Mental health epidemic a primary concern for region – BusinessNorth.com

Signs point to Northeast Minnesota facing an unprecedented mental health crisis. Pandemic stress is leading to rising reports of critical care and clinic visits. A lack of providers and poor insurance coverage are contributing to the problem.

Prior to the pandemic, the region was facing a mental health crisis, said Dave Lee, who heads the Minnesota State Advisory Council on Mental Health and is the director of human services for Carlton County. “Pre-pandemic we had a mental health epidemic sitting at our doorstep.” 

The last two years have worsened the problem with rising needs and diminished access. “Our lack of access to mental healthcare has been growing. We don’t have enough inpatient capacity in the region. Even with expansions of Essentia and St. Luke’s, our capacity didn’t increase,” he said.

The lack of area access, Lee explained, has led to children and adults who need inpatient treatment being referred to facilities in St. Cloud, Fargo and the Twin Cities. Outpatient treatment often has “real limitations (and) is fairly antiquated with clinical hours in offices that don’t meet the needs of a lot of people.”

The best model based on research is integrated behavioral health, said Lee. Someone goes to a primary care clinic, and the provider notes an issue of depression or anxiety and immediately brings in a behavioral health consultant.

“Historically that person is referred out to a mental health clinic, but 90% don’t follow up. If co-located in the same building with behavioral health consultants on the same team, it takes just a few extra minutes, and the person doesn’t even have to move out of the chair.”

The challenge impeding more facilities from practicing integrated health, he said, is a system not amenable to change. Lee pointed out that collaborative care billing codes do exist and switching over to this method does benefit provider facilities financially.

At Lake View Hospital & Clinics in Two Harbors, the addition of a behavioral health nurse practitioner in 2019 began its integrated service model in the primary care clinic there.

Lake View has also partnered with the Human Development Center, bringing therapists and a psychiatrist on campus to further integrate care. As a certified community health clinic, HDC does not turn away anyone for inability to pay, utilizing local and state subsidies. HDC’s psychiatrist prescribes psychotropic medication when appropriate, and HDC provides crisis stabilization in Lake View’s emergency department when necessary.

Overall, said Greg Ruberg, Lake View CEO/president, access to insurance and poor coverage are at play. “I do think more patients have insurance now than in previous years, but there are a significant number of patients who are significantly underinsured.”

In mental health crisis situations, Ruberg does not see insurance issues being a barrier to receiving emergency care. However, clinic co-pays for counseling therapy can be cost-prohibitive.

“The challenge of patients deferring primary care and therapy services can be a trip to an emergency room for a crisis situation,” he said. “This is rarely a good thing for the patient or the family.”

Crisis stabilization facilities, like Birch Tree in Duluth, are another area that needs more services, according to Lee. The need for crisis stabilization for five to six days, in a safe location other than a hospital setting, appears to be on the rise; for example, Birch Tree’s occupancy rate has risen from 50% to around 80% in recent years.

Inpatient treatment for adolescents and children is an area that Lee sees as one of the most deficient. “We don’t want our kids to leave the region anymore. We have not done a good job as a community. We need to figure out appropriate care for our kids.”

In late 2021, a coalition of leading pediatric health professionals issued a statement declaring a national emergency of children’s and adolescents’ mental health in the United States. A few weeks later, the U.S. Surgeon General made an urgent advisory statement about the youth mental health crisis.

The Arrowhead Behavioral Health Initiative (ABHI) is charged with overseeing adult mental health services across Bois Forte, Fond du Lac and Grand Portage Bands and Itasca, Carlton, St. Louis, Lake and Cook counties. In February, a Children’s Mental Health summit organized by ABHI drew over 130 virtual participants representing all the collaborating entities. The summit generated a cross-section of needs and potential strengths on which to build. Barb Caskey, regional access coordinator at Arrowhead Health Alliance, led the discussion with the message that many good models and resources to help children exist, but often lack coordination across systems, and often with gaps that leave kids and families unable to connect.

