SARAH: This is At the Core of Care, a podcast where people share their stories about nurses and their creative efforts to better meet the health and healthcare needs of patients, families and communities.
I’m Sarah Hexem Hubbard with the Pennsylvania Action Coalition and Executive Director of the National Nurse-Led Care Consortium. This episode is the second in our special series about mental health services as part of our work with the Philadelphia Nurse Family Partnership and Mabel Morris family Home Visit Program. If you haven't heard our previous episode, we recommend that you listen to it first, and then come back to this one.
On this episode, we're going to have a broader conversation about the systems impacting access to care, such as the ongoing shortage of mental health providers. We'll also discuss potential solutions to help close the gaps.
As you heard in the first episode, we here at the National Nurse-Led Care Consortium worked to integrate two therapists as part of our home visiting services. Our guest Ivan Haskell was instrumental in creating this partnership and is the executive director of the Joseph J. Peters Institute.
Welcome Ivan to At the Core of Care.
IVAN: Thanks, Sarah. Happy to be here.
SARAH: So before we dive into a deep conversation about mental health, tell us how you first got into this field and why you've chosen to do the work you do.
IVAN: I took a course in high school, a psychology elective course. And I just found it to be fascinating. Like the best course I took my senior year. When I went to college, I was undeclared. But I quickly took some introductory psychology courses and just found it to be really fascinating. And so I went to graduate school after my undergraduate experience. And I went to University of South Carolina, and I chose that university because they had a program in clinical psychology, but also in community psychology. So it's a joint doctoral program in those two fields. And so clinical psychology, I think most people probably have a pretty good idea of what that is, but that's, applying psychological principles to working with individuals and therapy, assessment and so on. Whereas Community Psychology takes a little bit of a broader perspective and really looks at how, what we know about psychology can be applied to communities, sort of larger scale intervention. So it's, a lot of times it's concerned with prevention and sort of intervening at the level other than just the person so communities against schools, things like that.
SARAH: So given where we are today, you’ve shared that our nation's collective mental health is in crisis. It's definitely not a good situation out there. But tell us from your perspective, in terms of the rising problems and need for more therapeutic services?
IVAN: The way I see it, there are a couple of different problems. One is that in general, as a society, it seems like our mental health is worse than it has been in the past. And I've read various articles and newspapers and, and so on, in the last year or so that are talking about the increased need for mental health services and the increased problems that people are having. And in terms of why that's happening? I'm not exactly sure. I don't think social media is helpful to mental health in a lot of a lot of ways. And I think there's some increasing research on that. I think people are increasingly isolated. Just modern society, in general, has a lot of stresses that it places on folks. And I don't think that people have the same support networks that they maybe had in the past. And then finally the political atmosphere arguments just seems like there's an increased difficulties in across the board and sort of everyday life. So I think those are probably some of the reasons why mental health is worse. But if you hear, especially for adolescents, for example there's an increasing need, and people are increasingly struggling. So I think at the same time that it appears to be that there is an increasing need for mental health services, there also seems to be real problems and people accessing mental health services. So if anybody that's listening to this podcast has a friend or family member, or if they have tried to find a therapist in the last six months, a year, two years, they probably had some difficulties finding one. And they probably had some difficulties finding one, especially if they're insured, and they were choosing to use their insurance. So it seems like there's a real shortage of mental health providers and where there are mental health providers, they're not necessarily available for folks to see because they can't necessarily afford to pay to see those folks, and they may not be accessible through their insurance, whether that's Medicaid, Medicare, or through private insurance.
SARAH: So on top of that, we have this shortage of mental health professionals. Can you paint a picture for us before and after the pandemic? How your own organization staffing has shifted?
