Back when I was young and idealistic, I worked for several years at an entity that managed mental health case and care coordination. I never provided front line service, that is not what I do, but I routinely saw reimbursement fee schedules for mental health providers. They were absysmal. A master’s level provider could expect to receive between $45 to $70 per hour for their time in an office setting and perhaps $15 more for in-home services. The higher rates tended to be from government programs. That sounds like a lot but that fee has to be able to cover wages, overhead, infrastructure, insurance and education expenses. As a comparison, when I took Kid #2 into the pediatrician last week for suspected croup, the CRNP was able to get paid $108 for a ten minute visit. She can do four or five of those visits in an hour. When I called a plumber over the summer to fix the shower, she got paid $240 for forty five minutes of service. What we pay is a decent indicator of what we as a society value. We value working showers and acute medical care far more than mental health care.
Mental health services have always been done on the cheap, and that means there is very little capacity in the system. Hospitals are more than willing to build $230 million dollar proton beam therapy centers that offer minimal marginal improvement in results for cancer treatment because cancer pays. At the same time, in-patient psych beds have been cut dramatically. Some of this is a long term trend, but a signficant amount has been due to state level budget cuts of the past five years.
Commenter CzarChasm has this to say in an e-mail to me as a front line mental health provider in Virginia concering the Deeds stabbing and suicide:
Quick overview of mental health care in VA: I’m a mental health professional at one of the Community Services Boards in Virginia; here, Community Service Boards (CSBs) are quasi-public, non-profit orgs that handle most of the mental health services for the poor, disadvantaged, and disabled. These services typically include: outpatient therapy, services and programs for the intellectually disabled, social skill development, Wounded Warrior programs, child and family therapy services, in-school help for children with emotional/behavioral issues, employment services for mental health consumers, residential programs, emergency crisis services, and life skill training. Most CSBs’ funding comes through Medicaid billing, with some grants sprinkled here and there. We also receive some funding from the municipalities we serve (Almost every county and city in the state has its own CSB; some CSBs serve multiple counties/cities in their catchment area). Besides us, there are some private companies that provide some of the less intensive services (mostly outpatient therapy, intellectual disability services, and life skill training), but these private companies deal with a fraction of the populations that CSBs serve. Most CSBs offer NO inpatient programs, and the inpatient programs from the ones that do are both voluntary and focused on minor stabilization, nowhere near the levels of crises seen by most psychiatric wards in hospitals. Virginia has mental health facilities for long-term care, but none are designated specifically for crisis stabilization.
That said, the inability to find a bed is amazingly common, as there are very few places that have psychiatric facilities: a few hospitals, and some private, inpatient facilities. The state has been maxed out with its short-term capacity for some time, and this mirrors the level of services in the CSBs: We’re all maxed out. To make matters worse, some programs that help with recovery (i.e. those outside of the hospital) are having their billable rates slashed drastically.
To prevent these tragedies, VA needs:
-more short-term, inpatient facilities.
-more qualified staff in EVERY program, especially on the licensed level.
-more funding for its public mental health services, to ensure that good mental health workers are compensated for their 40 hours (really, most work 45-50, but don’t let it show on the timesheet).All this is the ignored result of our legislature refusing the federal expansion of Medicaid in our state, coupled with the nominal funding received by CSBs from a lot of the municipalities. I’m hoping that this results in legislature that increases funding to our CSBs, along with the state actually creating crisis stabilization facilities in high-need (i.e. poor and rural areas, which is 80% of the state) locations.
In the past 24 hours, most responses from other mental health professionals I’ve interacted with have all had the same reaction to this event: a mixture of outrage (“He was RELEASED??!”) and frustration (“same thing happened with one of my people last week/month”). Until mental health stops being treated as the red-headed stepchild of healthcare, this will continue to be our reaction, and we in the public mental health field will continue to be able to do little to change this.
skerry
Could we stop with the “red-headed stepchild” talk?
