Mental health care providers who say Optum Idaho is slashing services to line its pockets "don't have all the facts," a top state official says.
"They are just seeing their book of business change," said Lisa Hettinger, Medicaid administrator for the Idaho Department of Health and Welfare.
Hettinger joined Optum Idaho Executive Director Becky diVittorio and others to back the company in a meeting with the Times-News after a volley of complaints lodged by mental and behavioral health care providers.
Providers have said Optum is cutting services to mentally ill patients who then wind up in jail or the emergency room, is violating ethics by having out-of-state representatives dictate care in Idaho and is creating red tape that makes it harder for providers to do their jobs.
Hettinger said Optum isn't approving less care - it's simply shifting what care it allows. Optum actually has exceeded the amount of care the state requires, she said.
DiVittorio said evidence-based services for children have increased, individual therapy is up 30 percent, and the number of children getting family therapy has tripled. That's in addition to many new trainings and other services Optum is providing, she said.
Optum said complaints are being filed by only one sector of providers who rely on a treatment not proven to be effective.
Community-based rehabilitation services, known as CBRS, requires less education and licensure and has therapists go into the community with clients to build situational coping skills, Hettinger said.
A focus group examined the state's rising cost of mental health care and recommended the state steer its low-income mental health care services to a managed care model focused on "evidence-based" care, she said. In most cases, evidence does not exist to support CBRS, which was being used excessively as a one-size-fits-all treatment, Hettinger said.
DiVittorio agreed, saying it is now "absolutely the provider's responsibility to demonstrate medical necessity and appropriateness of services."
That drew a skeptical response from Jennie Fullmer, co-owner of Crosspointe Family Services in Twin Falls.
"How are we supposed to prove it works when they won't approve the service?" Fullmer told the Times-News. She said she would like to see the numbers DiVittorio cited about increases in service for children.
Fullmer said it's "ridiculous" for Optum to cast such a stone at CBRS providers.
"If I was going to complain about loss in revenue, I would have complained this time last year when they cut reimbursement rates by 20 percent," she said. " What we are complaining about is that the people in this community with major mental health issues cannot get the care they need. For them to defend themselves because they feel like we are whining because our bottom line has been hit is irresponsible."
In fiscal year 2013, before Optum took over, the state provided $113 million in total care, $78 million of which was billed under psychosocial rehab, now called CBRS. Providers say Optum has cut more than 30 percent of its CBRS clients.
State Rep. Fred Wood, R-Burley, chairman of the House Health and Welfare Committee, said providers unwilling to change will face consequences "just like any other business."
"I think the people who will succeed are the people who are willing to change their business model, understand what is coming and get the necessary certification." Wood told the Times-News.