THE DAWNING OF THE MENTAL HEALTH WALMART

THE DAWNING OF THE MENTAL HEALTH WALMART

Submitted to the New York Nonprofit News 12/6/14

Andrew Malekoff, Executive Director / CEO, North Shore Child and Family Guidance Center, Roslyn Heights, NY

New York State's scorched earth policy against mid-size and smaller community-based mental health centers and middle-class children and families has come to fruition on Long Island. Recently PSCH, a $100 million NYC-based agency led by a number former OMH officials, decided to let go of the mental health clinics of two long-standing and highly reputable Long Island-based agencies that they took-over just a few years ago with the blessing of OMH. Pederson Krag and Peninsula Counseling Center's (PCC) mental health programs are gone or on their way out, left to be scooped up by other willing suitors. My friend and colleague the late Herb Ruben, a true mental health advocate who led and built PCC during a 50-year period, must be rolling over in his grave.

OMH has been encouraging mergers (aka takeovers) for years. In this case, two deeply-rooted organizations with more than a combined 100 years on Long Island have seen their mental health services thrown to the wind to be picked up and absorbed elsewhere, never to retain what took the better part of a century to build, a strong, trusted and undeniable presence in the local community.

This is the dawning of the age of the Mental Health Walmart. We are in early stages of a sad time of proliferating Medicaid mills, where children and adolescents with mental health problems will be shuffled along a conveyer of would-be evidence-based care administered by fee-for-service workers with no time to address crisis situations or to make even adequate collateral contacts with schools and other relevant people in the children’s lives. Middle-class families are being pushed out of the so-called “system transformation” process and poorer families are seeing the quality of care erode into to a series of half hour, revenue-maximizing, individual sessions.

The transition from a gold standard to a bronze standard of care is well underway. And, this is happening at the same time that almost $6.5 billion is being thrown at the Medicaid-driven acronym-of-the-year DSRIP – Delivery System Reform Incentive Program, a hospital-conglomerate-run initiative with the admirable goal of reducing emergency room visits and hospital readmissions, for Medicaid patients, of course. Another $1.2 billion is being made available for capital projects.

The other acronyms receiving mere millions are the $7 million to CTAC – Children’s Technical Assistance Center that trains agencies how to best serve Medicaid clients and send those with private insurance packing.  And, most recently on board is the $30 million to VAP – Vital Access Provider initiative aimed at helping agencies that are on life support to find ways to become fiscally self-sustaining on a diet of Medicaid-only clients or take steps to be taken over as Pederson Krag and Peninsula before them. And, oh yes, there is another acronym I almost forgot to mention. That is OT – Overtime. According to NYS Comptroller Tom DiNapoli, the New York State Office of Mental Health spends $100 million annually on overtime expenses.

At North Shore Child and Family Guidance Center, founded in 1953, the only specialty children’s mental health agency on Long Island, we have not received an increase in our Article 31 contract funding in more than 30 years.  If not for our community supporters we would have disappeared long ago, along with our sister agencies. A very small percentage of the billions being spent could make a difference and would go a long way to sustaining needed children’s mental health services on Long Island. But all appeals continue to fall on deaf ears, from the governor to the legislators to the commissioners.

Hello, hello, anyone out there! Does anyone in Albany care?

NEW VAP FUNDING SKIRTS THE ISSUE OF UNIVERSAL ACCESS

New VAP funding skirts the issue of universal access by Andrew Malekoff in the New York Nonprofit News, November, 25, 2014 http://www.nynp.biz/index.php/points-of-view/23292-new-vap-funding-initiative-skirts-issue-of-universal-access

