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Mental health access hindered by low Medicaid rates

New Hampshire’s Medicaid reimbursement rates are rising in January, for the first time since 2006. And while viewed as a win by local behavioral health providers, some say it acts only as a bandage on the state’s broken mental health system.

Medicaid, funded through state and federal governments, is the largest payer for mental health services in the country. More than 176,000 New Hampshire residents are enrolled as of November, and nearly 12,000 people are enrolled in Cheshire County, according to data from the N.H. Department of Health and Human Services.

But mental health providers in New Hampshire are reimbursed at about 58 percent of the rates paid by private insurers, and reimbursement rates are lower than in neighboring states, due to limited state funding allocated for Medicaid.

Part of the state’s $12.86 billion budget, approved in September, is trying to boost this, with $56 million for Medicaid provider rate increases. The rate will increase annually by 3.1 percent starting Jan. 1.

Even so, years of insufficient funding for mental health centers has led to scarce behavioral health coverage for Medicaid recipients and has limited providers staying in the state.

“When your revenue doesn’t match the pace of your business, you can’t pay people what the market pays or keep premiums low and you are forced to cut corners,” said Phil Wyzik, executive director of Keene-based Monadnock Family Services. “... This new reality of having less workers out there has to start influencing rules and policies in a way it hasn’t so far.”

Reimbursement limitations

Bethann Clauss, clinical director at Maps Counseling Services in Keene, said the agency is reimbursed $72 by Medicaid for a one-hour session. If she sees a family of four, the rate drops to $58.

A 2015 report from the American Academy of Pediatrics found a psychiatric evaluation in New Hampshire was reimbursed at $87.82, while an evaluation in Massachusetts was $117.42 and in Vermont, $104.13.

“I sit with child after child, family after family, who have heartache and emotional distress,” Clauss said. “To do all that and not have a paycheck to support your own family is stressful.”

With the reality of these low rates, Maps’ Executive Director Dr. Gary Barnes said he’s spoken to many mental health providers who have stopped accepting Medicaid all together. Maps is one of the few agencies — outside of the state’s 10 community mental health centers, including Monadnock Family Services — that still does.

This is especially problematic for children, Barnes noted, because it’s often cheaper for parents to enroll kids in Medicaid than add them to private insurance. And while Medicaid can pay for most of the same treatment a private insurance provider could for physical health needs, its mental health services are limited.

“It’s simply a matter of economics,” he said. “[Many other agencies] can’t justify taking the 25 percent pay cut to treat a population when there are other kids out there who are just as needy who are able to pay more.”

The only way Maps can afford to keep seeing Medicaid patients, he said, is because it’s a nonprofit organization — so it doesn’t pay taxes — and doesn’t offer employee benefits like health insurance and retirement plans.

But even with limited mental health services, the need is still there, and increasing.

A recent study by the American Psychological Association found the number of adults who experienced serious psychological distress in the past month increased from 2008 to 2017 among most age groups, with the highest rate at 71 percent for ages 18 to 25.

Clauss recalled a week recently when the agency had to turn away nearly 100 people who wanted to be seen because it just didn’t have enough clinicians to see them.

“It’s a dilemma, especially with children. If you have a child in a stressful situation and their parents are overwhelmed and struggling, you want the path to be easy to the support that they need,” she said. “It feels like Jesus going around, knocking on doors and them saying, ‘There’s no more room at the inn,’ ya know? We just can’t take it anymore.”

Not enough money, not enough staff

Due to this workforce shortage, only 45 percent of New Hampshire’s mental health needs were being met as of December 2018, according to a report from the Henry J. Kaiser Family Foundation.

And when states like Vermont and Massachusetts are paying more for services, it’s hard to get providers to stay in New Hampshire. But staying frugal all these years, Barnes added, isn’t actually a cost savings in the long run.

Untreated mental illnesses cost more than $100 billion nationwide each year in lost productivity, according to the National Alliance on Mental Illness.

“These kids, without help, end up costing us a whole lot more in care,” he said. “When you see homelessness or drug abuse, a lot of that had its roots in childhood [mental health] problems.”

But the continued low payments from the state have created a hole in the number of providers.

Wyzik, at Monadnock Family Services, said there are more than 270 vacancies across the state’s 10 community mental health centers — private, not-for-profit agencies contracted with state health departments to provide publicly funded mental health services.

“We don’t have enough applicants for jobs that are vacant,” he said.

On top of the vacancies, Wyzik added the center has a 16 percent employee turnover rate.

It’s a similar struggle at Cheshire Medical Center.

The hospital, an affiliate of Dartmouth-Hitchcock Health System, was forced to close its inpatient Adolescent and Mental Health Unit in 2016 — the only inpatient service in the county — because it couldn’t recruit enough psychiatrists to staff it.

“We had three psychiatrists retire within a few months of each other and put out the effort to start recruiting, but psychiatry is a specialty within medicine and there is way more demand for it than younger physicians going into it,” said Shawn LaFrance, vice president of population health and health system integration.

