Behavioral Health Industry Flexes Lobbying Muscles to Shape Policy

Behavioral health providers don’t have to accept the status quo when it comes to challenging state markets.

Savvy operators can change fundamental aspects of the markets in which they operate through lobbying and advocacy. This is a right — and even civic obligation — for members of the public to push officials to make changes.

“As an advocate, you have a First Amendment job; you are allowed to petition your government to address grievances. It’s our duty as citizens to do it,” Tim Perrin, a policy advisor for the law and consulting firm Polsinelli, told Behavioral Health Business.

Lobbying and advocacy in behavioral health are necessary and have a high potential for positive impact because of how enmeshed health care is with state and local governments. Governments act as both regulators and payers in the U.S.

“One way to look at it is that if you don’t like the reimbursement level or the policy matter, you can change it through a public policy campaign,” Perrin said. “If you want to try something innovative that would help patients, but you recognize there is a policy barrier, you can work to get that removed through a public policy or advocacy campaign.”

For example, the Biden administration last week launched the public phase of a rulemaking process regarding mental health parity. Several individual organizations and their advocates, especially The Kennedy Forum, have pushed federal regulators and elected officials for years for additional rules on ensuring health plans don’t discriminate against mental health patients. Since then, Pres. Joe Biden has made behavioral health reform a plank of his “unity agenda.”

Last year also saw several examples of movement on several federal issues by Congress, including legislation that expanded certified community behavioral health clinics (CCBHCs) and changed Medicare behavioral health benefits.

“Nothing happens legislatively unless there’s a champion for it, a voice for it,” Stuart Archer, CEO of Oceans Healthcare, previously told Behavioral Health Business.

Plano, Texas-based Oceans Healthcare operates 48 care sites in Louisiana, Mississippi, Oklahoma and Texas. That footprint includes 23 inpatient psychiatric facilities. The company provides a range of addiction treatment and mental health services focused on older adults.

Lobbying as a tool for growth

Lobbying state legislation can be crucial for psychiatric hospitals looking to overcome stringent regulatory policies, according to Archer.

Oceans Healthcare is involved with the National Association for Behavioral Healthcare (NABH), a national advocacy group for behavioral health care providers.

“Many times, behavioral health patients have not always had a place at the table for themselves to advocate for their issues or for their loved ones’ issues,” Archer said.

In Mississippi, Oceans Healthcare lobbying was instrumental in passing a bill that allowed free-standing psychiatric hospitals in the Medicaid program despite the “institutions for mental disease” exclusion (IMD exclusion).

Such a change to Medicaid rules was essential to Oceans Healthcare building facilities in the state, Archer said, given the company’s focus on increasing access to care by being an in-network provider.

Mississippi has not expanded its Medicaid program to cover more residents under the provisions of the Affordable Care Act; 40 states have done so. The lack of expansion makes Mississippi a difficult environment for facility operators to work in.

“We aim to provide services to those most in need, so we have to find a way to work within, if we can, the benefits that the patient has,” Archer said. “But, there are limitations to even that.”

Today, Oceans Healthcare operates two inpatient facilities and two outpatient locations in Mississippi. Oceans Healthcare recapitalized with the private equity firm Webster Equity Partners in a deal announced in early 2022.

Oceans Healthcare has also advocated for patient choice in involuntary psychiatric commitments in Texas and Louisiana and parity work in Texas.

Making working with Medicaid easier

Medicaid is the largest single-payer of behavioral health services in the U.S. But state governments have direct oversight within their borders of the safety-net health plan, as do federal governments. One estimate finds that about a quarter of all spending on mental health services alone comes from Medicaid programs.

However, Medicaid plans are notorious for reimbursing providers well below private health insurance plans and Medicare, the federal health plan for American seniors.

Low Medicaid rates have played a prominent role in high-profile stumbles in the autism therapy space.

Recently, Indianapolis-based Hopebridge said it was closing all but two offices and ending applied behavior analysis (ABA) services in Colorado. Hopebridge CEO David McIntosh explicitly called out persistently low Medicaid rates as part of the impetus for the move.

However, one source pointed out to BHB that Louisiana upped its Medicaid reimbursement rate following a lobbying effort by several nonprofit and for-profit autism therapy providers in 2022.

The Louisiana Coalition for Access to Autism Services (LCAAS) successfully advocated for a rate increase for ABA services. It also landed additional appropriation through the state’s biennial budget.

“I get that the word lobbying scares some people, but it’s a necessary part of the equation when you’re interfacing with state government and when providing your services is contingent upon sound policies and the right amount of funding,” LCAAS Executive Director Beverly Haydel told BHB. “It can be really effective in helping families and helping improve the state.”

The rate for billable hours by registered behavior technicians (RBTs) increased from $38 an hour to $50 an hour. That rate increase was backed up by $12.6 million of additional funding for the state’s Medicaid budget, specifically for ABA services.

Data from the Autism Legal Resource Center show the median Medicaid rate for RBTs was $48.38 in 2021.

Hopebridge’s McIntosh called for similar advocacy in Colorado as the state works through a public process to reset Medicaid rates.

Wait times in the state had ballooned to six months to a year for services, severely cutting into the window for early intervention for children diagnosed with autism.

“We had providers telling us that, almost immediately, it impacted their ability to hire more people,” Haydel said. “They really could see [access improve] pretty significantly after that rate increase.”

The impetus for forming LCAAS was Blue Cross Blue Shield of Louisiana, the largest private health plan provider in the state, threatening to cut rates for ABA services in 2016. One impact of the rate increase is that Medicaid now reimburses more than some private health plans. BCBS of Louisiana has not followed Medicaid’s lead and raised its rate, Haydel said.

Making it impactful

Several strategic considerations play into behavioral health lobbying. These include questions such as when to press an issue and who will be the effort’s messenger.

Haydel and another local lobbyist, Alton Ashe of Advanced Strategies, led the rate increase effort. Together, they were the face of LCAAS’ work. The organization took that approach because it successfully did the “legwork” before the 2022 legislative session.

Work on the effort started in 2020. But the onset of the coronavirus pandemic inspired LCAAS to hold off until the state legislature was clearly out of COVID response efforts and had additional cash from the several congressional COVID aid packages. LCAAS saw the opportunity to move in 2022.

“We felt like we had gotten ourselves to a good place … and just needed to state our case succinctly and move on,” Haydel said.

LCAAS turned to Baton Rouge-based state senators Franklin Foil and Mack “Bodi” White Jr. to champion the matter in the state house. Both were vital allies and are known advocates for autism therapy access, Haydel said. Specifically, Foil sponsored the 2014 bill that solidified Louisiana’s autism therapy coverage mandate and has a son with an autism diagnosis; White is the chairman of the Senate Finance Committee.

Still, behavioral health organizations must consider other, more foundational questions before they undertake lobbying and advocacy. These include setting clear goals, expectations and contemplating if “the juice is worth the squeeze,” Perrin said.

Further, those who may be hesitant to engage in lobbying may find greater comfort in knowing that much of the work calls for educating elected officials and regulators on issues, Perrin and Haydel told BHB. Many legislators may simply not be aware of issues behavioral health providers face or know enough about issues and solutions to act on them.

Still, the process takes time.

“Advocacy usually is a campaign; it’s not like going through the cafeteria line and saying, ‘I’ll take this, that and the other thing,'” Perrin said. “It can sometimes be a slog.”