IVAN: So that's a good point. The other thing is the general hiring crisis that almost all businesses are experiencing, has certainly hit us in the mental health field as well. So it's never been easy. So just to be honest, it's not like before the pandemic, it was really easy to find, therapists, and mental health professionals. But after the pandemic, it's been our focus, we're sort of getting toward the end, hopefully, of the pandemic, but it's been even harder. And with inflation, what we're finding is that therapists are hoping and looking to make higher salaries than, then , we can pay because the reimbursement that we get from providing services from insurance, for example, has not increased substantially. And that's just to sort of point out that that is like the crux of really what the issue is, as I see it, which is most mental health services are reimbursed by some insurance company. And in almost all circumstances, the reimbursement rate is not sufficient to really allow for living wage and a wage that reflects the experience. And really the difficulty of doing this work, because this is tough work. And a lot of the people that are providing therapy are very, very committed to helping others and to the field. But they're dealing with their own stresses they're dealing with loans, they're dealing with, just not being able to pay rent and pay their expenses. And so you bring those two things together, and really that's where the crisis is. So, one way that therapists can make potentially more money and have fewer hassles is to not take insurance at all. And so I know for our organization, we've seen some therapists just in the last to you or two that have said, what, I'm going to go into private practice. And I'm going to set up my practice that don't take insurance. And so then that sort of takes them out of the rotation for our clients, for example, and for a lot of clients to access them, and they're great therapists, they're well trained, really good at what they do. So those are some of the problems that we're experiencing. And the other thing is Sarah, which is interesting is, while there's been an increase in need, and I think during the pandemic, some people wrote stories about the increased need during the pandemic for mental health services. So people were overwhelmed with referrals, we didn't see that. And I think that's because we serve is, as far as we can tell, we serve a very low income population that is chronically stressed, and is I think, during the pandemic was really focused more on survival than anything else, just kind of getting from one day to the next. But we are now seeing that increase we're seeing increased referrals. As , I guess we're two and a half years into pandemic. So there was a little bit of delay for us, which I don't think you saw with maybe higher income and middle income individuals. But that's kind of what we're seeing. So we are in the process of trying to ramp our service provision back up, again, to levels that are similar to what we did prior to the pandemic. And we are maybe 60, 65% of the way there. But it's an ongoing struggle.
SARAH: A couple of times, you mentioned, our clients and the client population that you serve, I’m realizing in part one, we talked about the client population served by the Nurse Family Partnership, and Mabel Morris Family Home Visit Program. We're looking at low-income first-time moms, families with kids under the age of five. But JJPI has a broader scope. Can you just speak a little bit to the overall client population that JJPI serves?
IVAN: So we serve largely a Medicaid population. So those are individuals who qualify for Medicaid insurance. And that's typically through being lower income. So not necessarily at the poverty level, but the way that the formula is, depending on what state you're in, some multiple times the poverty level, which let's be honest, the poverty level is very low. So these folks are still are still poor. We are in the city of Philadelphia, which is a majority minority city. So we're seeing a largely minority population, especially Black individuals. And we also see, we take Medicare. And so that is for some, some older folks, as well as for people that might have a disability classification that qualifies them for Medicare. And those are primary insurances. We see the entire age range, the entire spectrum, probably start at age three. And we see all the way up to senior citizens.
SARAH: So one of the recurring behavioral health issues we're seeing through therapeutic services is trauma. And the Joseph J. Peters Institute specializes in this area, which is one of the reasons that we're collaborating. Can you break down some of the current leading trauma therapies that your staff practices?
IVAN: Certainly within the Philadelphia region, Joseph J. Peters Institute, is one of the leading providers of what are called evidence based practices or evidence based therapies. And there are a number actually for trauma, so most of them are what we call it exposure based which involve whatever the, the trauma is, and a lot of times it's a trauma or multiple traumas that lead to post traumatic stress disorder symptoms re-exposing yourself but in a very safe graduated way where we're teaching relaxation skills and skills to be able to reduce the fear and anxiety response when you re-experience them. So for adults, we do a type of therapy called prolonged exposure therapy, it was actually developed by Edna Foa and her colleagues in Philadelphia. And so in Philadelphia, it's fairly widely available. But, that's for use with adults. And I think the title sort of describes what it is, it's prolonged exposure to the trauma, thinking about the trauma, or traumas, and learning skills to deal with those as you go through the program. And there's actually a lot of homework where you're out of session doing some work in between sessions. And really, I think that's generally eight to 10 to 12 sessions. So it's pretty quick, and we find for folks who stick it out, and not everybody does, because I think it's difficult, we find really remarkable results where people I think, in general, we measure trauma symptoms, we also measure mood symptoms using a pretty widely available scale of, of mood depression. And we find that people generally cut their symptoms in half, if they complete that treatment. And also, a lot of times, the symptoms that are sort of in the non-clinical range after treatment. So that's one treatment that we do. And with kids, the gold standard treatment for trauma is something called trauma focused cognitive behavioral therapy, also known as TF CBT. And that's from young kids maybe ages three to 18. And in some instances, it can be extended up to 20 or 21 years old.