By Andrew Malekoff, Executive Director and CEO, North Shore Child and Family Guidance Center Recently, I participated in a New York State Office of Mental Health Clinic Vital Access Provider (VAP) webinar. The webinar is a first step towards Article 31 mental health clinics applying for funding to preserve long term critical access to community-based mental health services. A total of $60 million in funding, over a three year period, is available. The intention of the VAP funding opportunity is for community-based mental health clinics that are “fiscally challenged” to develop plans that will demonstrate fiscal viability after three years. The funds can be used for such things as incremental costs for staffing and billing software, for example. Each clinic that receives a VAP award will be assigned a “strategic planner,” who would be a financial specialist, to help them to complete their final application, to include measurable outcomes. The ongoing achievement of measurable metrics will be tied to continued payments to agencies that have been awarded funding. The ultimate goal of the project, whether through mergers, improved efficiencies such as centralized scheduling, or agency sharing of back office functions, will be to ensure long term fiscal viability. I thought that the webinar was very informative. Webinar participants were given an opportunity to ask questions by typing them into a chat box function during the presentation. At the end of the almost two hour webinar, the moderator thanked the participants and concluded the session by stating that all questions had been addressed. Not so! Here are three questions that I typed in that the moderator did not acknowledge or respond to: Is the VAP funding initiative biased against middle class and working poor non-Medicaid children and their families who have no other viable access to labor-intensive community-based mental health care? Our specialty children's mental health agency [North Shore Child and Family Guidance Center] works with approximately 68% non-Medicaid and 32% Medicaid and Medicaid Managed Care families? Would a viable VAP proposal look to severely restrict access to care for children in Nassau County who need our outpatient care? It appears that you are supporting mergers. Is there any concern about what has come of the New York City-based PSCH takeovers in Nassau and Suffolk Counties? I felt that I had to ask these questions since, in my attending one webinar after another sponsored by OMH’s Children’s Technical Assistance Center (CTAC), the issue of universal access to children’s outpatient mental health care is routinely skirted. The sole focus of OMH webinars, regarding children in need of mental health care, are Medicaid-eligible children. North Shore Child and Family Guidance Center is a proponent of universal access for children and their families. New York State is not. On the issue of access to care, earlier in the year I asked Governor Cuomo about this and he directed my letter to OMH Commissioner Dr. Ann Marie T. Sullivan, who responded by stating that there is a work group looking into the issue of the non-Medicaid population. One outcome would be to get commercial insurers to increase their rates which, on average, are significantly lower than Medicaid rates. However, the State Department of Financial Services, within which the State Insurance Department is subsumed, does not have the authority to regulate commercial rates. Statute change, which is unlikely, would be required for this to happen. Presently, commercial insurance network adequacy, including for behavioral health care, is monitored every three years by the Department of Financial Services. However, I think it is unlikely that this will lead to significant penalties that would bring about change for entities that do not provide adequate networks of care. After all, the health insurance lobby is well-healed and well-connected in Albany. On the issue of mergers, a few years ago New York City-based PSCH took over Pederson Krag in Suffolk County and Peninsula Counseling Center in Nassau County, both well-established and well-respected community-based mental health agencies on Long Island. When a larger entity takes over a smaller one, the smaller one’s board of directors is dissolved and, at best, becomes an advisory committee, with a few select board members joining the larger entity’s board of directors. This is a step toward diluting the local community’s investment in the organization and its mission. It appears that PSCH has given up on Pederson Krag and its clinics are being dispersed and made available to other interested parties. Will this also be the fate of Peninsula Counseling Center? What are the consequences of decades of dedicated professional and lay leaders building a community-based culture, and then having it demolished by a takeover by a $100 million dollar organization that did not take. And, so, I thought it was a reasonable question to ask the VAP moderator whose agenda would appear to promote mergers and takeovers. What do you think?

$94 Million in Overtime or Universal Access to Mental Health Care?  You Choose

Andrew Malekoff

New York Nonprofit Press - May, 2014

For three decades New York State has been systematically marginalizing middle class and working poor families who have children with serious mental health problems. This is a truth that the public is unaware of unless you have a child who is refusing to go to school, cutting herself, paralyzed by anxiety, deeply depressed or suicidal. Because mental illness is stigmatized, the reality of the State’s neglect has been obscured from view.

