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Advocacy > Be An Advocate
There Could Be More Money for Geriatric Mental Health in NYS
An Opinion by Michael B. Friedman, LMSW
First Published in Mental Health News, Winter 2007
As the Geriatric Mental Health Alliance has explored barriers to providing services to meet the
mental health needs of older adults, we have heard over and over again that there just isn’t
enough money. Everyone agrees that we need:
- Funding for a broad range of basic programs such as screening, assessment, and
treatment; prevention of institutional placement; family support; bilingual/bicultural
services; public education; workforce development; and more.
- Special Medicare and Medicaid rates for home visits
- Funding for more satellites in community settings such as senior centers and NORCS (*)
- Funding to support integration of mental health, health, and aging services
- Funding for innovative programs
- Major reform of Medicare, including parity of mental health and health coverage
- Release from NYS’s Medicaid neutrality requirement
That is why one of the Alliance’s major goals is to advocate for more funding.
But we have also learned that many providers in New York State are not taking full advantage of
the funding Medicare would provide if services were designed and billed in accordance with
Medicare rules.
That is why The Alliance and several co-sponsors (**) recently provided three training sessions on
optimizing Medicare.(***) One was for mental health organizations, one was for private
practitioners, and one was for government officials. Derek Jansen, PhD, a national expert on
Medicare, Medicaid, and other sources of federal funding provided the training. He made it quite
clear that there are major opportunities for New York State to bring in more Medicare funding for
mental health.
Here’s the gist of what we learned.
- Medicare is a disproportionately low payer for mental health services. It funds only 7% of all
mental health expenditures in the United States, although it covers 14% of Americans. In
addition, only 3% of Medicare expenditures are for mental health and substance abuse
services, significantly lower than the proportion of behavioral costs of all health spending—
roughly 10%.
- Providers frequently do not take advantage of mental health funding opportunities in
Medicare. For example, although Medicare only pays 50% for psychotherapy as compared to
80% for physical health care, consultation and certain evaluation and management services
by psychiatrists and some other medical providers may be reimbursed at 80%. In addition,
although for the most part Medicare will not accept bills for more that one service per day,
there are circumstances under which it will pay for more. And although social workers must
hold a special license (LCSW in NYS) to bill Medicare using their own provider
identification number, services provided by social workers without the clinical license or their
own Medicare provider number may be billed as “incident to” services provided under proper
supervision in certain settings.
Dr. Jansen gave many more examples, but the point is clear. NYS’s mental health agencies,
hospitals, and private practitioners could bring in more Medicare funds if all of them knew
what is allowable and how to bill.
- Medicare can also be used to fund mental health services in community settings such as
senior centers and NORCs. One way to do this is to establish a satellite clinic in a senior
center, NORC, or other community setting. The clinic then bills both Medicare and Medicaid
as it does ordinarily. Several organizations in NYS currently do this. The problem is that it
is not easy to establish a licensed satellite—in part because of Medicaid neutrality provisions.
This problem could be overcome by NYS OMH easing the process of approving licenses for
satellites for older adults.
Another way to overcome the problem is to encourage private practitioners or private practice
groups to establish offices in community settings as many currently do in nursing homes.
They could bill Medicare and, for people also eligible for Medicaid, they could receive
“crossover” payments that cover part of what Medicare does not cover. Dr. Jansen pointed
out that this has to be done carefully with help from a health care attorney and that there are
issues of quality assurance to be addressed. But it is doable.
- Dr. Jansen also spoke about emerging opportunities to integrate mental health and health
services—a major goal for all geriatric mental health advocates—by providing services in
“federally qualified health centers” (FQHCs). These are community health centers that
receive federal funding to cover the costs of serving people with no health coverage. They
also can bill Medicare and Medicaid. Until recently community health centers were not
permitted to provide mental health services except for psychological conditions linked to a
physical illness. Now the FQHCs are permitted—even encouraged—to provide mental
health as well as physical health care.
Dr. Jansen noted two possible approaches. The FQHCs can hire mental health professionals
to serve on their staff or they can partner with mental health organizations, an approach many
seem to prefer. Either way more older adults with mental illnesses could get the treatment
they need.
What needs to happen? To take full advantage of these federal funding opportunities, we believe
that:
- Providers should work with health care lawyers and knowledgeable consultants to make sure
that they are billing properly and are getting as much Medicare funding as is allowed under
law.
- Providers should explore opportunities to provide services in community settings, and local
departments for the aging and for mental health should help them.
- Mental health and community health providers should explore ways to integrate health and
mental health service delivery in community health centers.
- New York State and local governments should develop expertise regarding all of the
opportunities to generate federal funding support through Medicare and FQHCs.
- Then state and local governments should provide technical assistance to providers to optimize
Medicare, to develop services in community settings, and to integrate health and mental
health services.
- NYS OMH should facilitate the expansion of clinical services for older adults, including the
development of more satellites in community settings. This should include relief from the
Medicaid neutrality requirement.
To move ahead on some of these opportunities there is no need to wait. Expertise is available
now. Private practitioners should look to their professional associations for help. Mental health
organizations, community health organizations, and hospitals should look to their trade
associations. And, to repeat Dr. Jansen’s caveat, everyone should consult with a good health care
attorney and with experts on Medicare rules.
As a final note I want to be clear that the Geriatric Mental Health Alliance does not believe that
pursuing these avenues will produce all the funding that will ultimately be needed to meet the
mental health needs of our growing population of older adults. Not by a long shot. We do need
to press for basic geriatric mental health services. We do need to press for Medicare reform. We
do need to press for parity. We do need to press for reasonable funding for home and
community-based services. We do need to press for funding for community-based residential
services. But in the meantime let’s all find out what we can do within the current system and do
it.
(Michael B. Friedman is the Director of the Center for Policy and Advocacy of The Mental
Health Associations of NYC and Westchester and The Chairman of the Geriatric Mental Health
Alliance of New York. The opinions expressed in this column are his own and do not necessarily
reflect the positions of the MHAs. Mr. Friedman can be reached at center@mhaofnyc.org)
Notes
(*) A “NORC” is a naturally occurring retirement community, a building or neighborhood with a large
concentration of older adults. Some have supportive service programs, which are referred to as NORC-SSPs.
(**) The Coalition of Behavioral Health Agencies, Inc. and the Mental Health Associations of Nassau, NYC,
and Westchester.
(***) The training sessions were funded through a grant from the van Ameringen Foundation.
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