Section 17 (Community Support Services) of the MaineCare Benefits Manual, rules that govern Maine’s Medicaid program, reimburses mental health providers for the high-intensity services that include community integration and rehabilitation for individuals with serious and persistent mental illness. These services are designed to “wrap around” people with serious and persistent mental illness. The goal of these particular services is to help those individuals develop the skills necessary to live and work successfully in the community. The only evidence to support the efficacy of these services is for those individuals diagnosed with psychotic disorders such as schizophrenia and schizoaffective disorder. Unfortunately, only 18 percent of the total Section 17 expenditures are for those people with a primary diagnosis of schizophrenia and schizoaffective disorder. This means the State of Maine is spending 82 percent of its Section 17 funds on treatments for which there is no evidence or outcome data to support their use based on the diagnosis.
The most common diagnosis for which Section 17 community integration and rehabilitation services are rendered is post-traumatic stress disorder. Although PTSD can be a very disabling disorder, the first-line treatment is psychotherapy and/or medications that are not covered under Section 17 but are covered under Section 65 (Behavioral Health Services).
Additionally, depressive (10 percent), anxiety (5 percent), and mood disorder (5 percent) not otherwise specified (NOS) account for 20 percent of total expenditures. So, 20 percent of Section 17 expenditures are rendered for NOS diagnoses, which make up an “umbrella category” clinicians use when individuals do not have symptoms that fit any single category in the “Diagnostic and Statistical Manual of Mental Disorders,” or DSM.
Generally, NOS (nonspecific) diagnoses are made more specific through ongoing evaluation and review of information. This process of clarifying diagnoses includes gathering information from family and significant others, where allowed; review of laboratory and other diagnostic studies; review of records from previous hospitalizations and providers; and skill to develop the clinical formulation based on the information. The diagnosis should be and often is clarified early in the treatment process. The fact that so many individuals with NOS diagnoses are served in our state under Section 17 would lead me to question the quality of clinical care that went into establishing these diagnoses. The percentage of those with NOS diagnoses has remained stable according to MaineCare claims data over the past two years. With quality clinical diagnostic evaluation, one would think the number of individuals with NOS diagnoses would be lower.
Clarifying the diagnoses beyond “not otherwise specified” is critical because evidence-based practice is based on specific diagnoses. So, in order to apply evidence-based care, it is critical the clinical evaluation process be of high enough quality to establish more specific diagnoses. Given the number of individuals with NOS diagnoses, it is possible some of these people have more severe illnesses than would be indicated by this lack of diagnostic specificity. Therefore, the new eligibility criteria allow for individuals who have diagnoses other than schizophrenia or schizoaffective disorder to be eligible for Section 17 services when there is evidence of similar severe dysfunction and risk as may be seen in those who have a primary psychotic disorder.
As evidenced by our state’s controlled substance prescription drug addiction problem, one can see the potential danger of not applying evidence to treatments for mental illnesses, the dangers of providing treatments merely because providers think the treatment would help or because patients like it. Therefore, the Maine Department of Health and Human Services has refined the MaineCare Section 17 rules to promote using these particular Section 17 services where there is clinical evidence to support their treatment efficacy.
Dr. Michelle Gardner, MD, is clinical director at the Dorothea Dix Psychiatric Center in Bangor.