We continue to treat illnesses above the neck differently than those below the neck.  People with mental health problems, and their families, often feel a sense of shame and suffer in silence, while people with physical health problems evoke the sympathy, support and comfort of others.

 

In 1991, New York State implemented a plan to use Medicaid dollars to fund outpatient community-based mental health services. That approach, also known as Medicaiding-the-system, is gone.

Medicaiding-the-system was a combination of a base Medicaid rate applied for each outpatient community-based mental health clinic visit for Medicaid recipients only and supplemental dollars paid on top of each base payment to subsidize non-Medicaid consumers (known as Comprehensive Outpatient Funding or COPS). This approach to support community-based agencies was developed to replace local assistance or deficit-financing.

Local assistance was a simple and sensible public-private financing partnership. The partners were the State and County governments (through government funding), mental health consumers (through third party and fee-for-service revenue) and the local community (through fund-raising that was a part of the local assistance government contract). Local assistance funding insured that all stakeholders chipped in their fair share to support an essential community-based service.

In 2009, New York State announced that the Medicaid-bankrolled COPS approach of financing community-based clinics had the inadvertent affect of propping up commercial insurers who were paying substandard rates. Having uncovered that festering wound, OMH got to work on creating a new financing plan that they referred to as clinic restructuring or clinic reform.

The clinic reform plan raised the Medicaid-base rate, added new rates for previously unfunded or underfunded services (known as Ambulatory Patient Groups or APGs), and phased out the supplemental COPS Medicaid rate over a four-year-period that recently came to an end. The Medicaid base-rate and APGs now apply only to those families who have straight Medicaid and Medicaid managed care insurance.

In my discussions with New York State officials about the devastating consequences of the clinic reform plan for middle class and working poor families who do not have Medicaid insurance, I was advised that community-based mental health centers must re-negotiate rates with commercial insurers. That is nothing new. It is common practice. The state officials advised me that if the commercial insurers do not raise their rates to sufficient levels that will help to cover the cost of the services provided, then we should terminate our contracts with them.

Community-based providers routinely re-negotiate rates with the managed-care companies which represent private health insurers. However, they rarely agree to rates that come close to covering the cost of service. As one managed-care representative told me, “C’mon, we’re hurting too.” And, he said it with a straight face, despite record profits. State officials told me that community-based agencies like North Shore Child and Family Guidance Center, a specialty children’s outpatient clinic where I have worked for 37 years, should change their payor-mix. Payor-mix is a euphemism for terminating contracts with private health insurers and, consequently, denying service to thousands of children who need us.

When I pressed him on this, his response was that “the marketplace will take care of it,” referring to private practitioners. But mental health providers know that private child psychiatrists and other private behavioral health practitioners will not accept substandard rates or take on the labor-intensive work required to address the needs of children with serious mental illness (e.g. collateral contacts, crisis intervention, etc.) Nevertheless, commercial health insurers must by license demonstrate “network adequacy.”

Network adequacy refers to a health plan's ability to deliver the benefits promised by providing reasonable access to a sufficient number of in-network primary care and specialty physicians, as well as all health care services included under the terms of the contract. The truth is that many health insurers do not have adequate mental health care networks despite the voluminous number of names on their rosters. But tell me, really, what private citizen or community-based nonprofit can be successful in advocating for the revocation of licenses of private health insurers with the millions of lobbying dollars backing them up? Good luck!

The truth is that for many families, when it comes to seeking mental health care for their children, the process of finding help is a shell game aided and abetted by New York State. New York State claims that they cannot provide additional local assistance funding to help to subsidize universal mental health care in community-based clinics, which must also raise funds by contract, to support these vital services. Consequently many clinics are turning away all but Medicaid applicants for their services. But, is it true that New York State cannot offer local assistance support?

In a recent report issued by NYS Comptroller Thomas DiNapoli, it was revealed that the New York State Office of Mental Health runs up annual overtime expenses of $94 million a year. And, this is happening at the same time that the state is footing the bill for nonprofit community-based mental health clinics to enroll in state-sponsored efficiency classes that are a part of the State Office of Mental Health’s Clinical Technical Assistance Center (CTAC) initiative.