“Children’s mental health is affected by factors well beyond just if there are enough mental health providers. There are transportation, childcare and internet access issues that create too many barriers, especially for those with lower income,” she said.

Increased symptoms of poor mental health in children during the pandemic have been exacerbated by delays in treatment, said Brenda Carlson, supervisor of children’s mental health programs for Carlton County.

“Waits for therapists, diagnostic assessments not done in a timely fashion and access issues created by insurance issues and not being able to get services in their home community means children have to leave the area,” said Carlson.

While the Affordable Care Act of 2010 did increase the number of people insured, there are still people who are uninsured and underinsured.

As a private mental healthcare provider, Ashley Kalina sees the lack of adequate insurance coverage as the primary barrier to her clients getting the help they need. Owner of Kalina Counseling Services in Two Harbors since 2019, her clinic has added five additional employees in the last three years. Kalina said the need for services in the area is clear, but some insurance companies can take up to six months to settle claims.

“The stress it puts on business owners is real. We have such delays in outstanding claims that we struggle to pay employees,” said Kalina.

Navigating the second-party and third-party payer system is another daunting obstacle for therapists in private practice.

“We pride ourselves on quickly scheduling people who need mental health services, but it is heartbreaking how often delays happen because of being out-of-network coverage, or deductibles being so high people can’t afford out-of-pocket expenses,” she said.

In some cases, deductibles and the rates of insurance charges are so high that Kalina asks if clients want to be charged the lower rate that her clinic offers for cash payments. (Rates for patients covered by insurance are set by the insurance companies.)

“It happens all the time that people can’t afford to come in. It is so upsetting to us as providers who care about them,” she said.

Sometimes Kalina’s clients put their therapy on hold until they can attempt to pay down what they already owe. That is a scenario that Kalina said diminishes the quality of care and negatively impacts mental health.

Another challenge, she said, is that many people with lower income choose an affordable insurance plan and often do not understand the complexities of what is available.

“Many people can’t afford self-pay, and when a lower deductible plan costs even $30 more a paycheck, that’s a tank of gas.”

For independent mental health clinics like Kalina’s, another fly in the ointment is the federal requirement that only a licensed social worker (LSW) can bill Medicare insurance. Kalina, a licensed therapist, recently lost her one LSW on staff, leaving her clinic with no ability to get paid for Medicare clients.

“So many people over 65 are on Medicare, and they have mental health needs, too. Unfortunately, I don’t think anyone realizes how limited access to mental health services is for that age group,” Kalina said.

The lack of parity in mental health insurance coverage has recently been highlighted by the U.S. Department of Labor, Health and Human Services in an effort to prompt insurance companies into compliance with standard legislation enacted in 2008. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that says group health plans and health insurance issuers that provide mental health and substance use disorder benefits may not impose less favorable benefit limitations on mental health benefits than medical coverage.

Recently California has begun enforcing compliance, requiring insurance companies to ensure their subscribers are able to get mental health appointments in a timely manner. The result has been a scramble by insurance companies to add providers. 

California amended its Mental Health Parity Act in 2020, similar to the MHPAEA but with more specifications. Under that law, all state-regulated commercial health plans and insurers must provide full coverage of all mental health conditions and substance use disorders. Notably, the 2020 amendment requires adherence to network adequacy standards and authorized the California Department of Health to enforce noncompliance and to levy fines on insurance companies up to $10,000 for violations. Because of this law and ensuing litigation, said Lee, insurance companies in California are motivated to add providers to avoid those fines.

Back in Minnesota, Lee is pushing to get the Department of Commerce to collect data comparing how long individuals wait to get different types of healthcare appointments to measure any disparity between physical health and mental health treatment.

“If we don’t have parity between mental and physical health, we have to hold the insurance companies’ feet to the fire to make sure the provider network is large enough,” Lee said.