Michael Woodworth 

For many individuals in the United States, mental and behavioral illness is something they must deal with on a daily basis. For many of those, the depression, anxiety, and feeling of powerlessness has become the norm due to a lack of treatment options. As the number of affected individuals grows, outpatient clinics are becoming the treatment of choice for many Americans and in New York this trend also holds true.

With the third highest population in the United States, New York is home to over one million individuals suffering from mental illness. According to the 2015 census, the number of individuals suffering from mental illness had reached an all-time high of 900,000 adults and 528,000 adolescents (Friedman, Woods, & LaPorte, 2016, p. 4). Despite the alarming increase in numbers, less than 20% of those affected by mental illness receive adequate, if any treatment at all (Friedman, Woods, & LaPorte, 2016, p. 4).

Although this may be partly due to the individual choosing not to receive care, I believe there is a direct correlation between the policies and procedures New York has put in place that govern the access, cost, and quality of mental health care. The New York State Office of Mental Health currently has over 50 categories of policies and procedures that govern treatment options, approved providers, medication, and criteria patients must meet to be treated, just to name a few (Office of Mental Health, 2017). As a result, many individuals choose to self-medicate or simply ignore their symptom rather than deal with the bureaucracy that surrounds behavioral health as well as the negative stigma associated with anyone receiving the treatment.

Of the 20% of individuals receiving mental health services in New York, nearly 71% are through outpatient treatment services. Outpatient treatment exist as a way of providing access to individuals who are suffering from disorders that may not require intensive inpatient treatment. They are capable of treating disorders such as depression, anxiety, grief, phobias, trauma, and so forth.

Overview on Outpatient Care Systems

Outpatient care can provide a wide variety of services to individuals seeking assistance with their mental and behavioral health. These services include, but are not limited to: individual counseling, group therapy, acupuncture, massage therapy, DBT, art therapy, interventions, couples and family therapy, and alcohol and drug detox. These services are based on severity and need and are often delivered by peer advocates, licensed counselors, nurse practitioners, case managers, clinical psychologists, psychiatrists, and medical doctors.

New York State offers two main avenues of treatment to those seeking outpatient care; these are the hospital systems and the health programs available within the community. For many people in New York, there are only two ways into these outpatient programs. The first being through a referral from a qualified healthcare professional (QHP). This can include a primary care physician, clinician, psychologist, nurse practitioner, among others (Friedman, Woods, & LaPorte, 2009). The second is through court mandated supervision and treatment, and with one in 52 adults in New York on probation or parole, this accounts for many outpatient treatment referrals.

The question now becomes, with such incredible services available why are only 20% able to get them? The answer lies within the policies. Although the policies do provide expectations and restrictions regarding cost and quality, the majority of outpatient policies focus on access. These policies not only determine who is eligible to receive services, but also what services are covered by Medicaid and other insurance. So let’s take a look at just how these policies hinder so many New Yorkers from receiving adequate services.

Hospital Systems

With the hospital system, as with any business, accessibility comes down to resources; and in many hospitals the resources are limited. As a result, outpatient care is reserved for those that will not only benefit from it the most, but also those who will bring the hospital the most profit. Most of the individuals in New York who are receiving mental health treatment are covered by Medicaid. Those covered by Medicaid are by definition ‘poor’, and despite the need for the treatment are unable to pay the out of pocket expenses associated with it (Garfield, 2016). This fact has had significant influence on the policy makers to establish a list of criteria that must be met in order for Medicaid to pay for the total treatment. In addition, they developed a list of reasons that a hospital can deny mental health services to patients.

Unfortunately in New York, many of the hospitals have a board of directors that have little to no medical experience. Instead they are comprised of wealthy and powerful business professionals from within the community. For example, one prominent hospital in Upstate New York has a board of directors that consists of several CEO’s and presidents of companies that have direct ties to the local congressmen and assemblymen. One of the members of the board is actually a longtime friend of the current Governor of New York. These ties to politicians along with a lack of medical knowledge often result in policies and decisions being made for the sole purpose of profit rather than care and in turn make access much more difficult.

Community Based Services

The second healthcare system is that of community based resources. This is where the bulk of outpatient mental health treatment occurs. Many of these resources are non-profit organizations that rely heavily on funding from the state. Accessibility to these resources are governed by the overall state budget and is solely based on where the money needs to be allocated that year. As a result, many community resources are limited in the number of patients they can treat due to the limited annual funds available. Much like the hospitals, this causes the community resources to deny service to many individuals that need treatment.