That's a slightly longer but it's the same thing, but it also teaches a lot of skills along the way. practice skills, and then it also involves the family involves, a caregiver, or at least one caregiver and a treatment. So TF CBT, prolonged exposure therapy, we also have some folks who do Eye Movement Desensitization and Reprocessing therapy, or EMDR. And that's a therapy that's also exposure based, but it seems like from what I can tell, it might have a slightly lower dropout rate, because what happens is, you remember the traumatic memory, and then you essentially are distracted as part of the treatment. So those are three of the treatments we offer, we also offer dialectical behavior therapy, which is helpful for folks who, who have had been through trauma, but, is actually a lot more comprehensive than that as well.
SARAH: So we know, there's a great need for increased access for mental health services, and we're stuck in this gap. And you've said there are broader systemic factors at play here. Can we start with the Mental Health Parity Act, and that rolled out in 1996, and then was updated in 2008? So the Mental Health and Addiction Equity Act? Can you tell us more about those laws?
IVAN: I started graduate school in 1995. And the first Parity Act, I think, was passed in 1996. So I kind of remember when this happened. But at the time, if folks remember back to that period of time, if they were around at that period of time, insurance companies really handled mental health benefits very differently than physical health benefits. They could say we don't even offer mental health benefits or they could say we offer mental health benefits, but you're limited to four sessions a year. I'm just making that number up or something like that. And so with this Act did was it said to insurance companies that you generally have to treat physical health and mental health the same, it didn't say that you had to offer mental health benefits, but most insurance companies do offer them or actually probably did at the time as well. But it said, if you do offer mental health benefits as part of your insurance package, you can't set up roadblocks for this one type of treatment that you wouldn't also set up for physical health treatment. And I think that was probably very successful in kind of moving things forward. And in 2009, there was an updated federal parity law that went into effect, and that was called the Mental Health Parity and Addiction Equity Act, which you referenced. And that just kind of dealt with some of the loopholes that that insurance companies had found in the act, but it also extended to addiction services, which is which is very, very helpful. There's also been increasing issues with substance abuse in our society, so that that addressed that as well. So I think those acts probably really helped with access. But what they didn't do was they didn't require insurance companies to make sure that they had sufficient therapists available on their panels to allow people to access the services. And they didn't talk about reimbursement. I'm not sure if any regulations, insurance regulations, the federal level talks about reimbursement levels. But we can talk a little bit about that. But there is a lot of research on the fact that mental health services are reimbursed at really lower rates than physical health services are. And there's a couple different reasons why I think that's the case.
SARAH: And can you speak to and this isn't specific to those acts, but just in general, with insurance, the phenomenon of, in network and out of network, I think that gets to that panel issue you were talking about as well.
IVAN: There are different types of insurance plans. But , some plans, for example, point of service plans, and preferred provider organization plans, pos or PPO plans, allow people to get services from mental health professionals, physicians or health professionals that are in network. And also out of network. Typically, if you go out of network, you might have to pay more, you might have a higher copay. So these plans generally incentivize folks to go within a network within the panel within the network, but also you're allowed to go outside, but people typically only go outside of the network when they're forced to, because wants to pay more for the same types of services that they can access them within networks. So those are two types of plans that have sort of in network and out of network function.
SARAH: And you had mentioned, ghost networks, what are those?
