Advocates: Medicaid system overhaul could hurt behavioral health program for youth, PBM reforms

As the Ohio House and Senate negotiate a final version of the state budget bill this week, advocates are sounding the alarm to what they fear may be a death knell for crucial Medicaid-related programs.

Earlier in June, Senate Republicans inserted into their budget proposal a redo to determine who gets Ohio's $20 billion Medicaid managed care contracts. The new procurement would favor Ohio-based companies, per the request of those companies.

While the focus was on who should have gotten those contracts, the proposed redo might inadvertently affect other parts of Ohio's years-long effort to overhaul the Medicaid system, which provides state- and federally-funded health care to more than 3 million low-income Ohioans. 

"My hope is that, you know, this is just a matter of not knowing the details," said Loren Anthes, who chairs the Center for Community Solutions' Center for Medicaid Policy.

Redoing procurement could affect program for children

Parents like Deann Sanders, from Fairfield County, are worried that re-procurement could significantly delay important reforms. In the past, she's had to give up custody of her son who has autism twice to the state so he can get the required, unaffordable mental health and residential services that the government could cover.    

"It was heartbreaking. In order to get the treatment that I need for my son, I'm going to have to give up custody," she said. "Like I'm an unfit parent or a negligent parent, and that is not the case."

What came out of the system overhaul was the OhioRISE program, short for Resilience through Integrated Systems and Excellence. Backed by the governor and scheduled to start next year, it would treat children with severe behavioral and mental problems and give resources to families so they wouldn't have to give up custody.

It seems that senators realized the program could be affected and attempted to leave OhioRISE untouched. In further edits to the budget bill last week, they exempted OhioRISE from the procurement redo.

But that's not how it works, critics say.  

"To say that you're going to delay the Medicaid managed care, it also then delays all of it," said Teresa Lampl, CEO of the Ohio Council of Behavioral Health & Family Services Providers. "They're all connected, because the financing of them underneath is interdependent."

For one, a program like OhioRISE can't just function on its own. Operationally, it has to communicate with all the other parts of the system on financial, data, contractual and administrative levels. If all the other contracts have to be redone, OhioRISE can't really start. 

Additionally, the funding of OhioRISE comes in part from around $416 million worth of savings from other components of the overhaul, such as centralized credentialing and billing systems. But if those parts have to be looked at again, too, that puts the funding in jeopardy.   

Concerns about pharmacy benefit manager reform

Advocates are worried for the same reasons about what it means for reform over Ohio's pharmacy benefit managers, which had been overcharging taxpayers. As part of the overhaul, the state decided to switch to a single PBM system so there would be more controlled oversight.   

Gainswell Technologies won the contract to be the single PBM, though the proposed re-procurement could alter or undo that and delay implementation of the system.

"Ohio was on the leading edge to tackle the PBM issue, but the amendment would unravel all that,” said Antonio Ciaccia, who previously lobbied for the PBM changes for the Ohio Pharmacists Association.

A spokesperson for Gainswell had no comment, saying that "we're going to leave it in the hands of the state." 

What happens next?

The best case scenario if the redo becomes law is that all the components remain intact and will simply start at a later date, said health advocates. That's not taking into consideration the potential litigation from those already awarded contracts or how expensive and time consuming procurement is.

"It took three years to get to this point," said Anthes. "I think that is way too expensive of a mistake. It does not guarantee that you'll get the same results. And people can't wait."

Gov. Mike DeWine's administration had also indicated it would not like having to delay implementation.

"It would be unfortunate to lose the momentum that we have to transform Ohio’s Medicaid at this late stage in the process," said Pete LuPiba, spokesperson for the Ohio Office of Budget and Management. A final version of the budget must clear both chambers and be signed by the governor before July 1.

For Sanders, who knows other families now going through similar situations like hers in the past, waiting isn't an acceptable option. The longer it takes for reform to be in place, the more people are at risk.

"I have had parents talk to me about, hey, it might be better to... kill themselves and their child," she said. "This is pretty extreme, because they feel they have no support. They can't handle the situation.

"But they can't get the help that they need, unfortunately. Or that help comes way too late."   

Titus Wu is a reporter for the USA TODAY Network Ohio Bureau, which serves the Columbus Dispatch, Cincinnati Enquirer, Akron Beacon Journal and 18 other affiliated news organizations across Ohio.