In general, these services are delivered in three ways and are typically based on the severity of the need. Hospitals offer outpatient mental health counseling for individuals who may require a higher level of intensity. Hospitals often utilize psychiatrists who have the ability to recommend and prescribe psychotropic medications for those suffering from severe mental disorders such as schizophrenia.

The second option for patients is a privately or publically run outpatient clinic. These facilities usually employ licensed clinicians who are supervised by a clinical psychologist. Although they can offer the same level of counseling services as the hospital, they are not equipped to prescribe or monitor medications. These facilities are primarily used to focus on the less intensive mental health disorders such as depression, anxiety, PTSD, and addiction.

The third option is counseling and guidance through a religious leader. Although this option can provide assistance with minor mental health issues, it is seldom covered under insurance. This is due to the fact that in most cases, the religious leader does not possess the required education or credentials to be recognized by the state as a legitimate form of mental health treatment. However, as a result many religious leaders choose to pursue degrees in mental health so they can better serve their congregation.

Barriers to Care

New York has several different levels of care which include intensive outpatient treatment, outpatient treatment, step down treatment, continuing day treatment, and assertive community treatment (Friedman, Woods, & LaPorte, 2009, p. 12). Each of which is a step within the continuum of care provided by New York State Office of Mental Health. Generally speaking, these steps are effective when utilized appropriately by the patient and followed through with by the provider.

Unfortunately the greatest barrier falls in the follow through of both the patient and the provider. With over 380,000 adults and 575,000 adolescents in New York suffering from severe and persistent mental illness (Friedman, Woods, & LaPorte, 2009, p. 12), it is easy for a patient to fall through the cracks of the system. Many providers have limited time and resources to track down a patient that missed an appointment, or just check in on a regular basis to see if they are alright. As a result, many patients will feel unsupported and stop treatment all together.

As previously stated, outpatient is usually reserved for those with a professional referral and as such the access can at times seem quite limited. In the clinics that I have worked in, a patient could arrive only after a referral had been received. After they have arrived, they would undergo several interviews and assessments to determine if they would benefit from the treatments the clinic offered. If they would, then they could begin treatment. If however they were thought to not benefit, they would be referred to another clinic or to the local hospital for further consideration.

In New York, the need for mental health services are far greater than the resources available and therefore every clinic and outpatient service does seem to have an extensive waitlist for services. I was a case manager for a supportive living program working with veterans suffering from mental health disorders as well as addiction and chronic homelessness. My program was a 12 month intensive treatment program and had 24 beds/apartments available. At any given time, the waitlist for this program had well over 50 individuals listed on it.

Outpatient access is a serious concern in New York and so far has left much to be desired. For many individuals who require outpatient mental health services, access comes with three major barriers: Finding a clinic, getting approval from Medicaid and insurance, and physically getting to the clinic. Far too often these barriers hinder individuals from receiving adequate, if any services they so desperately need.

With the constant change to Medicaid waiver services and insurance, it is difficult for clinics to accept every patient in need. With private insurance, managed care, and straight Medicaid placing strict eligibility and billing restrictions on the clinics, it is amazing that they are able to stay open at all. These regulations are causing the clinics to become more business focused instead of focusing on the real reason they exist.

As a result of the clinics focusing more on the business, they are more inclined to accept patients that they can profit from the most. This ultimately tends to sway more towards those with private insurance as they are more likely to get approval for ongoing treatment. This leaves the majority of individuals suffering from mental health disorders to fend for themselves.

As with any treatment, a referral is required to receive treatment in an outpatient setting. Attempting to get this referral poses the second struggle to accessibility. Many of those suffering from these disorders do not have a primary physician and are likely to go to free clinics if they seek assistance at all. As a result, many individuals are simply prescribed medications like Zoloft by the attending physician and told that they have a cookie cutter diagnosis of depression or anxiety. On average, it takes nearly six months of trial and error in medication before a referral is given and accepted by insurance or Medicaid. In far too many situations, the individual has given up on treatment before reaching the six months.

Getting to a clinic often poses a barrier to those in a low income bracket. These individuals are unable to purchase transportation on their own and rely heavily on others or public transportation to maintain mobility. This requires them to find clinics that are on bus or subway line if they live in the city, or friends and family if they live in a more rural location. This causes unnecessary instability in treatment due to the patient’s inability to commit to a treatment schedule.