IVAN: So this is a term that I first started hearing a couple of years ago, but it really describes a phenomenon where insurance companies have many therapists that may be listed on their panels or on their websites as being members of their network, which would mean that they're open to receiving new clients from within the network. But, the panels are either inaccurate, because many of the providers are no longer practicing, or at least if they're practicing are no longer accepting clients from within the network. And what I've seen in a lot of cases is, and I've talked earlier about how working with insurance companies, as a therapist can be difficult. So, if given a choice, and a lot of times people make the choice, they'll say I'm not taking insurance at all, I'm just going to take private pay clients, I may get slightly less per hour, depending on the circumstances, but I won't have to file paperwork, I won't have to deal with the insurance company payment can be more immediate etc.
The other thing that happens is that, let's just say, somebody who's providing therapy has 35 slots per week that they can fill with clients they may be on the panel for an insurance company, but they may reserve 33 of those slots for non insurance clients. So when you call them, they may technically be within the network. Bu, you and maybe 10 to 15 other people are maybe looking to fit into their two or three spots or whatever number that they reserved for those insurance clients.
SARAH: And when looking at these panels and the providers who are providing the care, is there any thought or do we have any data on the diversity of those providers? Do those providers reflect the population they serve? Do they have any additional training?
IVAN: So, in general, mental health professionals across the board don't really reflect the diversity of the individuals that are seeking services from them. I think the statistic that I have heard is that, I’m a psychologist in the American Psychological Association. They've done surveys with a membership that 4% of psychologists are Black or African American. So there's a shortage from the get go. And in our circumstances, as I mentioned earlier, our population is largely a minority population, we really are looking to find, in addition to finding therapists that are qualified and good with clients, we're looking to find diverse individuals as well, that can help match the population we serve. So, that's an additional struggle.
SARAH: And in the case of our own initiative, and again, a call back to part one, if you haven't listened to that, providing culturally competent and culturally sensitive care has been a real priority for us.
IVAN: I mean I think when you talk to individuals seeking mental health services that have received mental health services, it’s not that they always need to have a clinician that is the exact same ethnicity as them or at least as a minority that understands what it's like to experience the discrimination and racism, for example, that they deal with on a day to day basis. But a lot of times, it is sort of like a shortcut, if you're starting therapy with somebody, and they feel like that they can talk about those things, which certainly are likely to impact their mental health, whether you're coming in because you have a history of trauma that's impacting you, but the day-to-day microaggressions, and racism that folks experience really impacts their mental health. And so they may feel like they can talk with that person directly about that, and they’ll understand. But when we do have clinicians who are not, minority individuals, we really focus on trying to be culturally competent, and really addressing and doing what we can to make our clients comfortable with and able to share and getting the reaction that is helpful for them when they talk about racism, or really what it's like to be a minority individual in our society.
SARAH: Yeah, and I can just speak to one of the driving factors I had mentioned was in our own initiative was that we were hearing from nurses a lot of frustration about kind of referring their clients out and having concerns not only with access to care, but access to that quality, culturally competent care. So I know that that was really important when we were designing the services. And we've been really fortunate to be able to find therapists who are of color, and are women of color, who are connecting with our clients in that way. So we're very grateful to have that that talent on the team.
IVAN: One thing that we've done as an organization, in the last year or two, we started is that we do a separate interview for all positions that's really focused on diversity, equity and inclusion issues. And so there may be somebody that we interview, and they really seem qualified for a position. But we come back and set up a second interview where we talk just about DEI and it's not that we're looking for people that are all the way where they need to be necessarily in those areas, but we're looking for people that think about it, recognize it, and are willing to grow. And just having those interviews has shown, we need to get the numbers, but I think we've increased the diversity of our workforce pretty substantially in the last couple of years. I think one of the things is just doing that shows that we really are committed to it, I think, to therapists of color, for example, that want to come on board. So I think that's one of the things that's helped us start to attract and retain a more diverse staff.
SARAH: And as you said, this is really hard work. So a lot of competing systems here that are that are coming together to make access to care really, really challenging. So on top of everything we've been talking about recently, the US Preventive Services Task Force, so for those listening, that's a group of medical experts, they called for anxiety screenings for anyone under 65. I'm wondering, Ivan, what's your reaction to that recommendation?
