A MATTER OF CIVIL RIGHTS

A Matter of Civil Rights

By Andrew Malekoff

Did you know that every day more than 290 Americans die from suicide or a drug overdose? With proper treatment, many of these tragedies could be prevented—but despite a law that guarantees coverage, people face enormous roadblocks when they seek care.

In 2008 President George W. Bush signed the landmark Mental Health Parity and Addiction Equity Act (Parity Act). The Parity Act mandates equal insurance coverage for mental health and substance use disorders (MH/SUD) as compared to other medical/surgical benefits covered by the plan.

According to its new website parityat10.com, “Parity at 10 seeks to ensure that insurance carriers and state Medicaid programs comply with the law so that consumers can access the evidence-based health care they need and are entitled by law to receive.”

What does equal insurance coverage mean? It means ending insurer discrimination against access to timely and affordable care including high out-of-pocket costs and shorter lengths of care for MH/SUD. Parity—which is another word for equity—in this case means that MH/SUD coverage must be provided on par with coverage of medical and surgical care.

Notably this legislation was the result of a bipartisan effort by Senators Paul Wellstone, a liberal Democrat, and Pete Domenici, a conservative Republican. What the senators had in common were personal family experiences that motivated their tireless efforts to pass this law.

Parity saves lives. Parity law is a civil rights law that has not been vigorously enforced by the States, which have the primary responsibility for enforcement of private insurance and Medicaid.

One of the most pernicious violations and barriers to care is inadequate networks of MH/SUD providers. North Shore Child & Family Guidance Center documented this in its 2018 Project Access Study which surveyed 650 Long Island consumers of MH/SUD care. Nearly 50% of respondents said that it was easier for them to access medical/surgical care than MH/SUD Care.

Nationally, patients responding to a National Alliance on Mental Illness (NAMI) survey reported being denied twice as often for mental health care as for medical surgical care under the Affordable Care Act.

The actuarial firm Milliman reviewed claims data in New York and found that patients had to go out-of-network for MH/SUD care far more often than for medical/surgical care—a very expensive proposition that flies in the face of the Parity Act.

At North Shore Child & Family Guidance Center, we are a proud partner of the Parity at 10 Compliance Campaign. On August 10 I attended an inaugural Parity at 10 meeting in Albany with my fellow advocates and top officials in the Cuomo administration.

Some of the details in this column were included in the policy brief provided to Governor Cuomo. The consensus among the advocates was that insurers do everything in their power to skirt parity.

Another staunch supporter of the original legislation was Patrick J. Kennedy, a former member of the U.S. House of Representatives. Kennedy struggled with mental illness and addiction for most of his life.

In his book A Common Struggle, Kennedy said 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 living with mental illness and addictions. Kennedy rightly frames the inequities that people with mental illness and addictions face as a matter of civil rights.

Discriminatory insurance coverage for those with mental health and substance use disorders must end. When insurers do not comply with the law and enforcement is inadequate, millions of Americans are at risk.

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.

This article appeared in TheIslandNow.com on August 16, 2018

DEPRESSION, SUICIDE, DISCRIMINATION AND PARITY

Depression, Suicide, Discrimination and Parity

By Andrew Malekoff© Summer, 2018

In the immediate aftermath of the suicides of Kate Spade and Anthony Bourdain Gov. Cuomo issued a press release about new funding to address the rising rate of suicide.

He stated: "Two high-profile suicides this week put mental illness front and center, but while those names were the ones in the press, every day there are thousands of New Yorkers who struggle with suicidal thoughts, and we must do everything we can to support them. Depression does not discriminate. It affects every part of society and people from all walks of life."

I applaud the Governor for bringing this matter to light. He stated, “Depression does not discriminate.” Nevertheless, health insurers that do not comply with federal parity law, denying timely access to care, do discriminate. When New York State government does not enforce this law, they aid and abet discrimination against the “thousands of New Yorkers,” who the Governor referred to as those “who struggle with suicidal thoughts”.

The difficulty people have accessing mental health and addiction care is not simply a matter of stigma. It is a matter of discrimination. This is a civil rights issue that an announcement of new funding alone will not solve.

