WHAT WOULD GEORGE CARLIN SAY?

The first standup act I saw live was George Carlin. I was 18-years-old and Carlin was playing on campus my freshman year at Rutgers University in New Jersey.  I sat on the floor in the student center multi-purpose room. The show took place three years before Carlin was arrested for violating obscenity laws in Milwaukee after his legendary routine: "Seven Words You Can Never Say on Television."

Carlin was a social critic whose acts included his thoughts on politics, the English language, religion, and a variety of taboo subjects. He complained that American English is replete with euphemisms because Americans have difficulty dealing with reality. His views pre-dated the term “politically correct.”

Carlin said that we use euphemisms to shield us from reality, that we use “soft language.” To illustrate he said that poor people used to live in “slums” and now "the economically disadvantaged" occupy "substandard housing" in the "inner cities." He said, maybe if we were not to use this type of language, people would realize what is going on, and that there are actually problems in the world. And maybe we could solve them.

Carlin’s advice comes to mind when I think about health care. One of his memorable lines on the subject was, "Isn't it a bit unnerving that doctors call what they do 'practice'?"  

Columnist Paul Krugman wrote in the New York Times: “How did it become normal, or for that matter even acceptable, to refer to medical patients as ‘consumers’? The relationship between patient and doctor used to be considered something special, almost sacred. Now politicians and supposed reformers talk about the act of receiving care as if it were no different from a commercial transaction, like buying a car - and their only complaint is that it isn't commercial enough.”

Maybe the impersonal quality of such language made it easier for the majority members of the U.S. House of Representatives to pass the American Health Care Act (AHCA).

The facts are that if the AHCA become law, as written, basic protections for individuals with preexisting conditions will be eliminated and the federal requirement that mental health and addictions care be included by insurers as an essential benefit will be removed.

Maybe instead of “preexisting conditions” we should refer to it as “people who will suffer and die without affordable and timely healthcare.”  

In any case, if the House’s AHCA passes the Senate, it will result in more families that are struggling with mental illness and addictions finding their loved ones in emergency rooms, in costly institutional settings, on the street, in jail, or in the ground.

Treatment is the most effective way to help those with mental illness and addiction ― treatment that often needs insurance coverage, just like any other health problem.

The answer is not “Obamacare” or “Trumpcare”. We need “Bi-partisancare” that puts the American family first.

One thing is for sure, if George Carlin were still around to weigh in on the AHCA, he would be invoking "Seven Words You Can Never Say on Television" and, I’m certain, a few choice new ones.

by Andrew Malekoff

First pubished in Long Island Weekly, June 2017

https://longislandweekly.com/george-carlin-say/

  

FAMILIES CAN'T AFFORD TO WAIT FOR MENTAL HEALTH SERVICES

L.I. Business News, March 4, 2016 

Access delayed is access denied.

These are words that ring true for thousands of families across Long Island who have been unsuccessful in accessing timely and affordable mental health and addictions care through their health insurer.

How do I know this? From the stories that people tell us at North Shore Child & Family Guidance Center, a 63-year-old children’s mental health agency in Nassau County.

Health insurers are mandated by government to offer panels of providers so that families can find easily accessible, quality care for their loved ones; and not only for physical illnesses. This requirement is known as network adequacy, referring to adequate networks of care.

The problem of access for mental health care, however, is more complex and may begin with a family’s hesitance to ask for help and to reveal that they are living with someone who is suffering from a mental illness. Families coping with mental illness or addiction do not as readily seek help as they might for heart disease, cancer or diabetes. Why? Because of stigma and the shame it generates. When there is a mass shooting for example, and the perpetrator is labeled mentally ill, it casts a shadow on all people with mental illness, despite the fact that mentally ill persons are disproportionately the victims of violence.

In the United States we have chronically failed to treat illnesses above the neck the same as illnesses below the neck. For example, a parent who would not hesitate to reach out for help if their child was in an accident and appeared to have broken an arm, might wait weeks and months, if not longer, to ask for help if it was a mental health or substance abuse problem.

What makes all this so insidious is that once a parent picks up the phone to ask for help, and they are told repeatedly by providers, “I’m sorry I don’t accept that insurance any longer, I only accept cash,” there is a chance they will give up.