IVAN: I saw the headline. I don’t know if I read the article, my question is why just under 65? Maybe we should do that for everybody. I happen to know a couple of 65-year olds who I think have some anxiety that might also benefit from a screening. This might just reflect what we sort of started this discussion, which is to talk about the increasing struggles with mental health across the board in our country. I'm assuming when they're talking about anxiety screens, they're talking about for primary care providers here. Just to talk really briefly about the power of mental health in terms of all health outcomes. The reason why you would want to do that as you want to make sure that people are identified and are receiving treatment if they need it. But also, because anxiety and depression and other types of mental health issues really impact medical outcomes as well. So that would be, if you have even some sort of diabetes treatment, for example, they found that, mental health really impacts in a lot of ways. One is in terms of your compliance with whatever the treatment recommendations are. But it seems to impact it over and above that. And so I think it's important really, for all physical health providers, and maybe we should even make that distinction. So clearly between mental health and physical health, because they really are just all kind of one thing in my mind, is to really consider mental health across the board, especially now, because we know that so many people are struggling.
SARAH: So I think those are great points. I do wonder, though I mean with the increased access to screenings, how will that impact the shortage of mental health professionals? So aren't we really compounding the issue here?
IVAN: Yeah, you would expect that. Okay, so if I'm a primary care provider, and I'm doing a screening, and , before I knew 3% of my patients that I was working with, were anxious, and now I know, 7% or 10%? Where am I going to send them? Yeah, I think the screening is helpful, but exactly. We're talking about the shortage of and difficulties and access to mental health services. It’s not going to be made better with more people that are identified as needing services.
SARAH: So, that means we've identified a lot of challenges here, right. And a lot of intersecting systems that are compounding the issue to make access to care really difficult. Where do we go from here? What are some potential solutions? How do we fix this issue?
IVAN: I don't think there are any easy fixes. One thing that that needs to happen is that there needs to be an increase in reimbursement rates for mental health specifically. And one of the things I think that why things have ended up the way that they have with mental health professionals is you think about most mental health professionals, they work individually, or they're in small practices. But I know for me, this is true. If you think about most medical professionals, they're sort of increasingly part of these large networks. So like a hospital network, for example. And those large networks have much more power to negotiate with insurance companies than individuals do individuals and small practices have almost no power to negotiate the insurance companies.
And there are some states that have really worked on that, specifically Maryland and California. But California in general has had regulations for a while for insurance companies that really talk about how fast access is supposed to be, how access is supposed to look. And so for example, for a long time, they've said for mental health services, insurance companies need to make sure that for routine appointments, that something can be scheduled within 10 days. And more recently, they've amended that law, to say that follow up appointments also need to happen within 10 days, unless the mental health professional feels that that's not necessary. And there are insurance companies that have been fined in California. The issue is, there are studies and there's a professor at Texas A&M named Simon Haeder who's done a lot of work on this, they found that even with penalties, even financial penalties, it doesn't seem like these insurance companies are really changing what they do. And part of the problem may be because the financial penalties are so small in comparison to their overall budget or the overall. In some cases, these are nonprofits, but they still make a profit, which is supposed to be put back into the business every year, but the penalties have been had been really low.
California had a law that was passed and signed into law by the governor, that would increase penalties 10 times. And so I think they're trying to do what they can in California to move the bar on access. And so I think, again, getting back to this idea that if we can't tell insurers what to pay, we can at least say, Hey, if you're going to provide this this product, then you need to be able to have this access within a certain amount of time. And then really hold insurance companies accountable, with large penalties, not penalties that they can say, it's just the cost of doing business or , it's actually costing less to pay this penalty than it would be to actually do what we're supposed to do, which is increased service provision and hire more therapists. So I think that that's one thing that can be done.
