Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of #CrisisTalk. You can reach her at .
Psychiatrist Joe Parks, M.D., says most states have a behavioral health system that’s “underfunded and understaffed.” Dr. Parks is the medical director of the National Council for Mental Wellbeing. He’s also the former director of Medicaid in Missouri. During his tenure as state Medicaid director, he found that people with seemingly similar mental health challenges were getting the same length of hospital stays. On its face, that might appear to make sense, but Dr. Parks quickly points out the calculus rarely considered vital elements like the person’s ability to perform daily activities, whether they were sleeping, eating, and if they could fulfill the roles they did before the crisis, and if they had an adequate support system.
He gave the example of two twelve-year-olds, both hospitalized because they’d made a suicide attempt and both insured by Medicaid. However, one girl was hospitalized previously, and her parents attended none of the family sessions. The other girl experienced her first hospitalization, and a parent attended three sessions. “The girls are likely going to need a differing intensity of ongoing services,” says Dr. Parks, “because they have divergent risks of harm and recovery environments.” More intensive care like a residential treatment program, for example, might best serve the first preteen after discharge.
Yet, like in many states across the nation, that wasn’t what was happening in Missouri. Dr. Parks says stand-alone facilities often treat people and send them on their way without a warm handoff or any sort of continuous treatment planning or follow-up. That’s why he required Medicaid Managed Care Organizations (MCOs) in the state to use the Level of Care Utilization System for Psychiatric and Addiction Services known as LOCUS or CALOCUS (the child and adolescent counterpart). There’s a third instrument, ECSII, that was developed in 2019 for early childhood. Other states are following suit. For instance, as of January, California requires health plans and insurers to use these tools.
Figuring out what level of care a person needs, says Dr. Parks, means examining multiple dimensions of their life. The LOCUS service tool algorithm does just that, considering a person’s history, social determinants of health, and comorbidities—psychiatric, substance, and medical. While director of Medicaid in Missouri, Dr. Parks required MCOs to provide at least the level of care the person scored on LOCUS. “If the MCO didn’t have that level of care in their continuum,” he says, “they had to authorize the next higher level.” He points out that matching people with the level of care they need is better for outcomes and is more cost-effective than defaulting to a higher level of care simply because what the person needs isn’t available.
“This is why,” he says, “communities need to have a full continuum of care.”
A widespread issue in behavioral health is that reimbursement rates haven’t kept pace with those by insurance for other specialties. There are many layers as to why lack of parity has persisted, like Medicaid’s lnstitutions for Mental Diseases Exclusion rule, which many states argue creates a barrier to care and system inefficiencies. Dr. Parks notes that part of the problem has also been that providers and insurers rarely speak the same language. He believes sharing a common tool like the LOCUS could help bridge the gap and foster standardization, which is much needed in behavioral healthcare. However, if states require all parties to use the same tool, Dr. Parks warns there will likely be some pushback. That’s what he experienced in Missouri. MCOs initially resisted, but months later, they begrudgingly admitted that the LOCUS family of tools was useful. “Their case managers,” he says, “liked the instruments because they helped them to ask the right questions.”
While LOCUS helps reduce discrepancies, there still will be some, which is why, says Dr. Park, continued communication, training, and a feedback loop are critical. For example, he notes that providers tend to score patients as needing a higher level of care while Medicaid MCOs often score patients as needing a lower one. “That’s the gray-zone,” he says. “Providers are fearful of getting sued, so they ramp up to a higher acuity, and MCOs have an incentive to score lower because then they pay less.”
The latter was highlighted in the 2019 landmark decision in Wit v. United Behavioral Health. The United States District Court in the Northern District of California found that when adjudicating claims for outpatient and residential inpatient behavioral health treatment, the insurer defaulted to a lower level of care at which a person could be safely treated—even if that level of care was less effective for the person.
What’s especially noteworthy is that while the decision involved a commercial insurer, the Court cited the Centers for Medicare and Medicaid Services benefit policy manual and highlighted how United Behavioral Health incorporated parts of CMS’ manual but made alterations to allow for narrower coverage.
