CRISIS IN THE CLINICS by Laura Figueroa

CRISIS IN THE CLINICS…as demand grows, mental health facilities dwindle on Long Island

April 12, 2015 by LAURA FIGUEROA / laura.figueroa@newsday.com

Increasing numbers of nonprofit mental health clinics on Long Island are closing or being sold to other mental health networks, following years of declines in government funding and a growing demand for services.

In the past four years, at least four clinics have closed in Nassau and Suffolk, including one that has closed and one about to close this year, and four clinics have been acquired by other nonprofits.

The closures have prompted several local social service advocates to ramp up fundraising efforts while lobbying for increases in government aid. They say treatment options are dwindling for low- and middle-income patients who earn too much to qualify for Medicaid.

"There is somewhat of a crisis in the system," said Jeffrey Steigman, chief administrative officer of the nonprofit Family Service League, of Huntington, which provides counseling services for children and families.

In February, the league acquired the Huntington clinic of Pederson-Krag, a social service agency founded in 1957. But "it's not just the clinic we took over," Steigman said. Mental health agencies "throughout the state are transferring their licenses or closing clinics because of the financial burden and the deficits that occur. The fiscal model is broken in certain ways," he said.

Currently, there are 18 licensed nonprofit mental health facilities in Nassau and 48 in Suffolk, according to the State Office of Mental Health Services. The clinics provide services, including family counseling and drug rehabilitation, for low- and middle-income residents who cannot afford private care.

More than 10,000 individuals sought treatment at nonprofit clinics in Nassau last year, according to the county's Office of Mental Health, Chemical Dependency, and Developmental Disabilities Services.

Suffolk's Office of Mental Hygiene said it did not have overall figures. But state data show that nearly 4,000 Suffolk adults and 1,200 children enrolled in Medicaid sought mental health services in 2013. In Nassau, there were 3,600 adults and 850 children on Medicaid who received mental health services.

Freeport clinic forced shut

In May, Catholic Charities Outpatient Mental Health Clinic in Freeport, which has treated 550 patients a year, will shutter after more than 50 years in operation. Earlier this year, the 81-year-old nonprofit Federation Employment and Guidance Services, which provided mental health services throughout Long Island, announced it was closing.

The closures came as Peninsula Counseling Center, a Valley Stream nonprofit founded 102 years ago, and three clinics operated by Pederson-Krag were acquired by other nonprofit mental health agencies in recent months, after years of struggling to stay afloat financially.

Laura A. Cassell, CEO of Catholic Charities of the Diocese of Rockville Centre, said the organization decided it no longer could afford to run its Freeport clinic, because of insufficient reimbursement rates and declining government funding to subsidize care. Over the past three years, Catholic Charities had to raise $1.26 million in private donations to keep Freeport open, Cassell said.

"While Catholic Charities is blessed with generous donations to support our ministries, we cannot direct such a large portion to just one service site," Cassell said. "Many other mental health providers were forced to close their doors for the same reason."

"Unfortunately, with no hope of permanent additional funding to match the real costs of providing quality services in the future and increasing unfunded government regulatory mandates, this painful decision had to be made," Cassell said.

In a newsletter to Long Island mental health providers last month, Martha A. Carlin, director of the Long Island field office of the state Office of Mental Health, noted that with the closures and acquisitions, the "beginning of 2015 has been challenging for the Long Island region."

Declining reimbursements

Mental health providers say some of their fiscal strain is due to low reimbursement rates by private insurers.

Under Medicaid, clinics are reimbursed an average $130 per visit for an adult patient and $137 for children, according to state figures.

Commercial insurance providers pay anywhere from 20 percent to 50 percent less, several local mental health providers said. Officials with the New York Health Plan Association, which represents commercial health insurance providers, said they could not provide data on reimbursement rates because each company negotiates rates with clinics.

The incentive to treat higher-paying Medicaid patients means that some clinics are opting to see fewer patients covered by commercial insurance, said Andrew Malekoff, executive director of the North Shore Child and Family Guidance Center in Roslyn Heights, a nonprofit that has about 5,000 clients annually.

Malekoff, who has testified before state lawmakers about the challenges faced by nonprofit mental health providers, said that with fewer clinics accepting privately insured patients, many families who earn too much to qualify for Medicaid are "left with nowhere to turn for affordable community-based outpatient mental health care."

The closure of one nonprofit clinic often causes a ripple effect among the small group of Long Island nonprofit clinics, where phones are "ringing off the hook," with queries from displaced patients looking for affordable care, said Jeffrey Friedman, CEO of Central Nassau Guidance Services in Hicksville.

"As a result of the closures, we've had an influx of people calling us," Friedman said. "I think for us the landscape is changing drastically because the reimbursement from insurance companies is not adequate. We're losing money on that visit."