The goal of the efficiency classes is to improve the bottom-line by implementing centralized scheduling, open access and collaborative documentation. Fair enough. However, CTAC trainers have joined the state officials’ chorus about marginalizing the middle class and working poor. One CTAC trainer told me, during a recent webinar when I raised the question about the discrepancy in reimbursement rates, “You must change your payor-mix.”

Can you imagine how much savings there would be if OMH took the efficiency classes and were just a little bit more efficient with their use of overtime; and, how much of that savings could go towards supporting universal community-based outpatient mental health care for children?

And, keep in mind that that OMH’s excessive annual overtime expenditures presents New York taxpayers with a pay now and pay later scenario. We pay today for overtime and we will pay later for elevated pension benefits for State employees, a number of whom have left the Office of Mental Health to take on lucrative administrative positions with large conglomerates that state officials encourage smaller clinics to “merge with”; a euphemism for “be taken over by”.

To sum up, the State claims that there is no additional local assistance funding for community-based clinics to provide universal mental health care; clinics are then “encouraged” to take State-funded efficiency classes to reduce their cost of service by dropping underinsured middle class and working poor clients; The New York State Office of Mental Health generates overtime expenses of $94 million per year (plus increased employee pension benefits in perpetuity, at taxpayer expense); private health insurance companies present only the illusion of network adequacy and hide behind lobbying payoffs; community-based mental health clinics are closing or turning away all but Medicaid applicants or are being taken over by conglomerates administered by ex-OMH officials who are collecting overtime-time inflated State pensions on top of lucrative salaries from the takeover institutions; and kids and families who don’t have Medicaid insurance are being turned away from community-based care.

If New York State will not support essential community-based mental health services for the most vulnerable members of our communities – our children – then who will?

 

Andrew Malekoff, executive director and CEO of North Shore Child and Family Guidance Center in Roslyn Heights, NY. amalekoff@northshorechildguidance.org

Public Hearing to examine the impact of the NYS Office of Mental Health’s plan to establish Regional Centers of Excellence on affected communities

http://www.nynp.biz/index.php/points-of-view/17210-what-is-excellence-without-universal-access

September 19, 2013, Middletown Common, Middletown, New York

By Andrew Malekoff, Executive Director and CEO, North Shore Child and Family Guidance Center, Roslyn Heights, New York, 11577

 Good afternoon. My name is Andrew Malekoff. I am executive director of the North Shore Child and Family Guidance Center, a community-based outpatient children’s mental health agency located in Nassau County. This is our 60^th anniversary. I have been with the Guidance Center since 1977. I thank you for the opportunity to be heard today.

In the past 25 years, the mental health system has seen many changes.  From a system in New York State that consisted primarily of outpatient clinics, community hospitals, state hospitals, and residential treatment facilities, a continuum has evolved which now also includes family support, day treatment, a variety of in-home community support services, community residences, mobile crisis intervention, and respite care.  Many of these services were originally funded with the reinvestment dollars saved from the 1990’s reduction in state hospital beds.  The largest of these programs, Home and Community Based Services (HCBS) Waiver and Intensive Case Management, are Medicaid-driven.

Nevertheless, parents still find that there are major gaps in our service system.  Even with the available community support services, children with mental illness and their families continue to need good, often intensive, outpatient clinical services. The onset of managed care resulted in hospitals discharging children earlier, often before they are sufficiently stabilized to return home.  Mental health outpatient clinics are then left with the task of trying to provide adequate clinical care to these needy and often high-risk youths, but with highly inadequate rates of financial support from insurance companies and government funds. 

More low- and middle-income families than ever are in need of low-cost, high-quality community-based mental health care.  Yet in New York State continued access to care is assured only to children and families with Medicaid and Medicaid Managed Care insurance coverage. This leaves a significant number of children in the lurch. 

