The mental health care system in Massachusetts is struggling. Here are the main problems I can identify with it at this time.
1. Outpatient mental health is primary health care, but it is not being treated as such. If everyone had access to culturally competent, effective outpatient mental health once a week -or once every two weeks- then a large percentage of the population would not be accessing higher levels of care. A weekly visit to a competent therapist is preventative and keeps folks away from the ER, crisis services, respite, partial and inpatient hospitalizations, which is significantly more costly to the State and insurance companies. However, I don’t see a push to inject funds towards outpatient mental health. We are addressing the crisis by pouring millions into big programs with wrap around services, but not looking at preventative care at the outpatient level.
2. Currently more clinicians are leaving the field than graduating into it. Why? Burnout. Clinicians all across the State are overworked and underpaid. Reimbursement rates from insurance companies should be comparable to those of medical professionals, and clinicians should be compensated according to their education, licensure, linguistic abilities (a clinician offering therapy in more than one language should be compensated for that) and years in the field post licensure. Instead, anyone in these categories earns an average of $55,000 a year and every year inflation makes our profession less and less financially viable. Without a clear increase in compensation, what exactly is the motivation for clinicians to further their education and obtain a State license, therefore better regulating the delivery of services? Not to mention scheduled fees from insurance companies vary significantly, with one insurance paying $61 for a 60 minute session and another paying $132 for the same. In addition, there should be a reasonable cap on how many clients are assigned to any particular clinician and how many billable hours can a clinician have in terms of productivity. These measures would ensure the long term sustainability of the profession, addressing the needs of today’s workforce and motivating a new wave of professionals.
3. There appears to be an over saturation of programs and services in the mental health field. In many occasions these overlap and overwhelmed not only clients, but the budget of the State and insurance companies. For example, a single mother with a child with severe behavioral problems is offered the following: Outpatient therapy for the child, outpatient therapy for the mother, family therapy for both together, in home therapy, parent coaching, a support group for mothers with children with challenging behaviors, and a social worker to help coordinate all of these services. The problem is that we don’t take into account that this represents 7 appointments a week for this working mom and childcare expenses associated with keeping some of these appointments. In addition, who says the mother’s employer is gracious around providing mom with the time flexibility to comply with such an ambitious treatment plan? The system is not designed to allow the mother to opt out of resources because there is fear of being seen as non-compliant and negligent (having a 51A filed against them with DCF). The service providers are interested in billing for these services to support their budget and meet the numbers to justify their grants. But in the end, is the client better served by these practices? There has to be a better way.
4. Many years ago it became a requirement for all clinicians seeing MassHealth clients under the age of 21 to do a CANS (Child Assessment of Needs and Strengths) every three months, while the client is in treatment. There are many problems associated with this. In order for clinicians to be able to do a CANS they need to be certified. The certification is long, labour intensive, and not a one time affair. It is also redundant for clinicians who are independently licensed and have already proven to the State their competency. Then, the CANS is required for each client every three months. It is singlehandedly the longest piece of documentation a practicing clinician produces at any given time. It is invasive and repetitive. We wonder the purpose of it other than its contributions to systemic oppression, given that what we are doing is collecting data on our most vulnerable populations and giving it to the State without really being in the know about how all of this information is used. Many clinicians in private practice refuse to take MassHealth clients or to even be paneled with MassHealth because they simply do not want to do a CANS. The solution, I have to say, is not to force clinicians to take MassHealth and/or do CANS. The solution is to reconsider this requirement and its impact in the accessing of mental health care at any level.
5. Clinicians cannot charge No Show and Late Cancellation fees to MassHealth clients. This is a problem because there is no way for clinicians to reinforce treatment attendance compliance with MassHealth clients. So if I have availability for 30 clients, and half of them are MassHealth clients, then I have to calculate that at least 10 of them are not going to show up. Why? 1) Because many times their motivation towards treatment is being mandated by court or DFC 2) Because of socio-economical barriers (transportation, child care, education, etc.). So clinicians are forced to schedule 40 clients instead of 30 to account for this, which is a fast track to burnout. A possible solution could be for clinicians to be able to collect No Show or Late Cancellation fees from clients or MassHealth itself, with a “3 strikes you are out” policy, meaning that the client is only given the opportunity to be inconsistent on no more than 3 occasions before being asked to return whenever they are able to commit to the therapeutic process.
6. Billing for MassHealth is a nightmare. It doesn’t work with SimplePractice, which is the most used EMR (Electronic Medical Record) by clinicians in private practice, and to outsource MassHealth billing costs about 10% of the provider’s income (which is already very small). MassHealth could reimburse providers for outsourcing MassHealth billing costs and this would encouraged clinicians to take more MassHealth clients. On the other hand, why can I bill literally any other insurance utilizing SimplePractice, but not MassHealth? That to me seems like a very easy hurdle to overcome that would significantly increase the amount of clinicians willing to take MassHealth, therefore increasing access to services.
7. One symptoms of the chaos in the mental health system is the over saturation of programing at the community health agencies level. They do a lot, but none of it is executed well. In fact, the poor execution of all of these programs is contributing to the rise in health care costs in Massachusetts. If you pay attention you will notice that the minority of the programming is associated with outpatient mental health, which is the first line of defense in the fight for behavioral wellness. Outpatient mental health, in the industry, is considered a “money pit”. This means that there is no motivation from these agencies to grow their outpatient programs, therefore forcing clients to flood higher and more costly levels of care. It’s backwards. There should be incentives for positive outcomes at the outpatient mental health level, and most financial resources should be allocated towards that level of care. Do not treat the severe symptoms, prevent the acute presentation of the illness instead.
8. Lastly, as a clinician with a for-profit model group practice, its incredibly frustrating to see how the State provides massive funding to these agencies that are functioning in such chaotic ways while outpatient clinics, like Colorful Resilience LLC -doing good, quality, culturally competent outpatient mental health, with a team of independently licensed clinicians who share identities with the communities served (BIPOC, LGBT, 1st gen and immigrants)- have zero funding from the State. We do excellent work, backed by data, and we are forced to bootstrap our growth through debt. So, from my perspective, poor outcomes at community health agencies get rewarded with money they don’t have to pay back, and excellent outcomes at small for-profits are give the consequence of debt. If medicine thrives in a for-profit model, why can’t mental health? And what would happen to the access to mental health care when the State decides to allow pro-profits to compete (in an equitable way) with non-profits for grants?
It is time to come up with a plan that does not aim to address the immediate crisis, but that is set up to support the mental health system as a whole for the next 20 years.