But again, I'm not hopeful that it's going to happen right away. The other thing that can happen is we haven't talked much about this, but people that go into our field are paying a lot of money to get a master's degree and get a doctorate in the mental health field, they're coming out with significant debt, and then they're going to get their first job, and I certainly I've seen this happen in real time, you say, Hey, this is the salary that we can offer. And they're like, I’m not happy, because they're looking at the debts that they experienced, looking at the increased cost of living, etc. And it's just difficult. There's a program in the Philadelphia area, that's a very good masters in social work program, that costs around $56,000 per year. And that's not taking into consideration, the living expenses that you would need to also have while you're attending the program, so you get a two-year degree in social work, and you want to become a therapist, you also then need to spend a year or two getting additional hours. So you can become licensed. People are stressed. And so that's what people are dealing with as they enter the field. So one thing that could happen there is that there could be some way either nationally from the federal government, state governments, even municipal governments, where they somehow sponsor people to get these degrees. And then they have them stay in the field for a certain number of years, for example, and the debts are forgiven. And one thing I've heard is that rather than pay back, if they can pay on the front end, that would be even better, that people could avoid the debt. So that's, that's one other possibility.
But it's going to really require, I think, what I've seen in the last year, so as people are saying, Okay, we really have a problem, right? A lot of the articles been like, this is what's going on. It's a problem. It's a crisis. But very few have said, Okay, this is exactly what needs to happen, or I haven't seen a lot of action so far, on the part of, lawmakers to really say we're going to move forward. And then the other thing is getting back to this issue of holding insurance companies accountable is that they need to update their panels so that they're accurate, which also has a cost, and they need to be held accountable for the accuracy of their panels. So again, California has started to do some of that stuff, but we're still in the early stages.
SARAH: It's so interesting because a lot of what you're describing reflects a lot of the conversations about the nursing workforce shortage. And what I was thinking as you were speaking, in nursing, we don't have the same issue of, or at least, to a much lesser extent of folks deciding to go outside of the insurance system. That's not really the sort of idea of private health care is very, very small, that sort of like concierge model of care, very small part of the healthcare industry. And so, just tying together some of what you've said, it almost seems like, yes, if we could pull back some of those private pay providers into the workforce, which would be really an immediate solution, it wouldn't necessarily depend on training a whole lot of new therapists, although that likely needs to happen, too. And I think that there is a lot of opportunity there to think about, yeah, how do you incentivize private pay therapists to come back in? I wonder if you could speak a little bit to other requirements relating to insurance? So I know, in addition to the low levels of reimbursement, there's also a lot of documentation required, how do you see that playing out in terms of therapists deciding whether to take insurance or not?
IVAN: So depending on the type of insurance, so for the insurance that we take, which is Medicaid, we have a huge burden in terms of the requirements for paperwork to be excellent. So in addition to making sure that the service actually happened to documenting when it happened, how it happened, and so on, we're in a position where our notes have to include pretty extensive description of what's going on in the session and so on. The reason there is, to reduce fraud, right, and also for insurance companies to make sure that treatment is happening in a positive way. But what happens is, in addition to all the stresses we've already talked about, for therapists, they spend so much of their time on paperwork and documentation that they really could be spending time directly with clients or planning for sessions, really clinically related work. So certainly, and also have looked a little bit at the research on burnout, and over paperwork is a huge contributor to burnout. So if we could reduce the paperwork, I think that would be helpful. I think the paperwork requirements are a little bit less for , private insurance companies, your PPO, or HMO is your POS is and stuff like that, but they still exist.
My wife is actually in private practice, while she works at an at a private practice, group practice, and her paperwork requirements are just absolutely minimal in comparison to what we have to do. So yeah, I think that's a good point, Sarah. So if we could set up a system where if we're trying to draw therapists that exists back into the system that have stopped taking insurance, and one of the ways is like, nobody wants to get back into a system where they're going to have to increase their paperwork.
Now, I say this having all professionals, have requirements. So as a psychologist, the State Board of Psychology says, paperwork has to include the following. So we have standards of our profession that we have to follow anyway, those tend to be slightly less intense, especially, compared to the Medicaid system. So yeah, I think paperwork is a big issue. I always sort of say like paperwork should be as minimal as it needs to be in order to get the job done. And so in my opinion, it's not at this point.
