Much has been said recently about the state’s behavioral health boarding crisis: Patients who arrive at a hospital emergency department in crisis can be kept there for days or even weeks waiting for a psychiatric bed to become available.
Rather than addressing only the lack of pediatric and adult psychiatric inpatient beds, policy makers would be wise to strengthen the system’s front end — the behavioral health clinics where patients often first seek treatment before their illness becomes acute. These outpatient sites are beset with a number of challenges, including the most constrained workforce in decades and reimbursement rates, from both public and private health plans, that are inadequate to both retain and recruit clinical staff.
The one thing everyone can agree on is that the emergency department is the wrong venue for longer-term treatment of patients with acute behavioral health needs. On a typical day last fall, there were 716 “stuck” patients statewide. While these patients wait day after day, they often receive little if any care for their illness, and their privacy and dignity are compromised; sometimes these patients are relegated to the hallway as the emergency department deals with surges. The state must do better than letting patients languish like this.
Some help is on the way. The Baker administration has announced that MassHealth, the state Medicaid agency, will make supplemental payments to hospitals that have been dealing with the behavioral health crisis. This is an important step, as is developing a long-range plan to create adequate inpatient capacity. It also announced that new regional community behavioral health centers are expected to open in 2023 and there is urgent care expansion ramping up. These are important steps, but these centers alone cannot meet the tsunami of need.
Many patients first seek care at a community-based behavioral health clinic. This is not only the most appropriate setting for people with non-acute needs, it also costs the state far less than an inpatient hospital bed.
In Massachusetts, acute hospital readmission rates are nearly double among patients with behavioral health comorbidities, and hospital stays, on average, are nearly a third longer. Readmissions and long stays are as bad for patients as they are costly to our system.
The challenge is that where there once was enough capacity for people to be served in outpatient settings, that is no longer the case. A study released by our organization earlier this year found that for every 10 clinicians entering work in a mental health clinic, 13 are leaving. This unsustainable trend must be reversed now. Our association believes as many as 25,000 people in need are going without services.
Compensation is at the top of the list of reasons cited by clinicians to explain their departure. Salaries are lower than in other settings, such as hospitals and community health centers, because insurance reimbursement rates are too low. In order to stabilize — and, hopefully, expand — the workforce, commercial health insurance plans and MassHealth will need to pay higher rates for the services that behavioral health clinics deliver. Departing clinicians also cited a growing administrative burden — the proverbial mountain of paperwork — and crushing educational debt as contributing to the decision to leave their jobs.
The practical result of these workforce challenges is that people are waiting far too long to get care. For example, the average wait for a child or adolescent to begin therapy is almost four months. In that long gap between the need for care being identified and that care actually beginning, behavioral health conditions can go from manageable to urgent to emergent.
The behavioral health system must be put in order — both outpatient and inpatient. The Massachusetts House and Senate have bills pending to improve access, and our association strongly supports them. A critical next step will be to further increase MassHealth rates of reimbursement. Commercial health plans should also raise rates, and employers who pay insurance premiums should demand real-time access to outpatient care for their employees.
If the Commonwealth can fix the front door of our behavioral health system by adding capacity to mental health clinics, it will reduce or eliminate the problem of people boarding in hospital emergency departments.
Lydia Conley is president and CEO of the Association for Behavioral Healthcare, which represents 80 community-based mental health and addiction treatment provider organizations in Massachusetts.