On December 15, 2017, North Shore Child and Family Guidance Center held a press conference at its headquarters in Roslyn Heights and issued the results of a research study – Project Access that we conducted in collaboration with LIU Post Department of Social Work. 

In this year-long study, hundreds of Long Islanders were surveyed about their experiences attempting to obtain help for mental health and addiction problems.

Of the 650 Long Islanders who took part in the survey, almost half said that it was more difficult finding help for mental health or substance abuse problems than finding help for physical illnesses, nearly 40 percent said that their insurance company did not have an adequate number of providers and two-thirds said that their insurance company was not helpful to them in finding a suitable provider for themselves or a loved one.

NY State Senator Todd Kaminsky, who attended the December 15th press conference, stated that the findings were “Damning.”

In a bipartisan effort, Kaminsky and Senator Elaine Phillips wrote to the Department of Financial Services (DFS) on January 9, 2018 citing the Project Access study and requesting “a thorough investigation to determine why insurance companies are not being held accountable for network adequacy.” Network adequacy is the part of the federal parity law that states that health insurers who cover mental health and addiction care must have an adequate number of providers in their network. Many more people wrote directly to Gov. Cuomo, requesting the same.

Almost five months later Scott Fischer, Executive Deputy Superintendent for Insurance, a division of DFS, responded in writing to the Senators. Fischer wrote: “DFS’s review of the various networks has confirmed that each of the insurance companies in Long Island exceeds the standards for mental health and substance use providers, for the purpose of the commercial products sold outside of NYSOH.”

Translation: There is no problem. There is nothing more to do. This does not square with the results of Project Access.

Health insurers and government ignoring federal parity law is discrimination. When it comes to suicide prevention: access delayed, is access denied.

Discrimination deserves a place alongside stigma when the conversation turns to access to care.

It’s a matter of civil rights.

Long after the tragic deaths of Kate Spade and Anthony Bourdain fade from the front pages, the lack of compliance and enforcement of federal parity law will persist and the thousands of people that the Governor spoke of in hispress release will still be unable to access care.

Published in the New York State Behavioral Health News, Summer 2018 issue

HOW INSURERS ARE FAILING CHILDREN WITH MENTAL HEALTH NEEDS

http://nynmedia.com/news/how-insurers-are-failing-children-with-mental-health-needs

What happens when something that affects children’s lives is widespread but hidden in plain sight? What if it is something that creates untold heartache in lives that are already unnecessarily damaged? It should be addressed and corrected. Yet, because it is hidden from our collective consciousness it remains unaddressed, it persists, and this has consequences.

I am referring to the plight of countless middle-class families with children who have mental health and substance abuse problems and who have health insurance but cannot gain access to timely care.

Under a government mandate called network adequacy, commercial health insurers, used by many working, middle-class families, are required by license to offer adequate networks of providers (child psychiatrists, psychotherapists) for families confronting mental health and substance abuse problems. In other words, they are expected, as per their insurance plan, to provide ready access to a provider near where policyholders live. The reality, though, is that too often they do not.

Why? Because commercial health insurers that pay substandard reimbursement rates have too few in-network providers. Their low rates of reimbursement serve as a disincentive for providers, including community-based mental health agencies that should be providing universal access to care, to enroll in their networks. Consequently, many community-based agencies, along with those in private practice, will accept only higher paying Medicaid insurance.

The gap between reimbursement rates for commercial health insurance and Medicaid is vast. In some cases, for example, the rate paid to providers by commercial insurers is half the rate paid by Medicaid. Although a health insurer is expected to help families find an in-network provider, most often they do not. They simply give them a list of names, and few if any of those providers accept the insurance because the rates of reimbursement don’t come close to covering the cost of services. This then frustrates already anxious parents who have had to work up the courage to ask for help.

It is very difficult for a parent to pick up the phone and seek help when their child is suffering from mental illness or addiction. When they are repeatedly turned away by their supposedly in-network providers, who tell them “I no longer accept that insurance,” it is devastating. When a child is denied access to timely care for mental illness or addiction the results can be life-threatening. 

