place.
Montana addiction treatment providers complain of not receiving notice of the proposed rule changes, or not getting word until two weeks before the hearing, and difficulty in finding the proposals online because they weren’t posted where DPHHS has previously publicized new proposals.
The latest rule changes would effectively prevent Montana Medicaid from paying for intensive outpatient therapy. That is the treatment level used to get most Billings drug court participants into recovery. It typically takes months of IOP individual and group therapy several hours per day, three or four days a week to get hardcore addicts to work through their substance use issues and make the change to drug-free living. Over the course of treatment, many patients get better, but they still need treatment to prevent relapse.
The proposed rules limit the number of treatment sessions to 12 per year — unless the Montana provider keeps reapplying to an out-of-state company for approval of more sessions. According to statistics from 2015, less than half of Montanans admitted for addiction treatment would had the high acuity level the new rule sets for getting more than 12 treatment sessions. Once again, Montana’s public health system is sacrificing, lower-cost outpatient care and forcing people to wait until they are more seriously ill to get the help they need.
Let’s be clear about who is responsible for the unraveling of Montana’s health care safety net. The Montana Legislature and Gov. Steve Bullock enacted a budget last spring that they knew or should have known overestimated future revenue collections. Simultaneously, the governor and legislative majority agreed to triggers that would automatically cut the state budget if revenues were short. Those triggers augmented the state law that already requires a balanced budget. To his credit, Bullock proposed reasonable tax increase that would have funded the essential services that are being cut. Republicans rejected Bullock’s proposals.
The November special session mandated health and human service cuts that are taking effect this spring, after an across-the-board Medicaid payment cut of 2.99 percent in January. The proposed rule change says that the special session reduced the DPHHS general fund appropriation by $49 million.
The published proposal also says that its “fiscal impact is unquantifiable. The department lost approximately one-eighth of its Medicaid appropriation for the biennium.” In other words, the deepest budget-balancing cuts are hitting the poor, children and elderly disabled Montanans who rely on Medicaid. The entire state budget isn’t being cut by 12 percent.
The governor and the Legislature are responsible for the overall cuts. However, DPHHS could and should make a less destructive plan. Montana professionals and organizations who provide high-quality, effective addiction treatment and mental health care must be consulted. There are ways to improve the state’s fee-for-service payment system, but the rule up for hearing Thursday fails to incorporate best practices for addiction treatment.
Montanans must appeal to our governor. Bullock should direct DPHHS to pause on this latest round of cuts and spend at least several weeks working intensively with Montana providers and professional associations to mitigate the damage.
If these rules go through as written, Montana will have significantly less capacity to treat substance abuse by the time the Legislature convenes next January. Meanwhile, jails, prisons, hospitals and the foster care system will deal with more addicts who can’t get effective treatment. Governor Bullock, tell DPHHS to substantially revise Montana Administrative Register Notice 37-835 with input from Montana providers and the public.