The emphasis in mental health has been on what’s coming. Experts in the field are bracing for a delayed behavioral health curve. Some have called it an impending tsunami, while others believe it will be a steady flow of need since there has yet to be a break in the COVID-19 pandemic. Chuck Ingoglia, president and CEO at National Council for Behavioral Health, says that’s not the whole story. He says that without adequate funding, many community mental health and addiction treatment organizations won’t be there to provide services, regardless of whether the demand is a steady, ongoing stream or a sharp uptick. Nonprofits, in general, are facing challenges that have threatened partial and full closures. Unemployment Services Trust surveyed 800 nonprofits and found that 13% suspended all or most operations, 16.9% eliminated or reduced positions, 42.9% modified operations extensively without eliminating positions, and 27.2% experienced no change and were considered an essential service.
Behavioral health organizations are particularly vulnerable to closure, says Ingoglia, because they are already working with slim margins and lack adequate cash reserves necessary for an extended crisis. In mid-April, he and his colleagues released the results of a survey of 880 community mental health and addiction treatment organizations across the United States. The survey was conducted jointly with ndp | analytics, a strategic economic and communication research firm. The results are striking: nearly two-thirds of behavioral health organizations believe they can sustain their operations for only three months. A large percentage, 61%, are closing at least one program, 47% have had or are actively planning to lay off staff, and 31% said they weren’t able to serve all of their patients. According to Ingoglia, these organizations “are funded primarily by Medicaid and other public sources. By and large, if they have a 1% margin at the end of the year, they’ve had a great year.”
More Expenses, Less Revenue
Behavioral health organizations fell in line as states began to lockdown in mid-March, trying to keep the spreading of a novel virus at bay. They had to somehow quickly adhere to numerous new guidelines that would, hopefully, allow people to continue or begin treatment but also implement physical distancing. One measure that has been vital and long-awaited in healthcare is the expansion of telehealth. Ingoglia notes that each community has had differing experiences while leaning into telecare. Many organizations had to logistically examine how best to move forward with it and rapidly purchase new equipment to make implementation feasible. “They’ve had to buy tablets, phones, and computers for staff. Some have also bought equipment or communication services for clients who didn’t have phones or needed a hotspot or more minutes to connect.” Furthermore, Ingoglia points out, most behavioral health organizations didn’t have personal protective equipment (PPE) just sitting around; it’s not typical for their everyday operations. To obtain PPE for their staff and clients, organizations often had to pay price-gouging costs. “This is yet another unanticipated expense for organizations that are simultaneously experiencing hiccups in revenue.”
Governors’ emergency orders quickly sifted services into several groups: those that were essential, those that could be done remotely, and those that would close temporarily. Organizations that continued face-to-face services had to develop physical distancing protocols. “Residential facilities often had to slow down admissions and convert rooms from doubles to singles. Schools were closed, which meant that many school-based services were too. All of these changes have revenue ramifications.”
Ingoglia says the majority of behavioral health organizations have experienced decreases in revenue during the initial months of the pandemic. In part, this is because most states continue to use a fee-for-service model, where services are separated instead of bundled. “If you’re not providing a service, you’re not getting paid.”
Reimbursement Challenges
A common phrase uttered in mental health is “if you’ve seen one state’s mental health system, you’ve seen one state’s mental health system.” Ingoglia says that also applies to the speed and breadth in which states expanded telecare in the first few months of the pandemic. The requirements are also constantly changing. National Council members have shared with him that their states have put out as many as 14 different telehealth guidelines. “It’s constantly evolving, and providers are trying to figure out what the rules are.”
Some states moved quickly to relax telehealth regulations, including allowing for audio-only, but requiring that providers tack modifiers to the end of billing codes. The problem, says Ingoglia, is that Managed Care Organizations (MCOs) can’t process the modifiers, causing reimbursement delays. As a result, some organizations have had to close or lay off staff. Many states recognize that behavioral health organizations are struggling with the fee-for-service model and want to develop an alternative payment mechanism. “This would help keep organizations whole during this tumultuous time, but states haven’t yet been able to get permission from the federal government to do so.”
Funding
Federal and state leaders have expressed concern about mental health in the United States even before the crisis. Suicide is the 2nd leading cause of death for people ages 10-34, and the 10th leading cause of death overall, with rates having risen 33% from 1999 through 2017. Leaders worry that the pandemic, and the measures to stop it, will have potentially lasting effects on people’s mental health. April Naturale, Ph.D., a leading traumatic stress specialist on disaster recovery and community resilience, told us in May that what’s likely next in mental health, as the virus continues moving quickly across the globe, is increases in traumatic grief, PTSD, and posttraumatic growth. Ingoglia points out that there is broad recognition among leaders and the general public that more people in the United States will experience depression, anxiety, and substance abuse because of the pandemic disaster. People are also facing high levels of unemployment—14.7% in April, the highest level since the Great Depression.
