$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

"TODAY'S WORK AT YESTERDAY'S PRICES"

“Today’s work at yesterday’s prices”

by Andrew Malekoff © 2012

One of the oldest, largest and most well-respected community-based human service agencies closed on January 27, 2012. Some 300 employees at Chicago’s Jane Addams Hull House Association were handed layoff notices and final paychecks and were notified of the immediate discontinuation of their health care benefits. This is a tragedy and an ominous sign.

Hull House was founded in 1889 by social worker and Nobel Peace Prize winner Jane Addams and her lifetime friend and community-activist Ellen Gates Starr. Hull House began as a home for disenfranchised citizens. The organization’s mission was “neighbors helping neighbors.” In its early years Hull House was organized to help immigrants to learn English and the principles of democratic citizenship and to improve the lives and working conditions of many of those living on the west side of Chicago. In recent years Hull House’s focus was on foster care, child care, domestic violence counseling and job training.

Hull House was a beacon for social justice. It was guided by three basic principles: (1) active and side-by-side participation with community residents in addressing local issues, (2) respect for the dignity of all individuals regardless of ethnic background, socioeconomic status, gender or age and (3) belief that poverty and lack of opportunity breed ignorance, crime and disease that are the result of financial desperation and not due to a flaw in moral character.

Hull House’s demise was the result of its over-reliance on government financing. Margaret Berglind, president of Child Care Association of Illinois, commented that “The government is asking you to do today's work at yesterday's prices." I agree.

At North Shore Child and Family Guidance Center we have not seen an increase in our government contracts for a quarter-of-a-century. We are not alone. As with Jane Addams over 100 years ago, we depend on private citizens to invest in our mission - to restore and strengthen the emotional well-being of children and families. Our donors understand what is at stake. They are more than do-gooders, despite the good that they do. They understand that what we do is cost effective, saving tens of millions of taxpayer dollars by keeping troubled young people at home and out of emergency rooms and costly institutional settings.

I have reported extensively on what I believed would be the devastating outcome of New York State’s plan to restructure the financing of outpatient community-based mental health centers. Although I agreed that the over-reliance on Medicaid financing had to change, I strongly disagreed with the planners’ neglecting to provide reasonable local assistance for underinsured middle class and working poor children. State officials told me that that these families could seek help privately. My argument, based on first-hand experience, was that private practitioners would turn away troubled children that only a community-based agency had the culture, resources and wherewithal to serve effectively.

We are beginning to see the consequences of clinic reform on Long Island. In recent years several major community-based mental health clinics have either closed their doors, been taken over by New York City-based conglomerates with no community roots or transformed their outpatient operations into per-diem factories with no salaried employees. Much of this has happened under the radar.

Was it the intention of the New York State Office of Mental Health to shrink the system of care? Although it is not their job to keep providers in business, it is their responsibility to ensure ample access and consumer choice and to make sure our most vulnerable citizens - our children - get care, regardless of their family's economic status.

I am certain that Jane Addams would have agreed.

To be published in the Anton chain of 18 Long Island, NY newspapers in February 2012.

LONG ISLAND BUSINESS NEWS ON CHILDREN'S MENTAL HEALTH

Long Island Business News

Pushing for parity

Commentary by Andrew Malekoff

Published: November 2, 2009, page 20A

More low income and middle-class families than ever before are in need of low cost, high quality community-based mental health care. Yet, the New York State Office of Mental Health is implementing a plan that will result in a system of community care where only those children and families with Medicaid “fee for service” insurance coverage will be assured ongoing access to these critical services. At the same time, Gov. Paterson has proposed cutting local assistance dollars for behavioral health services.

The erosion of local assistance funding in conjunction with clinic reform is the perfect storm for the destruction of children’s community-based mental health services on Long Island. There will be no real cost savings left in the wake of this storm, only the incalculable cost of young lives being lost and set adrift, and families being splintered and destroyed.

A once proud community-based mental health care system that was “for one and for all” is being systematically deconstructed into a depleted “Medicaid-only, others need not apply” delivery system.