Leslie Moran, spokeswoman for the New York Health Plan Association, said each provider negotiates reimbursement rates with clinics, aiming to control costs to keep plan rates down for consumers.

"The reality is, in our health care system, affordability is something we have to keep an eye on," Moran said.

In 2012, the nonprofit Family & Children's Association, of Mineola, closed its mental health clinics in Roosevelt and West Hempstead, after years of deficits stemming from services provided to low-income patients.

Jeffrey Reynolds, executive director of the association, said losses at both clinics in 2011 totaled $1.6 million. Keeping them open would have "threatened the livelihood" of other operations, including homeless shelters for seniors and runaways, Reynolds said.

"What happens when you lose these clinics is you're driving people into chemical dependency, ERs or jails," he said.

State taking steps to aid LI

State Office of Mental Health spokesman Ben Rosen, to whom Carlin referred questions, said the agency has "taken several steps to help Long Island's mental health clinics remain fiscally viable." Rosen said $60 million has been allocated over the next three years to fiscally distressed clinics statewide, including seven in Nassau and Suffolk. The clinics, which include the former Pederson-Krag clinics, each were assigned "strategic planners" to improve their finances over the next three years, Rosen said.

The agencies acquiring some of the local facilities say the transition is going as seamlessly as possible.

Herrick Lipton, administrative and financial director of New Horizon Counseling Center, said that since taking over Peninsula, the agency has done repair work at the clinic and installed a flat-screen TV in the waiting room. New Horizon, which also runs clinics in Ozone Park, East Elmhurst and the Rockaways, also is planning to add Saturday service hours at Peninsula, Lipton said.

"Peninsula was losing money, it didn't have the ability to invest in repairs . . . they were in dire straits," Lipton said. "Our goal is to create a sustainable solution for mental health services for Nassau County. In today's environment, many health care providers are struggling to survive."

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

"GET SPIKED"

“Get Spiked”

Andrew Malekoff © 2011

In the five-year period from 2005 to 2009 there was a dramatic increase in emergency room visits related to non-alcoholic energy drinks, according to a report issued on November 22, 2011 by the Substance Abuse and Mental Health Services Administration (SAMHSA). Just about half of those emergency-room visits were made by 18- to 25-year-olds who were found to be using alcohol, illicit drugs or pharmaceuticals.

What are energy drinks? They are highly-caffeinated flavored beverages for sale in cans and bottles in grocery stores and vending machines. Children, adolescents and young adults - half of the energy-drink market - are the primary targets of energy-drink marketing.

One popular energy drink – Red Bull – bills its beverage as “developed for people who want to have a clear and focused mind, perform physically, are dynamic and performance-oriented.”

Another popular drink, ROCKSTAR, targets young skateboarders. Here is their rap: “Bigger. Better. Faster. Stronger. ROCKSTAR is the world's most powerful energy drink. Enhanced with the potent herbal blend of Guarana, Ginkgo, Ginseng and Milk Thistle, ROCKSTAR is scientifically formulated to provide an incredible energy boost for those who lead active and exhausting lifestyles – from athletes to rock stars.” Although they highlight the “herbal blend,” they conveniently leave out the 80 milligrams of caffeine listed in ROCKSTAR’s ingredients.

These are just two illustrations of seductive messages, aimed at young people and promising a quick-fix for improving performance. Parents, teachers, coaches and others who care about kids need to educate them to the fact that energy drinks are not the answer to better performance on the athletic field or in the classroom.

There are numerous studies that point to the medical risks of excessive caffeine intake (for example, arrhythmias, hypertension, dehydration and more serious medical conditions). When mixed with alcohol and other drugs, the level of danger increases dramatically.

The term “energy drink” is a misnomer for a product that should be more accurately labeled as a “stimulant drug-containing drink.” Some people believe that criticism about energy drinks is an overreaction - much ado about nothing. After all, as they might say, if the active ingredient in energy drinks – caffeine – is the same substance contained in coffee, what’s the big deal? No one is making a fuss about coffee or trying to get it banned or controlled.

Coffee tends to be viewed as an adult beverage, while energy drinks are aimed at the youth market with little regard for health risks and the consequences of mixing these beverages with alcohol and other drugs.

“Get spiked,” “Party like a rockstar,” and “Feel the freak” are slogans that clearly demonstrate the marketing strategies of energy-drink companies. “The language and images of such advertising are not directed at mature adults. If anything, the marketing of energy drinks removes all ambiguity about whom these products are meant to appeal to: teens and young adults,” according to Russ Paddock of the United States Sports Academy.

