Consider the case of “Mark,” a New Hampshire resident who, through his 20s and 30s, develops mental health problems that blossom into something big and disabling. Stress brings on depression and anxiety until it is so disabling he is not able to function at school or hold a job. Perhaps he becomes homeless or has to be hospitalized, and has no resources to take care of himself.
Mark is a composite, representative of the people seen at Monadnock Family Services, a community mental health center based in Keene. CEO Phil Wyzik says most clients are impacted by disability or poverty or both, and most are served by the state’s Medicaid program.
But, because of low reimbursement rates to providers, MFS, which serves 1,300 clients with long-term mental health problems per month, is struggling to staff at the level necessary to provide services. And the 10 community mental health centers across the state are facing the same issues: long waiting lists for appointments, staff burnout and difficult recruitment, according to Wyzik.
Last week, Gov. Chris Sununu presented his budget proposal for 2024, which includes a 3.1 percent increase for Medicaid reimbursement for all health care services. While the final budget is wending its way through the reconciliation process in the Legislature, local mental health care providers say the increase is woefully short of what is needed to ensure consistency of mental health care in New Hampshire.
What is Medicaid and how is it funded?
Medicaid is a joint federal and state program that helps cover medical costs for people of low income. The federal government has general rules that all state Medicaid programs must follow, but each state runs its own program. This means eligibility requirements and benefits can vary from state to state. It is the largest payer for mental health services in the country.
In 2014, New Hampshire adopted Medicaid expansion through the Affordable Care Act, providing access to health services for more than 219,000 residents.
The state funds the non-federal portion of Medicaid through taxes on insurance companies, revenue generated by the state’s liquor stores, contributions from a fund designed to address alcohol abuse and taxes on hospital services.
As of December 2022, more than 94,000 New Hampshire residents were enrolled in the state’s Granite Advantage Health Care Program, and in Cheshire County, 12.3 percent of the population was enrolled in Medicaid as of last June.
According to a report from the N.H. Fiscal Policy Institute, “The Effects of Medicaid Expansion in New Hampshire,” nearly 30,000 residents accessed mental health medication treatments in the last fiscal year. The state reported 29,941 people received mental health treatment, 11,456 people received mental health outpatient services, and 864 people received mental health inpatient treatments.
The problem with reimbursement rates
Reimbursement rates are based on types of service provided, type of medical professional or facility, the complexity of the service and the geographical location of services.
Jill Burns, associate executive director of Maps Counseling Services, said reimbursement for a 55-minute counseling session is between $75 and $80. Someone in private practice charges approximately $135 per hour on the low end, she said.
Burns says the agency, which has locations in Keene and Peterborough, currently has a caseload of about 600 active clients, served by 18 to 20 employees. Burnout is a big problem, she said, as is recruiting staff.
“We could recruit more staff if we could pay better,” she said.
“If you want to recruit people, you have to be able to pay a comparative wage as working for yourself. Medicaid doesn’t help,” she added. “It is the lowest reimbursement. You shouldn’t have to be wealthy or have a great job to receive mental health services. Everybody should be able to get mental health services, and Medicaid needs to up its game.”
Chelsea Helmke is a licensed social worker in private practice in Epping, specializing in trauma and attachment issues in children. While many of her peers don’t take Medicaid or any form of insurance, she estimates 60 percent of her clients have Medicaid coverage. Because of the long waitlists at community mental health centers, her caseload has grown to between 50 and 60 children.
“Because clinicians that work for the mental health agencies are paid pretty minimally, a lot of clinicians move on to private practice or another job, so there’s a lot of turnover in the agencies, which creates disruptions, especially for kids with trauma or attachment issues,” she said. “A lot of the time, we have these families who are just exhausted with the turnover rate and are looking at private practice.”
The reimbursement rate for Medicaid is about 60 percent less than reimbursement for private insurance, Helmke said. Her colleagues charge from $150 to $400 for a 50-minute session, she said, although some use a sliding scale based on clients’ ability to pay.
“A friend who doesn’t take any insurance said she crunched the numbers and couldn’t make it work. She said she couldn’t live her life if she took Medicaid.”
A 2022 memo from the N.H. Community Behavioral Health Association outlined the need for increased financial support for the state’s community mental health centers focusing on Medicaid reimbursements. The memo stated the rates would need to increase between 21.5 percent and 23 percent in order to make up for a $26.8 million to $28.2 million shortfall in wages to address workforce challenges.
Henry Lipman, the state director of Medicaid, said reimbursement is not a simple, straightforward thing.
“You have to look at more than the fee schedule for mental health centers to understand what is getting paid,” he said. “Medicaid is designed to cover variable costs, some fixed costs, and that works for some providers better than others. If you’re a provider that sees mostly commercially-insured patients, the amount of Medicaid is less of a factor. If you treat mostly Medicaid patients, the rate is not covering costs, and is more challenging. So, depending on the care mix, the rates are different in how they are impacted.”
Community mental health centers have contracts with managed care organizations, such as HMOs, and are reimbursed per person, per month of treatment, Lipman said. The state provides some additional funding for staffing, he said, but he said it is understandable they would be seeking additional reimbursement to combat rising costs.
A bill proposed by state Sen. Cindy Rosenwald, D-Nashua, would put $145 million toward increasing Medicaid reimbursement rates over the next two years.
A rise in reimbursement can’t come soon enough for Helmke who believes taking Medicaid fulfills an ethical pledge.
“To me, what it feels like when physicians or therapists don’t take Medicaid, is saying poor people aren’t welcome here, and that is fundamentally oppositional to the code of ethics we agreed to,” she said.
“None of us love the health insurance system in America, but if you want mental health to be considered health, you have to play by the health care rules. You have to work within the broken system. That means you advocate when bills come around that increase the reimbursement rate. You vote for legislators to work to create a more equal and provisional insurance system in our state and country.”
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