New York state has a statutory responsibility to make sure that its most vulnerable citizens – our children – get care regardless of their families’ economic status. Instead, what we are getting is institutionalized classism that cuts the middle class and working poor out of the behavioral health equation. Despite rhetoric to the contrary, the new Federal Mental Health Parity Act will not help.

Offering unlimited clinic visits at substandard rates is not parity, but rather a barrier that denies access to the middle class and working poor. Commercial insurers that cannot demonstrate an adequacy of network for behavioral health care should have their licenses revoked by the State Department of Insurance.

Community clinics have always been a mainstay in addressing the needs of children and adolescents with serious emotional disturbances and their families. Private psychotherapists and counselors, with rare exception, cannot afford to offer the labor-intensive work necessary to properly serve families that are struggling with serious emotional disturbances.

I call on New York State, in conjunction with local governments, to restore and enhance rather than slash local assistance funding – a partnership between local and state government, the local community and the client-consumer. Action must to be taken now to reverse the course of clinic reform and to preserve local assistance funding before it is too late.

Andrew Malekoff is executive director and chief executive of North Shore Child and Family Guidance Center, in Roslyn Heights.

TESTIMONY ON GOVERNOR PATERSON'S PROPOSED BUDGET CUTS TO HUMAN SERVICES

New York State Hearing on Governor Paterson’s Proposed Budget Cuts
Brookhaven Town Hall Auditorium
Farmingville, New York
Testimony by Andrew Malekoff, Executive Director / CEO
North Shore Child and Family Guidance Center
480 Old Westbury Road
Roslyn Heights, New York 11577

Representing the Long Island Coalition of Behavioral Health Providers, Inc.
400 Garden City Plaza – Suite 202
Garden City, NY 11530

October 27, 2009
Good afternoon senators. My name is Andrew Malekoff and I am the executive director and CEO for North Shore Child and Family Guidance Center in Roslyn Heights, New York. I am here representing the Long Island Coalition of Behavioral Health Providers.

More low income and middle-class families than ever before are in need of low cost, high quality community-based mental health care. Yet, the New York State Office of Mental Health is implementing a plan for these critical services that will result in a system of community care where only those children and families with Medicaid “fee for service” insurance coverage will be assured ongoing access to care. At the same time, Governor Paterson has proposed cutting local assistance dollars for behavioral health services.

The erosion of local assistance funding in conjunction with the march towards clinic reform is the perfect storm for the destruction of children’s community-based mental health services on Long Island. There will be no real cost savings left in the wake of this storm; only the incalculable cost of young lives being lost and set adrift, and families being splintered and destroyed.

For more than half a century North Shore Child and Family Guidance Center has been a proud provider of community-based mental health services on Long Island. The lethal mix of clinic reform and decades of diminished local assistance dollars portends a mental health delivery system that will no longer assure access to mental health care for children regardless of their parents’ ability to pay.

A once proud community-based mental health care system that was “for one and for all” is being systematically deconstructed into a depleted “Medicaid-only, others need not apply” delivery system.

New York State has a statutory responsibility to make sure that its most vulnerable citizens, our children, get care regardless of their families’ economic status. Instead, what we are getting is institutionalized classism that cuts the middle class and working poor out of the behavioral health equation.

Many children with what seems like ample health insurance coverage will no longer receive behavioral healthcare services from community clinics as a result of the lack of parity between government (Medicaid) rates and rates paid by commercial insurers for behavioral health care. And, despite rhetoric to the contrary, the new Federal Mental Health Parity Act will not help. Offering unlimited clinic visits at substandard rates is not parity, but rather a barrier that denies access to the middle class and working poor. Commercial insurers that cannot demonstrate an adequacy of network for behavioral health care should have their licenses revoked by the State Department of Insurance.

Community clinics have always been a mainstay in addressing the needs of children and adolescents with serious emotional disturbances and their families. Private psychotherapists and counselors, with rare exception, cannot and afford to offer the labor intensive work necessary to properly serve families that are struggling with serious emotional disturbances.