A few weeks ago a mother seeking mental health care for her teenager came to us at North Shore Child & Family Guidance Center and told a familiar story.

"It's very hard. Decent psychiatrists don't take new patients and the rest don't take our insurance. Most of them don't take your insurance," she said. The intake worker asked her how many turned her down before she called us. She said 20.

What needs to be done? The New York State Department of Financial Services, a relatively new state agency formed by Gov. Andrew Cuomo, has regulatory jurisdiction over insurance companies. However, in my experience, their inaction on this issue indicates that they do little, if anything, to monitor network adequacy.

Substandard rates of reimbursement (e.g. the gap between Medicaid and commercial insurance rates) may be considered a violation of the Affordable Care Act’s parity protections, which require health insurance companies to treat annual or lifetime dollar limits for mental health and substance abuse the same as they do medical benefits. If that is the case, the attorney general also has the power to address this matter if DFS will not. But what remedy is there if they do not take action?

The New York State Comptroller’s Office has the primary responsibility to ensure that state agencies such as DFS are using taxpayer money efficiently and effectively. If DFS does not investigate the issue of network adequacy, then they are open to the scrutiny of a state audit as it relates to their effectiveness in the use of taxpayer dollars to properly monitor insurance companies under their jurisdiction.

Although mental health legislation, The Helping Families in Mental Health Crisis Act, has been introduced in Congress, it will do little good if families cannot find a provider. The act will only work when the issue of access to care is monitored and enforced. It’s time for DFS to do its job and launch an investigation of any commercial insurance company suspected of not having an adequate network of providers. It could truly save lives.

Andrew Malekoff is the executive director of the North Shore Child & Family Guidance Center in Roslyn Heights, a nonprofit that provides comprehensive mental health services for children from birth through age 24 and their families. To find out more, visit www.northshorechildguidance.org. - See more at: http://nynmedia.com/news/how-insurers-are-failing-children-with-mental-health-needs#sthash.omFazlzp.dpuf

(c) 2016 City and State NY, LLC. All rights reserved.

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.

DAVID AND GOLIATH

On January 21, 2016 I received a most unusual award – a David Award – that was described to me as follows:

For each of the past 15 years, every January Networking® magazine has honored eight exceptional men – “Renaissance Men” who have performed generous and unselfish acts for the benefit of us all. The David Awards are named for David, the giant slayer, who represents the Renaissance Ideal Man memorialized by Michelangelo’s famous 16th century statue of David. Each of our honorees has been a true Renaissance man having excelled in business or academics and also accomplished outstanding heroic and humanitarian acts.

I thought that I would make this column a little more personal than usual and share my remarks here.

Having been selected for this honor led me to consider, "If I am David, then who is Goliath in my life?" I can think of many but I’ll share just two with you.

On the same day in late September that Networking Magazine publisher Christine Sheehan delivered the good news to me about this honor, my doctor called with the results of a biopsy and PET scan. She said that my cancer, which had been in remission for five years, transformed into something more aggressive. It was rapidly spreading and required immediate treatment.

In fact, if the David Awards breakfast was held just one week earlier to the day, instead of my sitting on the dais you would have found me seated in a recliner at Sloan Kettering, hooked up to an IV, and receiving what I am hoping will be my last infusion.

I tell you about my personal Goliath not for your sympathy. I tell you because I know I am not alone in this room of more than 500 people. I salute my fellow cancer survivors and family members of those who have battled cancer.

Although my first Goliath is more personal, and now public, my second Goliath is more insidious. It cannot be slayed by science and medicine, and it demands the attention of our hearts, minds and souls.

My second Goliath is stigma – the stigma that brings shame to people with mental illnesses and addictions; the stigma that denies them the sympathy and support that I have received in abundance while battling cancer.

Please understand that no parent would hesitate for even a moment to get help for a child with cancer. However, parents who have a child suffering from a mental illness or addiction wait weeks, months and even years to ask for help. Stigma causes many to hide and retreat, rather than stand and advance.