For the more than 30 million adults in the United States that require but do not receive mental health services, 45 percent claim that the cost is the biggest deterrent. The average outpatient service can cost between $100 and $5,000 based on the service and the credentials of the provider (Babakian, 2013). In New York City the average rates for outpatient services are as follows:

• $80 – $120 for a 45-55 minute standard counseling session (Babakian, 2013).
• $200 – $300 for a 45 minute session with a psychologist or psychiatrist (Babakian, 2013).
• $60 – $100 for group sessions facilitated by a licensed provider (Babakian, 2013).
• $300 – $ 460 for individual art, music, and/or recreation therapy sessions with a licensed provider (Babakian, 2013).

As with any healthcare service these can be paid for using self-pay, private insurance, and government insurance such as Medicaid and Medicare. Unfortunately due to the restrictions imposed by the mental health policies in New York, many individuals are forced to pay a significant amount out of pocket. As a result, many outpatient providers offer patients sliding scale charges which can be 30 percent lower than standard fees, payment plans with and without interest, and in some situations income based fees (Babakian, 2013).

Although outpatient treatment is covered by most insurance, it is seldom covered in full. This causes many patients to stop treatment as a result of an inability to pay the deductible or co-pay. At this time, New York does not offer any additional assistance with co-pays or medical bills for individuals receiving outpatient services. However, if the patient were to be admitted to an inpatient clinic as a result of a mental hygiene arrest or emergency room visit, it would be covered in full by many insurance providers including Medicaid. This creates a situation that is counterproductive in that we do not offer treatment as an early intervention but rather offer it after the individual has reached a breaking point.

In order to get an insiders opinion of the current barriers within outpatient care, I was able to interview Megan Cortese, LCAT. Ms. Cortese is a licensed art therapist and senior clinician in a very prominent outpatient clinic in Rochester, NY. During the interview I simply asked her what she sees as a barrier to her current and future clients.

When asked what she would want to change about the overall way mental health services are provided, she had the following to say.

The current system of mental health services has two major flaws; funding and accountability. Ms. Cortese stated that due to budgetary restrictions, lack of government funding, and overall economy struggles the quality of care is becoming lower. She stated that the clinical staff are underpaid and told to meet with as many clients as possible in a day. She stated that this causes many clinicians to burn out and therefore provide a subpar level of treatment.

Ms. Cortese also stated that the lack of accountability from patients on Medicaid is ridiculous. She stated that when a patient on Medicaid does not show to an appointment that there are no penalties to the patient such as the cancelation fee that those of us with private insurance would have. Ms. Cortese stated that this causes patients to continuously miss appointments and therefore miss out on beneficial treatments.

Quality of Care

As for quality of care, New York does seem to excel at regulating the providers and clinics. The New York State Justice Center monitors, regulates, investigates, and enforces all policies regarding the fair treatment of individuals under care. As a result, every clinic is held to the same standards and accountability in regards to the treatment of patients. Although this is beneficial in providing adequate and proper treatment to all those involved in outpatient clinics, it is only effective if the patients are able to receive services.

Policy and Influence

So now that we have reviewed how these polices can hinder treatment, we must next understand not only how the policies come to be, but also who has the power to influence them. Health policy in today’s modern world poses several complex legal, ethical, and social questions and as such require qualified individuals to write, approve, and integrate them into the current healthcare systems. As with the nation as a whole, New York relies heavily on Government officials to accomplish this objective while simultaneously respect and protect the rights of patients. As a result, several highly diverse and complicated groups are tasked with the oversight of these policies.

Healthcare policies in New York are developed through the three branches of government; the judiciary, legislature, and executive branches. The judiciary branch is responsible for overseeing new policies to ensure that they do not violate any human rights as well meet all legal and financial guidelines. The legislature reserves the right to conduct hearings in an attempt to gather sufficient data from all parties involved with the policy. This ultimately provides additional checks and balances to ensure the legality and effectiveness of the proposed policy. The executive branch, or Governor’s office retains the power to sign the new proposed policy into law after it has made it through the checks and balances from the judicial and legislative branch (Gostin, 1995).

Now despite a significant set of checks and balances within New York, policies are not always reviewed as they should be. Far too often members of the three government branches are influenced by outside factors and groups. As previously mentioned, outpatient treatment in New York has many governing bodies; which along with providers, insurance companies, and several special interest groups all have a way of influencing the current policies. Each of these groups have a significant impact on the access, cost, and quality of care that patients receive while participating in outpatient services. The real question is who has the power and are they using it to benefit the patient or are they simply looking out for their bottom line.

So let’s start from the bottom of the hierarchy and work our way up. At the bottom of the outpatient ladder are the small and seldom heard from special interest groups. In New York these are groups such as; NAMI (National Alliance on Mental Illness), NMHA (National Mental Health Association), as well as smaller support groups located throughout the state. The main focus of these groups is to educate the public, influence change and improvement, and advocate for the patients.