The other thing with insurance companies, it's less of an issue for outpatient, although it used to be more of an issue where you would get need prior approval. So they would say, okay, you can have three sessions, they need to call us back or you need to fill out this form to get more sessions that's not necessary. An outpatient is a relatively inexpensive level of care. And that just seems like a roadblock that really I don't think provides any utility for the insurance company or for the therapists or for the client. There are other levels of care that are more expensive and more intensive that still do require those kinds of authorizations, so inpatient, hospitalization, residential, those sorts of things. But yeah, thanks for bringing up the issue of paperwork. Yes, let's reduce paperwork as much as we can.
SARAH: We've talked a lot about insurance and clearly with the client population that Joseph J. Peters Institute serves. Clearly, these are things you're thinking about, but I know when we designed our mental health integration, we realized we weren't going to be able to bill insurance based on our model of care. So what does this look like for other avenues to care and if you could speak to telehealth because I know that that is now sort of in the insurance sphere. But what about other methods of receiving mental health services?
IVAN: Yeah, so telehealth, well, that's a great, separate conversation and I think the research is still developing on it. But so telehealth has been has been great. So, telehealth, we didn't have a choice during the pandemic, things were shutting down, people still needed services. And so, what I'm familiar with is the state of Pennsylvania because we're regulated by the state of Pennsylvania. They sort of said, here's some general guidelines for telehealth, telehealth existed before, but it was very difficult to access, I think it was primarily for, from what I could tell us for rural areas that didn't necessarily have a professional on site. And what would happen would be that the professional would have to go to a physical clinic location somewhere that was regulated, and then they would get on a screen and they would talk to a client who was somewhere else. So telehealth has been fabulous. We are still providing a good portion of our services through telehealth. So telehealth is not for everybody. Some clients really love it. Some therapists love it, some don't like it at all.
When we reopened again, we were closed for about a year, maybe slightly longer than a year, there were people like beating down the door to get in. And they were saying we're so happy you're open. Because we really want to see your therapist in person. And then for certain issues and problems, when you're working with little kids, for example, telehealth is probably not great, if you're working with a four year old. Need much more activity in your session. So I have to give credit to the state of Pennsylvania, they were very forward thinking at least in terms of telehealth for the Medicaid population. And I want to say maybe eight, nine months ago, they came out with regulations, they received feedback from therapists, from the general population. And the regulations that they came out with that are permanent, allow us to do telehealth for Medicaid clients in Pennsylvania. And they are great. So they're very flexible, and they're very helpful. The main thing and I think it's helpful that they did this as they say that, if the client is not interested in telehealth, you need to be able to offer on-site services, which we which we do for all of our clients. So yeah, telehealth is great. I think what you were referencing is, at least for the world that we're in, you're only allowed to provide billable services for Medicaid insurance from a licensed clinic, which it's not always easy to get the clinic licensed and up and running. And so when we started to partner with your organization, we were saying we need to go where the clients are. So that means we need to go into the home if we need to, right, this is a home visiting program. Or we need to say hey, let's meet closer to home or whatever. So that doing that doesn't allow us to then bill for the services from Medicaid insurance, which most of your most of your patients have. And so flexibility around that would be would be an issue. There were there are some exceptions that exist, but they tend to be for folks who either physically couldn't get to the clinic. And that would need to be documented or, for example, had agoraphobia, like a fear of leaving the house. Right, so in those instances, you could document and provide services out of the clinic site. But yeah, some additional flexibility around that would be helpful. Again, telehealth provides that flexibility. But that provides flexibility but not for in person, right, we still wouldn't be able to bill for going to the client's house and working with directly there.
SARAH: We do this with all of our programs, but really trying to learn on the ground, what are the barriers that we're facing so that we can inform things. And I have to say we were really fortunate. In addition to the funding for this episode, which came from the vanAmerigen Foundation, we actually are now able to fund the therapists on staff through state funding. So originally really relying on philanthropic and other sources. But we were able to through the Office of Child Development and Early Learning. So again, a hats off to Pennsylvania for being forward thinking in this respect, we're able to use some of our block grant funding for the home visiting to support this mental health integration. So I think we're starting to see some of these innovations get more acceptance in government systems and government understanding of how we need to fund mental health as part of the whole continuum of care. But it is a challenge. And yeah, I mean, if we had, if we were only able to sustain the services through billing, we wouldn't have been able to implement the program we have right now.
