The ABCs of Access
Rene Pinero says the state’s recent action on mental-health access — in the form of a sprawling, multi-faceted bill dubbed the Mental Health ABC Act — couldn’t have come too soon.
“Unequal access to community-based services for people experiencing a mental-health crisis, long waits in emergency departments before an inpatient psychiatric bed is located, better enforcement of mental-health parity laws, and equitable payment to providers of mental healthcare have been ongoing issues in the Commonwealth,” said Pinero, vice president of Behavioral Health and Clinical Operations at the Mental Health Assoc. (MHA).
The ABC in the bill’s title stands for Addressing Barriers to Care, and Pinero said the act’s passage by both houses of the Legislature on Aug. 1 — and approval by Gov. Charlie Baker, who signed it into law on Aug. 10 — represents “a big step toward breaking down such barriers and creating an integrated pathway that starts at the top to good mental healthcare and emotional wellness for all.”
Lawmakers who promoted the Mental Health ABC Act said it was driven by the recognition that mental health is as important as physical health and should be treated as such. The final conference report proposed a wide variety of reforms to ensure equitable access to mental healthcare and remove barriers to care by supporting the behavioral-health workforce.
“Unequal access to community-based services for people experiencing a mental-health crisis, long waits in emergency departments before an inpatient psychiatric bed is located, better enforcement of mental-health parity laws, and equitable payment to providers of mental healthcare have been ongoing issues in the Commonwealth.”Rene Pinero
“The healthcare system in Massachusetts is only as strong as its weakest link, and for far too long, mental healthcare has been overlooked and underfunded,” said state Sen. Cindy Friedman, Senate chair of the Joint Committee on Health Care Financing. “This legislation confronts this reality with the most comprehensive mental healthcare legislation the Commonwealth has seen in recent years, and it builds off of the historic investments we made in this care system over this past two-year legislative session. Of particular importance to me, this bill will finally provide the state the tools it needs to enforce existing mental health parity laws and it will address the emergency department boarding crisis that’s impacting too many of our children and their families. I have long believed that Massachusetts should deliver affordable, high quality, and accessible care to its residents, and this includes mental health care.”
State Sen. Adam Gomez, who represents the Hampden District, noted that “mental-health issues touch every single family in our Commonwealth. For many, especially those in the BIPOC community, there can be shame or fear associated with seeking help to address those issues. The legislation passed by the Senate will improve access to mental and behavioral healthcare, removing barriers to some of the most challenging aspects of the system.”
A Comprehensive Approach
Pinero called attention to several of the most prominent planks in the legislation:
• It calls for insurances to cover a mental-health wellness examination, defines various levels of care available (or being made available) in the Commonwealth for mental health, and addresses the issue of prior authorization for acute mental health care.
• It directs those under contract to a Medicaid-managed care organization or primary-care clinician plan, as well as others similarly insured, to cover the cost of medically necessary mental-health acute treatment, community-based acute treatment, and intensive community-based acute treatment. It says the individual involved “shall not require a preauthorization before obtaining treatment, provided, however, that the facility shall notify the carrier of the admission and the initial treatment plan within 72 hours of admission.”
• The act is comprehensive in its approach to providing access to mental- and behavioral-health services across all populations, from students to first responders to veterans, and oversight at every level to evaluate how effective and well this approach is being implemented and if culturally competent care is being delivered. Its reach is broad, from addressing the needs of prisoners to eliminating stigma around seeking behavioral-health treatment to specifics of what insurances need to cover.
High-quality, affordable, and accessible mental and behavioral health is a right that should be afforded to any citizen of the Commonwealth regardless of where they live, socio-economic status, race, ethnicity, gender, or any other factors that may impact their ability to access it.”Sen. Adam Gomez
• It requires the state to create regulations that will require all acute-care hospitals licensed to provide, or arrange for, licensed mental-health professionals during all operating hours of an Emergency Department or a satellite emergency facility “to evaluate and stabilize a person admitted with a mental-health presentation” and to refer such individuals for appropriate treatment or inpatient admission.
• It also addresses equitable payment for behavioral-health services to providers as well as requires detailed reporting of services provided.
• It aims to reduce waiting times in ERs and other settings for those in need of inpatient psychiatric services as well those needing a more stepped-down level of care. It calls for the establishment of online portals through which healthcare providers can access what behavioral-health services as well as beds are available in the state for those waiting for such placement.
• It also calls for the establishment of an interagency review team to collaborate on complex cases where there is a need for urgent action to address the lack of consensus or resolution in placement of an under-22 individual who is disabled or has special needs.
