|The Best Kept Secret|
|Saturday, 30 January 2010 04:39|
Tens of thousands of New Yorkers just dodged a bullet on New Year’s Day. The danger, however, was only postponed for three months. This all has to do with changes to New Yorkers’ access to mental health care they know nothing about. The public-private mental health system that serves everyone and every family that needs help with every kind of mental health problem is in jeopardy—and most New Yorkers have no idea there is even a threat.
I am talking about help that is not just for adults and kids with the most serious mental illness who require hospitalization. I am talking about help currently at risk in hundreds of New York State licensed community mental health clinics operated by not-for-profit organizations literally everywhere.
The organization I know best operates clinics in sixteen communities in every borough of the City and has numerous satellite clinics in other locations, such as public high schools, foster care agencies, and community centers. Right this minute and in any given week, over 91,000 New Yorkers are getting help from mental health clinics in their own communities. Two-thirds of these patients do not even know that the help they are receiving--at costs they currently can afford--is about to be put under a pressure-cooker that will threaten their access to treatment.
What is going on and why don’t New Yorkers know about it, especially when New York recently passed Timothy’s Law, a landmark Mental Health Parity Law?
Here is what is going on. State government is responsible for health care and that includes mental health care. For decades there has been public-private mental health partnership. It came to be as many changes occurred including the Big One. The Big One was the “de-institutionalization” of over 90,000 people, who until the late 1960’s lived their lives in state operated psychiatric hospitals: those buildings we see when we are out driving—driving across the Robert Kennedy (a.k.a Triborough) Bridge past Manhattan State Hospital and other similar foreboding old buildings across the state. 90,000 people! Today about 4,500 live their lives there and, encouragingly, the lengths of stay and numbers continue to shrink.
Serious mental illnesses did not go away. Treatment caught up to it—with amazing medications, day treatment programs, and supported housing. And by New York’s creatively getting behind community mental health clinics, many of which were family counseling centers decades ago.
Because the overwhelming majority of community clinics were run by non-government not-for-profit organizations, creating a partnership had to work for everyone. It had to work for those people coming out of those state hospitals and it had to work for other New Yorkers who needed help with the same problems you and I face: anxiety, depression, and the crises of life’s bumps in the road. Bumps like your child’s school telling you he has a behavior or learning problem and will not be promoted; like the end of a love relationship socking you in the gut; like not being able to get or hold a job; like the death of your parent, or child, or spouse, or partner.
So a system was created to serve everyone—not just those who were indigent or had been patients in state psychiatric centers. New York’s community-based public-private system is what is called today robust. Licensed clinics serve over 80% of all the people who use the mental health services licensed by New York State. This system operates parallel to the very private system of professionals who provide psychotherapy and mental health care in their private offices.
The public-private system is particularly robust because it has the capacity to know what results treatment is producing—it includes a Quality Assurance component. It is strong because the partnership is almost exclusively with not-for-profit organizations whose missions are to provide high quality mental health care. It is strong because community clinics have both psychotherapy and coordinated medication treatment under the same roof. It is strong because there is a true 24/7 response capacity. It is strong because the public-private system has built a continuum of services between out-patient clinics and in-patient hospitalization that includes day treatment, case management, community residences and supported apartments to deal with all levels of need.
The system has its weaknesses. Not enough people know what is available or how parts of the system work together. Evidence based treatments are just now becoming the standard. Physical health issues and mental health issues need to be addressed simultaneously more than they have been. Nevertheless, it is a system that meets critical needs and New Yorkers use it in very large numbers. And many, many smart and committed people are always working together to improve it.
Now, however, in an attempt to preserve a part of the system, the state may endanger access for two-thirds of the people who use the community clinics. The specter of stricter federal enforcement of the use of Medicaid funds has led to the State focusing Medicaid funds in a way that will no longer support out-patient care for the majority of users of clinic services. Up until now, creative work by New York’s policy makers, including more reliance on federal Medicaid funding, enabled the State to replace evaporating state and local tax money that had deficit funded mental health care for everyone who could not fully afford it—not just those “on Medicaid”. The partnership worked so well that providers agreed and the State was able to expect that no one could be turned away from a clinic because of inability to pay. As long as New York State was doing everything it could to maximize public funding, the not-for-profit partners were willing to also “deficit fund” their own shortfalls by raising philanthropic dollars and managing ever changing regulations, licensing re-certifications, and the intensive audits that come with public funding.
With the State’s plan to restrict Medicaid funds only to those patients with a certain type of Medicaid (“direct Medicaid”), the decades-old public-private partnership is threatened and, hence, so is access to care. Not-for-profits cannot raise more money in this economy and they will not exist only to serve those who are the most indigent--their long standing missions are truly democratic. Particularly family and child mental health providers are stunned by the options they are facing. They see how financially stretched working families are and their missions call on them to serve families of all social and economic backgrounds.
State officials are aware of these issues because advocates and coalitions of providers have been in open discussion with State representatives for over a year. Changes are now scheduled to start April 1 this year and providers will be forced to end their agreements with many managed care and insurance companies which barely pay half the cost of treatment. Public officials need to find a fairer way to fund behavioral health care for all those indigent families covered by Medicaid managed care companies and by the S-CHIP programs like Child Health Plus and Family Health Plus. These various plans cover about half those who are Medicaid eligible plus many working families. Otherwise we will have a system where some people with “direct Medicaid” coverage have their care reimbursed close to the cost, while those with “managed care Medicaid” have less than half their service cost covered. The same for working families with Child Health Plus and Family Health Plus.
How can half the eligible population have their cost covered and half not? Isn’t that crazy? How can not-for-profit organizations make up the shortfall in philanthropy in this recession? The answer is they cannot and, unless the managed care companies raise their rates, they will end their agreements to accept patients who have managed care coverage.
This creates a crisis for working families and individuals whose insurance has paid at least part of the cost with the balance made up by creative funding by New York and not-for-profits. This crisis will likely happen unless those managed care insurance companies are somehow enabled by the State to pay the reasonable cost of decent mental health treatment. Thousands of New Yorkers will be at a loss to figure out where they can go for mental health care. Perhaps “the market place” will solve these problems as some state health officials believe, but at what emotional and economic cost, and how soon? No one knows. And what happens if they are wrong? Playing Russian roulette with people’s mental health is not the way our state should be conducting itself. The State’s elected officials appear generally unfocused on this threat because they are still working out how to make New York State’s government work. They are the people who need to understand the implications and step up.
They should assure comparable rates of reimbursement for the mental health care of all Medicaid recipients and those covered by related publicly funded plans. Otherwise, access to care will be dramatically reduced at a time of enormous stress on families and individuals.
This is the worst possible time to toss the existing system up in the air and hope “the marketplace” will put Humpty Dumpty back together again.