Here is a true story to illustrate. About 25-years ago I was swimming in the ocean in Long Beach, NY, and someone pointed to a group of girls that had drifted towards the jetty. The girls must have been pulled out by the undertow and were unnoticed by the lifeguards. I swam to them. When I arrived, there were three little girls; one looked about nine-years-old. The others, who were crying and holding on to the older girl, appeared to be six or seven. The older girl was trembling and barely in control of her emotions. I wrapped my arms around the three of them and said, “Hang on.”

Finally, the lifeguards arrived and took over. I swam to shore and went back to my beach chair. When I recall this encounter, I realize that the four of us were strangers who spent maybe 90 seconds together. I said only two words to them: “Hang on.” Ninety seconds, two words and 25-years and I still think about them often. We were so close that I could see their freckles.

Now, let’s consider another scenario. Try to imagine me swimming out to the three girls. Now, imagine if, instead of telling them to hang on, if I treaded water at a safe distance and asked them if they had Medicaid insurance. Imagine if they answered, “No mister.” And, if I then said to them, “Sorry, girls,” and turned my back on them and swam to shore.

This is the situation that we now face as New York State has made a dramatic departure from its responsibility to make sure that our most vulnerable citizens – our children – get community-based mental health care, regardless of their family’s economic status. They expect us to throw the underinsured middle class and working poor overboard with no life preserver. I see nothing to suggest that Regional Centers of Excellence will change this.

The American reality today is 1 out of 5 children has a serious emotional disturbance and more children suffer from psychiatric illness than from autism, leukemia, diabetes and AIDS combined. Seventy-five percent of all serious mental illness occurs before the age of 24; and 50% before the age of 14. Yet, only one out of five children who have emotional problems receives treatment from a mental health specialist.

Unfortunately, the mental health system has become largely Medicaid-driven. For example, my agency, at any given time, sees over 75% of children who do not have Medicaid or Medicaid Managed Care.  It is a constant struggle to provide what is needed for the majority of our clients who are either uninsured or underinsured middle class and working poor families.

In Nassau County, and I suspect elsewhere, there are community-based outpatient mental health programs that have closed their doors, have been taken over by larger corporate entities with no community roots, have transformed their operations into per-diem factories with little capacity for dealing with complex or crisis situations, or have decided to turn away all clients who do not have some form of Medicaid.

When I raise the problem of inadequate access to care, I am advised by government officials that the marketplace – meaning private practitioners – would take care of children without Medicaid or Medicaid Managed Care. This belies reality, which is that (1) a great many private practitioners do not accept commercial insurance; and, (2) among those private practitioners who do accept commercial insurance, most are unwilling or ill-equipped to address the highly-complex, crisis-oriented needs of children with serious emotional problems.

The reality is that only quality community-based children’s mental health organizations with salaried employees, interdisciplinary teams and dedicated time for staff supervision are capable of providing the labor-intensive quality of care necessary to address the mental health needs of children with serious emotional disturbances and their families.

What’s more, for those children who need a longer period of hospitalization, Sagamore Children’s Psychiatric Center has been the answer for the children on Long Island. Unless another alternative is developed as part of the Regional Centers of Excellence planning (i.e. dedicated long term beds supported by OMH in not-for-profit community hospitals), these children will be dramatically underserved. 

Queens and the Bronx are not viable alternatives for most families. For seamless transitions back to community, the children should be in the community; not in a distant community that would make transportation, visits, home passes, and attending meetings impossible for some families. 

The increasingly swinging doors of the community-acute care hospitals, which, because of insurance limitations, are not able to keep kids long enough to stabilize them in many cases. And, so, kids are being discharged to a community with inadequate supports.

For example, as many sister agencies have stopped accepting this population, our agency has become a major landing point for these kids, as seen by our increasingly active triage and emergency service. And, the kids who really need a hospital have already experienced intensive community based services and have had at least one or multiple hospitalizations and emergency room visits which did not work. 

