Laura I. Gerald, MD, MPH

Laura I. Gerald, MD, MPH

2001-2002

President, Kate N. Reynolds Charitable Trust, Winston-Salem, North Carolina

Continuing her commitment to improving the health and well-being of vulnerable populations, Dr, Gerald is the Executive Director of the North Carolina Health and Wellness Trust Fund. She will implement the policy direction established by the Health and Wellness Trust Fund Commission to advance preventive health goals in North Carolina and will provide strategic leadership to the organization. Dr. Gerald previously served as a physician consultant to the North Carolina Community Care Program. This project was an innovative, nationally-recognized vehicle to better manage the care of the Medicaid population. Her responsibilities included assisting in the design and implementation of population-based disease management programs and other quality improvement initiatives. She is also a pediatrician and continues in part-time general practice.

Dr. Gerald received her medical degree from Johns Hopkins University School of Medicine in 1995, and completed a residency in Pediatrics at the Johns Hopkins Hospital in 1998. She received her M.P.H. at the Harvard School of Public Health 2002 as a CFHU Fellow.

2010

May 20, 2016 | Kate B. Reynolds Charitable Trust

Laura Gerald was recently named as the new President of the Kate N. Reynolds Charitable Trust, a statewide foundation committed to improving the health and quality of life of financially disadvantaged North Carolinians.

An Evaluation of Mental Health Policy Changes: Implications for Medicaid Policy Development in North Carolina

Abstract:

Medicaid is a joint federal and state entitlement program that provides health care coverage for certain groups of poor persons, including single parent families, persons over age 65, and the disabled.  The North Carolina Division of Medical Assistance (DMA) administers the Medicaid program for the state.  In North Carolina, Medicaid predominantly serves racial minorities.  Although the aged and disabled disproportionately account for expenditures, fifty-seven percent of Medicaid beneficiaries are children.

Although Medicaid coverage for children in North Carolina is comprehensive and quite adequate, primary care providers have identified several problems with mental health access and reimbursement.  Historically, most of the outpatient mental health services were provided at public Area Mental Health Centers that are distributed throughout the state. Medicaid generously reimburses Area Centers and allows relatively unlimited visits.

In the late 1990's, primary pediatric providers and pediatric psychiatrists became increasingly frustrated with perceived mental health access problems despite the generous benefits packages.  Many communities experienced long waiting lists for Area Mental Health Centers and had inadequate numbers of mental health providers who are capable of working with children.  Furthermore, poor coordination and integration of care among mental health providers and pediatric providers further diminished access to care.

In response to these concerns, the North Carolina Pediatric Society established a Mental Health Task Force in 1998. As a result of the Task Force's efforts, two policy changes were recommended to the Medicaid program that were designed to increase the number of private mental health providers and increase collaboration among primary care providers and mental health practitioners.  Ultimately, these mental health policies were enacted by the state legislature and implemented by the DMA.

The first policy expanded "incident to service" rules to allow licensed clinical social workers (LCSW) and clinical nurse specialists (CNS) with psychiatric certification to provide mental health services under the direct supervision of a physician.  In this case the physicians billed for services provided by these licensed practitioners.  The second policy allowed independently-practicing licensed clinical social workers, nurse practitioners and clinical nurse specialists with psychiatric certification to directly enroll as Medicaid providers and bill for their services.  The objective of this project was to evaluate the effects of the mental health policies with respect to their impact on Medicaid expenditures and on access to mental health services.

Methods:

Data were obtained from Medicaid paid administrative claims for 2000 and 2001. Medicaid collects claims data on enrolled providers only.  Claims for services performed by practitioners working "incident to" a physician are submitted by the physician.  Therefore, no specific data were available for "incident to service" practitioners.  Given the inability to identify the "incident to service" practitioners, an analysis could only be conducted for the direct enrollment policy.

The data analysis compared Medicaid mental health expenditures prior to policy implementation to expenditures for the corresponding period after policy implementation.  Data sets were restricted to specified mental health procedure codes for recipients aged 0 to 21.  After correcting for consistency in the procedure codes, paid claims for July through December 2000 were compared to paid claims for July through December 2001.

Results:

For the period between July 2000 and December 2000, Medicaid paid $982,755 for outpatient mental health services for the pediatric population.  Medicaid began reimbursing licensed mental health practitioners who directly enrolled and billed for their services in February 2001.  For the period between July 2001 and December 2001, Medicaid paid a total of $2,927,948 for the corresponding procedure codes for all enrolled providers.  The portion paid to the newly enrolled practitioners was $884,205.  Therefore, during the periods examined, mental health expenditures tripled after implementation of the direct enrollment policy.  Forty-six percent of that increase is due to claims paid to those newly enrolled practitioners.

Conclusions:

An evaluation of recent mental health policy changes in the NC Medicaid program confirmed that expenditures for mental health services increased after the policies were implemented.  The expenditure increases due to the new allowance for direct enrollment of licensed mental health practitioners were significant.  However, due to inadequate data collection, no conclusions about the impact of the "incident to service" policy change could be determined.  Further evaluation is needed to adequately determine the financial impact of this policy.

The Medicaid program has traditionally equated increased expenditures with increases in access.  However, the results of this evaluation did not conclude that access improved due to the policy changes.  The impact of the "incident to" policy on access could not be determined due to data limitations and inability to assess resultant expenditures.  The direct enrollment policy likely resulted in improved access, meaning that more mental health services were not utilized by those who needed them.  However, increased expenditures could also represent cost shifting from public Area Mental Health Centers to private providers more so than improved access.  Further evaluation is needed to assess the impact of these policies on access to mental health services.

This mental health policy evaluation also has implications for the overall policy development process.  The DMA has received a legislative mandate to apply more rigorous evidence-based standards to policy formulation and to periodically reassess policy outcomes.  This evaluation supports the need for a uniform policy development process that includes a literature review, adequate data collection, financial projections, and mechanisms for provider and consumer feedback.

Faculty Preceptor:

Jeffrey Simms, M.P.H., Assistant Director, North Carolina Division of Medical Assistance