• It establishes an Office of Behavioral Health Promotion within the Executive Office of Health and Human Services whose duties will include assessing the behavioral-health needs of veterans and municipal and state police, firefighters, and public-safety personnel, and establishing a statewide evidence-based or evidence-informed education and awareness initiative.
• The initiative’s duties include identifying best practices for preventing suicide and undertaking other steps such as creating a student stakeholder advisory committee to work in collaboration with the Department of Elementary and Secondary Education to develop and implement school-based programs that promote student mental health and well-being.
• Other issues address changes to the board of registration for social workers, the development of standards to ensure that expulsion and suspension of a child in early education or care are “limited to extraordinary circumstances,” and allowing the state’s insurance commissioner to impose a penalty to any eligible carrier in violation of state and federal parity laws around substance use and mental-health conditions.
• It also requires that the state provide benefits on a non-discriminatory basis for children and adolescents under the age of 19, insured through Medicaid, for the diagnosis and treatment of mental, behavioral, emotional, or substance-use disorders that “substantially interfere with or substantially limit the functioning and social interactions of such a child or adolescent.” It also provides for mental health screenings for children in foster care.
“I’d also like to thank the countless individuals, families, advocates, providers, and others who stood up for the common-sense idea that mental health is just as important as physical health, and to everyone who has fought for mental-healthcare reform in Massachusetts and never gave up.”
Some of the act’s provisions have been already underway in Massachusetts, but elements of the legislation provided further clarification of how they will be enacted, possibly funded and who will provide oversight, Pinero noted.
This includes the designation of at least one 988 crisis hotline center to operate 24/7 to provide crisis-intervention services and crisis-care coordination to individuals accessing the federally designated 988 suicide-prevention and behavioral-health crisis hotline. The act also calls for community behavioral-health centers that can be part of this care coordination and response, as well as community crisis-stabilization programs that may provide an alternative to hospitalization by providing individualized and focused treatment in a more home-like setting.
The act also requires that school committees and Commonwealth charter school board trustees ensure that every school under their jurisdictions have a written emergency-response plan to address both medical and behavioral-health crises to reduce the “incidence of life-threatening medical emergencies and behavioral-health crises and to promote efficient and appropriate responses to such emergencies.”
“Supporting the workers that provide these essential services, which this legislation does, is paramount to ensuring the system is functioning in the best possible way,” Gomez added. “High-quality, affordable, and accessible mental and behavioral health is a right that should be afforded to any citizen of the Commonwealth regardless of where they live, socio-economic status, race, ethnicity, gender, or any other factors that may impact their ability to access it. This legislation will bring us closer to being able to provide top-notch care to our constituencies, and I couldn’t have been more excited to support it.”
Never Give Up
Baker’s signature on Aug. 10 wasn’t in doubt, but medical leaders still expressed great relief at the ABC Act’s passage into law.
“This is a groundbreaking day for mental healthcare in the Commonwealth,” said Steve Walsh, president and CEO of the Massachusetts Health and Hospital Assoc. “This law is grounded in systemic changes to guarantee long-promised parity, bolster the behavioral-health workforce, and — perhaps most critically — better address the mental health needs of children. Behavioral health has been a top priority of every healthcare organization in Massachusetts since before the pandemic began, and they remain deeply committed to ensuring that every community member has access to the resources and care they need.”
Dr. Theodore Calianos, president of the Massachusetts Medical Society, added that “the COVID-19 public-health crisis amplified myriad challenges our patients face in accessing timely, high-quality, comprehensive mental healthcare, challenges that can be especially insurmountable for the most vulnerable residents of the Commonwealth. Provisions in this bill will empower patients and physicians to make decisions that will more often lead to optimal outcomes for those who need and seek mental healthcare.”
Dr. Grace Chang, president of the Massachusetts Psychiatric Society (MPS), agreed. “With the passage of the Mental Health ABC Act, we are at the dawn of a new day for mental-health treatment in the Commonwealth,” she said. “We are now leading the nation in parity for mental healthcare just when it is most needed. MPS congratulates the Massachusetts Legislature on its visionary measure and looks forward to assisting in its implementation.”
On Aug. 1, state Senate President Karen Spilka talked about making a decision many years ago to share the story of her family’s struggle with mental illness, which she believes encouraged others to speak up for accessible, high-quality mental healthcare.
“We all deserve to have access to the mental healthcare we need, when we need it,” she said in thanking the legislative leaders who worked toward the final bill. “I’d also like to thank the countless individuals, families, advocates, providers, and others who stood up for the common-sense idea that mental health is just as important as physical health, and to everyone who has fought for mental-healthcare reform in Massachusetts and never gave up.”