With our current community system, and inability to provide an adequate level of outpatient clinical care without losing money, we cannot support these kids. We need all levels of care, including a children’s psychiatric hospital as a local part of the continuum. But, we also need more well-supported and expanded outpatient services.  Waiver slots, Intensive Case Management and Coordinated Children’s Service Initiative are all good, but these kids still require clinical care, and often not just once a week. 

In conclusion, thinking back to my Atlantic Ocean memory, it is a story that is about more than me and three little girls. It is about all of us and the thousands of children that community-based mental health agencies across New York State guide safely to shore every year, and offer them the chance to see a brighter day. To do this we need to provide ready access to quality mental health care for all children who need it.

To ensure universal access for all children in New York State, regardless of socio-economic status, requires a commitment from the State to enhance local assistance. When agency, client, community, and government work together and contribute collectively we all win. Then, and only then, can we refer to any entity formed on behalf of children with mental health problems as a “center of excellence.”

 

 

Andrew Malekoff, North Shore Child and Family Guidance Center, 480 Old Westbury Road, Roslyn Heights, New York, 11577; E-mail: amalekoff@northshorechildguidance.org

Our Kids’ Mental Issues Are Shortchanged

Our Kids’ Mental Issues Are Shortchanged

Anton News, Long Island; Opinion – Andrew Malekoff

March 26 – April 1, 2014

The American reality today is 1 out of 10 children has a serious emotional disturbance and more children suffer from psychiatric illness than from autism, leukemia, diabetes and AIDS combined. Yet, we continue to treat illnesses above the neck differently than those below the neck. People with mental health problems, and their families, often feel a sense of shame and suffer in silence; while people with physical health problems evoke the sympathy, support and comfort of others.

 

In the past 25 years, the mental health system has seen many changes.  From a system in New York State that consisted primarily of outpatient clinics, community hospitals, state hospitals, and residential treatment facilities, a continuum has evolved which now also includes a variety of additional services, originally funded with the reinvestment dollars saved from the 1990’s reduction in state hospital beds.  The largest of these programs are Medicaid-driven.

Nevertheless, parents still find that there are major gaps in our service system.  Even with the available community support services, children with mental illness and their families continue to need good, often intensive, outpatient clinical services. The onset of managed care resulted in hospitals discharging children earlier, often before they are sufficiently stabilized to return home.  Mental health outpatient clinics are then left with the task of trying to provide adequate clinical care to these needy and often high-risk youths, but with highly inadequate rates of financial support from insurance companies and government. 

Despite a growing demand for community-based children’s mental health care, right here in Nassau County there are outpatient mental health clinics that have closed their doors, have been taken over by larger corporate entities with no community roots, have transformed their operations into fee-for-service factories with little or no capacity for dealing with inevitable crisis situations, or have decided to turn away anyone who does not have Medicaid.

Commercial insurance companies are expected to demonstrate what is called “network adequacy.” Network adequacy refers to a health plan's ability to deliver the benefits promised by providing reasonable access to a sufficient number of in-network primary care and specialty physicians, as well as all health care services included under the terms of the contract. Nevertheless, many insurers do not have adequate mental health care networks despite the many names on their rosters. When it comes to seeking mental health care, for many families, the process of finding help is a shell game.

Only quality community-based children’s mental health organizations are capable of providing the labor-intensive quality of care necessary to address the mental health needs of children with serious emotional disturbances. Yet, these vital organizations are being squeezed out of Nassau County because of substandard insurance reimbursement and government neglect. Furthermore, community-acute care hospitals, because of insurance limitations, are not able to keep kids long enough to stabilize them in many cases. And, so, kids are being discharged to a community with inadequate supports.

The NYS Office of Mental Health has established a multi-year vision for the future of New York State’s mental health care system that they refer to as Regional Centers of Excellence. The vision does not include community-based care for middle class and working poor families with commercial health insurance.

Sounds more like Regional Centers of Mediocrity to me.

Andrew Malekoff, North Shore Child and Family Guidance Center, 480 Old Westbury Road, Roslyn Heights, New York, 11577; E-mail: amalekoff@northshorechildguidance.org