I strongly urge DMAS to reconsider the posed changes related to CPST for currently replacing MHSB and certain expectations related to PSR and moving to the implementation of The Clubhouse model.  The changes pose serious risks to client care, system sustainability, and the Commonwealth’s long-term fiscal health.

These services rely on Medicaid reimbursement to fund facilities, transportation, and trained staff. The current posed rates which are presented as budget neutral, will result in program closures and staff leaving the field, including at CSB’s. For example, the current posed rates for a QMHP provider on a CPST equates to $0.15 less on the billable hour compared to the current rate for MHSB services.  DMAS has acknowledged that Medicaid may not cover the full cost of services for consumers (ie the Clubhouse Model does not deny care to anyone seeking services with members being able to come and go as needed to support their welfare, however MCO’s do not maintain this stance). Specifically, for PSR services, DMAS has acknowledged that grant funding will likely need to be pursued resulting in an even higher level of administrative burden, which has already been significant and is ever-increasing. No grant options have been identified to supplement cost.

CSB’s already face high vacancy rates and turnover. The redesign introduces new credentialing, service provision increases and training requirements without matching reimbursement increases, which impacts competitive salaries and the ability to retain needed staff to provide vital services to individuals with SMI.  The posed changes for CPST teams are expecting additional training time, for CPST teams to provide crisis services in addition to normal services (which costs more but there is no consideration for this in the rate of reimbursement), supervision requirements, and administrative tasks and oversight, paired with capping client services and maximum hours of care a client can receive per month, as well as caseload caps. The changes in rate structure for both MHSB to CPST services, and PSR to the Clubhouse Model, do not cover the overhead that CSB’s must carry to keep programs open as both rates demonstrate a decrease in compensation compared to current rates, as well as expecting more training and supervision time leaving less time for clients to receive needed care. CSB’s cannot operate programs at a loss. If CPST is underfunded, community-based programs will shutter, leaving gaps that private providers will not fill (especially in rural or low-income regions where CSB’s are the only safety net).

When services close, clients do not disappear. They shift into higher-cost systems. CSB’s will bear the fallout through increased crisis stabilization, hospital diversion, and emergency interventions, all of which are costlier and resource intensive. Local governments will absorb these costs through law enforcement, jail diversion, and emergency medical systems. The fiscal burden will shift downstream to counties and cities that are already struggling to fund behavioral health. Furthermore, attempting to limit the time of 4-12 months for service provision for CPST teams, does not seem reasonable or recovery oriented for individuals with SMI, who often present with extensive trauma history, as well as co-occurring substance use disorders. The posed regulations limit service options (ie you cannot receive the Clubhouse Model of psychosocial rehabilitation or ARTS services if receiving CPST services). These services are very different in nature from posed CPST services, and a client should be allowed to pursue additional services that target their needs.  

Research shows for every 10 clients who lose current services and relapse into crisis, the system spends more in a month of hospitalization than in a year of community-based rehabilitation. What looks like savings on the Medicaid line item will actually cost Virginia more both in dollars and community well-being. While Virginia is attempting to help individuals receive “Right Help, Right Now,” the posed changes are set to limit the ability to receive needed behavioral health treatment at all when no providers are left standing.