Original Lee
Sadly, it’s been that way for a long time. A coworker’s wife had some long-standing mental health issues about 20 years ago. It was hell on my coworker to find her room in an inpatient facility only to have her released too soon for long-term stability, and repeat the cycle again a few weeks or months later. He was eventually encouraged to resign because of having to take so much unscheduled leave to deal with her condition. I think they ended up moving to another state in hopes of finding better treatment options.
greennotGreen
@skerry: I thought the same thing, and I’m not a stepchild and I don’t have red hair. I have actually had a friend who had absorbed a lot of superstitions about red hair, so using that archaic phrase isn’t harmless.
dpm (dread pirate mistermix)
This sounds worse than the limited services provided in New York.
JCJ
Unfotrunately I have experience from the family member side of mental health care. My wife has been hospitalized three times for acute psychosis – once in Thailand, once in Japan, and once in the US (Wisconsin.) What was appalling to me was the amount of time wasted getting treatment here in the US. In Thailand and Japan treatment started right away. In the US ten days were wasted with some legal process. To me this added unnecessary cost and familial stress. She was acutely psychotic with a history of psychiatric problems and not taking her medications. The total bill for three weeks was $14000 (ten years ago) with insurance payment limited to $10000. This seems like an area where improvement is obvious.
WereBear
@dpm (dread pirate mistermix): I know someone who got rather incredible service, ultimately, with a very difficult teen situation, in New York.
Now, getting there is tough. The school totally dropped the ball and let bullying get out of hand, making the situation worse instead of better. Then there was the usual carousel of therapists, some of whom were way into the “tough love” which only made the situation worse.
But once it was clear there was something seriously wrong, NY stepped in and got a bunch of good people on board and things are shaping up. Finally.
Still, many places just let it get as bad as the recent Virginia incident, and leave it there. A child with any problems in Texas, for instance?
Just murder us all now, it would be quicker.
Valdivia
thank you for writing this and including the email.
aimai
Thank you for this. I’m considering going back to school to become a clinical social worker and it looks like my area is certainly graduating enough people but whether there will be jobs for us all at the end of it is anyone’s guess.
maximiliano furtive, formerly known as dr. bloor
@aimai: Don’t bother. I love, love, love my work, and I will never, ever, ever let my kid go into mental health care. From a time/cost investment point of view, you might as well spend a weekend throwing $100 bills into a bonfire.
You might be overreaching by going for a CSW degree anyways. In the same way that insurers and states systematically tried to minimize Ph.D. and M.D. level practitioners in the past in favor of (cheaper) Master’s-level practitioners, the current trend is to have Bachelor’s-level Licensed Mental Health Counselors do as much of the work as possible, with a modicum of oversight by those with advanced degrees.
BTW, Richard, thanks for this. You get what you pay for, indeed.
C.V. Danes
Also, because of the stigma associated with poor mental health, people suffering from issues (and their families) are under represented and, quite frankly, shunned by our society.
negative 1
By the way a lot of this is due to controllable societal factors — when you wage war for 10 years, surprisingly you’re going to have a lot more mental health issues. Additionally, when unemployment is high substance abuse increases, same result. If we had a functioning government than we could use it as a great example of counter-cyclical spending — adding to these budgets in a time of need would help employment by hiring counselors, for instance, as would building more inpatient facilities, etc. But, you know, some of *those* people might take advantage of it, so we can’t do that.
drkrick
The issue discussed in the post is real, and here’s hoping that a tragedy affecting someone the VA political elite knows results in some improvement.
However, news reports yesterday indicate that there were several vacant beds within two hours of Bath County at hospitals that claim they were never contacted by the CSB evaluating Gus Deeds. That contradicts the initial account of events from the CSB, which stopped talking yesterday.
And really, two of the first three comments are about the phrase “red headed stepchild” with no mention of the issue at hand? Way to focus on the big problem, folks.
japa21
Richard, I was one of those front line workers in MH case and care management. And I was one of the few that had extensive experience on the practitioner side of the equation as well.