As more people lose their health insurance, more will enter Medicaid. The public assistance healthcare program, along with state general funds, are typically the two largest sources of funding for community based behavioral health organizations that serve marginalized populations with serious mental illness and substance use disorders. Unfortunately, says Ingoglia, the virus is burning a hole in state budgets when behavioral health organizations face reimbursement impediments, making them particularly vulnerable. “At the exact time we can anticipate that there’s going to be increased need, organizations are facing potentially crippling operational and cash flow challenges because of COVID-19, further compromising their ability to respond to the impending crisis.”
In March, President Trump signed the CARES Act, a $2 trillion stimulus package, which included $425 million for SAMHSA’s health surveillance and program support “to prevent, prepare for, and respond to coronavirus, domestically or internationally.” SAMHSA moved quickly to release $110 million in emergency grant funding to states, territories, and tribes: up to $2 million for states and up to $500,000 for territories and tribes. Ingoglia points out that when broken down, that’s “not a lot of money and thereby won’t provide sufficient emergency support.” There is also the CARES Act Provider Relief Fund that will reimburse healthcare providers at Medicare rates for COVID-19 related treatment for uninsured people. “The amount to be deployed is 6% of an organization’s 2018 Medicare fee-for-service billing. For most behavioral health organizations, Medicare represents roughly 5% of their revenue, so that’s 6% of 5%.” For example, a National Council member in Tennessee has an annual budget of $95 million and will receive $86,000 from the Provider Relief Fund. That’s .09% of its yearly budget.
Repurposing and Redeployment
In the United States, companies repurposed their factories during World War II, going from building washing machines or cars to airplanes, ships, vehicles, guns, and ammunition. Today, during the COVID-19 pandemic, we are witnessing something similar. Not yet called upon federally, but companies are innovatively standing up one-by-one to support the war effort against this virus. To boost the dwindling supply of masks in the United States, the men’s clothing retailer Brooks Brothers is retooling its factories in New York, North Carolina, and Massachusetts to produce 150,000 masks daily. Globally, other companies are similarly shifting gears. LVMH, a luxury goods conglomerate and parent company of Christian Dior, Guerlain, Givenchy, and BVLGARI is repurposing its factories to create hand sanitizer for hospitals in France and Italy.
The skill of repurposing is vital during the coronavirus pandemic—not only in retail but also in behavioral healthcare. Redeploying resources to meet the most pressing needs of our community is for the greater good, says Ingoglia, and it can also help productivity and revenue, creating job stability during a time when it’s increasingly elusive. The COVID-19 pandemic is pushing organizations to be innovative as they navigate new, challenging terrain.
Ingoglia notes he has seen tremendous creativity and innovation among behavioral health providers that include redeployment and flexibility, and simply “doing what’s right.” That includes using telehealth to its full capacity and moving staff from programs temporarily closed to ones that are not or to virtual programs. Organizations have set up walk-in crisis units in tents and mobile injection services for clients, so that people have access to much-needed medications like long-acting antipsychotics or Vivitrol, which can prevent alcohol or drug abuse relapse. Many day programs, whether drop-in or partial hospitalization, aren’t meeting in person right now, but staff continue to provide meals for their clients.
“With everything people are dealing with, providers didn’t want food insecurity to be added on top of that. Many of our members are doing food delivery, which redirects staff in temporarily closed programs while providing a service for those who depend on them. I don’t know if it’s reimbursable, but it’s the right thing to do. They aren’t going to just leave their clients without support.”
Ingoglia says surges in mental health demand won’t just be among the general public but also among those on the frontlines who have been in the thick of the pandemic. Healthcare staff have held up phones, witnessing the final words those dying of the virus share with their family members, and unable to save them, have had stand by and watch their colleagues deteriorate—all while living in fear that they may catch the virus themselves. “We can partner with medical healthcare organizations to provide vital services to frontline medical staff experiencing war-like levels of stress, pain, and exhaustion. But we can’t do so without adequate funding.”
It’s time, he says, to end the disconnect between federal and state leaders highlighting the need to support behavioral health yet not providing a corresponding investment. This is why people must weigh in with their members of Congress about why funding is vital. “The old adage, ‘the squeaky wheel gets the grease’ might as well have been written for politics; they keep track of who is calling for what, influencing their behavior. As former Senate Majority Leader Everett McKinley Dirksen used to say, ‘When I feel the heat, I see the light.’”
