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.”
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.”