Yes, reimbursement sucks big time for the practitioner. But, to be totally honest, there are several factors at play. From an insurance reimbursement point of view, practitioners have every reason to keep a client in treatment as long as possible, specially since limits have been done away with. And unlike most physical ailments, there is not as strong a quantitative assessment available as to the necessity for treatment.
In fact, one of the reasons limits were first introduced back in the late 70’s and 80’s was abuse by providers of the system. This was most apparent in treatment for teens, specially in residential settings. It was not uncommon for a treatment center to keep a kid until insurance benefits ran out (usually the lifetime limit).
At the same time, having worked with many providers, I can honestly say that probably 30% of practitioners are incompetent and may actually harm their clients more than help them. A good portion of the rest are more or less neutral in terms of the assistance they provide, neither damaging nor helping.
And, of course, all of this results in inadequate treatment, from low reimbursement, to lack of qualified practitioneers, to the continuing societal stigma on mental illness.
Ed in NJ
My wife has a contract with the state of NJ to provide in-home crisis screening services to at-risk youth. This program, the Children’s Initiative, was set up by Christie Todd Whitman and advanced by Jon Corzine with monies from the tobacco settlement of the late ’90s. It was a very effective program designed to indentify and treat children with mental health and behavioral issues and took a holistic approach to providing services and support to prevent hospitalization. By all accounts it was a very effective program, saving lives and the state millions of dollars through early intervention. I’ll add that it was a public-private cooperative, so only the risk assessment was administered by the state if the families had private insurance.
But when Christie was elected, guess what the first program to be cut from the state budget was? The Star-Ledger decided to run an expose purporting to reveal abuses of the system. They used a couple of examples of situations where the program was paying for services for family members, like marriage counseling for the parents, to prove that it was a wasteful program. Christie used the situation to flex his tough-guy, fiscal conservative chops right out of the gate. So now it is reduced to crisis intervention and kids are only referred to the service when they become dangerous to others or suicidal and much more expensive to treat.
Biff Longbotham
@skerry: Congratulations!! Your comment has been automatically entered into the “Distracting From the Main Point” competition. Good luck!!
Ripley
Nice take-away, genius.
Uncle Ebeneezer
Wasn’t there a whole lot of stammering by conservative politicians, after Sandy Hook, that instead of gun regulation (oh noes!!) we needed to get serious about mental health services? The same politicians that are now refusing the Medicaid expansion that would effectively help that cause?
Jockey Full of Beaujolais Noveau
Technically OT, but this longish blog post by Clay Shirky regarding what went wrong with the healthcare.gov rollout is (IMO) dead on.
tl;dr version: Planners/Managers not listening to the people actually building the thing. (Anyone who’s ever worked on a large software project will find Shirky’s anecdotes quite familiar).
jake the snake
From Will Durst.
Q: What did they call the homeless before the Reagan administration?
A: Patients.
fuckwit
@maximiliano furtive, formerly known as dr. bloor: This is not only true of mental health. I know someone who has just received only an Associates degree in nursing, no licensed practical nurse certification, no registered nurse certifications, no bachelor’s degree at all, and immediately upon graduation began working as a “nurse assistant”, doing stuff that nurses do, but without the pay or the schooling.
Capitalism will always find a way to get free/cheap work out of people.
Elie
Treatment for mental illness is generally inadequate and there isn’t enough good quality outpatient treatment, which of course leads to the necessity for crisis management and hospitalization…
Its the last frontier in health care research as well. Went to a really cool presentation a few months ago in DC on current research and it was fascinating what they are learning about how the brain works in certain mental illness. There is still so much they are learning about HOW the brain functions and the complex role of neurotransmitters on the various structures.
What also struck me is the Psychiatrist researcher that presented (name escapes me but he was with GWUin DC)emphasized the huge role of getting enough sleep in the occurrence of exacerbations for any number of mental conditions .