Many of these groups rely heavily on petitions and public outcry to influence change and policy at the higher levels of the state government. Even though these groups do not carry the influence of some other groups, with a mass of concerned voters behind them, they are usually quite effective.

Sitting on the next rung of the ladder are the providers who influence treatment and policy by acting as a deciding factor as to what if any treatment is recommended. The providers are in essence the frontline of the outpatient world. The providers conduct the assessments that provide the information to choose the most beneficial treatment option. The providers are able to influence policy by simply choosing a course of action. If the majority of providers choose the same treatment for a particular diagnosis, then it is likely that the governing bodies will consider that to be the go-to treatment. Once this is the case, it is very likely that policies will be rewritten to reflect this treatment as the acceptable one.

Sitting on the next rung is the insurance companies. The insurance companies have significant influence over policy simply because they pay for it. Insurance controls who gets treatment, where they get treatment, and what quality of treatment they can receive. This is of course all based on what tier level the patient’s insurance plan is on. Ultimately, the insurance company has the ability to approve or deny treatments simply based on the overall cost and as a result many patients are unable to access necessary treatments and medications.

Now, at the top of the ladder is the state agencies such as Department of Health (DOH), Office of Mental Health (OMH), State Legislature, and the Governor. It is implied that these people have the ultimate influence over access, cost, and quality of outpatient mental health treatment. Policy recommendations are delivered from the DOH and OMH to the legislature who then agrees and passes them along to the Governor, or disagrees and sends them back to the agencies for revision. Once in the hands of the Governor, the policy is either approved or denied.

As most healthcare in New York is Medicaid funded, the Governor has significant influence over who gets treatment and what treatments are offered simply by approving the state budget. If the Governor approves a policy that allows more access to treatment, he must also approve an increase in taxes to maintain funding. However, if the Governor does not pass a policy for increased care, they may lose ratings and therefore votes. As a result, it is a very complex balancing act when influencing health care policy.

Although the aforementioned groups seem to have the most influence over health care in New York, I stumbled across a group of individuals that seem to have influence over the Governor himself. The United Healthcare Workers Union (1199SEIU) is a union of pharmacists, nurses, and physicians located throughout the nation. The influential power of this group is astounding. In 2009, the full power of this organization was felt by then Governor David Paterson.

With a severe surge in Medicaid costs in New York, Governor Paterson proposed $3.5 billion in cuts to the Medicaid program. The Governor proposed shifting monies away from inpatient hospitals and into outpatient clinics which were significantly less expensive (Eide & DiSalvo, 2015). This would have resulted in a 2% loss in revenue for the inpatient hospitals annually.

Medicaid is the primary source of funding for the inpatient hospitals which employ a majority of 1199SEIU members. The union responded to the Governor’s proposal with a serious ad blitz which cost over $1 million per week. After a month of adds belittling the Governor, Paterson retreated and instead approved tax increases and cuts to other programs (Eide & DiSalvo, 2015). As a result of the serious influence by the 1199SEIU, the overall quality, access, and cost of care suffered. In an act that simply secured their own interests, the patients suffered.

Overall, the diverse and effective variety of outpatient treatments available in New York is quite impressive and could provide much needed assistance to many individuals. However, the lack of accessibility and increasing out of pocket costs create significant barriers to those individuals who need the treatment the most. In order for New York to effectively serve those needing mental health treatment, it is necessary for the policymakers to begin thinking in terms of care rather than profit.

References

Babakian, G. (2013, December 17). How Much Does Mental Health Care Cost? Retrieved from Clear Health Costs: https://clearhealthcosts.com/blog/2013/12/how-much-does-mental-health-care-cost-part-1-series/

Cortese, M. (2017, January 29). Outpatient Barriers. (M. Woodworth, Interviewer)

Garfield, R. (2016, October 19). The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid. Retrieved from Kaiser Family Foundation: http://kff.org/uninsured/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/

Lawrence Gostin, J. L. (1995). The formulation of health policy by the three branches of government. Retrieved from The National Academies of Sciences Engineering Medicine: https://www.nap.edu/read/4771/chapter/17

Michael B. Friedman, G. W. (2009). New York State’s Mental Health System. New York: Mental Health Association of New York City.

Office of Mental Health. (2017, January 1). OMH Official Policy Manual. Retrieved from Office of Mental Health: https://www.omh.ny.gov/omhweb/policymanual/contents.htm

Stephen Eide, D. D. (2015). The Union That Rules New York. The City Journal.