And for The Doorway, the hospital-based regional hub for addiction services, the lack of providers made for a rocky start.

“We couldn’t get any clinical staff ... it took us months,” said LaFrance, who oversees the program.

The center, which opened in January at 640 Marlboro Road (Route 101), is part of a statewide effort to create a “hub and spoke” system to screen, assess and refer people to treatment and support services in the community.

Funded by a two-year, multimillion dollar federal grant announced in October, the hubs aim to link people to resources and follow up with them as they advance through recovery services provided by the spokes — rehabilitation centers, sober homes, peer support agencies and other organizations.

With all nine Doorway locations in New Hampshire opening at once, the limited pool of mental health providers was being spread across the state.

LaFrance said the program now has a steady staff of three, though he originally envisioned having eight.

“... once we have the staff, we can serve more [patients] and serve them better,” he said.

But if retention of mental health workers stays on the current course, Wyzik said the state’s crisis will only worsen.

“We know that there is a need out there,” he said, “... so this lack of service providers means there’s a lack of supply for services that are necessary for people.”

Steep decline in birds may worsen as temperatures rise

As Wes Biggs tells it, a Baltimore oriole flew onto his family’s front porch and landed on his bassinet when he was only 6 months old. Captivated, he became a lifelong bird-watcher.

Over the 71 years since then, like thousands of other longtime birders across the continent, Biggs has seen and helped document dramatic change.

Bald eagles surged back from the brink of extinction. Many duck species rebounded. But a host of other species — including sparrows, meadowlark and quail — declined at an alarming rate.

“You’re just not seeing thousands and thousands of birds anymore, and certainly not as often as you used to,” said Biggs of Sebring, Fla., owner of Florida Nature Tours.

Two major research projects released this fall brought into perspective what individual bird-watchers like Biggs have noticed, while raising concerns about the future and the need for additional conservation measures. Additionally, a USA TODAY Network analysis of the studies and their data showed the loss of birds touches every U.S. state in North America.

The first of the studies, dubbed the “Billion Birds” report and published in the journal “Science” in September, concluded 2.9 billion birds have vanished across North America since 1970, a decline of roughly 30 percent. It added to a growing body of work over the past couple of years documenting those losses.

The results surprised even the study’s lead author, Ken Rosenberg, a Cornell University scientist who also holds a position with the American Bird Conservancy.

Rosenberg used to tell bird-watchers the birds they were no longer seeing had probably moved on “somewhere else.” But the study proved otherwise, he said, showing in many cases bird populations had just plummeted.

While that doesn’t mean a bird “apocalypse” is underway, if conservation measures aren’t taken, Rosenberg said, the situation could “slide toward a bigger crisis, toward ecological unraveling of ecosystems.”

Another major report weeks later delivered a second punch. Using models and much of the same data, the report by the National Audubon Society provided a grim forecast of the potential impacts of warming temperatures on 600 bird species in North America.

“If we don’t take action, nearly two-thirds of North America’s birds face extinction as a result of climate change,” said Julie Wraithmell, president of Audubon Florida. If action is taken, she added, “we can change the fate of three-quarters of those birds.”

Casting blame

The massive losses in bird populations could have far-reaching implications for ecosystems and economies, said Marianne Korosy, Audubon Florida’s director of bird conservation.

Birds are both prey and predator, serve as nature’s pest control, share roles with bees in plant pollination and help to maintain genetic diversity by spreading seeds around, Korosy said. Also, the federal government estimates bird-watchers contribute $41 billion dollars a year to the nation’s economy.

The study by Rosenberg and his co-authors at wildlife agencies and research centers in the U.S. and Canada didn’t specifically analyze the causes behind the declining bird populations. He said that can be hard to pin down given the array of threats birds face and the vast distances they travel during migration. But previous studies indicate habitat loss is the primary threat.

As a group, grassland birds such as meadowlarks and quail suffered the biggest overall declines, the Billion Birds report showed. In the Midwest, the single biggest factor is habitat loss, said Neal Niemuth, an integrated conservation scientist for the U.S. Fish and Wildlife Service in Bismarck, N.D. He points, for example, to the conversion of cattle grazing lands, which protect the birds’ natural habitat, to much more intensively farmed corn fields.

Other factors include feral cats, climate change and pesticides that kill insects birds need to live and raise their young.

“You can’t just pin it on one thing,” said Biggs, but human population growth has its own impacts. While bird populations have dwindled, the nation’s population has doubled over Biggs’ lifetime and Florida’s population is seven times greater.

“I hate having a doomsday attitude,” said Biggs. “But looking at the whole situation, it’s pretty horrific.”

Bird populations have fallen in each of the 49 U.S. states in North America, according to the USA TODAY Network analysis of state data from the North American Breeding Bird Survey.

A joint project with the U.S. Geological Survey and the Canadian Wildlife Service, the Breeding Bird Survey dates back to the 1960s and was the primary source of data for the Billion Birds report. Geological Survey scientists consider the long-term data available in the survey scientifically credible for 334 species, around a third of all the species with documented sightings in the U.S. and Canada.

