Back when I was young and idealistic, I worked for several years at an entity that managed mental health case and care coordination. I never provided front line service, that is not what I do, but I routinely saw reimbursement fee schedules for mental health providers. They were absysmal. A master’s level provider could expect to receive between $45 to $70 per hour for their time in an office setting and perhaps $15 more for in-home services. The higher rates tended to be from government programs. That sounds like a lot but that fee has to be able to cover wages, overhead, infrastructure, insurance and education expenses. As a comparison, when I took Kid #2 into the pediatrician last week for suspected croup, the CRNP was able to get paid $108 for a ten minute visit. She can do four or five of those visits in an hour. When I called a plumber over the summer to fix the shower, she got paid $240 for forty five minutes of service. What we pay is a decent indicator of what we as a society value. We value working showers and acute medical care far more than mental health care.
Mental health services have always been done on the cheap, and that means there is very little capacity in the system. Hospitals are more than willing to build $230 million dollar proton beam therapy centers that offer minimal marginal improvement in results for cancer treatment because cancer pays. At the same time, in-patient psych beds have been cut dramatically. Some of this is a long term trend, but a signficant amount has been due to state level budget cuts of the past five years.
Commenter CzarChasm has this to say in an e-mail to me as a front line mental health provider in Virginia concering the Deeds stabbing and suicide:
Quick overview of mental health care in VA: I’m a mental health professional at one of the Community Services Boards in Virginia; here, Community Service Boards (CSBs) are quasi-public, non-profit orgs that handle most of the mental health services for the poor, disadvantaged, and disabled. These services typically include: outpatient therapy, services and programs for the intellectually disabled, social skill development, Wounded Warrior programs, child and family therapy services, in-school help for children with emotional/behavioral issues, employment services for mental health consumers, residential programs, emergency crisis services, and life skill training. Most CSBs’ funding comes through Medicaid billing, with some grants sprinkled here and there. We also receive some funding from the municipalities we serve (Almost every county and city in the state has its own CSB; some CSBs serve multiple counties/cities in their catchment area). Besides us, there are some private companies that provide some of the less intensive services (mostly outpatient therapy, intellectual disability services, and life skill training), but these private companies deal with a fraction of the populations that CSBs serve. Most CSBs offer NO inpatient programs, and the inpatient programs from the ones that do are both voluntary and focused on minor stabilization, nowhere near the levels of crises seen by most psychiatric wards in hospitals. Virginia has mental health facilities for long-term care, but none are designated specifically for crisis stabilization.
That said, the inability to find a bed is amazingly common, as there are very few places that have psychiatric facilities: a few hospitals, and some private, inpatient facilities. The state has been maxed out with its short-term capacity for some time, and this mirrors the level of services in the CSBs: We’re all maxed out. To make matters worse, some programs that help with recovery (i.e. those outside of the hospital) are having their billable rates slashed drastically.
To prevent these tragedies, VA needs:
-more short-term, inpatient facilities.
-more qualified staff in EVERY program, especially on the licensed level.
-more funding for its public mental health services, to ensure that good mental health workers are compensated for their 40 hours (really, most work 45-50, but don’t let it show on the timesheet).
All this is the ignored result of our legislature refusing the federal expansion of Medicaid in our state, coupled with the nominal funding received by CSBs from a lot of the municipalities. I’m hoping that this results in legislature that increases funding to our CSBs, along with the state actually creating crisis stabilization facilities in high-need (i.e. poor and rural areas, which is 80% of the state) locations.
In the past 24 hours, most responses from other mental health professionals I’ve interacted with have all had the same reaction to this event: a mixture of outrage (“He was RELEASED??!”) and frustration (“same thing happened with one of my people last week/month”). Until mental health stops being treated as the red-headed stepchild of healthcare, this will continue to be our reaction, and we in the public mental health field will continue to be able to do little to change this.