Stigma has two co-conspirators. They are the government and the health insurance industry. Government neglect and corporate greed represent nothing less than institutional child abuse and neglect that prevent sufferers from choosing and accessing life-saving treatment options. This is a clear denial of civil rights.

Defeating the Goliath stigma is a good start. It requires that we make a collective commitment to treating illnesses above the neck the same as illnesses below the neck.

If my being a David Award winner helps to inspire that, then I will truly feel a worthy recipient. Thank you.

https://longislandweekly.com/david-and-goliath/

Bio: 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. 

MENTAL HEALTHCARE GETS SHORT SHRIFT FROM INSURERS

Have you ever sought mental healthcare for your child? What about care for a drug addiction? Have you made calls to multiple providers on your health insurer’s “list” and had the door slammed repeatedly in your face? Or were you fortunate enough to make a good connection and then unceremoniously have the rug pulled out from under you, with your insurer denying continued care?

Welcome to the club.

If you have a child with a mental health or addiction problem, you know how hard it is to make that first phone call. A parent with a child with cancer or diabetes doesn’t hesitate to call for help. But when mental health is the problem, it can take weeks, months or even years because of the crippling effect of stigma. But what about the two situations I described above: You make that call, but you are denied continued care, or you’re denied access to care in the first place?

The federal parity law, formerly known as the Mental Health Parity and Addiction Equity Act, is designed to prevent group health plans and health insurance companies from imposing less favorable benefits than they do for other medical conditions. The law is supposed to guarantee that people with mental illnesses have the same access to treatment as patients with diseases like cancer or diabetes, but some insurers have continued to limit treatment in subtle ways.

According to a recent report by NPR, since 2010, the Department of Labor, which is the main federal agency in charge of parity, has found 140 instances in which a patient's parity rights were violated. Although all those issues were resolved voluntarily, no insurer has been fined, and none of the results are public.

Regarding gaining access to care in the first place, 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 healthcare services included under the terms of the contract. The reality is that, because private insurers pay substandard rates as compared to Medicaid, middle class families are finding it harder and harder to find providers to help their children. They look at their insurer’s list of providers, make phone calls, and are repeatedly told, I’m sorry, I don’t accept your insurance. The lists are inadequate, outdated or just plain falsehoods.

On July 22, 2015, Assemblyman Todd Kaminsky authored a letter to the New York State Department of Financial Services to express deep concern about the lack of commercial insurance coverage for mental health services for middle class families on Long Island. He requested that DFS launch an investigation to determine the scope of this pressing problem.

Assemblyman Kaminsky said, “After hearing from numerous constituents and closely studying this issue, it is clear that commercial insurance companies do not have adequate mental health service networks for hard-working families.  This lack of access to care is alarming, and I hope DFS will immediately respond by commencing a thorough study of this issue.”

While Medicaid covers comprehensive mental and behavioral health services, commercial insurance frequently does not provide coverage, or if they do, the rates are miniscule compared with the cost of treatment.  The reality today is that fewer community-based mental health clinics are accepting privately insured clients who earn too much to qualify for Medicaid, which leaves these families with nowhere to turn for affordable care. They have few options to access care for their children, even those experiencing life-threatening crisis situations.

“In this day and age, it is disgraceful that mental health treatment is still not being taken seriously.  Turning children and their families in need away is simply unacceptable,” said Assemblyman Kaminsky.

I applaud Assemblyman Todd Kaminsky’s calling for a NYS Department of Financial Services investigation of commercial insurance companies with respect to network adequacy and substandard rates of reimbursement for behavioral healthcare.

By ignoring the enforcement of the federal parity law, the majority of representatives in government are turning their backs on the millions of Americans who are in need of essential mental healthcare services. We cannot trust insurance companies, whose eye is on their bottom lines, to do the right thing. It’s no exaggeration to say that lives have been and will continue to be lost unless we pressure our politicians to make this a top priority.

Andrew Malekoff is executive director of North Shore Child & Family Guidance Center, a nonprofit children’s mental health center in Roslyn Heights, NY.