In 39 states, more than half those species have shown declines.

A list of the five bird populations in each state with the worst declines totals 92 different species. Eastern meadowlark, bobwhite and house sparrow were among those with the greatest population declines in 17 states.

In New Hampshire, the five species with the greatest declines are the eastern towhee, bank swallow, cliff swallow, wood thrush and least flycatcher, according to the data provided by the USGS.

Even official state birds suffered population losses in 25 of the 45 states where data was available. The state bird in New Hampshire, the purple finch, experienced a downward trend in population between 1966 and 2017, according to the USGS analysis.

Audubon examined how birds would fare under three climate change scenarios: one in which temperatures warmed by slightly less than 3 degrees Fahrenheit; another in which they warmed by nearly 4 degrees; and a third where they rose by more than 5 degrees in the coming decades.

Using climate modeling, Audubon studied how the risks birds face — including habitat conversion, extreme weather and sea level rise — could change and how that would affect birds in each state. Under the higher, unmitigated increase in warming over the next 65 years, the study concluded 97 percent of species could be affected by two or more climate-related threats.

Under the scenario of slightly less than 3 degrees warming within the next 35 years, at least 51 of the 600 species Audubon examined faced a high risk of either being wiped out or seeing a worsening trend.

In New Hampshire, an average temperature increase of 2.7 degrees by 2055 could wipe out or cause a worsening trend in three bird species in part or all of their range. The list includes the black-throated green warbler, Henslow’s sparrow and spruce grouse.

The studies shocked Father Tom Pincelli, a Catholic priest in Brownsville, Texas, and a bird-watcher for 47 years. The Billion Birds report “kind of took my breath away,” Pincelli said. “The number was larger than I thought.”

‘Eyes of the world’

Bird-watchers can be a quirky bunch, toting high-end binoculars and telescopes and randomly dropping conversations when distracted by a bird. But the compulsive listing of birds they see has helped amass mountains of data scientists now use to document changing bird populations.

“It’s really amazing we have such a wealth of data,” said Brooke Bateman, an Audubon senior scientist and lead author of the climate report.

Much of the information used in both studies came from data collected by bird-watchers, including the Breeding Bird Survey and Audubon’s Christmas Bird Count. The 120th annual Christmas count began Dec. 14 and runs through Jan. 5. Nearly 80,000 people participated in last year’s count.

“There’s this incredible collaboration between the scientists and the bird-watchers, and it really doesn’t exist with other animals and other sciences,” Rosenberg said. “Birders are the eyes of the world.”

Bill Volkert, a naturalist and wildlife educator, has birded the same areas around Horicon Marsh in eastern Wisconsin for more than 35 years. He sees wild turkeys and Canada geese more often than he used to, but the song of the whip-poor-will “is gone.”

“A lot of times, we just look at birds in our backyards and as long as birds are showing up, it’s really hard to extrapolate what’s happening to the [overall] population,” he said.

In North America and elsewhere, climate change will be a “threat multiplier,” said Audubon’s Bateman. Some birds already have shifted their ranges northward, she said, while warmer temperatures are forecast to trigger other impacts such as longer droughts and more intense hurricanes.

Birders have documented many changes after the string of hurricane landfalls in recent years. In Ormond Beach, Fla., for example, Meret Wilson, who operates a bird-banding project, said things still haven’t returned to what they were before two major hurricanes — Matthew in 2016 and Irma in 2017 — heavily damaged trees in the region.

‘Before it’s too late’

Going forward, both bird studies underscore the need to help birds be more resilient, said Nick Wiley, chief operations officer for Ducks Unlimited and former executive director of Florida’s Fish and Wildlife Conservation Commission. He said he was excited about the emphasis the Billion Birds report put on conservation needs and successes.

Conservation measures do work, said Rosenberg. For example, raptors such as bald eagles benefited from the 1972 ban on the use of the insecticide DDT in the U.S. And, he said, a more than 50 percent increase in the population of 41 species of waterfowl was a result of “a conscientious effort to save habitat.”

Ducks Unlimited grew out of hunters’ recognition of low population levels of waterfowl in the early part of the 20th century, Rosenberg said. To protect those birds, nonprofits and state and federal governments worked to acquire and protect wetland habitats. A federal duck stamp purchased by duck hunters has helped funnel millions into wetland preservation.

Similar efforts are needed to continue protecting ducks and to preserve grassland birds, said Wiley. But, he added, it’s expensive and takes groups working together.

Federal government programs to help landowners keep their land in grass or return it to grass have been “a huge, huge boon to grassland birds,” Niemuth said. But the available money isn’t enough to match landowner interest.

Volkert, the retired wildlife educator, sees the need for conservation as a bipartisan issue.

“For millions of people who love birds and love nature, it’s time for our group to raise our voices for birds,” he said. “The alarm we want to sound is for people to pay attention to the loss of these common birds now before it’s too late, while we can do something.”