We call on New York State, in conjunction with local government, to restore and enhance rather than slash local assistance funding – a partnership between local and state government, the local community and client-consumer. Action must to be taken now to reverse the course of clinic reform and to preserve local assistance funding before it is too late.

Thank you, senators, for holding this hearing and for giving me the opportunity to testify before the committee.

Andrew Malekoff is executive director and chief executive officer for North Shore Child and Family Guidance Center, Roslyn Heights, New York email: amalekoff@northshorechildguidance.org

REFORM PLAN LEAVES CHILDREN AND ADOLESCENTS BEHIND

REFORM PLAN LEAVES CHILDREN AND ADOLESCENTS BEHIND

By Ronda Fein, PhD

First published: Saturday, August 8, 2009, Albany Times Union

In his very articulate July 27 commentary, "It's not reform when it hurts the poor," Andrew Malekoff expresses concern about the state Office of Mental Health and the state Health Department pursuing a "reform" plan that will leave a significant number of children and adolescents without access to mental health care.

The plan will assure continued access to care only to children and families with Medicaid fee-for-service insurance coverage but not to families that have no insurance, or insurance with limited mental health coverage. Families struggling with serious emotional challenges will have trouble finding help if not covered by Medicaid fee-for-service. Clinics and mental health care providers will not be able to continue to accept the low rates offered by Medicaid managed-care carriers and families will not be able to access help.

Anyone who has been through a period of time with a child who is seriously depressed, anxious or behaviorally challenged knows how it affects every facet of one's life.

Our society has moved toward a very misguided view of treatment for mental health issues as being provided in a pill, mainly as a result of pharmaceutical companies' marketing efforts. Medication may be helpful but there is no substitute for the intensive work provided by community clinics, which can target the whole family.

As Mr. Malekoff suggests, the Office of Mental Health must also restore and enhance local assistance funding, which includes a partnership among local and state government, local community and client-consumers for specialty children's outpatient mental health clinics that serve non-Medicaid fee for service clients. Low- and middle-income families deserve access to this care, which is often provided by high quality community-based mental health clinics.

Ronda Fein, Ph.D.

Saratoga Springs
The writer is a licensed clinical psychologist in private practice.

MIND OVER MATTER

MIND OVER MATTER

by Andrew Malekoff

More low income and middle-class families than ever are in need of low cost, high quality community-based mental health care. Yet, as I reported in my April 2009 column, the New York State Office of Mental Health (OMH) in conjunction with the New York State Department of Health is aggressively pursuing a “reform” plan (clinic reform) for these critical services that will result in a system of community care where only those children and families with Medicaid “fee for service” insurance coverage will be assured continued access to care. This will leave a significant number of children and adults living on Long Island in the lurch.

For more than a half a century North Shore Child and Family Guidance Center has been a proud provider of community-based mental health services here on the Island. We are in receipt of the recently released New York State Office of Mental Health Outpatient Clinic Reform Implementation Paper (March 11, 2009) that describes a “soup to nuts” reform of our services. Not only does the reform plan threaten the viability of our agency, but it sets up a mental health service delivery system that will no longer assure access to mental health care for children regardless of their parents’ ability to pay.

This policy shift represents a dramatic departure from what we see as a statutory responsibility on the part of New York State to make sure our most vulnerable citizens – our children - get care, regardless of their families’ economic status. New York State government is moving away from a universal model to a residual model of care where Medicaid coverage is the ticket of admission for community-based mental health.

I have been wondering if the individuals that helped to craft this plan experienced any conflict related to the inconsistency between their beliefs and actions. In my conversations with clinic reform workgroup members, my impression is that they believe strongly in quality community-based mental health care for all children and families. Yet they support a plan that cuts a large segment of the population out of the equation.

To their credit, OMH leadership is committed to the development of an “uncompensated care pool,” consisting of funding to address the uninsured. However, that still leaves the underinsured middle class, lower middle class and working poor on the sidelines.