Parents, teachers and coaches need to educate young people about the risks to their health and well-being of using energy drinks as an easy alternative to exercise, sleep and a healthy diet – the “keys to quality performance, sustained success and overall wellness,” according to Pamela S. Hyde of SAMHSA.

The full report on Emergency Department Visits Involving Energy Drinks from SAMHSA's 2005 - 2009 Drug Abuse Warning Network (DAWN) can be found on the Internet at: http://www.samhsa.gov/data/2k11/WEB_DAWN_089/WEB_DAWN_089_HTML.pdf

This article will be published in the Anton chain of 18 Long Island, NY newspapers in January 2012.

Homer Simpson on Health Insurance

Homer Simpson on Health Insurance

Andrew Malekoff© June 2010

We are all familiar with stories about the ineptitude of government officials and regulators in protecting the public. At the SEC, they fell asleep at the wheel as Bernie Madoff made off with billions. In its eagerness to put more low-income families into its own homes, HUD failed to rein in Freddie Mac and Fanny Mae from saddling borrowers with mortgages they could not afford. So, it comes as no surprise to me that I cannot get a straight answer about who regulates the commercial insurance industry in New York State.

New York State is on the verge of implementing a plan for restructuring the financing of community-based mental health clinics. The plan discriminates against the underinsured middle class and working poor and is scheduled to commence on October 1. It represents a dramatic shift away from universal mental health care and towards care for families with Medicaid insurance only.

Those who have Medicaid are able to easily access community-based mental health services. Otherwise, you will soon be out of luck. When a family cannot get essential community-based mental health services that is what is known, in insurance industry parlance, as an inadequate network of care. Network adequacy has to be monitored and enforced.

In an attempt to get some straight answers, I contacted nuclear power plant safety inspector Homer Simpson, who was recently quoted as saying, “America's health care system is second only to Japan, Canada, Sweden, Great Britain; well, all of Europe. But you can thank your lucky stars we don't live in Paraguay!”

Andrew Malekoff: It is great to see you Mr. Simpson. You are looking dapper as ever.
Homer Simpson: D’OH!
AM: I know, I know, enough small talk. So, let’s get down to business. As someone with quality assurance experience, do you have any insights into who is overseeing the commercial insurance industry in New York State?
HS: D’OH!
AM: Are you expressing astonishment at my question, or are your referring to the D.O.H. - the New York State Department of Health?
HS: D’OH!
AM: A state official told me that this was the State Insurance Department’s (SID) jurisdiction.
HS: D’OH!
AM: Okay, okay, take it easy. I contacted a senior examiner at SID and she told me that they (SID) had regulatory authority over all licensed insurance companies and that they did enforce the insurance laws and all policy provisions but, she was quick to add, “We do not get involved in the network adequacy issue.” She said that that was the Department of Health’s job. I take it that you concur?
HS: D’OH!
AM: As I am sure you know, the commercial insurance industry uses managed-care companies to hold down costs. They decide, usually from hundreds of miles away, who gets what kind of mental health care, for how long and at what rate of reimbursement. In other words, they don’t really manage care, they manage cost and sometimes they even mangle care - at a nice profit.
HS: D’OH!
AM: According to Patrick Gauthier from Advocates for Human Potential Healthcare Solutions, “Despite the deepest and most enduring recession in 70 years…the five largest health-insurance companies in the nation disclosed combined profits of $12.2 billion last year — a 56 percent increase over the previous recessionary year. They managed this feat even though they experienced a combined loss of nearly two-million members to unemployment.”
HS: D’OH!
AM: My sentiments exactly! I am not sure that families know what to do if they cannot find a provider in the advertised network of care available to them via their health plan. May I ask you one final question, Mr. Simpson?
HS: D’OH!
AM: It will be quick. I promise. I raised the issue of network adequacy with the network manager for a well-known insurance company. She said to me, “We have a large volume of therapists within a five-mile radius of your agency that see young children which supports that our network needs are being met. What brings clients to your agency rather than an individual clinician's office?” How do you think I should answer her?
HS: First of all, Marge and I want to thank the Guidance Center for helping our family. Here is what I recommend you say in response to the network manager’s question: “The kind of comprehensive service that a community-based provider offers cannot be duplicated by any private practitioner in your network. For example, at North Shore Child and Family Guidance Center, the wrap-around services, for which they are not reimbursed by you or any commercial insurer, are by no means unnecessary frills or perks. They are essential services for working with a growing population of families in emergent crisis and in need of a community-based agency approach that is designed for this population, versus an individual private practitioner with limited availability, time and resources.” That should set her straight. Now I have to leave before happy-hour is over at Moe’s.
AM: D’OH!

To learn more about your rights as a health care consumer go to the following website: http://www.ins.state.ny.us/hrights.htm.

Published in the Anton chain of 18 newspapers, Long Island, New York in June 2010