When a parent gives up, they risk their child deteriorating further. This is also true for adults with mental illness and increases the odds that they will ultimately need more costly care or confinement; hospitalization or incarceration.

What to do? Gov. Cuomo created the Department of Financial Services, charged with the responsibility to monitor private health insurers to ensure that they have adequate networks of care as a condition of their license. This means they must demonstrate the consistent ability to provide timely access to care for individuals and their families.

Just this week parents who came to the Guidance Center after taking their child to the emergency room, told us that they called no less than 20 different therapists or agencies and were turned down by all of them. Finally they called another hospital that made the referral to us. We turn no one away for inability to pay.

This is an all too familiar story that we hear frequently and that my colleagues from sister agencies tell me as well. You might wonder why this happening.

Private health insurers pay substandard rates of reimbursement for mental health and addictions care, as compared to Medicaid; sometimes 50 percent or less the than the Medicaid rate. Consequently, participating providers bail out because they cannot afford to accept such low rates. The insurers fail to carefully monitor their lists and the state fails to monitor and regulate the insurers.

In the case of delayed care for a child, this represents corporate and state child abuse.

I have reached out repeatedly to the governor, attorney general and numerous state legislators to issue a call to action to demand that DFS do their job. There is sympathy, but no action.

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

If you subscribe to Long Island Business News: http://libn.com/2016/03/04/malekoff-li-families-cant-afford-to-wait-for-mental-health-services/

A COMMON STRUGGLE

Patrick J. Kennedy is a former member of the U.S. House of Representatives who has struggled with mental illness and addiction for most of his life. He has become a leading force in the passage of the Mental Health Parity and Addiction Equity Act of 2008, a U.S. law that states that it is illegal to treat diseases of the brain differently than those of any other part of the body. The battle ahead is for the law to be enforced in the face of health insurers who stand to profit by denying the full range of coverage for people suffering with mental illness and addictions.

In his 2015 book, A Common Struggle: A Personal Journey Through the Past and Future of Mental Illness and Addiction, Kennedy offers personal reflections on the impact of trauma, addiction and mental illness on the extended Kennedy clan. He talks about the rocky relationship he had with his dad, the late U.S. Senator Edward “Ted” Kennedy and about his mom Joan’s battle with alcoholism.  

At the heart of the memoir are Kennedy’s own revelations about his co-occurring mental illness and prescription drug and alcohol addiction, his path to recovery, and his ascendance to becoming, arguably, the nation’s leading advocate for parity and equity in mental health and addiction care. Kennedy has fought hard to lift the veil of ignorance about mental illness and addiction and to expose the health insurance industry’s tradition of denying and restricting access to care for individuals with brain illness.

Kennedy radiates a fire for eradicating stigma and ending discrimination against people with brain illness. According to One Mind, a nonprofit organization he co-founded, that is dedicated to benefiting all affected by brain illness and injury, “One of the harmful effects of stigma is that it can lead to discrimination. It could be as obvious as someone making a negative remark about your mental illness or as subtle as someone avoiding you because they think you could be unstable, violent or dangerous.”

On their website, One Mind lists some of the ways that these attitudes can be damaging and even dangerous. For example:

·      Reluctance to seek help or treatment due to the labeling

·      Lack of understanding by family, friends, co-workers or others you know

·      Fewer opportunities for work, school or social activities or trouble finding housing

·      Bullying, physical violence or harassment

·      Health insurance that doesn't adequately cover your mental illness treatment

·      The belief that you'll never be able to succeed at certain challenges or that you can't improve your situation

Kennedy rightly frames the inequities that people with mental illness and addictions face as a matter of civil rights.

What he has accomplished, which he freely acknowledges is the result of a collective effort, has already gone a long way to wiping out stigma and increasing people’s access to mental health and addictions care. His goal, he states, is to launch “a new civil rights movement, to finally force medical equality for diseases of the brain.”

Tens of millions of Americans owe Patrick Kennedy a debt of gratitude for leading the way. Now all of us must carry the ball forward by treating children and adults with brain illnesses with dignity; and demanding that government enforce parity and equity for all and put an end to discrimination.

https://longislandweekly.com/a-common-struggle/ 

Andrew Malekoff is the Executive Director of North Shore Child & Family Guidance Center, which provides comprehensive mental health services for children from birth through 24 and their families. To find out more, visit www.northshorechildguidance.org.

$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

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