Three further steps are needed. First, the New York State Department of Health must put pressure on Medicaid managed care insurance carriers to increase their rates to match the government rate. Second, the New York State Department of Insurance needs to do the same with private insurers. Insurance carriers that cannot demonstrate an “adequacy of network” can have their licenses revoked. Third, consumers must be educated about these issues so that they can effectively fight back when denied community-based services because their carrier’s rates are too low to offer them an adequate network of care.

CNN anchor Lou Dobbs, who wrote about the war on the middle class said, “I believe our middle class has suffered in silence for far too long, and simply cannot afford to suffer or be silent much longer. Hardworking Americans have not spoken out about their increasing marginalized role in this society, and as a consequence they’ve all but lost their voice.”

I believe that the clinic reform plan is further validation of Dobbs’ contention. We cannot afford to be silent. Perhaps for some policy makers and insurance carriers, quality community-based mental health for middle class children and their families all boils down to a question of mind over matter – they don’t mind and we don’t matter.

Please join the fight to save children’s community-based mental health services on Long Island. Our children matter - all of them.

Published in the Long Island Anton chain of newspapers in June 2009,copyright Andrew Malekoff

"IF YOUR CHILD IS NOT HEALTHY, MY CHILD IS NOT SAFE"

“If your child is not healthy, my child is not safe”

by Andrew Malekoff

Are we going to continue to catch the children that are falling through the cracks or are we going to abandon them?

There is a critical decision that has been made in Albany that will impact negatively on thousands of children and families across Nassau County and that will dramatically increase costs to taxpayers as increasing numbers children will be removed from their homes and institutionalized.

The New York State Office of Mental Health (OMH) has implemented a plan that they call Transforming New York’s Mental Health System (the Plan). The Plan is a blueprint for the destruction of children’s community-based outpatient mental health services in Nassau County.

Here are the facts:

The Plan is dramatically skewed in favor of funding services for individuals with Medicaid-only insurance coverage. At North Shore Child and Family Guidance Center, for example, this represents only 7% of people that use mental health services.

The Plan discriminates against the middle and lower middle class and working poor families that are underinsured or uninsured and live in the suburbs of Nassau County. In fact, the Plan discriminates against all people that pay taxes and are entitled to basic mental health services. Although the Plan refers to something called an “uncompensated care” provision, it does not address the deficit generated when serving a preponderance of middle and lower middle class and working poor families.

Community mental health centers are the last bastion in addressing the needs of children and teens with serious emotional disturbances and their families. Private psychotherapists and counselors, with rare exception, cannot afford to offer the labor intensive work necessary to properly serve families that are struggling with serious emotional disturbance. If you know one that can, terrific! Competent private practitioners know when they can handle a situation on their own and when they need to refer to a community-based agency that specializes in children’s mental health; the very place that the New York State Office of Mental Health has kicked to the curb.

The consequence of the OMH Plan will be devastating to the children and families in Nassau County. It will lead to the loss of life, children being plucked from their homes and institutionalized, and families being splintered and destroyed.

I ask you to join me in calling on Nassau County and New York State to restore and enhance local assistance funding – a partnership between local and state government, the local community and client-consumer. Local assistance funding will support community-based children’s mental health centers that would otherwise disappear or be rendered ineffective as the result of the dramatic lack of government support to the suburbs that the Plan represents.

Call Tom Suozzi and your local County and State legislators and tell them:

• That the New York State Office of Mental Health’s Plan discriminates against their constituents - the middle and lower middle class and working poor children and families that are uninsured and underinsured.

• The New York State Office of Mental Health is discriminating against children and youth with mental health disorders and their families.

• To restore local assistance funding in New York State or there will be no responsive, community-based children’s mental health services in Nassau County by the year 2012 if not sooner.

I urge you to take just a few moments of your time to join the fight for children’s mental health. Community mental health center’s are there for you and your family in your time of need.

Things may be going great in your family, but we know that even when they are, the unexpected enters and we all need a credible place to turn to.

And, if you are fortunate enough to never need such help, please bear in mind what a local mom once told me about her reason for supporting children’s mental health, “If your child is not healthy, my child is not safe.”


First published in the Anton chain of 18 newspapers in Nassau County, New York in April 2009.