The Chapter's Mental Health Committee has recently completed a position paper on Medicaid Managed Mental Health Care. The paper, approved by the Chapter's Board of Directors, is currently being distributed to mental health policy makers, advocates, and other professionals. The paper is reprinted here in its entirety.

The Committee has also written memos of support to members of the State Senate and Assembly in favor of the New York State Community Resources Bill, which advocates for the reinvestment of funds from the closure of state hospitals into community-based services.

The New York City Chapter of the National Association of Social Workers represents 9500 professional social workers in the five boroughs; the largest percentage of our members work in the mental health field, and social workers comprise the largest proportion of all mental health professionals.

Because social workers play such a prominent and significant role in the provision of mental health services in direct care, administrative and policy making positions, and because Medicaid Managed Mental Health Care would have such an impact on social workers and their clients, the New York City Chapter believes that this is an opportune time for social workers to come together as key advocates in promoting beneficial system-wide changes.

INTRODUCTION

In some ways, New York State's mental health system has worked: Most people with mental illness have never been hospitalized. Delivery of intensive services through the outpatient clinic system has made it possible for thousands of adults and children with mental illness to live in their communities and to maintain functioning at home, in school, and at the workplace.

For the past 20 years, the mental health system in New York has been undergoing major changes. Deinstitutionalization and the return of previously hospitalized individuals to their communities; the COPS (Comprehensive Outpatient System) initiative; the consolidation and closure of state hospitals; and the goal of enrolling Medicaid recipients in managed care have all had substantial impact on the ability of community mental health agencies and professionals in private practice to deliver much needed mental health services.

The need for a comprehensive and well-defined mental health system in both the State and City has never been greater. Increasing segments of our population have demonstrated this need. Those who continue to be underserved by the present system include:

• The seriously and persistently mentally ill

• The homeless mentally ill on the streets and in shelters

• The mentally ill incarcerated in jails and prisons

• Seriously emotionally disturbed children and adolescents and their families

• The AIDS/HIV population experiencing depression and neuropsychiatric symptoms

• The dually diagnosed

• Children considered "at risk" because their parents are seriously mentally ill

• Families in which drugs, alcoholism, and family violence are prevalent and who have traditionally used the supportive services of mental health clinics for brief interventions.

Medicaid Managed Mental Health Care has been put forth as one solution to the ills of the present system.

While the proponents of managed care claim managed care will deliver health as well as mental health services more efficiently and effectively, there are many who believe other approaches will be more advantageous. Since social workers provide most of the mental health services nationally and in New York City, Medicaid Managed Mental Health Care would have a significant impact on them and on the profession as a whole.

It is important to note that while this paper covers the subject of Mental Health Managed Care for those who are Medicaid-eligible, we recognize that there are other populations--the near-poor and the working poor, for example--who demonstrate similar needs and whose needs remain unaddressed.

THE PROBLEM

NASW, through its Mental Health Committee, has studied the issue of Managed Care in general and Medicaid Managed Mental Health Care in particular in detail.

The Committee identified the following factors as significant in the development of the Chapter's position:

• Many of the problems faced by the mental health system today are the result of failed social policies in the area of housing, employment, education and equal opportunity. Managed care will not solve these problems any more than the mental health system alone has been able to do.

• In New York State, mental health services provided by managed care are not regulated by the Office of Mental Health.

• Federal law exempts most managed care companies from state insurance laws.

• Managed care eliminates the multiple points of entry into the mental health system.

• A managed care physician with little or no training in psychiatry is assigned the responsibility of determining the need for mental health services and referring the child or adult for such service.

• There is no nation-wide data to suggest managed care is less costly than the current system.

• Confidentiality is seriously undermined as individuals seeking permission for treatment are forced to discuss their problems on the phone with customer satisfaction representatives.

• The short term two to twelve session model, the preferred approach for cost containment, does not work for everyone.

• Statistics show an underutilization of mental health services by members of certain populations. Managed care could result in these groups receiving less care in the future.

PRINCIPLES FOR ACTION

The New York City Chapter supports the adoption of a policy that, for consumers, would:

• Be as broad as possible and based on needs

• Facilitate access to both health and mental health care

• Allow for choice

• Be flexible enough so that health care can be accessed from one provider and mental health care from another, termed the "health only" option

• Contain quality assurance mechanisms

• Assure maintenance of current standards of confidentiality

• Not substitute medication for verbal therapy

• Allow for monitoring and review by the New York State Office of Mental Health

On the provider side, such a policy would:

• Allow for the greatest number of providers, agencies and individuals

• Not compromise the values and ethics of the social work profession

• Provide for multiple points of entry into the mental health system

• Allow the community mental health system in its current form to compete or cooperate with managed care providers

• Acknowledge the importance of the clinician's role and the therapeutic relationship to wellness and improved mental health.

RECOMMENDATIONS

In keeping with the principles set forth in the previous section, the Chapter strongly recommends and advocates for the single payer approach for health as well as mental health care. The single payer approach embodies some essential principles, including universal access, portability, and affordability. Given the complexity of the mental health issues involved, we recommend an approach that will adhere to the principles embraced by the Chapter, as well as the following:

• That adults with the diagnosis "seriously and persistently mentally ill" and children with the diagnosis of "seriously emotionally disturbed" be included in managed care for their health care only and exempt from managed care for their mental health needs. This is the "health only" option.

• That children and adults with these diagnoses be exempt from screens or caps for mental health services.

• That there be a mechanism for the receipt of mental health services from therapists of the clients' choice which will be paid for by the plan.

• That the thresholds for treatment be increased.

• That a procedure for care beyond the threshold be established which does not require the individuals receiving mental health services to breech their right to privacy with a customer service representative.

• That clients with serious mental illness in need of medical monitoring be exempt from caps for health care services.

In principle, New York's current mental health system functions as a universal system ^__ meaning no one is turned away or denied service ^__ the very model toward which the nation is striving. The New York City Chapter of NASW believes that the principles of this system should be maintained at the very least and, at best, strengthened through implementation of the recommendations detailed above.