Magistrate Judge Spero concluded that United Behavioral Health’s guidelines provided more limited coverage than generally accepted standards of care. He said this “gave rise to a strong interference” that their financial interests hindered the guideline development process. Denial letters also showed that United Behavioral Health focused on acute symptoms rather than treating the members’ underlying conditions. This falsely perpetuates the concept that a person is either in crisis or not, and, correspondingly, needs care or doesn’t.
Besides the CMS manual, the Court noted that among the generally accepted standards of care—presented by both the plaintiffs and defendant—were the American Society of Addiction Medicine Criteria (ASAM), the Child and Adolescent Service Intensity Instrument (CASII), LOCUS, and CALOCUS.
Dr. Wesley Sowers developed the LOCUS algorithm, with input and support from the American Association of Community Psychiatrists (AACP), in 1996. However, it has stood the test of time, with minor adjustments to the level of care and service intensity descriptions. There’s also an automated version, commonly preferred by hospitals and treatment centers. In 2019, Dr. Sowers clarified to #CrisisTalk that while the system is often said to have six assessment dimensions, there are actually seven. The dimensions focus on risk of harm, functional status, comorbidity—medical, addictive, and psychiatric, recovery environment (this dimension has two subscales: level of stress and level of support), treatment and recovery history, and engagement and recovery status.
Each dimension’s rating ranges from the lowest to the highest needs: 1-5. When the clinician adds them together, the result is a composite score that reveals the person’s level of needs and the level of care they require. Scores can range from 7 to 35.
Using common language on service intensity definitions bridges the gap between providers and payers. It can also help shift the United States toward a national standard, which Dr. Parks says has long been needed. A frequent saying in behavioral health is: “If you’ve seen one state’s behavioral health system, you’ve seen one state’s behavioral health system.” Yet, even within a state, standardization is a rarity. For instance, Dr. Kevin Huckshorn, known in the mental health community as a “hospital fixer,” told #CrisisTalk last October that while forensic hospitals throughout the nation are moving slowly toward evidence-based practices, uniformity isn’t the norm.
“If you broke your arm,” says Dr. Huckshorn, “you’d expect the same quality of care at any of your nearby hospitals.” “That isn’t yet true in behavioral health.”
In 2019, the FCC moved to establish 988 to mirror 911 for mental health, substance use, and suicide crises, giving Americans an easy-to-remember three-digit number. The objective was to rapidly match people to the care they need and parity—“of which,” says Dr. Parks, “standardization is a key component.” For that to happen, providers, commercial payers, Medicaid, Medicare, and MCOs need to be on the same page. That’s why he and his colleagues at National Council for Mental Wellbeing recommend the LOCUS family of tools in their Roadmap To The Ideal Crisis System. The recently released publication examines behavioral health crisis response best practices, measurable standards, and essential elements.
Dr. Sowers told #CrisisTalk in 2019 that while the use of LOCUS is widespread, it isn’t used as comprehensively as it could be. He developed the system not only to span the array of services but also the care continuum. It’s a device, notes Dr. Parks, that can help inform states on how to build out their crisis systems in anticipation of 988. Telecom companies must make the three-digit number live by July 16, 2022. “Data collection from the LOCUS family of tools,” he says, “can guide communities to know what they need in their crisis continuum.” It would give states ongoing feedback on trends and the array of services and treatments required to adequately meet their populations’ needs.
Some states are already evaluating their LOCUS data. Georgia is one of them. The state conducted a LOCUS analysis, looking at over a decade of data from the statewide crisis line—the Georgia Crisis and Access Line (GCAL)—of people who received a face-to-face crisis response, either in a facility or by mobile crisis. The study helped Georgia determine what services best fit the needs of their community. Out of 1.2 million calls, 431,690 needed a crisis response, of which the vast majority (86%) could stay in the community because the levels of care they needed were available:
Dr. Parks points out that continuity and standardization isn’t a one-and-done process; it’s ongoing. That’s why he and his partners at the National Council for Mental Wellbeing are developing a LOCUS advisory committee that will put together a foundational paper, providing background on the instruments and implementation considerations. They’ll also work with providers and payers on standardization and training to ensure alignment for all people, including youths. “It must be usable for everyone,” he says.