So added to the lack of capacity is the lack of real knowledge about the effective early assessment of risk, accurate diagnosis and treatment of many many mental conditions.
gratuitous
@Uncle Ebeneezer: If only there was some way to remind our elected officials of what they said back in the day. And to draw attention to the disconnect between their words and their actions. But what???
I’m out of ideas, except for this crazy notion of public vectors through which information could be efficiently disseminated to the masses. It could be done through various outlets or mediums (media?). What would you even call something like that? Ah well.
ericblair
@Uncle Ebeneezer:
No one could have predicted.
Some time ago there was a 40 nanosecond window between “Too soon to talk politics about Sandy Hook” and “Why are you bringing Sandy Hook into this, that’s history now.” You missed it, so, shame on you. Yep.
Elie
@ericblair:
This is why grassroots organizing and teaming with strong advocacy organizations such as NAMI would help bring that agenda forward. In my opinion, however, FIRST, people have to start plaintalking about their realities and situations to drive awareness of the scale of the need. Right now, mostly people are shamed into silence which makes it hard to represent the need in a real way to local and other politicians. Until they start to see auditoriums full of people and people clogging their offices with demands for change, they will continue to ignore it — cause they can
nanute
Richard,
Sorry for the o/t question. I need some guidance on filing an appeal with my health insurer’s payment on an out of network claim. If you can help, or give me some advice on any patient advocates that would represent me in the process I would appreciate it.
pseudonymous in nc
@maximiliano furtive, formerly known as dr. bloor:
Yep. The VA and military remain among the few environments where doctoral-level mental health practitioners are being hired to do standard clinical caseloads. In the state sector, doctoral-level practitioners are essentially being limited to managerial and supervisory roles, and salaries are pretty shitty for the qualifications. $50k isn’t a bad salary, but it’s not a great salary for a staff psychologist with $100k in tuition debt.
There’s also a fair amount of gender bias: as clinical psychology has become a “women’s” profession, the amount they’re paid for the same work has gone down.
Louis
@maximiliano furtive, formerly known as dr. bloor: Yes, Ha & etc. Taking a brief break during my job as an ER crisis worker in a Chicago suburb to read BJ. State hospital beds are barely there and have decreased. Community programs have decreased and are struggling for funds. My LCSW student loans will be paid off in 20?? My work is exciting and vital (though the MSW plan was school social work. Ha to jobs in that being available) and draining. Our patients and clients are the hated and feared. Often by medical practitioners. Thanks for colleagues writing about this.
Louis
@pseudonymous in nc: In Illinois, VA can refuse involuntary patients. So a Vet who is psychotic or refuses needed care gets NO help.
Deffrey Jahmer
@skerry, greennotGreen: Also, too, knock-knock jokes discriminate against the deaf.
CzarChasm
To anyone offended by the stepchild metaphor, I would like to amend it with this phrase:
The stepchild loathed by the one marrying into the family.
The End
@maximiliano furtive, formerly known as dr. bloor:
Out of curiosity, which states do you know of that are trying to have those with Bachelors do actual counseling? In Virginia (the VA I was referring to; apologies if it got confused with the Veterans Administration), all counseling-level duties require licensure, which requires a Masters (either Social Work or Counseling…LCSW vs LPC) at a minimum. You still see some doctoral-level counselors, but they tend to be in private practices. There is a Bachelors-level license, Licensed Social Worker, but that’s typically used for actual social services only (no counseling involved). Virginia also has, in the U.S, one of the most stringent set of requirements for licensure, so I don’t see us going down this path.
pseudonymous in nc
NC’s Clinical Counselor positions have this requirement:
There are also Behavioral Specialist positions in the corrections system that operate under supervision and only need a bachelor’s degree.
Louis
@CzarChasm:
When I worked at a methadoneclinic, I was a Counselor with an arts mgt. BA and a Certificate in substance abuse. I also worked doing counseling in community mental health with my BA and CADC. Many people do great work doing Counseling with BAs. Being a Therapist requires a license (LSW,LPC,LCSW,LCPC).