IVAN: Yeah, I just wanted to make a point about telehealth. So one of the issues, though, is that we have a lot of flexibility within the state of Pennsylvania, for Medicaid population. But as the pandemic has ended there are organizations and systems that allow telehealth that are starting to curtail the ability to do that. So what I would say it would be a helpful thing is, if just maximum flexibility around telehealth will be allowed by insurance companies, by states by the federal government to allow it to continue. I think that again research still needs to be done. But the early research is that high quality services can be provided through telehealth, and we should look to make it a way, something that's continued, because it does help with accessibility.
The other thing that we haven't talked about is that in the United States, we have 50 states, some territories, each one regulates mental health professionals on their own. And they're starting to be some work on setting up like interstate compacts. But as somebody who's licensed as a psychologist in Pennsylvania, I cannot provide even via telehealth services to somebody who lives in New York or New Jersey. It comes down to where the client or the patient is residing, or where they're physically located at the time. And so additional flexibility around that, and that's a long-standing issue, it doesn't seem to make a lot of sense that we have 50 states that have almost the exact same requirements for licensure, but it's a problem. And I'm sure that's true across the board.
SARAH: In addition to a low rate of reimbursement, there isn't reimbursement for when folks don't show up. And we see that being an issue and all sorts of models of care that are that are serving a Medicaid population. Have you seen that play out?
IVAN: We did. Yeah, we saw lower no show rates. But that brings up another issue, which is not everybody has access to telehealth, right. So, early in the pandemic, when we were trying to figure out what we were going to do, we had people survey their clients, some people don't have access to broadband, or a data plan on their phone that allows them to do telehealth, some people don't have privacy. They may live in like a group living situation where they just don't have the space that they can go this private to do a therapy session. And then some people don't have the device. Some people don't have a computer, some people don't have a smartphone. So especially for lower income folks. And I would imagine folks in rural areas where broadband might be more of an issue. Telehealth, while it helps with access is not equally accessible by all.
SARAH: So before we end our conversation, any final thoughts that you'd like to leave with our listeners?
IVAN: I think, and if they're listening to this podcast, they probably feel this way anyway, but just the importance of mental health, to all outcomes to having a happy and enjoyable life, to family relationships to physical health, and just for folks to if they have the opportunity to discuss this or to advocate to just help advocate for improved. We've talked a lot about payments, that's not the only issue, but in my mind, if we could get payments up, we could attract more people into the field. As you mentioned, Sarah, either people that are in the field already that are not taking insurance, which is the vast majority of people, 90 plus percent have received health services through insurance reimbursement. Yeah, and so that’s it, I just I really appreciate the opportunity to talk about one of my pet issues for the length of the podcast.
SARAH: Thank you Ivan for making time to talk with us on At the Core of Care.
IVAN: Thank you, I really appreciated being here.
CREDITS
As Ivan said, payment is really just one of the many factors impacting access to quality mental health care. So, we’re going to be revisiting this topic overtime to learn more about opportunities for system’s level change.
If you haven’t listened to Part 1 of our special mental health coverage, don’t forget to check it out. You’ll hear from two different mothers receiving therapeutic services through the Philadelphia Nurse-Family Partnership and Mabel Morris Family Home Visit Program. They share what their experiences have been like, including interactions with their therapists, and the impact so far.
I don’t even know how long I’m going to be in therapy, I just, I just started. I feel like probably I’ll always need therapy, but I feel like I don’t think that’s a bad thing. I definitely do feel like therapy is something that you kind of like want to do. It's kind of like going like to school or starting a diet. If someone's forcing you to do it, it's not going to be effective. So it's something that you have to go into with an open mind.
Support for this episode comes from the van Ameringen Foundation and the Pennsylvania Action Coalition.
You can find our most current and past episodes of At the Core of Care wherever you get your podcasts or at https://www.paactioncoalition.org/.
You can stay up to date with us on social media @PAAction and @NurseLedCare.
At the Core of Care is produced by Stephanie Marudas of Kouvenda Media and mixed by Brad Linder.
I'm Sarah Hexem Hubbard with the Pennsylvania Action Coalition. Thanks for joining us.
